Florida Senate - 2016                                    SB 1250
       By Senator Latvala
       20-01631-16                                           20161250__
    1                        A bill to be entitled                      
    2         An act relating to the behavioral health workforce;
    3         amending s. 394.453, F.S.; revising legislative
    4         intent; amending s. 394.463, F.S.; expanding the
    5         authority of a psychiatric nurse to approve the
    6         release of a patient from a receiving facility;
    7         amending s. 394.467, F.S.; authorizing procedures for
    8         recommending admission of a patient to a treatment
    9         facility; amending s. 397.451, F.S.; revising
   10         provisions relating to exemptions from
   11         disqualification for certain service provider
   12         personnel; amending s. 409.909, F.S.; adding
   13         psychiatry to a list of primary care specialties under
   14         the Statewide Medicaid Residency Program; amending s.
   15         456.44, F.S.; deleting an obsolete date; requiring
   16         advanced registered nurse practitioners and physician
   17         assistants who prescribe controlled substances for
   18         pain management to make a certain designation, comply
   19         with registration requirements, and follow specified
   20         standards of practice; providing applicability;
   21         providing an effective date.
   23  Be It Enacted by the Legislature of the State of Florida:
   25         Section 1. Section 394.453, Florida Statutes, is amended to
   26  read:
   27         394.453 Legislative intent.—It is the intent of the
   28  Legislature to authorize and direct the Department of Children
   29  and Families to evaluate, research, plan, and recommend to the
   30  Governor and the Legislature programs designed to reduce the
   31  occurrence, severity, duration, and disabling aspects of mental,
   32  emotional, and behavioral disorders. It is the intent of the
   33  Legislature that treatment programs for such disorders shall
   34  include, but not be limited to, comprehensive health, social,
   35  educational, and rehabilitative services to persons requiring
   36  intensive short-term and continued treatment in order to
   37  encourage them to assume responsibility for their treatment and
   38  recovery. It is intended that such persons be provided with
   39  emergency service and temporary detention for evaluation when
   40  required; that they be admitted to treatment facilities on a
   41  voluntary basis when extended or continuing care is needed and
   42  unavailable in the community; that involuntary placement be
   43  provided only when expert evaluation determines that it is
   44  necessary; that any involuntary treatment or examination be
   45  accomplished in a setting which is clinically appropriate and
   46  most likely to facilitate the person’s return to the community
   47  as soon as possible; and that individual dignity and human
   48  rights be guaranteed to all persons who are admitted to mental
   49  health facilities or who are being held under s. 394.463. It is
   50  the further intent of the Legislature that the least restrictive
   51  means of intervention be employed based on the individual needs
   52  of each person, within the scope of available services. It is
   53  the policy of this state that the use of restraint and seclusion
   54  on clients is justified only as an emergency safety measure to
   55  be used in response to imminent danger to the client or others.
   56  It is, therefore, the intent of the Legislature to achieve an
   57  ongoing reduction in the use of restraint and seclusion in
   58  programs and facilities serving persons with mental illness. The
   59  Legislature further finds the need for additional psychiatrists
   60  to be of critical state concern and authorizes the establishment
   61  of an additional psychiatry program to be offered by one of
   62  Florida’s schools of medicine currently not offering psychiatry.
   63  The program shall seek to integrate primary care and psychiatry
   64  and other evolving models of care for persons with mental health
   65  and substance abuse disorders. Additionally, the Legislature
   66  finds that the use of telemedicine for patient evaluation, case
   67  management, and ongoing care will improve management of patient
   68  care and reduce costs of transportation.
   69         Section 2. Paragraph (f) of subsection (2) of section
   70  394.463, Florida Statutes, is amended to read:
   71         394.463 Involuntary examination.—
   73         (f) A patient shall be examined by a physician, a clinical
   74  psychologist, or a psychiatric nurse performing within the
   75  framework of an established protocol with a psychiatrist at a
   76  receiving facility without unnecessary delay and may, upon the
   77  order of a physician, be given emergency treatment if it is
   78  determined that such treatment is necessary for the safety of
   79  the patient or others. The patient may not be released by the
   80  receiving facility or its contractor without the documented
   81  approval of a psychiatrist, or a clinical psychologist, or, if
   82  the receiving facility is owned or operated by a hospital or
   83  health system, the release may also be approved by a psychiatric
   84  nurse performing within the framework of an established protocol
   85  with a psychiatrist or an attending emergency department
   86  physician with experience in the diagnosis and treatment of
   87  mental and nervous disorders and after completion of an
   88  involuntary examination pursuant to this subsection. A
   89  psychiatric nurse may not approve the release of a patient if
   90  the involuntary examination was initiated by a psychiatrist
   91  unless the release is approved by the initiating psychiatrist.
   92  However, a patient may not be held in a receiving facility for
   93  involuntary examination longer than 72 hours.
   94         Section 3. Subsection (2) of section 394.467, Florida
   95  Statutes, is amended to read:
   96         394.467 Involuntary inpatient placement.—
   97         (2) ADMISSION TO A TREATMENT FACILITY.—A patient may be
   98  retained by a receiving facility or involuntarily placed in a
   99  treatment facility upon the recommendation of the administrator
  100  of the receiving facility where the patient has been examined
  101  and after adherence to the notice and hearing procedures
  102  provided in s. 394.4599. The recommendation must be supported by
  103  the opinion of a psychiatrist and the second opinion of a
  104  clinical psychologist or another psychiatrist, both of whom have
  105  personally examined the patient within the preceding 72 hours,
  106  that the criteria for involuntary inpatient placement are met.
  107  However, in a county that has a population of fewer than 50,000,
  108  if the administrator certifies that a psychiatrist or clinical
  109  psychologist is not available to provide the second opinion, the
  110  second opinion may be provided by a licensed physician who has
  111  postgraduate training and experience in diagnosis and treatment
  112  of mental and nervous disorders or by a psychiatric nurse. Any
  113  second opinion authorized in this subsection may be conducted
  114  through a face-to-face examination, in person or by electronic
  115  means. Such recommendation shall be entered on an involuntary
  116  inpatient placement certificate that authorizes the receiving
  117  facility to retain the patient pending transfer to a treatment
  118  facility or completion of a hearing.
  119         Section 4. Paragraphs (e) and (f) of subsection (1) and
  120  paragraph (b) of subsection (4) of section 397.451, Florida
  121  Statutes, are amended to read:
  122         397.451 Background checks of service provider personnel.—
  125         (e) Personnel employed directly or under contract with the
  126  Department of Corrections in an inmate substance abuse program
  127  who have direct contact with unmarried inmates under the age of
  128  18 or with inmates who are developmentally disabled are exempt
  129  from the fingerprinting and background check requirements of
  130  this section unless they have direct contact with unmarried
  131  inmates under the age of 18 or with inmates who are
  132  developmentally disabled.
  133         (f) Service provider personnel who request an exemption
  134  from disqualification must submit the request within 30 days
  135  after being notified of the disqualification. If 5 years or more
  136  have elapsed since the most recent disqualifying offense,
  137  service provider personnel may work with adults with substance
  138  use disorders under the supervision of a qualified professional
  139  licensed under chapter 490 or chapter 491 or a master’s level
  140  certified addiction professional until the agency makes a final
  141  determination regarding the request for an exemption from
  142  disqualification Upon notification of the disqualification, the
  143  service provider shall comply with requirements regarding
  144  exclusion from employment in s. 435.06.
  146         (b) Since rehabilitated substance abuse impaired persons
  147  are effective in the successful treatment and rehabilitation of
  148  individuals with substance use disorders substance abuse
  149  impaired adolescents, for service providers which treat
  150  adolescents 13 years of age and older, service provider
  151  personnel whose background checks indicate crimes under s.
  152  817.563, s. 893.13, or s. 893.147 may be exempted from
  153  disqualification from employment pursuant to this paragraph.
  154         Section 5. Paragraph (a) of subsection (2) of section
  155  409.909, Florida Statutes, is amended to read:
  156         409.909 Statewide Medicaid Residency Program.—
  157         (2) On or before September 15 of each year, the agency
  158  shall calculate an allocation fraction to be used for
  159  distributing funds to participating hospitals. On or before the
  160  final business day of each quarter of a state fiscal year, the
  161  agency shall distribute to each participating hospital one
  162  fourth of that hospital’s annual allocation calculated under
  163  subsection (4). The allocation fraction for each participating
  164  hospital is based on the hospital’s number of full-time
  165  equivalent residents and the amount of its Medicaid payments. As
  166  used in this section, the term:
  167         (a) “Full-time equivalent,” or “FTE,” means a resident who
  168  is in his or her residency period, with the initial residency
  169  period defined as the minimum number of years of training
  170  required before the resident may become eligible for board
  171  certification by the American Osteopathic Association Bureau of
  172  Osteopathic Specialists or the American Board of Medical
  173  Specialties in the specialty in which he or she first began
  174  training, not to exceed 5 years. The residency specialty is
  175  defined as reported using the current residency type codes in
  176  the Intern and Resident Information System (IRIS), required by
  177  Medicare. A resident training beyond the initial residency
  178  period is counted as 0.5 FTE, unless his or her chosen specialty
  179  is in primary care, in which case the resident is counted as 1.0
  180  FTE. For the purposes of this section, primary care specialties
  181  include:
  182         1. Family medicine;
  183         2. General internal medicine;
  184         3. General pediatrics;
  185         4. Preventive medicine;
  186         5. Geriatric medicine;
  187         6. Osteopathic general practice;
  188         7. Obstetrics and gynecology;
  189         8. Emergency medicine; and
  190         9. General surgery; and.
  191         10.Psychiatry.
  192         Section 6. Subsections (2) and (3) of section 456.44,
  193  Florida Statutes, are amended to read:
  194         456.44 Controlled substance prescribing.—
  195         (2) REGISTRATION.—Effective January 1, 2012, A physician
  196  licensed under chapter 458, chapter 459, chapter 461, or chapter
  197  466, a physician assistant licensed under chapter 458 or chapter
  198  459, or an advanced registered nurse practitioner certified
  199  under part I of chapter 464 who prescribes any controlled
  200  substance, listed in Schedule II, Schedule III, or Schedule IV
  201  as defined in s. 893.03, for the treatment of chronic
  202  nonmalignant pain, must:
  203         (a) Designate himself or herself as a controlled substance
  204  prescribing practitioner on his or her the physician’s
  205  practitioner profile.
  206         (b) Comply with the requirements of this section and
  207  applicable board rules.
  208         (3) STANDARDS OF PRACTICE.—The standards of practice in
  209  this section do not supersede the level of care, skill, and
  210  treatment recognized in general law related to health care
  211  licensure.
  212         (a) A complete medical history and a physical examination
  213  must be conducted before beginning any treatment and must be
  214  documented in the medical record. The exact components of the
  215  physical examination shall be left to the judgment of the
  216  registrant clinician who is expected to perform a physical
  217  examination proportionate to the diagnosis that justifies a
  218  treatment. The medical record must, at a minimum, document the
  219  nature and intensity of the pain, current and past treatments
  220  for pain, underlying or coexisting diseases or conditions, the
  221  effect of the pain on physical and psychological function, a
  222  review of previous medical records, previous diagnostic studies,
  223  and history of alcohol and substance abuse. The medical record
  224  shall also document the presence of one or more recognized
  225  medical indications for the use of a controlled substance. Each
  226  registrant must develop a written plan for assessing each
  227  patient’s risk of aberrant drug-related behavior, which may
  228  include patient drug testing. Registrants must assess each
  229  patient’s risk for aberrant drug-related behavior and monitor
  230  that risk on an ongoing basis in accordance with the plan.
  231         (b) Each registrant must develop a written individualized
  232  treatment plan for each patient. The treatment plan shall state
  233  objectives that will be used to determine treatment success,
  234  such as pain relief and improved physical and psychosocial
  235  function, and shall indicate if any further diagnostic
  236  evaluations or other treatments are planned. After treatment
  237  begins, the registrant physician shall adjust drug therapy to
  238  the individual medical needs of each patient. Other treatment
  239  modalities, including a rehabilitation program, shall be
  240  considered depending on the etiology of the pain and the extent
  241  to which the pain is associated with physical and psychosocial
  242  impairment. The interdisciplinary nature of the treatment plan
  243  shall be documented.
  244         (c) The registrant physician shall discuss the risks and
  245  benefits of the use of controlled substances, including the
  246  risks of abuse and addiction, as well as physical dependence and
  247  its consequences, with the patient, persons designated by the
  248  patient, or the patient’s surrogate or guardian if the patient
  249  is incompetent. The registrant physician shall use a written
  250  controlled substance agreement between the registrant physician
  251  and the patient outlining the patient’s responsibilities,
  252  including, but not limited to:
  253         1. Number and frequency of controlled substance
  254  prescriptions and refills.
  255         2. Patient compliance and reasons for which drug therapy
  256  may be discontinued, such as a violation of the agreement.
  257         3. An agreement that controlled substances for the
  258  treatment of chronic nonmalignant pain shall be prescribed by a
  259  single treating registrant physician unless otherwise authorized
  260  by the treating registrant physician and documented in the
  261  medical record.
  262         (d) The patient shall be seen by the registrant physician
  263  at regular intervals, not to exceed 3 months, to assess the
  264  efficacy of treatment, ensure that controlled substance therapy
  265  remains indicated, evaluate the patient’s progress toward
  266  treatment objectives, consider adverse drug effects, and review
  267  the etiology of the pain. Continuation or modification of
  268  therapy shall depend on the registrant’s physician’s evaluation
  269  of the patient’s progress. If treatment goals are not being
  270  achieved, despite medication adjustments, the registrant
  271  physician shall reevaluate the appropriateness of continued
  272  treatment. The registrant physician shall monitor patient
  273  compliance in medication usage, related treatment plans,
  274  controlled substance agreements, and indications of substance
  275  abuse or diversion at a minimum of 3-month intervals.
  276         (e) The registrant physician shall refer the patient as
  277  necessary for additional evaluation and treatment in order to
  278  achieve treatment objectives. Special attention shall be given
  279  to those patients who are at risk for misusing their medications
  280  and those whose living arrangements pose a risk for medication
  281  misuse or diversion. The management of pain in patients with a
  282  history of substance abuse or with a comorbid psychiatric
  283  disorder requires extra care, monitoring, and documentation and
  284  requires consultation with or referral to an addiction medicine
  285  specialist or psychiatrist.
  286         (f) A registrant physician registered under this section
  287  must maintain accurate, current, and complete records that are
  288  accessible and readily available for review and comply with the
  289  requirements of this section, the applicable practice act, and
  290  applicable board rules. The medical records must include, but
  291  are not limited to:
  292         1. The complete medical history and a physical examination,
  293  including history of drug abuse or dependence.
  294         2. Diagnostic, therapeutic, and laboratory results.
  295         3. Evaluations and consultations.
  296         4. Treatment objectives.
  297         5. Discussion of risks and benefits.
  298         6. Treatments.
  299         7. Medications, including date, type, dosage, and quantity
  300  prescribed.
  301         8. Instructions and agreements.
  302         9. Periodic reviews.
  303         10. Results of any drug testing.
  304         11. A photocopy of the patient’s government-issued photo
  305  identification.
  306         12. If a written prescription for a controlled substance is
  307  given to the patient, a duplicate of the prescription.
  308         13. The registrant’s physician’s full name presented in a
  309  legible manner.
  310         (g) Patients with signs or symptoms of substance abuse
  311  shall be immediately referred to a board-certified pain
  312  management physician, an addiction medicine specialist, or a
  313  mental health addiction facility as it pertains to drug abuse or
  314  addiction unless the registrant is a physician who is board
  315  certified or board-eligible in pain management. Throughout the
  316  period of time before receiving the consultant’s report, a
  317  prescribing registrant physician shall clearly and completely
  318  document medical justification for continued treatment with
  319  controlled substances and those steps taken to ensure medically
  320  appropriate use of controlled substances by the patient. Upon
  321  receipt of the consultant’s written report, the prescribing
  322  registrant physician shall incorporate the consultant’s
  323  recommendations for continuing, modifying, or discontinuing
  324  controlled substance therapy. The resulting changes in treatment
  325  shall be specifically documented in the patient’s medical
  326  record. Evidence or behavioral indications of diversion shall be
  327  followed by discontinuation of controlled substance therapy, and
  328  the patient shall be discharged, and all results of testing and
  329  actions taken by the registrant physician shall be documented in
  330  the patient’s medical record.
  332  This subsection does not apply to a board-eligible or board
  333  certified anesthesiologist, physiatrist, rheumatologist, or
  334  neurologist, or to a board-certified physician who has surgical
  335  privileges at a hospital or ambulatory surgery center and
  336  primarily provides surgical services. This subsection does not
  337  apply to a board-eligible or board-certified medical specialist
  338  who has also completed a fellowship in pain medicine approved by
  339  the Accreditation Council for Graduate Medical Education or the
  340  American Osteopathic Association, or who is board eligible or
  341  board certified in pain medicine by the American Board of Pain
  342  Medicine, the American Board of Interventional Pain Physicians,
  343  the American Association of Physician Specialists, or a board
  344  approved by the American Board of Medical Specialties or the
  345  American Osteopathic Association and performs interventional
  346  pain procedures of the type routinely billed using surgical
  347  codes. This subsection does not apply to a registrant, advanced
  348  registered nurse practitioner, or physician assistant who
  349  prescribes medically necessary controlled substances for a
  350  patient during an inpatient stay in a hospital licensed under
  351  chapter 395.
  352         Section 7. This act shall take effect July 1, 2016.