Florida Senate - 2013 CS for CS for SB 1724
By the Committees on Health Policy; and Children, Families, and
Elder Affairs; and Senators Garcia and Grimsley
588-03975-13 20131724c2
1 A bill to be entitled
2 An act relating to transitional living facilities;
3 creating part XI of ch. 400, F.S., entitled
4 “Transitional Living Facilities”; creating s.
5 400.9970, F.S.; providing legislative intent; creating
6 s. 400.9971, F.S.; providing definitions; creating s.
7 400.9972, F.S.; requiring the licensure of
8 transitional living facilities; providing fees;
9 providing license application requirements; creating
10 s. 400.9973, F.S.; providing requirements for
11 transitional living facilities relating to client
12 admission, transfer, and discharge; creating s.
13 400.9974, F.S.; requiring a comprehensive treatment
14 plan to be developed for each client; providing plan
15 requirements; creating s. 400.9975, F.S.; providing
16 licensee responsibilities; providing notice
17 requirements; prohibiting a licensee or employee of a
18 facility from serving notice upon a client to leave
19 the premises or take other retaliatory action;
20 requiring the client and client’s representative to be
21 provided with certain information; requiring the
22 licensee to develop and implement certain policies and
23 procedures; creating s. 400.9976, F.S.; providing
24 licensee requirements relating to medication
25 practices; creating s. 400.9977, F.S.; providing
26 requirements for the screening of potential employees
27 and monitoring of employees for the protection of
28 clients; requiring licensees to implement certain
29 procedures; creating s. 400.9978, F.S.; requiring a
30 facility to provide a therapeutic milieu that supports
31 a culture of individual empowerment and
32 responsibility; providing that the health and safety
33 of the client is the primary concern of the facility;
34 providing requirements and limitations for the use of
35 physical restraints, seclusion, and chemical restraint
36 medication on clients; requiring the Agency for Health
37 Care Administration to adopt rules; creating s.
38 400.9979, F.S.; providing background screening
39 requirements; requiring the licensee to maintain
40 certain personnel records; providing administrative
41 responsibilities for licensees; providing
42 recordkeeping requirements; creating s. 400.9980,
43 F.S.; providing requirements relating to property and
44 personal affairs of clients; providing requirements
45 for a licensee with respect to obtaining surety bonds;
46 providing recordkeeping requirements relating to the
47 safekeeping of personal effects; providing
48 requirements for trust funds received by licensee and
49 credited to the client; providing a penalty for
50 certain misuse of a resident’s personal needs
51 allowance; providing criminal penalties for
52 violations; providing for the disposition of property
53 in the event of the death of a client; authorizing the
54 Agency for Health Care Administration to adopt rules;
55 creating s. 400.9981, F.S.; authorizing the agency to
56 adopt and enforce certain rules; creating s. 400.9982,
57 F.S.; providing procedures relating to violations and
58 penalties; providing administrative fines for
59 specified classes of violations; creating s. 400.9983,
60 F.S.; authorizing the agency to apply certain
61 provisions with regard to receivership proceedings;
62 creating s. 400.9984, F.S.; requiring the Agency for
63 Health Care Administration, the Department of Health,
64 the Agency for Persons with Disabilities, and the
65 Department of Children and Families to develop
66 electronic systems for certain purposes; repealing s.
67 400.805, F.S., relating to transitional living
68 facilities; providing that every transitional living
69 facility licensed under s. 400.805, F.S., on or before
70 a specified date is licensed under the provisions of
71 the act; amending s. 381.745, F.S.; revising a
72 definition; amending s. 381.75, F.S.; revising the
73 duties of the Department of Health as they relate to
74 transitional living facilities; amending s. 381.78,
75 F.S.; conforming provisions to changes made by the
76 act; amending ss. 408.802 and 408.820, F.S.;
77 conforming a provision to changes made by the act;
78 amending s. 400.93, F.S.; providing that transitional
79 living facilities licensed under part XI of ch. 400,
80 F.S., are exempt from home medical equipment provider
81 licensure; amending s. 400.9905, F.S.; revising a
82 definition; providing an effective date.
83
84 Be It Enacted by the Legislature of the State of Florida:
85
86 Section 1. Sections 400.9970 through 400.9984, Florida
87 Statutes, are designated as part XI of chapter 400, Florida
88 Statutes, entitled “Transitional Living Facilities.”
89 Section 2. Section 400.9970, Florida Statutes, is created
90 to read:
91 400.9970 Legislative intent.—It is the intent of the
92 Legislature to provide for the licensure of transitional living
93 facilities and require the development, establishment, and
94 enforcement of basic standards by the Agency for Health Care
95 Administration to ensure quality of care and services to clients
96 in transitional living facilities. It is the policy of the state
97 that the least restrictive appropriate available treatment be
98 used based on the individual needs and best interest of the
99 client and consistent with optimum improvement of the client’s
100 condition. The goal of a transitional living program for
101 individuals who have brain or spinal cord injuries is to assist
102 each individual who has such an injury to achieve a higher level
103 of independent functioning and to enable that individual to
104 reenter the community. It is also the policy of this state that
105 the use of restraints and seclusion on clients is justified only
106 as an emergency safety measure to be used in response to danger
107 to the client or others. It is, therefore, the intent of the
108 Legislature to achieve an ongoing reduction in the use of
109 restraints and seclusion in programs and facilities that serve
110 persons who have brain injury or spinal cord injuries.
111 Section 3. Section 400.9971, Florida Statutes, is created
112 to read:
113 400.9971 Definitions.—As used in this part, the term:
114 (1) “Agency” means the Agency for Health Care
115 Administration.
116 (2) “Chemical restraint” means a pharmacologic drug that
117 physically limits, restricts, or deprives an individual of
118 movement or mobility, is used for client protection or safety,
119 and is not required for the treatment of medical conditions or
120 symptoms.
121 (3) “Client’s representative” means the parent of a child
122 client or the client’s guardian, designated representative or
123 designee, surrogate, or attorney in fact.
124 (4) “Department” means the Department of Health.
125 (5) “Physical restraint” means any manual method to
126 restrict freedom of movement of or normal access to an
127 individual’s body or a physical or mechanical device, material,
128 or equipment attached or adjacent to the individual’s body so
129 that he or she cannot easily remove the restraint and which
130 restricts freedom of movement of or normal access to one’s body,
131 including, but not limited to, a half-bed rail, a full-bed rail,
132 a geriatric chair, and a posey restraint. The term includes any
133 device that was not specifically manufactured as a restraint but
134 which has been altered, arranged, or otherwise used for this
135 purpose. The term does not include bandage material used for the
136 purpose of binding a wound or injury.
137 (6) “Seclusion” means the physical segregation of a person
138 in any fashion or the involuntary isolation of a person in a
139 room or area from which the person is prevented from leaving.
140 The prevention may be by physical barrier or by a staff member
141 who is acting in a manner, or who is physically situated, so as
142 to prevent the person from leaving the room or area. For
143 purposes of this chapter, the term does not mean isolation due
144 to a person’s medical condition or symptoms.
145 (7) “Transitional living facility” means a site where
146 specialized health care services are provided, including, but
147 not limited to, rehabilitative services, behavior modification,
148 community reentry training, aids for independent living, and
149 counseling to individuals who have brain injuries or spinal cord
150 injuries. The term does not require a provider that is licensed
151 by the agency to obtain a separate transitional living facility
152 license to serve persons who have brain injuries or spinal cord
153 injuries as long as the services provided are within the scope
154 of the provider’s license.
155 Section 4. Section 400.9972, Florida Statutes, is created
156 to read:
157 400.9972 License required; fee; application.—
158 (1) The requirements of part II of chapter 408 apply to the
159 provision of services that require licensure pursuant to this
160 part and part II of chapter 408 and to entities licensed by or
161 applying for such licensure from the agency pursuant to this
162 part. A license issued by the agency is required for the
163 operation of a transitional living facility in this state.
164 (2) In accordance with this part, an applicant or a
165 licensee shall pay a fee for each license application submitted
166 under this part. The license fee shall consist of a $4,588
167 license fee and a $90 per-bed fee per biennium and shall conform
168 to the annual adjustment authorized in s. 408.805.
169 (3) Each applicant for licensure must provide the
170 following:
171 (a) The location of the facility for which a license is
172 sought and documentation, signed by the appropriate local
173 government official, which states that the applicant has met
174 local zoning requirements.
175 (b) Proof of liability insurance as provided in s. 624.605.
176 (c) Proof of compliance with local zoning requirements,
177 including compliance with the requirements of chapter 419 if the
178 proposed facility is a community residential home.
179 (d) Proof that the facility has received a satisfactory
180 firesafety inspection.
181 (e) Documentation of a satisfactory sanitation inspection
182 of the facility by the county health department.
183
184 The applicant’s proposed facility must attain and continuously
185 maintain accreditation by an accrediting organization
186 specializing in evaluating rehabilitation facilities whose
187 standards incorporate comparable licensure regulations required
188 by the state. An applicant for licensure as a transitional
189 living facility must acquire accreditation within 12 months
190 after the issuance of an initial license. The agency shall
191 accept the accreditation survey report of the accrediting
192 organization in lieu of conducting a licensure inspection if the
193 standards included in the survey report are determined by the
194 agency to document that the facility is in substantial
195 compliance with state licensure requirements. The applicant
196 shall submit to the agency within 10 days after receipt a copy
197 of any accreditation survey report and evidence of the
198 accreditation decision subsequent to a survey by the accrediting
199 organization on the facility. This part does not preclude the
200 agency from conducting periodic inspections of a transitional
201 living facility to ensure compliance with all licensure
202 requirements, and as it deems necessary to carry out the
203 functions of the agency. An inspection may be conducted to
204 ensure compliance with licensure requirements of this part, to
205 validate the inspection process of accrediting organizations, to
206 respond to licensure complaints, or to protect the public health
207 and safety.
208 Section 5. Section 400.9973, Florida Statutes, is created
209 to read:
210 400.9973 Client admission, transfer, and discharge.—
211 (1) Each transitional living facility must have written
212 policies and procedures governing the admission, transfer, and
213 discharge of clients.
214 (2) The admission of each client to a transitional living
215 facility must be in accordance with the licensee’s policies and
216 procedures.
217 (3) A client admitted to a transitional living facility
218 must have a brain or spinal cord injury, such as a lesion to the
219 spinal cord or cauda equina syndrome, with evidence of
220 significant involvement of two of the following deficits or
221 dysfunctions:
222 (a) A motor deficit.
223 (b) A sensory deficit.
224 (c) Bowel and bladder dysfunction.
225 (d) An acquired internal or external injury to the skull,
226 the brain, or the brain’s covering, whether caused by a
227 traumatic or nontraumatic event, which produces an altered state
228 of consciousness or an anatomic motor, sensory, cognitive, or
229 behavioral deficit.
230 (4) A client whose medical condition and diagnosis does not
231 positively identify a cause of the client’s condition, whose
232 symptoms are inconsistent with the known cause of injury, or
233 whose recovery is inconsistent with the known medical condition
234 may be admitted to a transitional living facility for evaluation
235 for a period not to exceed 90 days.
236 (5) A client admitted to a transitional living facility
237 must be admitted upon prescription by a licensed physician and
238 must remain under the care of a licensed physician for the
239 duration of the client’s stay in the facility.
240 (6) A transitional living facility may not admit a client
241 whose primary admitting diagnosis is mental illness or an
242 intellectual or a developmental disability.
243 (7) An individual may not be admitted to a transitional
244 living facility if the individual:
245 (a) Presents significant risk of infection to other clients
246 or personnel. A health care practitioner must provide
247 documentation that the individual is free of apparent signs and
248 symptoms of communicable disease;
249 (b) Is a danger to self or others as determined by a
250 physician or mental health practitioner licensed under chapter
251 490 or chapter 491, unless the facility provides adequate
252 staffing and support to ensure patient safety;
253 (c) Is bedridden; or
254 (d) Requires 24-hour nursing supervision.
255 (8) If the client meets the admission criteria, the medical
256 or nursing director of the facility must complete an initial
257 evaluation of the client’s functional skills, behavioral status,
258 cognitive status, educational or vocational potential, medical
259 status, psychosocial status, sensorimotor capacity, and other
260 related skills and abilities within the first 72 hours after the
261 client’s admission to the facility. An initial comprehensive
262 treatment plan that delineates services to be provided and
263 appropriate sources for such services must be implemented within
264 the first 4 days after admission.
265 (9) Each transitional living facility shall develop a
266 discharge plan for each client before or upon admission to the
267 facility. The discharge plan must identify the intended
268 discharge site and possible alternative discharge sites. For
269 each discharge site identified, the discharge plan must identify
270 the skills, behaviors, and other conditions that the client must
271 achieve to be appropriate for discharge. Discharge plans must be
272 reviewed and updated as necessary, but no less often than once
273 monthly.
274 (10) As soon as practicable, a transitional living facility
275 shall discharge a client when he or she no longer requires any
276 of the specialized services described in s. 400.9971(7) or is
277 not making measurable progress in accordance with his or her
278 comprehensive treatment plan, or if the transitional living
279 facility is no longer the most appropriate, least restrictive
280 treatment option.
281 (11) Each transitional living facility shall provide at
282 least 30 days’ notice to clients of transfer or discharge plans,
283 including the location of an acceptable transfer location if the
284 client is unable to live independently. This requirement does
285 not apply if a client voluntarily terminates residency.
286 Section 6. Section 400.9974, Florida Statutes, is created
287 to read:
288 400.9974 Client comprehensive treatment plans; client
289 services.—
290 (1) Each transitional living facility shall develop a
291 comprehensive treatment plan for each client as soon as
292 possible, but no later than 30 days following development of the
293 initial comprehensive treatment plan. Comprehensive treatment
294 plans must be reviewed and updated if the client fails to meet
295 projected improvements in the plan or if a significant change in
296 the client’s condition occurs. Comprehensive treatment plans
297 must be reviewed and updated at least once monthly.
298 Comprehensive treatment plans must be developed by an
299 interdisciplinary team consisting of the case manager, the
300 program director, the nurse, and appropriate therapists. The
301 client or, if appropriate, the client’s representative must be
302 included in developing the comprehensive treatment plan.
303 (2) The comprehensive treatment plan must include the
304 following:
305 (a) The physician’s orders and the client’s diagnosis,
306 medical history, physical examination, and rehabilitative or
307 restorative needs.
308 (b) A preliminary nursing evaluation with physician’s
309 orders for immediate care, completed on admission.
310 (c) A comprehensive, accurate, reproducible, and
311 standardized assessment of the client’s functional capability;
312 the treatments designed to achieve skills, behaviors, and other
313 conditions necessary to return to the community; and specific
314 measurable goals.
315 (d) Steps necessary for the client to achieve transition to
316 the community and estimated length of time to achieve the goals.
317 (3) The client or, if appropriate, the client’s
318 representative must consent to the continued treatment at the
319 transitional living facility. Consent may be for a period of up
320 to 3 months. If such consent is not given, the transitional
321 living facility shall discharge the client as soon as
322 practicable.
323 (4) Each client must receive the professional program
324 services needed to implement the client’s comprehensive
325 treatment plan.
326 (5) The licensee must employ qualified professional staff
327 to carry out and monitor the various professional interventions
328 in accordance with the stated goals and objectives of every
329 client’s comprehensive treatment plan.
330 (6) Each client must receive a continuous treatment program
331 that includes appropriate, consistent implementation of a
332 program of specialized and general training, treatment, health
333 services, and related services which is directed toward:
334 (a) The acquisition of the behaviors and skills necessary
335 for the client to function with as much self-determination and
336 independence as possible;
337 (b) The prevention or deceleration of regression or loss of
338 current optimal functional status; and
339 (c) The management of behavioral issues that preclude
340 independent functioning in the community.
341 Section 7. Section 400.9975, Florida Statutes, is created
342 to read:
343 400.9975 Licensee responsibilities.—
344 (1) The licensee shall ensure that each client:
345 (a) Lives in a safe environment free from abuse, neglect,
346 and exploitation.
347 (b) Is treated with consideration and respect and with due
348 recognition of personal dignity, individuality, and the need for
349 privacy.
350 (c) Retains and uses his or her own clothes and other
351 personal property in his or her immediate living quarters, so as
352 to maintain individuality and personal dignity, except when the
353 licensee can demonstrate that such retention and use would be
354 unsafe, impractical, or an infringement upon the rights of other
355 clients.
356 (d) Has unrestricted private communication, including
357 receiving and sending unopened correspondence, access to a
358 telephone, and visiting with any person of his or her choice.
359 Upon request, the licensee shall make provisions to modify
360 visiting hours for caregivers and guests. The facility shall
361 restrict communication in accordance with any court order or
362 written instruction of a client’s representative. Any
363 restriction on a client’s communication for therapeutic reasons
364 shall be documented and reviewed at least weekly and shall be
365 removed as soon as it is no longer clinically indicated. The
366 basis for the restriction shall be explained to the client and,
367 if applicable, the client’s representative. The client shall
368 nonetheless retain the right to call the abuse hotline, the
369 agency, and Disability Rights Florida at any and all times.
370 (e) Has the opportunity to participate in and benefits from
371 community services and activities to achieve the highest
372 possible level of independence, autonomy, and interaction within
373 the community.
374 (f) Has the opportunity to manage his or her financial
375 affairs unless the client or, if applicable, the client’s
376 representative authorizes the administrator of the facility to
377 provide safekeeping for funds as provided in this part.
378 (g) Has reasonable opportunity for regular exercise several
379 times a week and to be outdoors at regular and frequent
380 intervals except when prevented by inclement weather.
381 (h) Has the opportunity to exercise civil and religious
382 liberties, including the right to independent personal
383 decisions. No religious belief or practice, including attendance
384 at religious services, shall be imposed upon any client.
385 (i) Has access to adequate and appropriate health care
386 consistent with established and recognized standards within the
387 community.
388 (j) Has the ability to present grievances and recommend
389 changes in policies, procedures, and services to the staff of
390 the licensee, governing officials, or any other person without
391 restraint, interference, coercion, discrimination, or reprisal.
392 Each licensee shall establish a grievance procedure to
393 facilitate a client’s ability to present grievances, including a
394 system for investigating, tracking, managing, and responding to
395 complaints by persons receiving services or individuals acting
396 on their behalf, and an appeals process. This process must
397 include access to Disability Rights Florida and other advocates
398 and the right to be a member of, be active in, and associate
399 with advocacy or special interest groups.
400 (2) The licensee shall:
401 (a) Promote participation of each client’s representative
402 in the process of providing treatment to the client unless the
403 representative’s participation is unobtainable or inappropriate.
404 (b) Answer communications from each client’s family,
405 guardians, and friends promptly and appropriately.
406 (c) Promote visits by individuals with a relationship to
407 the client at any reasonable hour, without requiring prior
408 notice, or in any area of the facility which provides direct
409 client care services to the client, consistent with the client’s
410 and other clients’ privacy, unless the interdisciplinary team
411 determines that such a visit would not be appropriate.
412 (d) Promote leave from the facility for visits, trips, or
413 vacations.
414 (e) Promptly notify the client’s representative of any
415 significant incidents or changes in the client’s condition,
416 including, but not limited to, serious illness, accident, abuse,
417 unauthorized absence, or death.
418 (3) The administrator of a facility shall ensure that a
419 written notice of licensee responsibilities is posted in a
420 prominent place in each building where clients reside and read
421 or explained to clients who cannot read. This notice shall
422 include the statewide toll-free telephone number for reporting
423 complaints to the agency, must be provided to clients in a
424 manner that is clearly legible, and must include the words: “To
425 report a complaint regarding the services you receive, please
426 call toll-free ...[telephone number]... or Disability Rights
427 Florida ...[telephone number]...”; and the statewide toll-free
428 telephone number for the central abuse hotline must be provided
429 to clients in a manner that is clearly legible and must include
430 the words: “To report abuse, neglect or exploitation, please
431 call toll-free ...[telephone number where complaints may be
432 lodged]....” The licensee must ensure a client’s access to a
433 telephone, where telephone numbers required in this subsection
434 are readily available to call the agency, central abuse hotline,
435 or Disability Rights Florida.
436 (4) A licensee or employee of a facility may not serve
437 notice upon a client to leave the premises or take any other
438 retaliatory action against any person solely due to the
439 following:
440 (a) The client or other person files an internal or
441 external complaint or grievance regarding the facility.
442 (b) The client or other person appears as a witness in any
443 hearing inside or outside the facility.
444 (5) Before or at the time of admission, the client and the
445 client’s representative shall be provided with a copy of the
446 licensee’s responsibilities as provided in this section,
447 including grievance procedures and the telephone numbers
448 provided in this section.
449 (6) The licensee must develop and implement policies and
450 procedures governing the release of any client information,
451 including consent necessary from the client or the client’s
452 representative.
453 Section 8. Section 400.9976, Florida Statutes, is created
454 to read:
455 400.9976 Medication practices.—
456 (1) An individual medication administration record must be
457 maintained for each client. Each dose of medication, including a
458 self-administered dose, shall be properly recorded in the
459 client’s record. Each client who self-administers medication
460 shall be given a pill organizer. Medication must be placed in
461 the pill organizer by a nurse. A nurse shall document the date
462 and time medication is placed into each client’s pill organizer.
463 All medications must be administered in compliance with the
464 physician’s orders.
465 (2) If the interdisciplinary team determines that self
466 administration of medications is an appropriate objective, and
467 if the physician does not specify otherwise, a client must be
468 taught to self-administer his or her medication without a staff
469 person. This includes all forms of administration, including
470 orally, via injection, and via suppository. The client’s
471 physician must be informed of the interdisciplinary team’s
472 decision that self-administration of medications is an objective
473 for the client. A client may not self-administer medication
474 until he or she demonstrates the competency to take the correct
475 medication in the correct dosage at the correct time, to respond
476 to missed doses, and to contact an appropriate person with
477 questions.
478 (3) Medication administration discrepancies and adverse
479 drug reactions must be recorded and reported immediately to a
480 physician.
481 Section 9. Section 400.9977, Florida Statutes, is created
482 to read:
483 400.9977 Protection from abuse, neglect, mistreatment, and
484 exploitation.—The licensee must develop and implement policies
485 and procedures for the screening and training of employees, the
486 protection of clients, and the prevention, identification,
487 investigation, and reporting of abuse, neglect, and
488 exploitation. This includes the licensee’s identification of
489 clients whose personal histories render them at risk for abusing
490 other clients, development of intervention strategies to prevent
491 occurrences, monitoring for changes that would trigger abusive
492 behavior, and reassessment of the interventions on a regular
493 basis. A licensee shall implement procedures to:
494 (1) Screen potential employees for a history of abuse,
495 neglect, or mistreatment of clients. The screening shall include
496 an attempt to obtain information from previous employers and
497 current employers and verification with the appropriate
498 licensing boards.
499 (2) Train employees, through orientation and ongoing
500 sessions, on issues related to abuse prohibition practices,
501 including identification of abuse, neglect, mistreatment, and
502 exploitation, appropriate interventions to deal with aggressive
503 or catastrophic reactions of clients, the process to report
504 allegations without fear of reprisal, and recognition of signs
505 of frustration and stress that may lead to abuse.
506 (3) Provide clients, families, and staff with information
507 on how and to whom they may report concerns, incidents, and
508 grievances without the fear of retribution and provide feedback
509 regarding the concerns that have been expressed. A licensee must
510 identify, correct, and intervene in situations in which abuse,
511 neglect, mistreatment, or exploitation is likely to occur,
512 including:
513 (a) Evaluating the physical environment of the facility to
514 identify characteristics that may make abuse or neglect more
515 likely to occur, such as secluded areas.
516 (b) Providing sufficient staff on each shift to meet the
517 needs of the clients, and ensuring that the staff assigned have
518 knowledge of the individual clients’ care needs. The licensee
519 shall identify inappropriate behaviors of its staff, such as
520 using derogatory language, rough handling, ignoring clients
521 while giving care, and directing clients who need toileting
522 assistance to urinate or defecate in their beds.
523 (c) Assessing, planning care for, and monitoring clients
524 with needs and behaviors that might lead to conflict or neglect,
525 such as clients with a history of aggressive behaviors, clients
526 who have behaviors such as entering other clients’ rooms,
527 clients with self-injurious behaviors, clients with
528 communication disorders, and clients who require heavy nursing
529 care or are totally dependent on staff.
530 (4) Identify events, such as suspicious bruising of
531 clients, occurrences, patterns, and trends that may constitute
532 abuse and determine the direction of the investigation.
533 (5) Investigate different types of incidents, identify the
534 staff member responsible for the initial reporting, investigate
535 alleged violations, and report results to the proper
536 authorities. The licensee must analyze the occurrences to
537 determine what changes are needed, if any, to policies and
538 procedures to prevent further occurrences and to take all
539 necessary corrective action depending on the results of the
540 investigation.
541 (6) Protect clients from harm during an investigation.
542 (7) Report all alleged violations and all substantiated
543 incidents, as required under chapters 39 and 415, to the
544 licensing authorities and all other agencies as required and to
545 report any knowledge it has of any actions by a court of law
546 that would indicate an employee is unfit for service.
547 Section 10. Section 400.9978, Florida Statutes, is created
548 to read:
549 400.9978 Restraints and seclusion; client safety.—
550 (1) Each facility shall provide a therapeutic milieu that
551 supports a culture of individual empowerment and responsibility.
552 The health and safety of the client shall be the primary concern
553 at all times.
554 (2) The use of physical restraints must be ordered and
555 documented by a physician and must be consistent with policies
556 and procedures adopted by the facility. The client or, if
557 applicable, the client’s representative must be informed of the
558 facility’s physical restraint policies and procedures at the
559 time of the client’s admission.
560 (3) The use of chemical restraints is limited to prescribed
561 dosages of medications as ordered by a physician and must be
562 consistent with the client’s diagnosis and the policies and
563 procedures adopted by the facility. The client and, if
564 applicable, the client’s representative must be informed of the
565 facility’s chemical restraint policies and procedures at the
566 time of the client’s admission.
567 (4) Based on a physician’s assessment, if a client exhibits
568 symptoms that present an immediate risk of injury or death to
569 self or others, a physician may issue an emergency treatment
570 order to immediately administer rapid response psychotropic
571 medications or other chemical restraints. Each emergency
572 treatment order must be documented and maintained in the
573 client’s record.
574 (a) An emergency treatment order is effective for no more
575 than 24 hours.
576 (b) Whenever a client is medicated in accordance with this
577 subsection, the client’s representative or responsible party and
578 the client’s physician must be notified as soon as practicable.
579 (5) A client who is prescribed and receiving a medication
580 that can serve as a chemical restraint for a purpose other than
581 an emergency treatment order must be evaluated by his or her
582 physician at least monthly to assess the following:
583 (a) The continued need for the medication.
584 (b) The level of the medication in the client’s blood, as
585 appropriate.
586 (c) The need for adjustments in the prescription.
587 (6) The licensee shall ensure that clients are free from
588 unnecessary drugs and physical restraints and are provided
589 treatment to reduce dependency on drugs and physical restraints.
590 (7) The licensee may use physical restraints and seclusion
591 only as authorized by the facility’s written physical restraint
592 and seclusion policies, which must be in compliance with this
593 section and applicable rules.
594 (8) Interventions to manage dangerous client behavior must
595 be employed with sufficient safeguards and supervision to ensure
596 that the safety, welfare, and civil and human rights of each
597 client are adequately protected.
598 (9) A facility shall notify the parent or guardian of a
599 client each time restraint or seclusion is used. Such
600 notification must be within 24 hours from the time the restraint
601 or seclusion occurs. Reasonable efforts must be taken to notify
602 the parent or guardian by telephone or e-mail, or both, and
603 these efforts must be documented.
604 (10) The agency may adopt by rule standards and procedures
605 relating to the use of restraints, restraint positioning,
606 seclusion, and emergency treatment orders for psychotropic
607 medications, restraint, and seclusion. These rules must include
608 duration of restraint use, staff training, client observation
609 during restraint, and documentation and reporting standards.
610 Section 11. Section 400.9979, Florida Statutes, is created
611 to read:
612 400.9979 Background screening; administration and
613 management.—
614 (1) The agency shall require level 2 background screening
615 for personnel as required in s. 408.809(1)(e) pursuant to
616 chapter 435 and s. 408.809.
617 (2) The licensee shall maintain personnel records for each
618 staff member which contain, at a minimum, documentation of
619 background screening, if applicable, a job description,
620 documentation of compliance with all training requirements of
621 this part or applicable rule, the employment application,
622 references, a copy of all job performance evaluations, and, for
623 each staff member who performs services for which licensure or
624 certification is required, a copy of all licenses or
625 certification held by the staff member.
626 (3) The licensee must:
627 (a) Develop and implement infection control policies and
628 procedures and include such policies and procedures in the
629 licensee’s policy manual.
630 (b) Maintain liability insurance as defined in s. 624.605.
631 (c) Designate one person as an administrator who is
632 responsible and accountable for the overall management of the
633 facility.
634 (d) Designate a person in writing to be responsible for the
635 facility when the administrator is absent from the facility for
636 more than 24 hours.
637 (e) Designate in writing a program director who is
638 responsible for supervising the therapeutic and behavioral
639 staff, determining the levels of supervision, and determining
640 room placement for each client.
641 (f) Designate in writing a person to be responsible when
642 the program director is absent from the facility for more than
643 24 hours.
644 (g) Obtain approval of the comprehensive emergency
645 management plan, pursuant to s. 400.9981(2)(e), from the local
646 emergency management agency. Pending the approval of the plan,
647 the local emergency management agency shall ensure that the
648 following agencies, at a minimum, are given the opportunity to
649 review the plan: the Department of Health, the Agency for Health
650 Care Administration, and the Division of Emergency Management.
651 Appropriate volunteer organizations must also be given the
652 opportunity to review the plan. The local emergency management
653 agency shall complete its review within 60 days and either
654 approve the plan or advise the licensee of necessary revisions.
655 (h) Maintain written records in a form and system that
656 comply with medical and business practices and make such records
657 available in the facility for review or submission to the agency
658 upon request. The records shall include:
659 1. A daily census record that indicates the number of
660 clients currently receiving services in the facility, including
661 information regarding any public funding of such clients.
662 2. A record of all accidents or unusual incidents involving
663 any client or staff member that caused, or had the potential to
664 cause, injury or harm to any person or property within the
665 facility. Such records must contain a clear description of each
666 accident or incident, the names of the persons involved, a
667 description of all medical or other services provided to these
668 persons specifying who provided such services, and the steps
669 taken to prevent recurrence of such accidents or incidents.
670 3. A copy of current agreements with third-party providers.
671 4. A copy of current agreements with each consultant
672 employed by the licensee and documentation of each consultant’s
673 visits and required written, dated reports.
674 Section 12. Section 400.9980, Florida Statutes, is created
675 to read:
676 400.9980 Property and personal affairs of clients.—
677 (1) A client shall be given the option of using his or her
678 own belongings, as space permits; choosing his or her roommate
679 if practical and not clinically contraindicated; and, whenever
680 possible, unless the client is adjudicated incompetent or
681 incapacitated under state law, managing his or her own affairs.
682 (2) The admission of a client to a facility and his or her
683 presence therein shall not confer on a licensee, administrator,
684 employee, or representative thereof any authority to manage,
685 use, or dispose of any property of the client, nor shall such
686 admission or presence confer on any of such persons any
687 authority or responsibility for the personal affairs of the
688 client except that which may be necessary for the safe
689 management of the facility or for the safety of the client.
690 (3) A licensee, administrator, employee, or representative
691 thereof may:
692 (a) Not act as the guardian, trustee, or conservator for
693 any client or any of such client’s property.
694 (b) Act as a competent client’s payee for social security,
695 veteran’s, or railroad benefits if the client provides consent
696 and the licensee files a surety bond with the agency in an
697 amount equal to twice the average monthly aggregate income or
698 personal funds due to the client, or expendable for the client’s
699 account, that are received by a licensee.
700 (c) Act as the power of attorney for a client if the
701 licensee has filed a surety bond with the agency in an amount
702 equal to twice the average monthly income of the client, plus
703 the value of any client’s property under the control of the
704 attorney in fact.
705
706 The bond under paragraph (b) or paragraph (c) shall be executed
707 by the licensee as principal and a licensed surety company. The
708 bond shall be conditioned upon the faithful compliance of the
709 licensee with the requirements of licensure and shall be payable
710 to the agency for the benefit of any client who suffers a
711 financial loss as a result of the misuse or misappropriation of
712 funds held pursuant to this subsection. Any surety company that
713 cancels or does not renew the bond of any licensee shall notify
714 the agency in writing not less than 30 days in advance of such
715 action, giving the reason for the cancellation or nonrenewal.
716 Any licensee, administrator, employee, or representative thereof
717 who is granted power of attorney for any client of the facility
718 shall, on a monthly basis, notify the client in writing of any
719 transaction made on behalf of the client pursuant to this
720 subsection, and a copy of such notification given to the client
721 shall be retained in each client’s file and available for agency
722 inspection.
723 (4) A licensee, upon mutual consent with the client, shall
724 provide for the safekeeping in the facility of the client’s
725 personal effects of a value not in excess of $1,000 and the
726 client’s funds not in excess of $500 cash and shall keep
727 complete and accurate records of all such funds and personal
728 effects received. If a client is absent from a facility for 24
729 hours or more, the licensee may provide for the safekeeping of
730 the client’s personal effects of a value in excess of $1,000.
731 (5) Any funds or other property belonging to or due to a
732 client or expendable for his or her account that is received by
733 licensee shall be trust funds and shall be kept separate from
734 the funds and property of the licensee and other clients or
735 shall be specifically credited to such client. Such trust funds
736 shall be used or otherwise expended only for the account of the
737 client. At least once every month, unless upon order of a court
738 of competent jurisdiction, the licensee shall furnish the client
739 and the client’s representative a complete and verified
740 statement of all funds and other property to which this
741 subsection applies, detailing the amount and items received,
742 together with their sources and disposition. In any event, the
743 licensee shall furnish such statement annually and upon the
744 discharge or transfer of a client. Any governmental agency or
745 private charitable agency contributing funds or other property
746 to the account of a client shall also be entitled to receive
747 such statement monthly and upon the discharge or transfer of the
748 client.
749 (6)(a) In addition to any damages or civil penalties to
750 which a person is subject, any person who:
751 1. Intentionally withholds a client’s personal funds,
752 personal property, or personal needs allowance, or who demands,
753 beneficially receives, or contracts for payment of all or any
754 part of a client’s personal property or personal needs allowance
755 in satisfaction of the facility rate for supplies and services;
756 or
757 2. Borrows from or pledges any personal funds of a client,
758 other than the amount agreed to by written contract under s.
759 429.24,
760
761 commits a misdemeanor of the first degree, punishable as
762 provided in s. 775.082 or s. 775.083.
763 (b) Any licensee, administrator, employee, or
764 representative thereof who is granted power of attorney for any
765 client of the facility and who misuses or misappropriates funds
766 obtained through this power commits a felony of the third
767 degree, punishable as provided in s. 775.082, s. 775.083, or s.
768 775.084.
769 (7) In the event of the death of a client, a licensee shall
770 return all refunds, funds, and property held in trust to the
771 client’s personal representative, if one has been appointed at
772 the time the licensee disburses such funds, or, if not, to the
773 client’s spouse or adult next of kin named in a beneficiary
774 designation form provided by the licensee to the client. If the
775 client has no spouse or adult next of kin or such person cannot
776 be located, funds due the client shall be placed in an interest
777 bearing account and all property held in trust by the licensee
778 shall be safeguarded until such time as the funds and property
779 are disbursed pursuant to the Florida Probate Code. Such funds
780 shall be kept separate from the funds and property of the
781 licensee and other clients of the facility. If the funds of the
782 deceased client are not disbursed pursuant to the Florida
783 Probate Code within 2 years after the client’s death, the funds
784 shall be deposited in the Health Care Trust Fund administered by
785 the agency.
786 (8) The agency, by rule, may clarify terms and specify
787 procedures and documentation necessary to administer the
788 provisions of this section relating to the proper management of
789 clients’ funds and personal property and the execution of surety
790 bonds.
791 Section 13. Section 400.9981, Florida Statutes, is created
792 to read:
793 400.9981 Rules establishing standards.—
794 (1) It is the intent of the Legislature that rules
795 published and enforced pursuant to this part and part II of
796 chapter 408 include criteria to ensure reasonable and consistent
797 quality of care and client safety. Rules should make reasonable
798 efforts to accommodate the needs and preferences of clients to
799 enhance the quality of life in transitional living facilities.
800 (2) The agency may adopt and enforce rules to implement
801 this part and part II of chapter 408, which shall include
802 reasonable and fair criteria in relation to the following:
803 (a) The location of transitional living facilities.
804 (b) The number of qualifications of all personnel,
805 including management, medical, nursing, and other professional
806 personnel and nursing assistants and support personnel having
807 responsibility for any part of the care given to clients. The
808 licensee must have enough qualified professional staff available
809 to carry out and monitor the various professional interventions
810 in accordance with the stated goals and objectives of each
811 comprehensive treatment plan.
812 (c) Requirements for personnel procedures, reporting
813 procedures, and documentation necessary to implement this part.
814 (d) Services provided to clients of transitional living
815 facilities.
816 (e) The preparation and annual update of a comprehensive
817 emergency management plan in consultation with the Division of
818 Emergency Management. At a minimum, the rules must provide for
819 plan components that address emergency evacuation
820 transportation; adequate sheltering arrangements; postdisaster
821 activities, including provision of emergency power, food, and
822 water; postdisaster transportation; supplies; staffing;
823 emergency equipment; individual identification of clients and
824 transfer of records; communication with families; and responses
825 to family inquiries.
826 Section 14. Section 400.9982, Florida Statutes, is created
827 to read:
828 400.9982 Violations; penalties.—
829 (1) Each violation of this part and rules adopted pursuant
830 thereto shall be classified according to the nature of the
831 violation and the gravity of its probable effect on facility
832 clients. The agency shall indicate the classification on the
833 written notice of the violation as follows:
834 (a) Class “I” violations are defined in s. 408.813. The
835 agency shall issue a citation regardless of correction and
836 impose an administrative fine of $5,000 for an isolated
837 violation, $7,500 for a patterned violation, and $10,000 for a
838 widespread violation. Violations may be identified and a fine
839 must be levied notwithstanding the correction of the deficiency
840 giving rise to the violation.
841 (b) Class “II” violations are defined in s. 408.813. The
842 agency shall impose an administrative fine of $1,000 for an
843 isolated violation, $2,500 for a patterned violation, and $5,000
844 for a widespread violation. A fine must be levied
845 notwithstanding the correction of the deficiency giving rise to
846 the violation.
847 (c) Class “III” violations are defined in s. 408.813. The
848 agency shall impose an administrative fine of $500 for an
849 isolated violation, $750 for a patterned violation, and $1,000
850 for a widespread violation. If a deficiency giving rise to a
851 class “III” violation is corrected within the time specified by
852 the agency, a fine may not be imposed.
853 (d) Class “IV” violations are defined in s. 408.813. The
854 agency shall impose an administrative fine for a cited class IV
855 violation in an amount not less than $100 and not exceeding $200
856 for each violation. If a deficiency giving rise to a class “IV”
857 violation is corrected within the time specified by the agency,
858 a fine may not be imposed.
859 Section 15. Section 400.9983, Florida Statutes, is created
860 to read:
861 400.9983 Receivership proceedings.—The agency may apply s.
862 429.22 with regard to receivership proceedings for transitional
863 living facilities.
864 Section 16. Section 400.9984, Florida Statutes, is created
865 to read:
866 400.9984 Interagency communication.—The agency, the
867 department, the Agency for Persons with Disabilities, and the
868 Department of Children and Families shall develop electronic
869 systems to ensure that relevant information pertaining to the
870 regulation of transitional living facilities and clients is
871 timely and effectively communicated among agencies in order to
872 facilitate the protection of clients. Electronic sharing of
873 information shall include, at a minimum, a brain and spinal cord
874 injury registry and a client abuse registry.
875 Section 17. Section 400.805, Florida Statutes, is repealed.
876 Every transitional living facility licensed under s. 400.805 on
877 or before July 1, 2013, shall be licensed under the provisions
878 of this act.
879 Section 18. Subsection (9) of section 381.745, Florida
880 Statutes, is amended to read:
881 381.745 Definitions; ss. 381.739-381.79.—As used in ss.
882 381.739-381.79, the term:
883 (9) “Transitional living facility,” for the purpose of this
884 part, means a state-approved facility, as defined and licensed
885 under chapter 400 or chapter 429, or a facility approved by the
886 brain and spinal cord injury program in accordance with this
887 chapter.
888 Section 19. Section 381.75, Florida Statutes, is amended to
889 read:
890 381.75 Duties and responsibilities of the department, of
891 transitional living facilities, and of residents.—Consistent
892 with the mandate of s. 381.7395, the department shall develop
893 and administer a multilevel treatment program for individuals
894 who sustain brain or spinal cord injuries and who are referred
895 to the brain and spinal cord injury program.
896 (1) Within 15 days after any report of an individual who
897 has sustained a brain or spinal cord injury, the department
898 shall notify the individual or the most immediate available
899 family members of their right to assistance from the state, the
900 services available, and the eligibility requirements.
901 (2) The department shall refer individuals who have brain
902 or spinal cord injuries to other state agencies to assure that
903 rehabilitative services, if desired, are obtained by that
904 individual.
905 (3) The department, in consultation with emergency medical
906 service, shall develop standards for an emergency medical
907 evacuation system that will ensure that all individuals who
908 sustain traumatic brain or spinal cord injuries are transported
909 to a department-approved trauma center that meets the standards
910 and criteria established by the emergency medical service and
911 the acute-care standards of the brain and spinal cord injury
912 program.
913 (4) The department shall develop standards for designation
914 of rehabilitation centers to provide rehabilitation services for
915 individuals who have brain or spinal cord injuries.
916 (5) The department shall determine the appropriate number
917 of designated acute-care facilities, inpatient rehabilitation
918 centers, and outpatient rehabilitation centers, needed based on
919 incidence, volume of admissions, and other appropriate criteria.
920 (6) The department shall develop standards for designation
921 of transitional living facilities to provide transitional living
922 services for individuals who participate in the brain and spinal
923 cord injury program the opportunity to adjust to their
924 disabilities and to develop physical and functional skills in a
925 supported living environment.
926 (a) The Agency for Health Care Administration, in
927 consultation with the department, shall develop rules for the
928 licensure of transitional living facilities for individuals who
929 have brain or spinal cord injuries.
930 (b) The goal of a transitional living program for
931 individuals who have brain or spinal cord injuries is to assist
932 each individual who has such a disability to achieve a higher
933 level of independent functioning and to enable that person to
934 reenter the community. The program shall be focused on preparing
935 participants to return to community living.
936 (c) A transitional living facility for an individual who
937 has a brain or spinal cord injury shall provide to such
938 individual, in a residential setting, a goal-oriented treatment
939 program designed to improve the individual’s physical,
940 cognitive, communicative, behavioral, psychological, and social
941 functioning, as well as to provide necessary support and
942 supervision. A transitional living facility shall offer at least
943 the following therapies: physical, occupational, speech,
944 neuropsychology, independent living skills training, behavior
945 analysis for programs serving brain-injured individuals, health
946 education, and recreation.
947 (d) All residents shall use the transitional living
948 facility as a temporary measure and not as a permanent home or
949 domicile. The transitional living facility shall develop an
950 initial treatment plan for each resident within 3 days after the
951 resident’s admission. The transitional living facility shall
952 develop a comprehensive plan of treatment and a discharge plan
953 for each resident as soon as practical, but no later than 30
954 days after the resident’s admission. Each comprehensive
955 treatment plan and discharge plan must be reviewed and updated
956 as necessary, but no less often than quarterly. This subsection
957 does not require the discharge of an individual who continues to
958 require any of the specialized services described in paragraph
959 (c) or who is making measurable progress in accordance with that
960 individual’s comprehensive treatment plan. The transitional
961 living facility shall discharge any individual who has an
962 appropriate discharge site and who has achieved the goals of his
963 or her discharge plan or who is no longer making progress toward
964 the goals established in the comprehensive treatment plan and
965 the discharge plan. The discharge location must be the least
966 restrictive environment in which an individual’s health, well
967 being, and safety is preserved.
968 (7) Recipients of services, under this section, from any of
969 the facilities referred to in this section shall pay a fee based
970 on ability to pay.
971 Section 20. Subsection (4) of section 381.78, Florida
972 Statutes, is amended to read:
973 381.78 Advisory council on brain and spinal cord injuries.—
974 (4) The council shall:
975 (a) provide advice and expertise to the department in the
976 preparation, implementation, and periodic review of the brain
977 and spinal cord injury program.
978 (b) Annually appoint a five-member committee composed of
979 one individual who has a brain injury or has a family member
980 with a brain injury, one individual who has a spinal cord injury
981 or has a family member with a spinal cord injury, and three
982 members who shall be chosen from among these representative
983 groups: physicians, other allied health professionals,
984 administrators of brain and spinal cord injury programs, and
985 representatives from support groups with expertise in areas
986 related to the rehabilitation of individuals who have brain or
987 spinal cord injuries, except that one and only one member of the
988 committee shall be an administrator of a transitional living
989 facility. Membership on the council is not a prerequisite for
990 membership on this committee.
991 1. The committee shall perform onsite visits to those
992 transitional living facilities identified by the Agency for
993 Health Care Administration as being in possible violation of the
994 statutes and rules regulating such facilities. The committee
995 members have the same rights of entry and inspection granted
996 under s. 400.805(4) to designated representatives of the agency.
997 2. Factual findings of the committee resulting from an
998 onsite investigation of a facility pursuant to subparagraph 1.
999 shall be adopted by the agency in developing its administrative
1000 response regarding enforcement of statutes and rules regulating
1001 the operation of the facility.
1002 3. Onsite investigations by the committee shall be funded
1003 by the Health Care Trust Fund.
1004 4. Travel expenses for committee members shall be
1005 reimbursed in accordance with s. 112.061.
1006 5. Members of the committee shall recuse themselves from
1007 participating in any investigation that would create a conflict
1008 of interest under state law, and the council shall replace the
1009 member, either temporarily or permanently.
1010 Section 21. Subsection (21) of section 408.802, Florida
1011 Statutes, is amended to read:
1012 408.802 Applicability.—The provisions of this part apply to
1013 the provision of services that require licensure as defined in
1014 this part and to the following entities licensed, registered, or
1015 certified by the agency, as described in chapters 112, 383, 390,
1016 394, 395, 400, 429, 440, 483, and 765:
1017 (21) Transitional living facilities, as provided under part
1018 XI V of chapter 400.
1019 Section 22. Subsection (20) of section 408.820, Florida
1020 Statutes, is amended to read:
1021 408.820 Exemptions.—Except as prescribed in authorizing
1022 statutes, the following exemptions shall apply to specified
1023 requirements of this part:
1024 (20) Transitional living facilities, as provided under part
1025 XI V of chapter 400, are exempt from s. 408.810(10).
1026 Section 23. Subsection (5) of section 400.93, Florida
1027 Statutes, is amended to read:
1028 400.93 Licensure required; exemptions; unlawful acts;
1029 penalties.—
1030 (5) The following are exempt from home medical equipment
1031 provider licensure, unless they have a separate company,
1032 corporation, or division that is in the business of providing
1033 home medical equipment and services for sale or rent to
1034 consumers at their regular or temporary place of residence
1035 pursuant to the provisions of this part:
1036 (a) Providers operated by the Department of Health or
1037 Federal Government.
1038 (b) Nursing homes licensed under part II.
1039 (c) Assisted living facilities licensed under chapter 429,
1040 when serving their residents.
1041 (d) Home health agencies licensed under part III.
1042 (e) Hospices licensed under part IV.
1043 (f) Intermediate care facilities, homes for special
1044 services, and transitional living facilities licensed under part
1045 V.
1046 (g) Transitional living facilities licensed under part XI.
1047 (h)(g) Hospitals and ambulatory surgical centers licensed
1048 under chapter 395.
1049 (i)(h) Manufacturers and wholesale distributors when not
1050 selling directly to consumers.
1051 (j)(i) Licensed health care practitioners who utilize home
1052 medical equipment in the course of their practice, but do not
1053 sell or rent home medical equipment to their patients.
1054 (k)(j) Pharmacies licensed under chapter 465.
1055 Section 24. Paragraph (l) of subsection (4) of section
1056 400.9905, Florida Statutes, is amended to read:
1057 400.9905 Definitions.—
1058 (4) “Clinic” means an entity where health care services are
1059 provided to individuals and which tenders charges for
1060 reimbursement for such services, including a mobile clinic and a
1061 portable equipment provider. As used in this part, the term does
1062 not include and the licensure requirements of this part do not
1063 apply to:
1064 (l) Orthotic, or prosthetic, pediatric cardiology, or
1065 perinatology clinical facilities or anesthesia clinical
1066 facilities that are not otherwise exempt under paragraph (a) or
1067 paragraph (k) and that are a publicly traded corporation or that
1068 are wholly owned, directly or indirectly, by a publicly traded
1069 corporation. As used in this paragraph, a publicly traded
1070 corporation is a corporation that issues securities traded on an
1071 exchange registered with the United States Securities and
1072 Exchange Commission as a national securities exchange.
1073
1074 Notwithstanding this subsection, an entity shall be deemed a
1075 clinic and must be licensed under this part in order to receive
1076 reimbursement under the Florida Motor Vehicle No-Fault Law, ss.
1077 627.730-627.7405, unless exempted under s. 627.736(5)(h).
1078 Section 25. This act shall take effect July 1, 2013.