Bill Amendment: FL H0977 | 2016 | Regular Session
NOTE: For additional amemendments please see the Bill Drafting List
Bill Title: Behavioral Health Workforce
Status: 2016-04-14 - Chapter No. 2016-231, companion bill(s) passed, see HB 423 (Ch. 2016-224) [H0977 Detail]
Download: Florida-2016-H0977-Senate_Floor_Amendment_654244_to_Amendment_510114_.html
Bill Title: Behavioral Health Workforce
Status: 2016-04-14 - Chapter No. 2016-231, companion bill(s) passed, see HB 423 (Ch. 2016-224) [H0977 Detail]
Download: Florida-2016-H0977-Senate_Floor_Amendment_654244_to_Amendment_510114_.html
Florida Senate - 2016 SENATOR AMENDMENT Bill No. CS for HB 977 Ì654244%Î654244 LEGISLATIVE ACTION Senate . House . . . Floor: 1b/RE/2R . 03/09/2016 06:42 PM . ————————————————————————————————————————————————————————————————— ————————————————————————————————————————————————————————————————— Senator Grimsley moved the following: 1 Senate Amendment to Amendment (510114) (with title 2 amendment) 3 4 Between lines 108 and 109 5 insert: 6 Section 4. Paragraph (g) is added to subsection (1) of 7 section 456.44, Florida Statutes, and subsections (2) and (3) of 8 that section are amended, to read: 9 456.44 Controlled substance prescribing.— 10 (1) DEFINITIONS.—As used in this section, the term: 11 (g) “Registrant” means a physician who meets the 12 requirements of subsection (2). 13 (2) REGISTRATION.—Effective January 1, 2012,A physician 14 licensed under chapter 458, chapter 459, chapter 461, or chapter 15 466 who prescribes any controlled substance, listed in Schedule 16 II, Schedule III, or Schedule IV as defined in s. 893.03, for 17 the treatment of chronic nonmalignant pain, must: 18 (a) Designate himself or herself as a controlled substance 19 prescribing practitioner on his or herthe physician’s20 practitioner profile. 21 (b) Comply with the requirements of this section and 22 applicable board rules. 23 (3) STANDARDS OF PRACTICE.—The standards of practice in 24 this section do not supersede the level of care, skill, and 25 treatment recognized in general law related to health care 26 licensure. 27 (a) A complete medical history and a physical examination 28 must be conducted before beginning any treatment and must be 29 documented in the medical record. The exact components of the 30 physical examination shall be left to the judgment of the 31 registrantclinicianwho is expected to perform a physical 32 examination proportionate to the diagnosis that justifies a 33 treatment. The medical record must, at a minimum, document the 34 nature and intensity of the pain, current and past treatments 35 for pain, underlying or coexisting diseases or conditions, the 36 effect of the pain on physical and psychological function, a 37 review of previous medical records, previous diagnostic studies, 38 and history of alcohol and substance abuse. The medical record 39 shall also document the presence of one or more recognized 40 medical indications for the use of a controlled substance. Each 41 registrant must develop a written plan for assessing each 42 patient’s risk of aberrant drug-related behavior, which may 43 include patient drug testing. Registrants must assess each 44 patient’s risk for aberrant drug-related behavior and monitor 45 that risk on an ongoing basis in accordance with the plan. 46 (b) Each registrant must develop a written individualized 47 treatment plan for each patient. The treatment plan shall state 48 objectives that will be used to determine treatment success, 49 such as pain relief and improved physical and psychosocial 50 function, and shall indicate if any further diagnostic 51 evaluations or other treatments are planned. After treatment 52 begins, the registrantphysicianshall adjust drug therapy to 53 the individual medical needs of each patient. Other treatment 54 modalities, including a rehabilitation program, shall be 55 considered depending on the etiology of the pain and the extent 56 to which the pain is associated with physical and psychosocial 57 impairment. The interdisciplinary nature of the treatment plan 58 shall be documented. 59 (c) The registrantphysicianshall discuss the risks and 60 benefits of the use of controlled substances, including the 61 risks of abuse and addiction, as well as physical dependence and 62 its consequences, with the patient, persons designated by the 63 patient, or the patient’s surrogate or guardian if the patient 64 is incompetent. The registrantphysicianshall use a written 65 controlled substance agreement between the registrantphysician66 and the patient outlining the patient’s responsibilities, 67 including, but not limited to: 68 1. Number and frequency of controlled substance 69 prescriptions and refills. 70 2. Patient compliance and reasons for which drug therapy 71 may be discontinued, such as a violation of the agreement. 72 3. An agreement that controlled substances for the 73 treatment of chronic nonmalignant pain shall be prescribed by a 74 single treating registrantphysicianunless otherwise authorized 75 by the treating registrantphysicianand documented in the 76 medical record. 77 (d) The patient shall be seen by the registrantphysician78 at regular intervals, not to exceed 3 months, to assess the 79 efficacy of treatment, ensure that controlled substance therapy 80 remains indicated, evaluate the patient’s progress toward 81 treatment objectives, consider adverse drug effects, and review 82 the etiology of the pain. Continuation or modification of 83 therapy shall depend on the registrant’sphysician’sevaluation 84 of the patient’s progress. If treatment goals are not being 85 achieved, despite medication adjustments, the registrant 86physicianshall reevaluate the appropriateness of continued 87 treatment. The registrantphysicianshall monitor patient 88 compliance in medication usage, related treatment plans, 89 controlled substance agreements, and indications of substance 90 abuse or diversion at a minimum of 3-month intervals. 91 (e) The registrantphysicianshall refer the patient as 92 necessary for additional evaluation and treatment in order to 93 achieve treatment objectives. Special attention shall be given 94 to those patients who are at risk for misusing their medications 95 and those whose living arrangements pose a risk for medication 96 misuse or diversion. The management of pain in patients with a 97 history of substance abuse or with a comorbid psychiatric 98 disorder requires extra care, monitoring, and documentation and 99 requires consultation with or referral to an addiction medicine 100 specialist or a psychiatrist. 101 (f) A registrantphysician registered under this section102 must maintain accurate, current, and complete records that are 103 accessible and readily available for review and comply with the 104 requirements of this section, the applicable practice act, and 105 applicable board rules. The medical records must include, but 106 are not limited to: 107 1. The complete medical history and a physical examination, 108 including history of drug abuse or dependence. 109 2. Diagnostic, therapeutic, and laboratory results. 110 3. Evaluations and consultations. 111 4. Treatment objectives. 112 5. Discussion of risks and benefits. 113 6. Treatments. 114 7. Medications, including date, type, dosage, and quantity 115 prescribed. 116 8. Instructions and agreements. 117 9. Periodic reviews. 118 10. Results of any drug testing. 119 11. A photocopy of the patient’s government-issued photo 120 identification. 121 12. If a written prescription for a controlled substance is 122 given to the patient, a duplicate of the prescription. 123 13. The registrant’sphysician’sfull name presented in a 124 legible manner. 125 (g) A registrant shall immediately refer patients with 126 signs or symptoms of substance abuseshall be immediately127referredto a board-certified pain management physician, an 128 addiction medicine specialist, or a mental health addiction 129 facility as it pertains to drug abuse or addiction unless the 130 registrant is a physician who is board-certified or board- 131 eligible in pain management. Throughout the period of time 132 before receiving the consultant’s report, a prescribing 133 registrantphysicianshall clearly and completely document 134 medical justification for continued treatment with controlled 135 substances and those steps taken to ensure medically appropriate 136 use of controlled substances by the patient. Upon receipt of the 137 consultant’s written report, the prescribing registrant 138physicianshall incorporate the consultant’s recommendations for 139 continuing, modifying, or discontinuing controlled substance 140 therapy. The resulting changes in treatment shall be 141 specifically documented in the patient’s medical record. 142 Evidence or behavioral indications of diversion shall be 143 followed by discontinuation of controlled substance therapy, and 144 the patient shall be discharged, and all results of testing and 145 actions taken by the registrantphysicianshall be documented in 146 the patient’s medical record. 147 148 This subsection does not apply to a board-eligible or board 149 certified anesthesiologist, physiatrist, rheumatologist, or 150 neurologist, or to a board-certified physician who has surgical 151 privileges at a hospital or ambulatory surgery center and 152 primarily provides surgical services. This subsection does not 153 apply to a board-eligible or board-certified medical specialist 154 who has also completed a fellowship in pain medicine approved by 155 the Accreditation Council for Graduate Medical Education or the 156 American Osteopathic Association, or who is board eligible or 157 board certified in pain medicine by the American Board of Pain 158 Medicine, the American Board of Interventional Pain Physicians, 159 the American Association of Physician Specialists, or a board 160 approved by the American Board of Medical Specialties or the 161 American Osteopathic Association and performs interventional 162 pain procedures of the type routinely billed using surgical 163 codes. This subsection does not apply to a registrantphysician164 who prescribes medically necessary controlled substances for a 165 patient during an inpatient stay in a hospital licensed under 166 chapter 395. 167 Section 5. Paragraph (b) of subsection (2) of section 168 458.3265, Florida Statutes, is amended to read: 169 458.3265 Pain-management clinics.— 170 (2) PHYSICIAN RESPONSIBILITIES.—These responsibilities 171 apply to any physician who provides professional services in a 172 pain-management clinic that is required to be registered in 173 subsection (1). 174 (b) Onlya person may not dispense any medication on the175premises of a registered pain-management clinic unless he or she176isa physician licensed under this chapter or chapter 459 may 177 dispense medication or prescribe a controlled substance 178 regulated under chapter 893 on the premises of a registered 179 pain-management clinic. 180 Section 6. Paragraph (b) of subsection (2) of section 181 459.0137, Florida Statutes, is amended to read: 182 459.0137 Pain-management clinics.— 183 (2) PHYSICIAN RESPONSIBILITIES.—These responsibilities 184 apply to any osteopathic physician who provides professional 185 services in a pain-management clinic that is required to be 186 registered in subsection (1). 187 (b) Onlya person may not dispense any medication on the188premises of a registered pain-management clinic unless he or she189isa physician licensed under this chapter or chapter 458 may 190 dispense medication or prescribe a controlled substance 191 regulated under chapter 893 on the premises of a registered 192 pain-management clinic. 193 Section 7. Section 464.012, Florida Statutes, is amended to 194 read: 195 464.012 Certification of advanced registered nurse 196 practitioners; fees.— 197 (1) Any nurse desiring to be certified as an advanced 198 registered nurse practitioner shall apply to the department and 199 submit proof that he or she holds a current license to practice 200 professional nursing and that he or she meets one or more of the 201 following requirements as determined by the board: 202 (a) Satisfactory completion of a formal postbasic 203 educational program of at least one academic year, the primary 204 purpose of which is to prepare nurses for advanced or 205 specialized practice. 206 (b) Certification by an appropriate specialty board. Such 207 certification shall be required for initial state certification 208 and any recertification as a registered nurse anesthetist, 209 psychiatric nurse, or nurse midwife. The board may by rule 210 provide for provisional state certification of graduate nurse 211 anesthetists, psychiatric nurses, and nurse midwives for a 212 period of time determined to be appropriate for preparing for 213 and passing the national certification examination. 214 (c) Graduation from a program leading to a master’s degree 215 in a nursing clinical specialty area with preparation in 216 specialized practitioner skills. For applicants graduating on or 217 after October 1, 1998, graduation from a master’s degree program 218 shall be required for initial certification as a nurse 219 practitioner under paragraph (4)(c). For applicants graduating 220 on or after October 1, 2001, graduation from a master’s degree 221 program shall be required for initial certification as a 222 registered nurse anesthetist under paragraph (4)(a). 223 (2) The board shall provide by rule the appropriate 224 requirements for advanced registered nurse practitioners in the 225 categories of certified registered nurse anesthetist, certified 226 nurse midwife, and nurse practitioner. 227 (3) An advanced registered nurse practitioner shall perform 228 those functions authorized in this section within the framework 229 of an established protocol that is filed with the board upon 230 biennial license renewal and within 30 days after entering into 231 a supervisory relationship with a physician or changes to the 232 protocol. The board shall review the protocol to ensure 233 compliance with applicable regulatory standards for protocols. 234 The board shall refer to the department licensees submitting 235 protocols that are not compliant with the regulatory standards 236 for protocols. A practitioner currently licensed under chapter 237 458, chapter 459, or chapter 466 shall maintain supervision for 238 directing the specific course of medical treatment. Within the 239 established framework, an advanced registered nurse practitioner 240 may: 241 (a) Monitor and alter drug therapies. 242 (b) Initiate appropriate therapies for certain conditions. 243 (c) Perform additional functions as may be determined by 244 rule in accordance with s. 464.003(2). 245 (d) Order diagnostic tests and physical and occupational 246 therapy. 247 (4) In addition to the general functions specified in 248 subsection (3), an advanced registered nurse practitioner may 249 perform the following acts within his or her specialty: 250 (a) The certified registered nurse anesthetist may, to the 251 extent authorized by established protocol approved by the 252 medical staff of the facility in which the anesthetic service is 253 performed, perform any or all of the following: 254 1. Determine the health status of the patient as it relates 255 to the risk factors and to the anesthetic management of the 256 patient through the performance of the general functions. 257 2. Based on history, physical assessment, and supplemental 258 laboratory results, determine, with the consent of the 259 responsible physician, the appropriate type of anesthesia within 260 the framework of the protocol. 261 3. Order under the protocol preanesthetic medication. 262 4. Perform under the protocol procedures commonly used to 263 render the patient insensible to pain during the performance of 264 surgical, obstetrical, therapeutic, or diagnostic clinical 265 procedures. These procedures include ordering and administering 266 regional, spinal, and general anesthesia; inhalation agents and 267 techniques; intravenous agents and techniques; and techniques of 268 hypnosis. 269 5. Order or perform monitoring procedures indicated as 270 pertinent to the anesthetic health care management of the 271 patient. 272 6. Support life functions during anesthesia health care, 273 including induction and intubation procedures, the use of 274 appropriate mechanical supportive devices, and the management of 275 fluid, electrolyte, and blood component balances. 276 7. Recognize and take appropriate corrective action for 277 abnormal patient responses to anesthesia, adjunctive medication, 278 or other forms of therapy. 279 8. Recognize and treat a cardiac arrhythmia while the 280 patient is under anesthetic care. 281 9. Participate in management of the patient while in the 282 postanesthesia recovery area, including ordering the 283 administration of fluids and drugs. 284 10. Place special peripheral and central venous and 285 arterial lines for blood sampling and monitoring as appropriate. 286 (b) The certified nurse midwife may, to the extent 287 authorized by an established protocol which has been approved by 288 the medical staff of the health care facility in which the 289 midwifery services are performed, or approved by the nurse 290 midwife’s physician backup when the delivery is performed in a 291 patient’s home, perform any or all of the following: 292 1. Perform superficial minor surgical procedures. 293 2. Manage the patient during labor and delivery to include 294 amniotomy, episiotomy, and repair. 295 3. Order, initiate, and perform appropriate anesthetic 296 procedures. 297 4. Perform postpartum examination. 298 5. Order appropriate medications. 299 6. Provide family-planning services and well-woman care. 300 7. Manage the medical care of the normal obstetrical 301 patient and the initial care of a newborn patient. 302 (c) The nurse practitioner may perform any or all of the 303 following acts within the framework of established protocol: 304 1. Manage selected medical problems. 305 2. Order physical and occupational therapy. 306 3. Initiate, monitor, or alter therapies for certain 307 uncomplicated acute illnesses. 308 4. Monitor and manage patients with stable chronic 309 diseases. 310 5. Establish behavioral problems and diagnosis and make 311 treatment recommendations. 312 (5) A psychiatric nurse, as defined in s. 394.455, within 313 the framework of an established protocol with a psychiatrist, 314 may prescribe psychotropic controlled substances for the 315 treatment of mental disorders. 316 (6) The board shall certify, and the department shall issue 317 a certificate to, any nurse meeting the qualifications in this 318 section. The board shall establish an application fee not to 319 exceed $100 and a biennial renewal fee not to exceed $50. The 320 board is authorized to adopt such other rules as are necessary 321 to implement the provisions of this section. 322 Section 8. Paragraph (p) is added to subsection (1) of 323 section 464.018, Florida Statutes, and subsection (2) of that 324 section is republished, to read: 325 464.018 Disciplinary actions.— 326 (1) The following acts constitute grounds for denial of a 327 license or disciplinary action, as specified in s. 456.072(2): 328 (p) For a psychiatric nurse: 329 1. Presigning blank prescription forms. 330 2. Prescribing for office use any medicinal drug appearing 331 in Schedule II of s. 893.03. 332 3. Prescribing, ordering, dispensing, administering, 333 supplying, selling, or giving a drug that is an amphetamine, a 334 sympathomimetic amine drug, or a compound designated in s. 335 893.03(2) as a Schedule II controlled substance, to or for any 336 person except for: 337 a. The treatment of narcolepsy; hyperkinesis; behavioral 338 syndrome in children characterized by the developmentally 339 inappropriate symptoms of moderate to severe distractibility, 340 short attention span, hyperactivity, emotional lability, and 341 impulsivity; or drug-induced brain dysfunction. 342 b. The differential diagnostic psychiatric evaluation of 343 depression or the treatment of depression shown to be refractory 344 to other therapeutic modalities. 345 c. The clinical investigation of the effects of such drugs 346 or compounds when an investigative protocol is submitted to, 347 reviewed by, and approved by the department before such 348 investigation is begun. 349 4. Prescribing, ordering, dispensing, administering, 350 supplying, selling, or giving growth hormones, testosterone or 351 its analogs, human chorionic gonadotropin (HCG), or other 352 hormones for the purpose of muscle building or to enhance 353 athletic performance. As used in this subparagraph, the term 354 “muscle building” does not include the treatment of injured 355 muscle. A prescription written for the drug products identified 356 in this subparagraph may be dispensed by a pharmacist with the 357 presumption that the prescription is for legitimate medical use. 358 5. Promoting or advertising on any prescription form a 359 community pharmacy unless the form also states: “This 360 prescription may be filled at any pharmacy of your choice.” 361 6. Prescribing, dispensing, administering, mixing, or 362 otherwise preparing a legend drug, including a controlled 363 substance, other than in the course of his or her professional 364 practice. For the purposes of this subparagraph, it is legally 365 presumed that prescribing, dispensing, administering, mixing, or 366 otherwise preparing legend drugs, including all controlled 367 substances, inappropriately or in excessive or inappropriate 368 quantities is not in the best interest of the patient and is not 369 in the course of the advanced registered nurse practitioner’s 370 professional practice, without regard to his or her intent. 371 7. Prescribing, dispensing, or administering a medicinal 372 drug appearing on any schedule set forth in chapter 893 to 373 himself or herself, except a drug prescribed, dispensed, or 374 administered to the psychiatric nurse by another practitioner 375 authorized to prescribe, dispense, or administer medicinal 376 drugs. 377 8. Prescribing, ordering, dispensing, administering, 378 supplying, selling, or giving amygdalin (laetrile) to any 379 person. 380 9. Dispensing a substance designated in s. 893.03(2) or (3) 381 as a substance controlled in Schedule II or Schedule III, 382 respectively, in violation of s. 465.0276. 383 10. Promoting or advertising through any communication 384 medium the use, sale, or dispensing of a substance designated in 385 s. 893.03 as a controlled substance. 386 (2) The board may enter an order denying licensure or 387 imposing any of the penalties in s. 456.072(2) against any 388 applicant for licensure or licensee who is found guilty of 389 violating any provision of subsection (1) of this section or who 390 is found guilty of violating any provision of s. 456.072(1). 391 Section 9. Subsection (21) of section 893.02, Florida 392 Statutes, is amended to read: 393 893.02 Definitions.—The following words and phrases as used 394 in this chapter shall have the following meanings, unless the 395 context otherwise requires: 396 (21) “Practitioner” means a physician licensed pursuant to 397 chapter 458, a dentist licensed pursuant to chapter 466, a 398 veterinarian licensed pursuant to chapter 474, an osteopathic 399 physician licensed pursuant to chapter 459, a naturopath 400 licensed pursuant to chapter 462, a certified optometrist 401 licensed pursuant to chapter 463, a psychiatric nurse as defined 402 in s. 394.455, or a podiatric physician licensed pursuant to 403 chapter 461, provided such practitioner holds a valid federal 404 controlled substance registry number. 405 406 ================= T I T L E A M E N D M E N T ================ 407 And the title is amended as follows: 408 Delete line 123 409 and insert: 410 provider personnel; amending s. 456.44, F.S.; defining 411 the term “registrant”; requiring psychiatric nurses to 412 make certain designations and comply with certain 413 requirements under specified circumstances; amending 414 s. 458.3265, F.S.; restricting to physicians the 415 authorization to dispense certain medications or 416 prescribe certain controlled substances on the 417 premises of a registered pain-management clinic; 418 amending s. 459.0137, F.S.; restricting to osteopathic 419 physicians the authorization to dispense certain 420 medications or prescribe certain controlled substances 421 on the premises of a registered pain-management 422 clinic; amending s. 464.012, F.S.; providing 423 certification criteria for psychiatric nurses; 424 authorizing psychiatric nurses to prescribe certain 425 psychotropic controlled substances under certain 426 circumstances; amending s. 464.018; providing that 427 certain acts by a psychiatric nurse constitute grounds 428 for denial of a license or disciplinary action; 429 amending s. 893.02, F.S.; revising the definition of 430 the term “practitioner”; providing an effective date.