SB 1676 — Direct Care Workers

specifying circumstances under which a physician is no longer eligible to receive funds from the program;

requiring the department to adopt rules;

providing that implementation of the program is subject to a legislative appropriation;

amending s.

464.003, F.S.;

defining the term “advanced practice registered nurse - independent practitioner” (APRN-IP);

creating s.

464.0123, F.S.;

creating the Patient Access to Primary Care Program for a specified purpose;

requiring the department to implement the program;

defining terms;

creating the Council on Advanced Practice Registered Nurse Independent Practice within the department;

providing council membership requirements, terms, and duties;

requiring the council to develop certain proposed rules;

providing for the adoption of the proposed rules;

authorizing the council to enter an order to refuse to register an applicant or to approve an applicant for restricted registration or conditional registration under certain circumstances;

providing registration and registration renewal requirements;

requiring the department to update the practitioner’s profile to reflect specified information;

providing limitations on the scope of practice of an APRN-IP;

requiring the department to adopt specified rules related to the scope of practice for APRN-IPS;

requiring APRN-IPs to report adverse incidents to the department within a specified timeframe;

defining the term “adverse incident”;

requiring the department to review adverse incidents and make specified determinations;

providing for disciplinary action;

requiring the department to adopt certain rules;

providing for the reactivation of registration;

providing construction;

requiring the department to adopt rules;

amending s.

464.015, F.S.;

prohibiting unregistered persons from using the title or abbreviation of APRN-IP;

amending s.

464.018, F.S.;

providing additional grounds for denial of a license or disciplinary action for APRN-IPs;

amending s.

381.026, F.S.;

revising the definition of the term “health care provider”;

amending s.

382.008, F.S.;

authorizing an APRN-IP to file a certificate of death or fetal death under certain circumstances;

requiring an APRN-IP to provide certain information to a funeral director within a specified timeframe;

defining the term “primary or attending practitioner”;

conforming provisions to changes made by the act;

amending s.

382.011, F.S.;

conforming a provision to changes made by the act;

amending s.

394.463, F.S.;

authorizing APRN-IPs to examine patients and initiate involuntary examinations for mental illness under certain circumstances;

amending s.

397.501, F.S.;

prohibiting service providers from denying an individual certain services under certain circumstances;

amending s.

456.053, F.S.;

revising definitions;

providing disciplinary action;

conforming provisions to changes made by the act;

amending s.

626.9707, F.S.;

prohibiting an insurer from refusing to issue and deliver certain disability insurance policies that cover any medical treatment or service furnished by an advanced practice registered nurse or an APRN-IP;

creating ss.

627.64025 and 627.6621, F.S.;

prohibiting certain health insurance policies and certain group, blanket, or franchise health insurance policies, respectively, from requiring or incentivizing an insured to receive services from an APRN-IP in place of a primary care physician;

amending s.

627.6699, F.S.;

prohibiting certain health benefit plans from requiring or incentivizing an insured to receive services from an APRN-IP in place of a primary care physician;

amending s.

627.736, F.S.;

requiring personal injury protection insurance policies to cover a certain percentage of medical services and care provided by an APRN-IP;

providing for specified reimbursement of APRN-IPs;

amending s.

633.412, F.S.;

authorizing an APRN-IP to medically examine an applicant for firefighter certification;

creating s.

641.31075, F.S.;

prohibiting certain health maintenance contracts from requiring or incentivizing a subscriber to receive services from an APRN-IP in place of a primary care physician;

amending s.

641.495, F.S.;

requiring certain health maintenance organization documents to disclose specified information;

amending s.

744.3675, F.S.;

authorizing an APRN-IP to provide the medical report of a ward in an annual guardianship plan;

amending s.

766.118, F.S.;

revising the definition of the term “practitioner”;

amending s.

768.135, F.S.;

providing immunity from liability for an APRN-IP who provides volunteer services, under certain circumstances;

amending s.

960.28, F.S.;

conforming a cross reference;

providing appropriations;

providing effective dates.

197 Be It Enacted by the Legislature of the State of Florida:

199 Section 1. Paragraph (v) is added to subsection (1) of section 400.141, Florida Statutes, to read:

h. Recognizing changes in residents which are inconsistent with their normal behaviorbehavior, and the importance of reporting those changes to the supervisory nurse.

227126 The agency may adopt rules to implement this paragraph.

Section 3. Subsection (1)(15) of section 400.461,400.462, Florida Statutes, is amended to read:

400.461 Short title;

purpose.— (1) This part, consisting of ss.

400.461-400.52 ss.

400.461-400.518, may be cited as the “Home Health Services Act.” Section 4. Subsection (15) of section 400.462, Florida Statutes, is amended to read:

Section 5. Present4. Present subsections (5) and (6) of section 400.464, Florida Statutes, are redesignated as subsections (6) and (7), respectively, a new subsection (5) is added to that section, and present subsection (6) of that section is amended, to read:

Section 6. Subsections5. Subsections (2) and (3) of section 400.488, Florida Statutes, are amended to read:

(d) Applying topical medications, including providing routine preventivepreventative skin care and basic wound care.

Section 7. Section6. Section 400.489, Florida Statutes, is created to read:

Section 8. Section7. Section 400.490, Florida Statutes, is created to read:

400.490 Nurse-delegated tasks.—A certified nursing assistant or home health aide may perform any task delegated by a registered nurse as authorized in this part and in chapter 464, including, but not limited to, medication administration.

Section 9. Section8. Section 400.52, Florida Statutes, is created to read:

400.52 Excellence in Home Health Program.— (1) There is created within the agency the Excellence in Home Health Program for the purpose of awarding program designations to home health agencies or nurse registries that meet the criteria specified in this section.

(b) The agency shall annually evaluate home health agencies and nurse registries seeking the program designation which apply on a form and in the manner designated by rule.

(3) To receive a program designation, the home health agency or nurse registry must:

A designation awarded under the program is not transferabletransferrable to another licensee, unless the existing home health agency or nurse registry is being relicensed in the name of an entity related to the current licenseholder by common control or ownership and there will be no change in the management, operation, or programs of the home health agency or nurse registry as a result of the relicensure.

(b) Have not had any licensure denials, revocations, or classClass I, classClass II, or uncorrected classClass III deficiencies within the 24 months before the application for the program designation.

(4) The program designation expires on the same date as the home health agency’s or nurse registry’s license.

A home health agency or nurse registry must reapply and be approved biennially for the program designation to continue using the program designation in the manner authorized under subsection (5).

(5) A home health agency or nurse registry that is awarded a designation under the program may use the designation in advertising and marketing,marketing. unless the home health agency or nurse registry:

A home health agency may not use the program designation in any advertising or marketing if the home health agency:

(6) AnSection application9. Section for408.822, anFlorida awardStatutes, designation under the program is notcreated anto applicationread: for licensure.

A designation award or denial by the agency under this section does not constitute final agency action subject to chapter 120.

Section 10. Section 408.822, Florida Statutes, is created to read:

(2) Beginning January 1, 2021, each licensee that applies for licensure renewal as a nursing home facility licensed under part II of chapter 400,400; an assisted living facility licensed under part I of chapter 429, or a home health agency or companion services or homemaker services provider licensed under part III of chapter 400 shall furnish all of the following information to the agency in a survey on the direct care workforce:

an assisted living facility licensed under part I of chapter 429;

or a home health agency, nurse registry, or companion services or homemaker services provider licensed under part III of chapter 400 shall furnish the following information to the agency in a survey on the direct care workforce:

(4) The licensee must submit the completed survey beforeprior to the agency issuesissuing the license renewal.

Section 11. Section10. Section 464.0156, Florida Statutes, is created to read:

400.462400.462, if the registered nurse determines that the certified nursing assistant or the home health aide is competent to perform the task, the task is delegable under federal law, and the tasktask: meets all of the following criteria:

(2) A registered nurse may delegate to a certified nursing assistant or a home health aide the administration of oral, transdermal, ophthalmic, otic, rectal, inhaled, enteral, or topical prescription medicationsmedications, to a patient of a home health agency, if the certified nursing assistant or home health aide meets the requirements of s.

Section 12. Paragraph11. Paragraph (r) is added to subsection (1) of section 464.018, Florida Statutes, to read:

Section 13. Section12. Section 464.2035, Florida Statutes, is created to read:

The training, determination of competency, and initial and annual validationvalidations required under this section must be conducted by a registered nurse licensed under this chapter or a physician licensed under chapter 458 or chapter 459.

(3) The board, in consultation with the Agency for Health Care Administration, shall establish by rule standards and procedures that a certified nursing assistant must follow when administering medication to a patientpatient. of a home health agency.

Section 14. Effective13. This Julyact 1,shall 2020,take sectioneffect 381.40185,upon Floridabecoming Statutes,a islaw. created to read:

381.40185 Physician Student Loan Repayment Program.—The Physician Student Loan Repayment Program is established to promote access to primary care by supporting qualified physicians who treat medically underserved populations in primary care health professional shortage areas or medically underserved areas.

(1) As used in this section, the term:

(a) “Department” means the Department of Health.

(b) “Loan program” means the Physician Student Loan Repayment Program.

(c) “Medically underserved area” means a geographic area designated as such by the Health Resources and Services Administration of the United States Department of Health and Human Services.

(d) “Primary care health professional shortage area” means a geographic area, an area having a special population, or a facility that is designated by the Health Resources and Services Administration of the United States Department of Health and Human Services as a health professional shortage area as defined by federal regulation and that has a shortage of primary care professionals who serve Medicaid recipients and other low-income patients.

(e) “Public health program” means a county health department, the Children’s Medical Services program, a federally funded community health center, a federally funded migrant health center, or any other publicly funded or nonprofit health care program designated by the department.

(2) The department shall establish a physician student loan repayment program to benefit physicians licensed under chapter 458 or chapter 459 who demonstrate, as required by department rule, active employment providing primary care services in a public health program, an independent practice, or a group practice that serves Medicaid recipients and other low-income patients and that is located in a primary care health professional shortage area or in a medically underserved area.

(3) The department shall award funds from the loan program to repay the student loans of a physician who meets the requirements of subsection (2).

(a) An award may not exceed $50,000 per year per eligible physician.

(b) Only loans to pay the costs of tuition, books, medical equipment and supplies, uniforms, and living expenses may be covered.

(c) All repayments are contingent upon continued proof of eligibility and must be made directly to the holder of the loan.

The state bears no responsibility for the collection of any interest charges or other remaining balances.

(d) A physician may receive funds under the loan program for at least 1 year, up to a maximum of 5 years.

(e) The department may only grant up to 10 new awards per fiscal year and shall limit the total number of physicians participating in the loan program to not more than 50 per fiscal year.

(4) A physician is no longer eligible to receive funds under the loan program if the physician:

(a) Is no longer employed as required under subsection (2);

(b) Ceases to participate in the Florida Medicaid program;

or (c) Has disciplinary action taken against his or her license by the Board of Medicine for a violation of s.

458.331 or by the Board of Osteopathic Medicine for a violation of s.

459.015.

(5) The department shall adopt rules to implement the loan program.

(6) Implementation of the loan program is subject to legislative appropriation.

Section 15. Effective July 1, 2020, present subsections (4) through (21) of section 464.003, Florida Statutes, are redesignated as subsections (5) through (22), respectively, and a new subsection (4) is added to that section, to read:

464.003 Definitions.—As used in this part, the term:

(4) “Advanced practice registered nurse - independent practitioner” or “APRN-IP” means an advanced practice registered nurse who is registered under s.

464.0123 to provide primary health care services without a protocol agreement or supervision.

Section 16. Effective July 1, 2020, section 464.0123, Florida Statutes, is created to read:

464.0123 Patient Access to Primary Care Program.— (1) PROGRAM PURPOSE.—The Patient Access to Primary Care Program is created for the purpose of providing primary health care services in primary care health professional shortage areas.

The department shall implement this program.

(2) DEFINITIONS.—As used in this section, the term:

(a) “Council” means the Council on Advanced Practice Registered Nurse Independent Practice established in subsection (3).

(b) “Physician” means a person licensed under chapter 458 to practice medicine or a person licensed under chapter 459 to practice osteopathic medicine.

(c) “Primary care health professional shortage area” means a geographic area, an area having a special population, or a facility with a score of at least 18, as designated and calculated by the Federal Health Resources and Services Administration or a rural area as defined by the Federal Office of Rural Health Policy.

(3) COUNCIL ON ADVANCED PRACTICE REGISTERED NURSE INDEPENDENT PRACTICE.— (a) The Council on Advanced Practice Registered Nurse Independent Practice is created within the department.

(b) The council shall consist of the following nine members:

1. Two members appointed by the chair of the Board of Medicine who are physicians and members of the Board of Medicine.

2. Two members appointed by the chair of the Board of Osteopathic Medicine who are physicians and members of the Board of Osteopathic Medicine.

3. Four members appointed by the chair of the Board of Nursing who are advanced practice registered nurses and who have each completed at least 10,000 hours of supervised practice over a period of at least 5 years under a protocol with a supervising physician.

4. The State Surgeon General or his or her designee.

(c) The Board of Medicine members, the Board of Osteopathic Medicine members, and the Board of Nursing appointee members shall be appointed for terms of 4 years.

The initial appointments shall be staggered so that one member from the Board of Medicine, one member from the Board of Osteopathic Medicine, and one appointee member from the Board of Nursing shall each be appointed for a term of 4 years;

one member from the Board of Medicine and one appointee member from the Board of Nursing shall each be appointed for a term of 3 years;

and one member from the Board of Osteopathic Medicine and two appointee members from the Board of Nursing shall each be appointed for a term of 2 years.

Initial physician members appointed to the council must be physicians who have practiced with advanced practice registered nurses under a protocol in their practice.

(d) Council members may not serve more than two consecutive terms.

The council shall annually elect a chair from among its members.

(e) All recommendations made by the council must be made by a majority of members present.

(f) The council shall:

1. Review applications for and recommend to the department the registration of APRN-IPs.

2. Develop proposed rules regulating the practice of APRN IPs.

The council shall also develop proposed rules to ensure that the continuity of practice of APRN-IPs is maintained in primary care health professional shortage areas.

The language of proposed rules developed by the council must be submitted to the department.

Based on the council′s proposed rules, the department shall adopt rules regulating the practice of APRN IPs.

3. Make recommendations to the department regarding all matters relating to APRN-IPs.

4. Address concerns and problems of APRN-IPs in order to improve safety in the clinical practices of APRN-IPs.

(g) When the council finds that an applicant for licensure has failed to meet, to the council’s satisfaction, each of the requirements for registration set forth in this section, the council may enter an order to:

1. Refuse to register the applicant;

2. Approve the applicant for registration with restrictions on the scope of practice or registration;

or 3. Approve the applicant for limited registration with conditions.

Such conditions may include placement of the registrant on probation for a period of time and subject to such conditions as the council may specify, including, but not limited to, requiring the registrant to undergo treatment, to attend continuing education courses, to work under the direct supervision of a physician licensed in this state, or to take corrective action, as determined by the council.

(4) REGISTRATION.—To be registered as an APRN-IP, an advanced practice registered nurse must apply to the department on forms developed by the department.

The council shall review the application and recommend to the department the registration of the advanced practice registered nurse with the Board of Medicine as an APRN-IP if the applicant submits proof that he or she holds an unrestricted license issued under s.

464.012 and provides all of the following information:

(a) The name of each location at which the applicant has practiced as an advanced practice registered nurse pursuant to an established written protocol under the direct or indirect supervision of a physician for 2,000 hours within the last 4 years and the names and addresses of all supervising physicians during that period.

(b) Any certification or designation that the applicant has received from a specialty or certification board which is recognized or approved by the Board of Nursing, the Board of Medicine, the Board of Osteopathic Medicine, or the department.

(c) The calendar years in which the applicant:

1. Received his or her initial advanced practice registered nurse certification, licensure, or registration;

2. Began practicing in any jurisdiction;

and 3. Received initial advanced practice registered nurse licensure in this state.

(d) The address at which the applicant will primarily conduct his or her practice, if known.

(e) The name of each school or training program that the applicant has attended, with the months and years of attendance and the month and year of graduation, and a description of all graduate professional education completed by the applicant, excluding any coursework taken to satisfy continuing education requirements.

(f) Any appointment to the faculty of a school related to the profession which the applicant currently holds or has held within the past 10 years and an indication as to whether the applicant has been responsible for graduate education within the past 10 years.

(g) A description of any criminal offense of which the applicant has been found guilty, regardless of whether adjudication of guilt was withheld, or to which the applicant has pled guilty or nolo contendere.

A criminal offense committed in another jurisdiction which would have been a felony or misdemeanor if committed in this state must be reported.

If the applicant indicates to the department that a criminal offense is under appeal and submits a copy of the notice for appeal of that criminal offense, the department must state that the criminal offense is under appeal if the criminal offense is reported in the applicant’s profile.

If the applicant indicates to the department that a criminal offense is under appeal, the applicant must, within 15 days after the disposition of the appeal, submit to the department a copy of the final written order of disposition.

(h) A description of any disciplinary action as specified in s.

456.077, s.

458.320, or s.

464.018 or any similar disciplinary action in any other jurisdiction of the United States by a licensing or regulatory body;

by a specialty board that is recognized by the Board of Nursing, the Board of Medicine, the Board of Osteopathic Medicine, or the department;

or by a licensed hospital, health maintenance organization, prepaid health clinic, ambulatory surgical center, or nursing home.

Disciplinary action includes resignation from or nonrenewal of staff membership or the restriction of privileges at a licensed hospital, health maintenance organization, prepaid health clinic, ambulatory surgical center, or nursing home taken in lieu of or in settlement of a pending disciplinary case related to competence or character.

If the applicant indicates to the department that a disciplinary action is under appeal and submits a copy of the document initiating an appeal of the disciplinary action, the department must state that the disciplinary action is under appeal if the disciplinary action is reported in the applicant’s profile.

If the applicant indicates to the department that a disciplinary action is under appeal, the applicant must, within 15 days after the disposition of the appeal, submit to the department a copy of the final written order of disposition.

(i)1. Proof that he or she has obtained or will be obtaining and will maintain professional liability insurance coverage in an amount not less than $100,000 per claim, with a minimum annual aggregate of not less than $300,000, from an authorized insurer as defined in s.

624.09, from one of the following:

a. An eligible surplus lines insurer as defined in s.

626.914(2);

b. A risk retention group as defined in s.

627.942, from the Joint Underwriting Association established under s.

627.351(4);

or c. A plan of self-insurance as provided in s.

627.357;

or 2. Proof that he or she has obtained and will be maintaining an unexpired, irrevocable letter of credit, established pursuant to chapter 675, in an amount of not less than $100,000 per claim, with a minimum aggregate availability of credit of not less than $300,000.

The letter of credit must be payable to the APRN-IP as beneficiary upon presentment of a final judgment indicating liability and awarding damages to be paid by the APRN-IP or upon presentment of a settlement agreement signed by all parties to such agreement when such final judgment or settlement is a result of a claim arising out of the rendering of, or the failure to render, medical or nursing care and services while practicing as an APRN-IP.

(j) Documentation of completion within the last 5 years of three graduate-level semester hours, or the equivalent, in differential diagnosis and three graduate-level semester hours, or the equivalent, in pharmacology, and any additional coursework as recommended by the council.

Such hours may not be continuing education courses.

(k) Any additional information that the council may require from the applicant, as determined by the council.

(5) REGISTRATION RENEWAL.—An APRN-IP may seek renewal of his or her registration biennially by applying to the department on forms developed by the department.

(a) An APRN-IP seeking registration renewal must provide documentation proving his or her completion of a minimum of 40 continuing medical education hours.

The required continuing medical education hours must include 3 hours on the safe and effective prescribing of controlled substances;

2 hours on human trafficking;

2 hours on the prevention of medical errors;

2 hours on domestic violence;

and 2 hours on suicide prevention, which must address suicide risk assessment, treatment, and management, if such topics are not required for licensure under this part.

(b) The continuing medical education hours required under paragraph (a):

1. Must be obtained in courses approved by the Board of Medicine or the Board of Osteopathic Medicine and offered by a statewide professional association of physicians or osteopathic physicians in this state which is accredited to provide educational activities designated for the American Medical Association Physician’s Recognition Award Category 1 credit or the American Osteopathic Category 1-A continuing medical education credit.

2. May be counted toward the required continuing education hours, including required subject area hours, for an APRN-IP’s renewal of his or her APRN or RN license, as provided under board rule.

(6) PRACTITIONER PROFILE.—Upon issuing a registration or a renewal of registration, the department shall update the practitioner’s profile, as described in s.

456.041, to reflect that the advanced practice registered nurse is registered as an APRN-IP.

(7) APRN-IP SCOPE OF PRACTICE.—An APRN-IP may provide primary health care services without a protocol agreement or supervision only in primary care health professional shortage areas during the first 3 years of his or her independent practice without such agreement or supervision.

After 3 years of such independent practice in a primary care health professional shortage area, an APRN-IP may practice independently for the provision of primary health care services in any area of the state.

For the purposes of this subsection, “3 years of such independent practice” means an APRN-IP has established an independent practice in a primary care health professional shortage area under this section which serves as his or her primary professional practice and has actively provided primary health care services to patients under that practice for 3 full years.

(a) An APRN-IP may not practice in a hospital licensed under chapter 395 or in a facility licensed under chapter 400, except under an established written protocol with a supervising physician which is maintained at the hospital or facility.

(b) The department shall adopt by rule the scope of practice for an APRN-IP.

Such rules must address, but are not limited to, all of the following topics:

1. The scope of the medical care, treatment, and services an APRN-IP may provide to patients.

2. Medical care, treatment, and services that are outside the scope of the practice of an APRN-IP.

3. Patient populations to which an APRN-IP may provide primary care, treatment, and services.

4. Patient populations to which an APRN-IP may not provide primary care, treatment, or services.

5. Patient populations that the APRN-IP must refer to a physician.

6. Guidelines for prescribing controlled substances for the treatment of chronic nonmalignant pain and acute pain, including evaluation of the patient, creation and maintenance of a treatment plan, obtaining informed consent and agreement for treatment, periodic review of the treatment plan, consultation, medical record review, and compliance with controlled substance laws and regulations.

7. Information regarding the credentials of the APRN-IP which must be disclosed to patients in a written informed consent to care and treatment, including, but not limited to, notification to the patient that the APRN-IP is not a physician and may not be referred to as a “doctor” or a “physician” in a medical setting.

8. Requirements relating to the APRN-IP practice’s recordkeeping, record retention, and availability of records for inspection by the department.

9. Advertising restrictions and disclosure requirements for APRN-IPs, including that the APRN-IP may not be referred to as a “doctor” or a “physician” in a medical setting.

(8) REPORTS OF ADVERSE INCIDENTS BY APRN-IPs.— (a) Any APRN-IP practicing in this state must notify the department if he or she was involved in an adverse incident.

(b) The required notification to the department must be submitted in writing by certified mail and postmarked within 15 days after the occurrence of the adverse incident.

(c) For purposes of notifying the department under this section, the term “adverse incident” means an event over which the APRN-IP could exercise control and which is associated in whole or in part with a medical intervention, rather than the condition for which such intervention occurred, and which results in any of the following patient injuries:

1. The death of a patient.

2. An injury to the patient that is likely to be permanent.

3. Any condition that required the transfer of a patient from the APRN-IP’s practice location to a hospital licensed under chapter 395.

(d) The department shall review each incident and determine whether it potentially involved conduct by the APRN-IP which is grounds for disciplinary action, in which case s.

456.073 applies.

Disciplinary action, if any, shall be taken by the Board of Medicine or the Board of Nursing, depending on the conduct involved, as determined by the department.

(e) The department shall adopt rules to implement this subsection.

(9) INACTIVE AND DELINQUENT STATUS.—An APRN-IP registration that is in an inactive or delinquent status may be reactivated only as provided in s.

456.036.

(10) CONSTRUCTION.—This section may not be construed to prevent third-party payors from reimbursing an APRN-IP for covered services rendered by the registered APRN-IP.

(11) RULEMAKING.—The department shall adopt rules to implement this section.

Section 17. Effective July 1, 2020, present subsections (9) and (10) of section 464.015, Florida Statutes, are redesignated as subsections (10) and (11), respectively, a new subsection (9) is added to that section, present subsection (9) of that section is amended, and present subsection (10) of that section is republished, to read:

464.015 Titles and abbreviations;

restrictions;

penalty.— (9) Only persons who hold valid registrations to practice as APRN-IPs in this state may use the title “advanced practice registered nurse - independent practitioner” and the abbreviation “A.P.R.N.-I.P.” A health care practitioner or personnel within a health care facility may not refer to an APRN-IP as a “doctor” or a “physician” in a medical setting.

(10)(9) A person may not practice or advertise as, or assume the title of, registered nurse, licensed practical nurse, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, certified nurse practitioner, or advanced practice registered nurse, or advanced practice registered nurse - independent practitioner;

use the abbreviation “R.N.,” “L.P.N.,” “C.N.S.,” “C.R.N.A.,” “C.N.M.,” “C.N.P.,” or “A.P.R.N.,” or “A.P.R.N.-I.P.”;

or take any other action that would lead the public to believe that person was authorized by law to practice as such or is performing nursing services pursuant to the exception set forth in s.

464.022(8) unless that person is licensed, certified, or authorized pursuant to s.

464.0095 to practice as such.

(11)(10) A violation of this section is a misdemeanor of the first degree, punishable as provided in s.

775.082 or s.

775.083.

Section 18. Effective July 1, 2020, paragraph (s) is added to subsection (1) of section 464.018, Florida Statutes, as amended by section 12 of this act, to read:

464.018 Disciplinary actions.— (1) The following acts constitute grounds for denial of a license or disciplinary action, as specified in ss.

456.072(2) and 464.0095:

(s) For an APRN-IP registered under s.

464.0123, in addition to the grounds for discipline set forth in paragraph (p) and in s.

456.072(1), any of the following are grounds for discipline:

1. Paying or receiving any commission, bonus, kickback, or rebate from, or engaging in any split-fee arrangement in any form whatsoever with, a health care practitioner, an organization, an agency, or a person, either directly or implicitly, for referring patients to providers of health care goods or services, including, but not limited to, hospitals, nursing homes, clinical laboratories, ambulatory surgical centers, or pharmacies.

This subparagraph may not be construed to prevent an APRN-IP from receiving a fee for professional consultation services.

2. Exercising influence within a patient’s relationship with an APRN-IP for purposes of engaging a patient in sexual activity.

A patient shall be presumed to be incapable of giving free, full, and informed consent to sexual activity with his or her APRN-IP.

3. Making deceptive, untrue, or fraudulent representations, or employing a trick or scheme, in or related to advanced practice registered nurse independent practice.

4. Soliciting patients, either personally or through an agent, by the use of fraud, intimidation, undue influence, or a form of overreaching or vexatious conduct.

As used in this subparagraph, the term “soliciting” means directly or implicitly requesting an immediate oral response from the recipient.

5. Failing to keep legible medical records, as defined by rules of the Board of Medicine and the Board of Osteopathic Medicine, that identify the APRN-IP, by name and professional title, who is responsible for rendering, ordering, supervising, or billing for the patient’s medically necessary care, treatment, services, diagnostic tests, or treatment procedures;

and the medical justification for the patient’s course of care and treatment, including, but not limited to, patient histories, examination results, and test results;

drugs prescribed, dispensed, or administered;

and reports of consultations or referrals.

6. Exercising influence on a patient to exploit the patient for the financial gain of the APRN-IP or a third party, including, but not limited to, the promoting or selling of services, goods, appliances, or drugs.

7. Performing professional services that have not been duly authorized by the patient or his or her legal representative, except as provided in s.

766.103 or s.

768.13.

8. Performing any procedure or prescribing any medication or therapy that would constitute experimentation on a human subject.

9. Delegating professional responsibilities to a person when the APRN-IP knows, or has reason to believe, that such person is not qualified by education, training, experience, or licensure to perform such responsibilities.

10. Committing, or conspiring with another to commit, an act that would coerce, intimidate, or preclude another APRN-IP from lawfully advertising his or her services.

11. Advertising or holding himself or herself out as having a certification in a specialty which he or she has not received.

12. Failing to comply with the requirements of ss.

381.026 and 381.0261 related to providing patients with information about their rights and how to file a complaint.

13. Providing deceptive or fraudulent expert witness testimony related to advanced practice registered nurse independent practice.

Section 19. Effective July 1, 2020, paragraph (c) of subsection (2) of section 381.026, Florida Statutes, is amended to read:

381.026 Florida Patient’s Bill of Rights and Responsibilities.— (2) DEFINITIONS.—As used in this section and s.

381.0261, the term:

(c) “Health care provider” means a physician licensed under chapter 458, an osteopathic physician licensed under chapter 459, or a podiatric physician licensed under chapter 461, or an APRN-IP registered under s.

464.0123.

Section 20. Effective July 1, 2020, paragraph (a) of subsection (2) and subsections (3), (4), and (5) of section 382.008, Florida Statutes, are amended to read:

382.008 Death, fetal death, and nonviable birth registration.— (2)(a) The funeral director who first assumes custody of a dead body or fetus shall file the certificate of death or fetal death.

In the absence of the funeral director, the physician, APRN-IP registered under s.

464.0123, or other person in attendance at or after the death or the district medical examiner of the county in which the death occurred or the body was found shall file the certificate of death or fetal death.

The person who files the certificate shall obtain personal data from a legally authorized person as described in s.

497.005 or the best qualified person or source available.

The medical certification of cause of death shall be furnished to the funeral director, either in person or via certified mail or electronic transfer, by the physician, APRN-IP registered under s.

464.0123, or medical examiner responsible for furnishing such information.

For fetal deaths, the physician, APRN-IP registered under s.

464.0123, midwife, or hospital administrator shall provide any medical or health information to the funeral director within 72 hours after expulsion or extraction.

(3) Within 72 hours after receipt of a death or fetal death certificate from the funeral director, the medical certification of cause of death shall be completed and made available to the funeral director by the decedent’s primary or attending practitioner physician or, if s.

382.011 applies, the district medical examiner of the county in which the death occurred or the body was found.

The primary or attending practitioner physician or the medical examiner shall certify over his or her signature the cause of death to the best of his or her knowledge and belief.

As used in this section, the term “primary or attending practitioner physician” means a physician or an APRN IP registered under s.

464.0123 who treated the decedent through examination, medical advice, or medication during the 12 months preceding the date of death.

(a) The department may grant the funeral director an extension of time upon a good and sufficient showing of any of the following conditions:

1. An autopsy is pending.

2. Toxicology, laboratory, or other diagnostic reports have not been completed.

3. The identity of the decedent is unknown and further investigation or identification is required.

(b) If the decedent’s primary or attending practitioner physician or the district medical examiner of the county in which the death occurred or the body was found indicates that he or she will sign and complete the medical certification of cause of death but will not be available until after the 5-day registration deadline, the local registrar may grant an extension of 5 days.

If a further extension is required, the funeral director must provide written justification to the registrar.

(4) If the department or local registrar grants an extension of time to provide the medical certification of cause of death, the funeral director shall file a temporary certificate of death or fetal death which shall contain all available information, including the fact that the cause of death is pending.

The decedent’s primary or attending practitioner physician or the district medical examiner of the county in which the death occurred or the body was found shall provide an estimated date for completion of the permanent certificate.

(5) A permanent certificate of death or fetal death, containing the cause of death and any other information that was previously unavailable, shall be registered as a replacement for the temporary certificate.

The permanent certificate may also include corrected information if the items being corrected are noted on the back of the certificate and dated and signed by the funeral director, physician, APRN-IP registered under s.

464.0123, or district medical examiner of the county in which the death occurred or the body was found, as appropriate.

Section 21. Effective July 1, 2020, subsection (1) of section 382.011, Florida Statutes, is amended to read:

382.011 Medical examiner determination of cause of death.— (1) In the case of any death or fetal death due to causes or conditions listed in s.

406.11, any death that occurred more than 12 months after the decedent was last treated by a primary or attending physician or an APRN-IP registered under s.

464.0123 as defined in s.

382.008(3), or any death for which there is reason to believe that the death may have been due to an unlawful act or neglect, the funeral director or other person to whose attention the death may come shall refer the case to the district medical examiner of the county in which the death occurred or the body was found for investigation and determination of the cause of death.

Section 22. Effective July 1, 2020, paragraphs (a) and (f) of subsection (2) of section 394.463, Florida Statutes, are amended to read:

394.463 Involuntary examination.— (2) INVOLUNTARY EXAMINATION.— (a) An involuntary examination may be initiated by any one of the following means:

1. A circuit or county court may enter an ex parte order stating that a person appears to meet the criteria for involuntary examination and specifying the findings on which that conclusion is based.

The ex parte order for involuntary examination must be based on written or oral sworn testimony that includes specific facts that support the findings.

If other less restrictive means are not available, such as voluntary appearance for outpatient evaluation, a law enforcement officer, or other designated agent of the court, shall take the person into custody and deliver him or her to an appropriate, or the nearest, facility within the designated receiving system pursuant to s.

394.462 for involuntary examination.

The order of the court shall be made a part of the patient’s clinical record.

A fee may not be charged for the filing of an order under this subsection.

A facility accepting the patient based on this order must send a copy of the order to the department within 5 working days.

The order may be submitted electronically through existing data systems, if available.

The order shall be valid only until the person is delivered to the facility or for the period specified in the order itself, whichever comes first.

If a no time limit is not specified in the order, the order is shall be valid for 7 days after the date that the order was signed.

2. A law enforcement officer shall take a person who appears to meet the criteria for involuntary examination into custody and deliver the person or have him or her delivered to an appropriate, or the nearest, facility within the designated receiving system pursuant to s.

394.462 for examination.

The officer shall execute a written report detailing the circumstances under which the person was taken into custody, which must be made a part of the patient’s clinical record.

Any facility accepting the patient based on this report must send a copy of the report to the department within 5 working days.

3. A physician, a clinical psychologist, a psychiatric nurse, an APRN-IP registered under s.

464.0123, a mental health counselor, a marriage and family therapist, or a clinical social worker may execute a certificate stating that he or she has examined a person within the preceding 48 hours and finds that the person appears to meet the criteria for involuntary examination and stating the observations upon which that conclusion is based.

If other less restrictive means, such as voluntary appearance for outpatient evaluation, are not available, a law enforcement officer shall take into custody the person named in the certificate and deliver him or her to the appropriate, or nearest, facility within the designated receiving system pursuant to s.

394.462 for involuntary examination.

The law enforcement officer shall execute a written report detailing the circumstances under which the person was taken into custody.

The report and certificate shall be made a part of the patient’s clinical record.

Any facility accepting the patient based on this certificate must send a copy of the certificate to the department within 5 working days.

The document may be submitted electronically through existing data systems, if applicable.

1177 When sending the order, report, or certificate to the department, a facility shall, at a minimum, provide information about which action was taken regarding the patient under paragraph (g), which information shall also be made a part of the patient’s clinical record.

(f) A patient shall be examined by a physician, an APRN-IP registered under s.

464.0123, or a clinical psychologist, or by a psychiatric nurse performing within the framework of an established protocol with a psychiatrist, at a facility without unnecessary delay to determine if the criteria for involuntary services are met.

Emergency treatment may be provided upon the order of a physician if the physician determines that such treatment is necessary for the safety of the patient or others.

The patient may not be released by the receiving facility or its contractor without the documented approval of a psychiatrist or a clinical psychologist or, if the receiving facility is owned or operated by a hospital or health system, the release may also be approved by a psychiatric nurse performing within the framework of an established protocol with a psychiatrist, or an attending emergency department physician with experience in the diagnosis and treatment of mental illness after completion of an involuntary examination pursuant to this subsection.

A psychiatric nurse may not approve the release of a patient if the involuntary examination was initiated by a psychiatrist unless the release is approved by the initiating psychiatrist.

Section 23. Effective July 1, 2020, paragraph (a) of subsection (2) of section 397.501, Florida Statutes, is amended to read:

397.501 Rights of individuals.—Individuals receiving substance abuse services from any service provider are guaranteed protection of the rights specified in this section, unless otherwise expressly provided, and service providers must ensure the protection of such rights.

(2) RIGHT TO NONDISCRIMINATORY SERVICES.— (a) Service providers may not deny an individual access to substance abuse services solely on the basis of race, gender, ethnicity, age, sexual preference, human immunodeficiency virus status, prior service departures against medical advice, disability, or number of relapse episodes.

Service providers may not deny an individual who takes medication prescribed by a physician or an APRN-IP registered under s.

464.0123 access to substance abuse services solely on that basis.

Service providers who receive state funds to provide substance abuse services may not, if space and sufficient state resources are available, deny access to services based solely on inability to pay.

Section 24. Effective July 1, 2020, paragraphs (i), (o), and (r) of subsection (3) and paragraph (g) of subsection (5) of section 456.053, Florida Statutes, are amended to read:

456.053 Financial arrangements between referring health care providers and providers of health care services.— (3) DEFINITIONS.—For the purpose of this section, the word, phrase, or term:

(i) “Health care provider” means a any physician licensed under chapter 458, chapter 459, chapter 460, or chapter 461;

an APRN-IP registered under s.

464.0123;, or any health care provider licensed under chapter 463 or chapter 466.

(o)1. “Referral” means any referral of a patient by a health care provider for health care services, including, without limitation:

a.1. The forwarding of a patient by a health care provider to another health care provider or to an entity which provides or supplies designated health services or any other health care item or service;

or b.2. The request or establishment of a plan of care by a health care provider, which includes the provision of designated health services or other health care item or service.

2.3. The following orders, recommendations, or plans of care do not shall not constitute a referral by a health care provider:

a. By a radiologist for diagnostic-imaging services.

b. By a physician specializing in the provision of radiation therapy services for such services.

c. By a medical oncologist for drugs and solutions to be prepared and administered intravenously to such oncologist’s patient, as well as for the supplies and equipment used in connection therewith to treat such patient for cancer and the complications thereof.

d. By a cardiologist for cardiac catheterization services.

e. By a pathologist for diagnostic clinical laboratory tests and pathological examination services, if furnished by or under the supervision of such pathologist pursuant to a consultation requested by another physician.

f. By a health care provider who is the sole provider or member of a group practice for designated health services or other health care items or services that are prescribed or provided solely for such referring health care provider’s or group practice’s own patients, and that are provided or performed by or under the direct supervision of such referring health care provider or group practice;

provided, however, that effective July 1, 1999, a health care provider physician licensed pursuant to chapter 458, chapter 459, chapter 460, or chapter 461 may refer a patient to a sole provider or group practice for diagnostic imaging services, excluding radiation therapy services, for which the sole provider or group practice billed both the technical and the professional fee for or on behalf of the patient, if the referring health care provider does not have an physician has no investment interest in the practice.

The diagnostic imaging service referred to a group practice or sole provider must be a diagnostic imaging service normally provided within the scope of practice to the patients of the group practice or sole provider.

The group practice or sole provider may accept no more than 15 percent of their patients receiving diagnostic imaging services from outside referrals, excluding radiation therapy services.

g. By a health care provider for services provided by an ambulatory surgical center licensed under chapter 395.

h. By a urologist for lithotripsy services.

i. By a dentist for dental services performed by an employee of or health care provider who is an independent contractor with the dentist or group practice of which the dentist is a member.

j. By a physician for infusion therapy services to a patient of that physician or a member of that physician’s group practice.

k. By a nephrologist for renal dialysis services and supplies, except laboratory services.

l. By a health care provider whose principal professional practice consists of treating patients in their private residences for services to be rendered in such private residences, except for services rendered by a home health agency licensed under chapter 400.

For purposes of this sub subparagraph, the term “private residences” includes patients’ private homes, independent living centers, and assisted living facilities, but does not include skilled nursing facilities.

m. By a health care provider for sleep-related testing.

(r) “Sole provider” means one health care provider licensed under chapter 458, chapter 459, chapter 460, or chapter 461, or registered under s.

464.0123, who maintains a separate medical office and a medical practice separate from any other health care provider and who bills for his or her services separately from the services provided by any other health care provider.

A sole provider may not shall not share overhead expenses or professional income with any other person or group practice.

(5) PROHIBITED REFERRALS AND CLAIMS FOR PAYMENT.—Except as provided in this section:

(g) A violation of this section by a health care provider shall constitute grounds for disciplinary action to be taken by the applicable board pursuant to s.

458.331(2), s.

459.015(2), s.

460.413(2), s.

461.013(2), s.

463.016(2), s.

464.018, or s.

466.028(2).

Any hospital licensed under chapter 395 found in violation of this section shall be subject to s.

395.0185(2).

Section 25. Effective July 1, 2020, subsection (1) of section 626.9707, Florida Statutes, is amended to read:

626.9707 Disability insurance;

discrimination on basis of sickle-cell trait prohibited.— (1) An No insurer authorized to transact insurance in this state may not shall refuse to issue and deliver in this state any policy of disability insurance, whether such policy is defined as individual, group, blanket, franchise, industrial, or otherwise, which is currently being issued for delivery in this state and which affords benefits and coverage for any medical treatment or service authorized and permitted to be furnished by a hospital, a clinic, a health clinic, a neighborhood health clinic, a health maintenance organization, a physician, a physician’s assistant, an advanced practice registered nurse, an APRN-IP registered under s.

464.0123 practitioner, or a medical service facility or personnel solely because the person to be insured has the sickle-cell trait.

Section 26. Effective July 1, 2020, section 627.64025, Florida Statutes, is created to read:

627.64025 APRN-IP services.—A health insurance policy that provides major medical coverage and that is delivered, issued, or renewed in this state on or after January 1, 2021, may not require an insured to receive services from an APRN-IP registered under s.

464.0123 in place of a primary care physician;

incentivize the insured to do so through cost sharing as defined in s.

627.42391 which is lower for services provided by an APRN-IP than for the same services provided by a primary care physician;

or incentivize the insured do so through a program authorized pursuant to s.

627.6387.

Section 27. Effective July 1, 2020, section 627.6621, Florida Statutes, is created to read:

627.6621 APRN-IP services.—A group, blanket, or franchise health insurance policy that is delivered, issued, or renewed in this state on or after January 1, 2021, may not require an insured to receive services from an APRN-IP registered under s.

464.0123 in place of a primary care physician;

incentivize the insured to do so through cost sharing as defined in s.

627.42391 which is lower for services provided by an APRN-IP than for the same services provided by a primary care physician;

or incentivize the insured do so through a program authorized pursuant to s.

627.6387.

Section 28. Effective July 1, 2020, paragraph (g) is added to subsection (5) of section 627.6699, Florida Statutes, to read:

627.6699 Employee Health Care Access Act.— (5) AVAILABILITY OF COVERAGE.— (g) A health benefit plan covering small employers which is delivered, issued, or renewed in this state on or after January 1, 2021, may not require an insured to receive services from an APRN-IP registered under s.

464.0123 in place of a primary care physician;

incentivize the insured to do so through cost sharing as defined in s.

627.42391 which is lower for services provided by an APRN-IP than for the same services provided by a primary care physician;

or incentivize the insured do so through a program authorized pursuant to s.

627.6387.

Section 29. Effective July 1, 2020, paragraph (a) of subsection (1) of section 627.736, Florida Statutes, is amended to read:

627.736 Required personal injury protection benefits;

exclusions;

priority;

claims.— (1) REQUIRED BENEFITS.—An insurance policy complying with the security requirements of s.

627.733 must provide personal injury protection to the named insured, relatives residing in the same household, persons operating the insured motor vehicle, passengers in the motor vehicle, and other persons struck by the motor vehicle and suffering bodily injury while not an occupant of a self-propelled vehicle, subject to subsection (2) and paragraph (4)(e), to a limit of $10,000 in medical and disability benefits and $5,000 in death benefits resulting from bodily injury, sickness, disease, or death arising out of the ownership, maintenance, or use of a motor vehicle as follows:

(a) Medical benefits.—Eighty percent of all reasonable expenses for medically necessary medical, surgical, X-ray, dental, and rehabilitative services, including prosthetic devices and medically necessary ambulance, hospital, and nursing services if the individual receives initial services and care pursuant to subparagraph 1.

within 14 days after the motor vehicle accident.

The medical benefits provide reimbursement only for: