Bill Text: FL S0732 | 2019 | Regular Session | Comm Sub
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Office Surgery
Spectrum: Slight Partisan Bill (? 2-1)
Status: (Passed) 2019-06-26 - Chapter No. 2019-130 [S0732 Detail]
Download: Florida-2019-S0732-Comm_Sub.html
Bill Title: Office Surgery
Spectrum: Slight Partisan Bill (? 2-1)
Status: (Passed) 2019-06-26 - Chapter No. 2019-130 [S0732 Detail]
Download: Florida-2019-S0732-Comm_Sub.html
Florida Senate - 2019 CS for SB 732 By the Committee on Health Policy; and Senator Flores 588-02904-19 2019732c1 1 A bill to be entitled 2 An act relating to clinics and office surgery; 3 amending s. 400.9905, F.S.; revising the definition of 4 the term “clinic”; amending s. 400.991, F.S.; 5 requiring a clinic to provide proof of its financial 6 responsibility to pay certain claims and costs along 7 with its application for licensure to the Agency for 8 Health Care Administration; amending s. 400.9935, 9 F.S.; requiring a medical director or a clinic 10 director to ensure that the clinic complies with 11 specified rules; amending s. 400.995, F.S.; requiring 12 the agency to impose a specified administrative fine 13 on an unregistered clinic that performs certain office 14 surgeries; amending s. 456.004, F.S.; requiring the 15 Department of Health to deny or revoke the 16 registration of or impose certain penalties against a 17 facility where certain office surgeries are performed 18 under certain circumstances; specifying provisions 19 that apply enforcement actions against such 20 facilities; authorizing the department to deny certain 21 persons associated with an office of which the 22 registration was revoked from registering a new office 23 to perform certain office surgery; amending s. 24 456.074, F.S.; authorizing the department to issue an 25 emergency order suspending or restricting the 26 registration of a certain office if it makes certain 27 findings; amending s. 458.305, F.S.; defining terms; 28 amending s. 458.309, F.S.; requiring a physician who 29 performs certain office surgery and the office in 30 which the surgery is performed to maintain specified 31 levels of financial responsibility; authorizing the 32 department to adopt rules to administer the 33 registration, inspection, and safety of offices that 34 perform certain office surgery; requiring the Board of 35 Medicine to adopt rules governing the standard of care 36 for physicians practicing in such offices; requiring 37 the board to impose a specified fine on physicians who 38 perform certain office surgeries in an unregistered 39 office; amending s. 458.331, F.S.; providing that a 40 physician performing certain office surgeries in an 41 unregistered office constitutes grounds for denial of 42 a license or disciplinary action; amending s. 459.003, 43 F.S.; defining terms; amending s. 459.005, F.S.; 44 requiring a physician who performs certain office 45 surgery and the office in which the surgery is 46 performed to maintain specified levels of financial 47 responsibility; authorizing the department to adopt 48 rules to administer the registration, inspection, and 49 safety of offices that perform certain office surgery; 50 requiring the Board of Osteopathic Medicine to adopt 51 rules governing the standard of care for physicians 52 practicing in such offices; requiring the board to 53 impose a specified fine on physicians who perform 54 certain office surgeries in an unregistered office; 55 amending s. 459.015, F.S.; providing that a physician 56 performing certain office surgeries in an unregistered 57 office constitutes grounds for denial of a license or 58 disciplinary action; amending s. 464.012, F.S.; 59 authorizing a certified registered nurse anesthetist 60 to provide specified services in a an office 61 registered to perform office surgery within the 62 framework of an established protocol with a licensed 63 anesthesiologist; amending s. 766.101, F.S.; 64 conforming a cross-reference; providing an effective 65 date. 66 67 Be It Enacted by the Legislature of the State of Florida: 68 69 Section 1. Subsection (4) of section 400.9905, Florida 70 Statutes, is amended to read: 71 400.9905 Definitions.— 72 (4) “Clinic” means an entity that provideswherehealth 73 care servicesare providedto individuals and that receives 74 compensationand which tenders charges for reimbursementfor 75 thosesuchservices, including a mobile clinic and a portable 76 equipment provider. As used in this part, the term does not 77 include and the licensure requirements of this part do not apply 78 to: 79 (a) Entities licensed or registered by the state under 80 chapter 395; entities licensed or registered by the state and 81 providing only health care services within the scope of services 82 authorized under their respective licenses under ss. 383.30 83 383.332, chapter 390, chapter 394, chapter 397, this chapter 84 except part X, chapter 429, chapter 463, chapter 465, chapter 85 466, chapter 478, chapter 484, or chapter 651; end-stage renal 86 disease providers authorized under 42 C.F.R. part 405, subpart 87 U; providers certified under 42 C.F.R. part 485, subpart B or 88 subpart H; or any entity that provides neonatal or pediatric 89 hospital-based health care services or other health care 90 services by licensed practitioners solely within a hospital 91 licensed under chapter 395. 92 (b) Entities that own, directly or indirectly, entities 93 licensed or registered by the state pursuant to chapter 395; 94 entities that own, directly or indirectly, entities licensed or 95 registered by the state and providing only health care services 96 within the scope of services authorized pursuant to their 97 respective licenses under ss. 383.30-383.332, chapter 390, 98 chapter 394, chapter 397, this chapter except part X, chapter 99 429, chapter 463, chapter 465, chapter 466, chapter 478, chapter 100 484, or chapter 651; end-stage renal disease providers 101 authorized under 42 C.F.R. part 405, subpart U; providers 102 certified under 42 C.F.R. part 485, subpart B or subpart H; or 103 any entity that provides neonatal or pediatric hospital-based 104 health care services by licensed practitioners solely within a 105 hospital licensed under chapter 395. 106 (c) Entities that are owned, directly or indirectly, by an 107 entity licensed or registered by the state pursuant to chapter 108 395; entities that are owned, directly or indirectly, by an 109 entity licensed or registered by the state and providing only 110 health care services within the scope of services authorized 111 pursuant to their respective licenses under ss. 383.30-383.332, 112 chapter 390, chapter 394, chapter 397, this chapter except part 113 X, chapter 429, chapter 463, chapter 465, chapter 466, chapter 114 478, chapter 484, or chapter 651; end-stage renal disease 115 providers authorized under 42 C.F.R. part 405, subpart U; 116 providers certified under 42 C.F.R. part 485, subpart B or 117 subpart H; or any entity that provides neonatal or pediatric 118 hospital-based health care services by licensed practitioners 119 solely within a hospital under chapter 395. 120 (d) Entities that are under common ownership, directly or 121 indirectly, with an entity licensed or registered by the state 122 pursuant to chapter 395; entities that are under common 123 ownership, directly or indirectly, with an entity licensed or 124 registered by the state and providing only health care services 125 within the scope of services authorized pursuant to their 126 respective licenses under ss. 383.30-383.332, chapter 390, 127 chapter 394, chapter 397, this chapter except part X, chapter 128 429, chapter 463, chapter 465, chapter 466, chapter 478, chapter 129 484, or chapter 651; end-stage renal disease providers 130 authorized under 42 C.F.R. part 405, subpart U; providers 131 certified under 42 C.F.R. part 485, subpart B or subpart H; or 132 any entity that provides neonatal or pediatric hospital-based 133 health care services by licensed practitioners solely within a 134 hospital licensed under chapter 395. 135 (e) An entity that is exempt from federal taxation under 26 136 U.S.C. s. 501(c)(3) or (4), an employee stock ownership plan 137 under 26 U.S.C. s. 409 that has a board of trustees at least 138 two-thirds of which are Florida-licensed health care 139 practitioners and provides only physical therapy services under 140 physician orders, any community college or university clinic, 141 and any entity owned or operated by the federal or state 142 government, including agencies, subdivisions, or municipalities 143 thereof. 144 (f) A sole proprietorship, group practice, partnership, or 145 corporation that provides health care services by physicians 146 covered by s. 627.419, that is directly supervised by one or 147 more of such physicians, and that is wholly owned by one or more 148 of those physicians or by a physician and the spouse, parent, 149 child, or sibling of that physician. 150 (g) A sole proprietorship, group practice, partnership, or 151 corporation that provides health care services by licensed 152 health care practitioners under chapter 457, chapter 458, 153 chapter 459, chapter 460, chapter 461, chapter 462, chapter 463, 154 chapter 466, chapter 467, chapter 480, chapter 484, chapter 486, 155 chapter 490, chapter 491, or part I, part III, part X, part 156 XIII, or part XIV of chapter 468, or s. 464.012, and that is 157 wholly owned by one or more licensed health care practitioners, 158 or the licensed health care practitioners set forth in this 159 paragraph and the spouse, parent, child, or sibling of a 160 licensed health care practitioner if one of the owners who is a 161 licensed health care practitioner is supervising the business 162 activities and is legally responsible for the entity’s 163 compliance with all federal and state laws. However, a health 164 care practitioner may not supervise services beyond the scope of 165 the practitioner’s license, except that, for the purposes of 166 this part, a clinic owned by a licensee in s. 456.053(3)(b) 167 which provides only services authorized pursuant to s. 168 456.053(3)(b) may be supervised by a licensee specified in s. 169 456.053(3)(b). 170 (h) Clinical facilities affiliated with an accredited 171 medical school at which training is provided for medical 172 students, residents, or fellows. 173 (i) Entities that provide only oncology or radiation 174 therapy services by physicians licensed under chapter 458 or 175 chapter 459 or entities that provide oncology or radiation 176 therapy services by physicians licensed under chapter 458 or 177 chapter 459 which are owned by a corporation whose shares are 178 publicly traded on a recognized stock exchange. 179 (j) Clinical facilities affiliated with a college of 180 chiropractic accredited by the Council on Chiropractic Education 181 at which training is provided for chiropractic students. 182 (k) Entities that provide licensed practitioners to staff 183 emergency departments or to deliver anesthesia services in 184 facilities licensed under chapter 395 and that derive at least 185 90 percent of their gross annual revenues from the provision of 186 such services. Entities claiming an exemption from licensure 187 under this paragraph must provide documentation demonstrating 188 compliance. 189 (l) Orthotic, prosthetic, pediatric cardiology, or 190 perinatology clinical facilities or anesthesia clinical 191 facilities that are not otherwise exempt under paragraph (a) or 192 paragraph (k) and that are a publicly traded corporation or are 193 wholly owned, directly or indirectly, by a publicly traded 194 corporation. As used in this paragraph, a publicly traded 195 corporation is a corporation that issues securities traded on an 196 exchange registered with the United States Securities and 197 Exchange Commission as a national securities exchange. 198 (m) Entities that are owned by a corporation that has $250 199 million or more in total annual sales of health care services 200 provided by licensed health care practitioners where one or more 201 of the persons responsible for the operations of the entity is a 202 health care practitioner who is licensed in this state and who 203 is responsible for supervising the business activities of the 204 entity and is responsible for the entity’s compliance with state 205 law for purposes of this part. 206 (n) Entities that employ 50 or more licensed health care 207 practitioners licensed under chapter 458 or chapter 459 where 208 the billing for medical services is under a single tax 209 identification number. The application for exemption under this 210 subsection shall contain information that includes: the name, 211 residence, and business address and phone number of the entity 212 that owns the practice; a complete list of the names and contact 213 information of all the officers and directors of the 214 corporation; the name, residence address, business address, and 215 medical license number of each licensed Florida health care 216 practitioner employed by the entity; the corporate tax 217 identification number of the entity seeking an exemption; a 218 listing of health care services to be provided by the entity at 219 the health care clinics owned or operated by the entity and a 220 certified statement prepared by an independent certified public 221 accountant which states that the entity and the health care 222 clinics owned or operated by the entity have not received 223 payment for health care services under personal injury 224 protection insurance coverage for the preceding year. If the 225 agency determines that an entity which is exempt under this 226 subsection has received payments for medical services under 227 personal injury protection insurance coverage, the agency may 228 deny or revoke the exemption from licensure under this 229 subsection. 230 231 Notwithstanding this subsection, an entity shall be deemed a 232 clinic and must be licensed under this part in order to receive 233 reimbursement under the Florida Motor Vehicle No-Fault Law, ss. 234 627.730-627.7405, unless exempted under s. 627.736(5)(h). 235 Section 2. Subsection (4) of section 400.991, Florida 236 Statutes, is amended to read: 237 400.991 License requirements; background screenings; 238 prohibitions.— 239 (4) In addition to the requirements of part II of chapter 240 408, the applicant must file with the application satisfactory 241 proof that the clinic is in compliance with this part and 242 applicable rules, including: 243 (a) A listing of services to be provided either directly by 244 the applicant or through contractual arrangements with existing 245 providers; 246 (b) The number and discipline of each professional staff 247 member to be employed;and248 (c) Proof of financial ability to operate as required under 249 s. 408.810(8). As an alternative to submitting proof of 250 financial ability to operate as required under s. 408.810(8), 251 the applicant may file a surety bond of at least $500,000 which 252 guarantees that the clinic will act in full conformity with all 253 legal requirements for operating a clinic, payable to the 254 agency. The agency may adopt rules to specify related 255 requirements for such surety bond; and 256 (d) Proof that the clinic maintains the financial 257 responsibility in the manner set forth in s. 458.320(2) or s. 258 459.0085(2), as applicable, to pay claims and costs ancillary 259 thereto arising out of the rendering of or the failure to render 260 medical care and services, for physicians and osteopathic 261 physicians who perform liposuction procedures in which more than 262 1,000 cubic centimeters of supernatant fat is removed, Level II 263 office surgery, or Level III office surgery as those terms are 264 defined in ss. 458.305(8) and 459.003(9), in an office setting. 265 Section 3. Paragraph (j) is added to subsection (1) of 266 section 400.9935, Florida Statutes, to read: 267 400.9935 Clinic responsibilities.— 268 (1) Each clinic shall appoint a medical director or clinic 269 director who shall agree in writing to accept legal 270 responsibility for the following activities on behalf of the 271 clinic. The medical director or the clinic director shall: 272 (j) If the clinic is registered with the department to 273 perform office surgery, ensure that the clinic complies with the 274 standards of practice for office surgery adopted by rule under 275 ss. 458.309(4) and 459.005(3). 276 Section 4. Subsection (4) of section 400.995, Florida 277 Statutes, is amended to read: 278 400.995 Agency administrative penalties.— 279 (4) Any licensed clinic whose owner, medical director, or 280 clinic director concurrently operates an unlicensed clinic or a 281 clinic that is not registered with the department where any 282 liposuction procedure in which more than 1,000 cubic centimeters 283 of supernatant fat is removed or where any Level II office 284 surgery or Level III office surgery, as those terms are defined 285 in ss. 458.305(8) and 459.003(9), is performed, isshall be286 subject to an administrative fine of $5,000 per day. 287 Section 5. Subsection (12) is added to section 456.004, 288 Florida Statutes, to read: 289 456.004 Department; powers and duties.—The department, for 290 the professions under its jurisdiction, shall: 291 (12) Deny or revoke the registration of, or impose any 292 penalty set forth in s. 456.072(2) against, any facility where 293 office surgery, as defined in ss. 458.305(8) and 459.003(9), is 294 performed for failure of any of its physicians, owners, or 295 operators to comply with rules adopted under ss. 458.309(3) and 296 459.005(2). Section 456.073 applies to enforcement actions 297 brought against such facilities. If a facility’s registration is 298 revoked, the department may deny any person named in the 299 registration documents of the facility, including the persons 300 who own or operate the facility, individually or as part of a 301 group, from registering a facility to perform surgical 302 procedures pursuant to s. 458.309(3) or s. 459.005(2) for 5 303 years after the revocation date. 304 Section 6. Subsection (6) is added to section 456.074, 305 Florida Statutes, to read: 306 456.074 Certain health care practitioners; immediate 307 suspension of license.— 308 (6) The department may issue an emergency order suspending 309 or restricting the registration of a facility in which 310 liposuction procedures in which more than 1,000 cubic 311 centimeters of supernatant fat is removed, Level II office 312 surgery, or Level III office surgery as those terms are defined 313 in ss. 458.305(8) and 459.003(9), are performed upon a finding 314 of probable cause that the facility or its surgeons are not in 315 compliance with the standards of practice for office surgery 316 adopted by the boards pursuant to s. 458.309(4) or s. 317 459.005(3), as applicable, or are in violation of s. 318 458.331(1)(v) or s. 459.015(1)(z) and that such noncompliance 319 constitutes an immediate danger to the public. 320 Section 7. Section 458.305, Florida Statutes, is amended to 321 read: 322 458.305 Definitions.—As used in this chapter, the term: 323 (1) “Board” means the Board of Medicine. 324 (2) “Deep sedation and analgesia” means a drug-induced 325 depression of consciousness during which all of the following 326 apply: 327 (a) The patient cannot be easily aroused but responds by 328 purposefully following repeated or painful stimulation. 329 (b) The patient’s ability to independently maintain 330 ventilatory function may be impaired. 331 (c) The patient may require assistance in maintaining a 332 patent airway, and spontaneous ventilation may be inadequate. 333 (d) The patient’s cardiovascular function is usually 334 maintained. 335 (e) The patient’s reflex withdrawal from painful stimulus 336 is not considered a purposeful response. 337 (3)(2)“Department” means the Department of Health. 338 (4) “Epidural anesthesia” means anesthesia produced by the 339 injection of an anesthetic agent into the space on or around the 340 dura mater of the spinal cord. 341 (5) “General anesthesia” means a drug-induced loss of 342 consciousness administered by a qualified general anesthesia 343 provider during which all of the following apply: 344 (a) The patient is not able to be aroused, even by painful 345 stimulation. 346 (b) The patient’s ability to independently maintain 347 ventilatory function is often impaired. 348 (c) The patient has a level of depressed neuromuscular 349 function. 350 (d) The patient may require assistance in maintaining a 351 patent airway, and positive pressure ventilation may be 352 required. 353 (e) The patient’s cardiovascular function may be impaired. 354 (6) “Minimal sedation” means a drug-induced state during 355 which patients respond normally to verbal commands. Although 356 cognitive function and physical coordination may be impaired, 357 airway reflexes and respiratory and cardiovascular functions are 358 unaffected. 359 (7) “Moderate sedation and analgesia” or “conscious 360 sedation” means drug-induced depression of consciousness and a 361 state of consciousness during which all of the following apply: 362 (a) The patient responds purposefully to verbal commands, 363 either alone or accompanied by light tactile stimulation. 364 (b) Interventions are not required to maintain a patent 365 airway, and spontaneous ventilation is adequate. 366 (c) Cardiovascular function is maintained. 367 (d) Reflex withdrawal from a painful stimulus is not 368 considered a purposeful response. 369 (8) “Office surgery” means a surgery that is performed in a 370 physician’s office or any facility that is not licensed under 371 chapter 390 or chapter 395. 372 (a) “Level I office surgery” includes any surgery that 373 consists of only minor procedures and in which anesthesia is 374 limited to minimal sedation. 375 (b) “Level II office surgery” includes any surgery in which 376 the patient’s level of sedation is that of moderate sedation and 377 analgesia or conscious sedation. 378 (c) ”Level III office surgery” includes any surgery in 379 which the patient’s level of sedation is that of deep sedation 380 and analgesia or general anesthesia. The term includes any 381 surgery that includes the use of spinal anesthesia or epidural 382 anesthesia. 383 (10)(3)“Practice of medicine” means the diagnosis, 384 treatment, operation, or prescription for any human disease, 385 pain, injury, deformity, or other physical or mental condition. 386 (11) “Spinal anesthesia” means anesthesia produced by the 387 injection of an anesthetic agent into the subarachnoid space of 388 the spinal cord. 389 (12) “Surgeon” means a physician who performs surgery. 390 (13) “Surgery” means any manual or operative procedure, 391 including the use of lasers, performed upon the body of a living 392 human being for the purposes of preserving health, diagnosing or 393 curing disease, repairing injury, correcting deformity or 394 defects, prolonging life, or relieving suffering or any elective 395 procedure for aesthetic, reconstructive, or cosmetic purposes, 396 including, but not limited to: incision or curettage of tissue 397 or an organ; suture or other repair of tissue or organ, 398 including a closed as well as an open reduction of a fracture; 399 extraction of tissue including premature extraction of the 400 products of conception from the uterus; insertion of natural or 401 artificial implants; or an endoscopic procedure with use of 402 local or general anesthetic. 403 (9)(4)“Physician” means a person who is licensed to 404 practice medicine in this state. 405 Section 8. Subsection (3) of section 458.309, Florida 406 Statutes, is amended and subsection (4) is added to that 407 section, to read: 408 458.309 Rulemaking authority.— 409 (3) A physician who performs any liposuction procedure 410proceduresin which more than 1,000 cubic centimeters of 411 supernatant fat is removed, any Level II office surgerylevel 2412procedureslasting more than 5 minutes, or any Level III office 413 surgeryandall level 3 surgical proceduresin an office setting 414 must register the office with the department unless that office 415 is licensed as a facility under chapter 395. The department 416 shall inspect the physician’s office annually unless the office 417 is accredited by a nationally recognized accrediting agency or 418 an accrediting organizationsubsequentlyapproved by the Board 419 of Medicine. The actual costs for registration and inspection or 420 accreditation shall be paid by the person seeking to register 421 and operate the office setting in which office surgery is 422 performed. As a condition of registration, a physician who 423 performs such surgical procedures in an office setting, and the 424 office itself if it is a separate legal entity from the 425 physician, must maintain the same levels of financial 426 responsibility required in s. 458.320. 427 (4) The department may adopt rules to administer the 428 registration, inspection, and safety of offices in which a 429 physician performs office surgery. The board shall adopt by rule 430 standards of practice for physicians who perform office surgery. 431 The board shall impose a fine of $5,000 per day on a physician 432 who performs a surgical procedure identified in subsection (3) 433 in an office that is not registered with the department. 434 Section 9. Paragraph (vv) is added to subsection (1) of 435 section 458.331, Florida Statutes, to read: 436 458.331 Grounds for disciplinary action; action by the 437 board and department.— 438 (1) The following acts constitute grounds for denial of a 439 license or disciplinary action, as specified in s. 456.072(2): 440 (vv) Performing a liposuction procedure in which more than 441 1,000 cubic centimeters of supernatant fat is removed, a Level 442 II office surgery, or a Level III office surgery in an office 443 that is not registered with the department pursuant to s. 444 458.309(3). 445 Section 10. Section 459.003, Florida Statutes, is amended 446 to read: 447 459.003 Definitions.—As used in this chapter, the term: 448 (1) “Board” means the Board of Osteopathic Medicine. 449 (2) “Deep sedation and analgesia” means a drug-induced 450 depression of consciousness during which all of the following 451 apply: 452 (a) The patient cannot be easily aroused but responds by 453 purposefully following repeated or painful stimulation. 454 (b) The patient’s ability to independently maintain 455 ventilatory function may be impaired. 456 (c) The patient may require assistance in maintaining a 457 patent airway, and spontaneous ventilation may be inadequate. 458 (d) The patient’s cardiovascular function is usually 459 maintained. 460 (e) The patient’s reflex withdrawal from painful stimulus 461 is not considered a purposeful response. 462 (3)(2)“Department” means the Department of Health. 463 (5) “Epidural anesthesia” means anesthesia produced by the 464 injection of an anesthetic agent into the space on or around the 465 dura mater of the spinal cord. 466 (6) “General anesthesia” means a drug-induced loss of 467 consciousness administered by a qualified general anesthesia 468 provider during which all of the following apply: 469 (a) The patient is not able to be aroused, even by painful 470 stimulation. 471 (b) The patient’s ability to independently maintain 472 ventilatory function is often impaired. 473 (c) The patient has a level of depressed neuromuscular 474 function. 475 (d) The patient may require assistance in maintaining a 476 patent airway, and positive pressure ventilation may be 477 required. 478 (e) The patient’s cardiovascular function may be impaired. 479 (7) “Minimal sedation” means a drug-induced state during 480 which patients respond normally to verbal commands. Although 481 cognitive function and physical coordination may be impaired, 482 airway reflexes, and respiratory and cardiovascular functions 483 are unaffected. 484 (8) “Moderate sedation and analgesia” or “conscious 485 sedation” means drug-induced depression of consciousness and a 486 state of consciousness during which all of the following apply: 487 (a) The patient responds purposefully to verbal commands, 488 either alone or accompanied by light tactile stimulation. 489 (b) Interventions are not required to maintain a patent 490 airway, and spontaneous ventilation is adequate. 491 (c) Cardiovascular function is maintained. 492 (d) Reflex withdrawal from a painful stimulus is not 493 considered a purposeful response. 494 (9) “Office surgery” means a surgery that is performed in a 495 physician’s office or any facility that is not licensed under 496 chapter 390 or chapter 395. 497 (a) “Level I office surgery” includes any surgery that 498 consists of only minor procedures and in which anesthesia is 499 limited to minimal sedation. 500 (b) “Level II office surgery” includes any surgery in which 501 the patient’s level of sedation is that of moderate sedation and 502 analgesia or conscious sedation. 503 (c) ”Level III office surgery” includes any surgery in 504 which the patient’s level of sedation is that of deep sedation 505 and analgesia or general anesthesia. The term includes any 506 surgery that includes the use of spinal anesthesia or epidural 507 anesthesia. 508 (11)(3)“Practice of osteopathic medicine” means the 509 diagnosis, treatment, operation, or prescription for any human 510 disease, pain, injury, deformity, or other physical or mental 511 condition, which practice is based in part upon educational 512 standards and requirements which emphasize the importance of the 513 musculoskeletal structure and manipulative therapy in the 514 maintenance and restoration of health. 515 (12) “Spinal anesthesia” means anesthesia produced by the 516 injection of an anesthetic agent into the subarachnoid space of 517 the spinal cord. 518 (13) “Surgeon” means a physician who performs surgery. 519 (14) “Surgery” means any manual or operative procedure, 520 including the use of lasers, performed upon the body of a living 521 human being for the purposes of preserving health, diagnosing or 522 curing disease, repairing injury, correcting deformity or 523 defects, prolonging life, or relieving suffering or any elective 524 procedure for aesthetic, reconstructive, or cosmetic purposes, 525 including, but not limited to: incision or curettage of tissue 526 or an organ; suture or other repair of tissue or organ, 527 including a closed as well as an open reduction of a fracture; 528 extraction of tissue including premature extraction of the 529 products of conception from the uterus; insertion of natural or 530 artificial implants; or an endoscopic procedure with use of 531 local or general anesthetic. 532 (10)(4)“Osteopathic physician” means a person who is 533 licensed to practice osteopathic medicine in this state. 534 (4)(5)“Doctor of Osteopathy” and “Doctor of Osteopathic 535 Medicine,” when referring to degrees, shall be construed to be 536 equivalent and equal degrees. 537 Section 11. Subsection (2) of section 459.005, Florida 538 Statutes, is amended and subsection (3) is added to that 539 section, to read: 540 459.005 Rulemaking authority.— 541 (2) A physician who performs any liposuction procedure 542proceduresin which more than 1,000 cubic centimeters of 543 supernatant fat is removed, any Level II office surgerylevel 2544procedureslasting more than 5 minutes, or any Level III office 545 surgeryandall level 3 surgical proceduresin an office setting 546 must register the office with the department unless that office 547 is licensed as a facility under chapter 395. The department 548 shall inspect the physician’s office annually unless the office 549 is accredited by a nationally recognized accrediting agency or 550 an accrediting organizationsubsequentlyapproved by the Board 551 of Osteopathic Medicine. The actual costs for registration and 552 inspection or accreditation shall be paid by the person seeking 553 to register and operate the office setting in which office 554 surgery is performed. As a condition of registration, a 555 physician who performs such surgical procedures in an office 556 setting, and the office itself if it is a separate legal entity 557 from the physician, must maintain the same levels of financial 558 responsibility required in s. 459.0085. 559 (3) The department may adopt rules to administer the 560 registration, inspection, and safety of offices in which a 561 physician performs office surgery. The board shall adopt by rule 562 standards of practice for physicians who perform office surgery. 563 The board shall impose a fine of $5,000 per day on a physician 564 who performs a surgical procedure identified in subsection (2) 565 in an office that is not registered with the department. 566 Section 12. Paragraph (xx) is added to subsection (1) of 567 section 459.015, Florida Statutes, to read: 568 459.015 Grounds for disciplinary action; action by the 569 board and department.— 570 (1) The following acts constitute grounds for denial of a 571 license or disciplinary action, as specified in s. 456.072(2): 572 (xx) Performing a liposuction procedure in which more than 573 1,000 cubic centimeters of supernatant fat is removed, a Level 574 II office surgery, or a Level III office surgery in an office 575 that is not registered with the department pursuant to s. 576 459.005(2). 577 Section 13. Paragraph (b) of subsection (4) of section 578 464.012, Florida Statutes, is amended to read: 579 464.012 Licensure of advanced practice registered nurses; 580 fees; controlled substance prescribing.— 581 (4) In addition to the general functions specified in 582 subsection (3), an advanced practice registered nurse may 583 perform the following acts within his or her specialty: 584 (b) The certified registered nurse anesthetist may, to the 585 extent authorized by established protocol approved by the 586 medical staff of the facility in which the anesthetic service is 587 performed, perform any or all of the following: 588 1. Determine the health status of the patient as it relates 589 to the risk factors and to the anesthetic management of the 590 patient through the performance of the general functions. 591 2. Based on history, physical assessment, and supplemental 592 laboratory results, determine, with the consent of the 593 responsible physician, the appropriate type of anesthesia within 594 the framework of the protocol. 595 3. Order under the protocol preanesthetic medication. 596 4. Perform under the protocol procedures commonly used to 597 render the patient insensible to pain during the performance of 598 surgical, obstetrical, therapeutic, or diagnostic clinical 599 procedures. These procedures include ordering and administering 600 regional, spinal, and general anesthesia; inhalation agents and 601 techniques; intravenous agents and techniques; and techniques of 602 hypnosis. 603 5. Order or perform monitoring procedures indicated as 604 pertinent to the anesthetic health care management of the 605 patient. 606 6. Support life functions during anesthesia health care, 607 including induction and intubation procedures, the use of 608 appropriate mechanical supportive devices, and the management of 609 fluid, electrolyte, and blood component balances. 610 7. Recognize and take appropriate corrective action for 611 abnormal patient responses to anesthesia, adjunctive medication, 612 or other forms of therapy. 613 8. Recognize and treat a cardiac arrhythmia while the 614 patient is under anesthetic care. 615 9. Participate in management of the patient while in the 616 postanesthesia recovery area, including ordering the 617 administration of fluids and drugs. 618 10. Place special peripheral and central venous and 619 arterial lines for blood sampling and monitoring as appropriate. 620 11. Provide the services identified in subsections 1.-10. 621 in an office registered to perform office surgery pursuant to s. 622 458.309(3) or s. 459.005(2) within the framework of an 623 established protocol with an anesthesiologist licensed under 624 chapter 458 or chapter 459. 625 Section 14. Paragraph (a) of subsection (1) of section 626 766.101, Florida Statutes, is amended to read: 627 766.101 Medical review committee, immunity from liability.— 628 (1) As used in this section: 629 (a) The term “medical review committee” or “committee” 630 means: 631 1.a. A committee of a hospital or ambulatory surgical 632 center licensed under chapter 395 or a health maintenance 633 organization certificated under part I of chapter 641; 634 b. A committee of a physician-hospital organization, a 635 provider-sponsored organization, or an integrated delivery 636 system; 637 c. A committee of a state or local professional society of 638 health care providers; 639 d. A committee of a medical staff of a licensed hospital or 640 nursing home, provided the medical staff operates pursuant to 641 written bylaws that have been approved by the governing board of 642 the hospital or nursing home; 643 e. A committee of the Department of Corrections or the 644 Correctional Medical Authority as created under s. 945.602, or 645 employees, agents, or consultants of either the department or 646 the authority or both; 647 f. A committee of a professional service corporation formed 648 under chapter 621 or a corporation organized under part I of 649 chapter 607 or chapter 617, which is formed and operated for the 650 practice of medicine as defined in s. 458.305s. 458.305(3), and 651 which has at least 25 health care providers who routinely 652 provide health care services directly to patients; 653 g. A committee of the Department of Children and Families 654 which includes employees, agents, or consultants to the 655 department as deemed necessary to provide peer review, 656 utilization review, and mortality review of treatment services 657 provided pursuant to chapters 394, 397, and 916; 658 h. A committee of a mental health treatment facility 659 licensed under chapter 394 or a community mental health center 660 as defined in s. 394.907, provided the quality assurance program 661 operates pursuant to the guidelines that have been approved by 662 the governing board of the agency; 663 i. A committee of a substance abuse treatment and education 664 prevention program licensed under chapter 397 provided the 665 quality assurance program operates pursuant to the guidelines 666 that have been approved by the governing board of the agency; 667 j. A peer review or utilization review committee organized 668 under chapter 440; 669 k. A committee of the Department of Health, a county health 670 department, healthy start coalition, or certified rural health 671 network, when reviewing quality of care, or employees of these 672 entities when reviewing mortality records; or 673 l. A continuous quality improvement committee of a pharmacy 674 licensed pursuant to chapter 465, 675 676 which committee is formed to evaluate and improve the quality of 677 health care rendered by providers of health service, to 678 determine that health services rendered were professionally 679 indicated or were performed in compliance with the applicable 680 standard of care, or that the cost of health care rendered was 681 considered reasonable by the providers of professional health 682 services in the area; or 683 2. A committee of an insurer, self-insurer, or joint 684 underwriting association of medical malpractice insurance, or 685 other persons conducting review under s. 766.106. 686 Section 15. This act shall take effect upon becoming a law.