Agency for Health Care Administration

Transcription

1 Page 1 of 80 ST - G INITIAL COMMENTS Title INITIAL COMMENTS Statute or Rule Type Memo Tag These guidelines are meant solely to provide guidance to surveyors in the survey process. ST - G Licensure of Sites Title Licensure of Sites Statute or Rule (1), F.S. (1) A nurse registry is exempt from the licensing requirements of a home health agency but must be licensed as a nurse registry. Each operational site of the nurse registry must be licensed, unless there is more than one site within a county. If there is more than one site within a county, only one license per county is required. Each operational site must be listed on the license. The surveyor should determine if the nurse registry has additional office locations. Each office outside the county of the licensed nurse registry must be licensed. Only one license per county is required. For example, a nurse registry located in West Palm Beach and licensed for this county and all the other counties in Area 9 may have an another office in Delray Beach on the same license. The nurse registry could not have an office in Port St. Lucie unless it was separately licensed since it is in a different county. Review the license in comparison with the Nurse Registry (NR) current brochures (or other materials or information provided by the NR) to determine if there is a separate license for each county where there is a nurse registry office. Note: Nurse registries cannot have drop off sites for independent contractors since there is no legal authority for nurse registries to have drop off sites in state law or rules.

2 Page 2 of 80 ST - G License Number in Ads Title License Number in Ads Statute or Rule (7), F.S. A person that provides offers or advertises to the public any service for which licensure is required under this section must include in such advertisement the license number issued to it by the Agency for Health Care Administration. The agency shall assess a fine of not less than $100 against any licensee who fails to include the license number when submitting the advertisement for publication, broadcast, or printing. The fine for a second or subsequent offense is $500. The surveyor should review advertisements to determine if the license number is included. Check area newspaper ads or phone book to determine if criterion is met. The license # is only required when services are offered. It is not required on business cards or stationery where no services are listed. If violations are found, cite and provide examples along with survey report. The Home Care Unit will assess this fine. ST - G Nurse Registry Operational Title Nurse Registry Operational Statute or Rule (21) & (29), F.S. Nurse Registry Operational s (21), F.S. "Nurse registry" means any person that procures, offers, promises, or attempts to secure health-care-related contracts for registered nurses, licensed practical nurses, certified nursing assistants, home health aides, companions, or homemakers, who are compensated by fees as independent contractors, including, but not limited to, contracts for the provision of services to patients and contracts to provide private duty or staffing services to health care facilities The nurse registry must meet this definition in s (21). It must have set up contracts for RNs, LPNs, CNAs, HH aides, companions and or homemakers during the licensure period. If not, cite as not met and request correction. Failure to be in compliance on the follow-up visit is legal basis for denying or revoking the license per (1) (c.), F.S.

3 Page 3 of 80 licensed under chapter 395 or this chapter or other business entities. s (29), F.S. "Staffing services" means services provided to a health care facility, school, or other business entity on a temporary or school-year basis pursuant to a written contract by licensed health care personnel and by certified nursing assistants and home health aides who are employed by, or work under the auspices of, a licensed home health agency or who are registered with a licensed nurse registry. ST - G Geographic Area Title Geographic Area Statute or Rule 59A (7) FAC; (29) FS Geographic Area 59A (7) All nurse registries must apply for a geographic service area on their initial license application. Nurse registries may apply for a geographic service area which encompasses one or more of the counties within the specific AHCA area boundaries, pursuant to Section (5), F.S., and Section (9), F.S., in which the main office is located. However, any agency holding a current nurse registry license from AHCA, as of the effective date of this rule December 24, 2000, may continue to serve patients or clients in those counties listed on its current license. The rule shown in this standard has been in effect since 12/24/2000. The approved geographic service area is listed on the official license. In the Entrance Interview, ask the administrator what is the geographic service area of the nurse registry. When reviewing the sample of patient records, check the patient's home address to determine if the address is located within the geographic area shown on the NR license. Staffing services may be provided anywhere within the state (29) "Staffing services" means services provided to a health care facility or other business entity on a temporary basis...staffing services may be provided anywhere within the state.

4 Page 4 of 80 ST - G Information to Contractors Title Information to Contractors Statute or Rule 59A (1), F.A.C. (1) Each nurse registry shall disseminate the following rules and statutes to each applicable independent contractor at the time of registration. The rules and statutes may be provided by paper copy, by or other means of electronic communication. (a) Registered nurses and licensed practical nurses shall receive for their use and reference: 1. Rule 59A , F.A.C., Registration Policies 2. Rule 59A , F.A.C., Registered Nurses and Licensed Practical Nurses. 3. Rule 59A , F.A.C., Medical Plan of Treatment. 4. Rule 59A , F.A.C., Clinical Records. 5. Rule 59A , F.A.C., Administration of Biologicals. 6. Sections , , , , and (5), F.S. with the telephone numbers referred to in the law. 7. Rule 59A Emergency Management Plans. (b) Certified nursing assistants and home health aides shall receive for their use and reference: 1. Rule 59A , F.A.C., Registration Policies 2. Rule 59A , F.A.C., Certified Nursing Assistant and Home Health Aide. 3. Sections , , , , and (5), F.S. with the telephone numbers referred to in the law. 4. Rule 59A , F.A.C., Emergency Management Plans. (c) Homemakers and Companions shall receive for their use and reference: The surveyor finds evidence that the nurse registry has given the rules and statutes listed in the standards to each independent contractor. The surveyor may ask a contractor if he or she has received the above information from the nurse registry.

5 Page 5 of Rule 59A , F.A.C., Homemakers or Companions. 2. Sections , , , , and (5), F.S. with the telephone numbers referred to in the law. ST - G Communicable Disease Title Communicable Disease Statute or Rule 59A (6) FAC; (6)(a) FS Communicable Disease 59A (6), F.A.C. Prior to contact with patients or clients, each independent contractor referred for client care must furnish to the registry a statement from a health care professional licensed under Chapter 458, F.S., or Chapter 459, F.S., a physician ' s assistant, or an advanced registered nurse practitioner (ARNP) or a registered nurse licensed under Chapter 464, F.S., under the supervision of a licensed physician, or acting pursuant to an established protocol signed by a licensed physician, dated within the last six months, that the contractor is free from communicable diseases. The independent contractor will provide this statement to the nurse registry when first referred. The surveyor samples independent contractor file to verify a statement from health care professional stating the independent contractor is free from communicable disease is present as stated in the standard. The health care professional could be a medical doctor (chapter 458), osteopathic physician (chapter 459), a physician's assistant or an ARNP or RN (chapter 464). Health statements are required for all types of independent contractors referred by Nurse Registries including homemakers and companions. s (6)(a), F.S. (a)...each person referred by a nurse registry must provide current documentation that he or she is free from communicable diseases.

6 Page 6 of 80 ST - G Contractor Registration Folders Title Contractor Registration Folders Statute or Rule 59A (7-8) FAC; (8-10) FS Contractor Registration Folders 59A , F.A.C. (7) Registration folders on each independent contractor must contain the information required in Section (8), F.S., and the following: (a) For home health aides, evidence of completion of a home health aide training course or certification from the Florida Board of Nursing, Department of Health as a certified nursing assistant; (b) Evidence of a contract with the nurse registry; (c) Evidence of background screening that meets the requirements in Section (4), F.S.; and (8) Each nurse registry shall establish a system for the recording of complaints involving individuals they refer. If the complaints are violations of state law, the nurse registry shall take the actions specified in Section (19), F.S. Records of complaints and actions taken by the nurse registry shall be kept in the individual ' s registration file or retained in the central files of the nurse registry. The surveyor reviews a sample of registration folders of independent contractors to verify all required information. Verify from a sample of closed registration folders that a file was kept three years following the last patient or client related entry as time permits. Ask if the nurse registry has provided the complainant with with information on how to report the complaint to the appropriate entity: (a) Report theft to local law enforcement; (b) Report abuse, neglect or exploitation to the central abuse hotline 1(800) ; (c) Report nurses and certified nursing assistants to the Department of Health by completing and submitting the complaint form at < if there are alleged professional practice violations. (d) Report other complaints to the Agency for Health Care Administration by calling (888) or submitting the on-line complaint form at < s , F.S. (8) Each nurse registry must require every applicant for contract to complete an application form providing the following information: (a) The name, address, date of birth, and social security number of the applicant. (b) The educational background and employment history of

7 Page 7 of 80 the applicant. (c) The number and date of the applicable license or certification. (d) When appropriate, information concerning the renewal of the applicable license, registration, or certification. (9) Each nurse registry must comply with the procedures set forth in s for maintaining records of the work history of all persons referred for contract and is subject to the standards and conditions set forth in that section. (10) The nurse registry must maintain the application on file, and that file must be open to the inspection of the Agency for Health Care Administration. The nurse registry must maintain on file the name and address of the patient or client to whom nurse registry personnel are referred for contract and the amount of the fee received by the nurse registry. A nurse registry must maintain the file that includes the application and other applicable documentation for 3 years after the date of the last file entry of patient-related or client-related information. ST - G Advise Patient of Independent Contractor Title Advise Patient of Independent Contractor Statute or Rule (6)(e), F.S. Upon referral of a registered nurse, licensed practical nurse, certified nursing assistant, companion or homemaker, or home health aide for contract in a private residence or facility, the nurse registry shall advise the patient, the patient ' s family, or any other person acting on behalf of the patient, at the time of the contract for services, that the caregiver referred by the nurse registry is an independent contractor and that it is not Ask the nurse registry what evidence it can provide that shows it is advising the patient, the patient ' s family or any other person acting on behalf of the patient at the time of contract for services that: 1. The caregiver referred is an independent contractor 2. The nurse registry is not obligated to monitor, supervisor, manage, or train the caregiver. In the telephone interview with the patient or the patient ' s family or responsible party, ask if they were advised by the nurse registry that the caregiver is an independent contractor and that the nurse registry is not obligated to

8 Page 8 of 80 the obligation of a nurse registry to monitor, supervise, manage, or train a caregiver referred for contract under this chapter. monitor, supervise, manage or train the caregiver. ST - G Notify Patient and Report Caregiver Title Notify Patient and Report Caregiver Statute or Rule (19), F.S. It is not the obligation of a nurse registry to monitor, supervise, manage, or train a registered nurse, licensed practical nurse, certified nursing assistant, companion or homemaker, or home health aide referred for contract under this chapter. In the event of a violation of this chapter or a violation of any other law of this state by a referred registered nurse, licensed practical nurse, certified nursing assistant, companion or homemaker, or home health aide, or a deficiency in credentials which comes to the attention of the nurse registry, the nurse registry shall advise the patient to terminate the referred person ' s contract, providing the reason for the suggested termination; cease referring the person to other patients or facilities; and, if practice violations are involved, notify the licensing board. This section does not affect or negate any other obligations imposed on a nurse registry under chapter 408. Has there been any evidence of a violation of state laws or a deficiency in the caregiver ' s credentials? If the nurse registry becomes aware of the violation or problem with credentials, such as licensing or background screening, or other violations of state laws, did the nurse registry do the following? 1. advise the patient to terminate the referred individual, 2. provide the reason for termination, 3. cease to refer the person to other patients or facilities, and, 4. if there are practice violations, notify the appropriate licensing board (Board of Nursing, Department of Health for RN, LPN, and CNAs). Notify the Department of Health by completing the " Healthcare Practitioner Complaint Form " at and mailing it to: Florida Department of Health Consumer Services Unit 4052 Bald Cypress Way, Bin C-75 Tallahassee, FL If an RN or LPN continues to work as a nurse and is no longer licensed, call HALT-ULA( ) or mail the complaint form referred to above. If the nurse registry did not know about the violations or problem with credentials, then inform the nurse registry in writing and provide the opportunity to do the items listed in law before citing a deficiency in the survey report.

9 Page 9 of 80 ST - G Administrator Title Administrator Statute or Rule (18); (7); 59A (18) An administrator may manage only one nurse registry, except that an administrator may manage up to five registries if all five registries have identical controlling interests as defined in s and are located within one agency geographic service area or within an immediately contiguous county. An administrator shall designate, in writing, for each licensed entity, a qualified alternate administrator to serve during the administrator ' s absence (7) " Controlling interest " means: (a) The applicant or licensee: (b) A person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the applicant or licensee; or (c) A person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the management company or other entity, related or unrelated, with which the applicant or licensee contracts to manage the provider. The term does not include a voluntary board member. 59A , FAC The administrator of the nurse registry shall: (1) Be a licensed physician, an advanced registered nurse practitioner, a registered nurse, or an individual with training and experience in health service administration and at least one year of supervisory or administrative experience in the health care field; The surveyor reviews file and credentials of any administrator hired since the last survey. Does the administrator manage other nurse registries? How many? Cannot exceed 5 nurse registries if the requirements in law are met: A. Do all of the nurse registries have " identical controlling interests "? This means that all of the nurse registries administered by the one administrator must have (1) the same legal entity/licensee; (2) the exact same owners (people and/or entities) with the exact same percentage of ownership; (3) the exact same board of directors (when there is a board of directors); and (4) if there is management company, have the exact same people or entities with the exact same percentage of ownership in the management company which manages all of the nurse registries. If all of the nurse registries do not have identical controlling interests, cite this standard as not met. B. Where are the nurse registries located? Same AHCA geographic area? If not, the administrator can only manage a nurse registry that has its licensed office located in a county that is immediately contiguous to the county in another AHCA geographic service area where the other nurse registry ' s licensed office is located (county boundaries must touch). For example, a nurse registry administrator of a nurse registry located in Orange County can be the nurse registry administrator of a nurse registry located in Lake County (immediately contiguous) but not in Marion County; a nurse registry administrator in Miami-Dade County can be the administrator of a nurse registry in Broward County but not in Palm Beach County. The surveyor interviews the administrator to determine familiarity with the law and rules of the agency and determines whether the laws and rules are available. The surveyor reviews the document designating a qualified representative to serve during the absence of the administrator.

10 Page 10 of 80 (2) Have knowledge, through training, experience or education, with the work requirements and the prerequisites for licensure or certification in each of the health care disciplines and specialties for which the registry is providing referrals; (3) Have knowledge with the rules of AHCA and maintain them in the nurse registry; (4) Be available, or have the alternate administrator available, at all times during operating hours as stated in paragraph 59A (8)(a), F.A.C., and be responsible for the total operation of the nurse registry. Available during operating hours means being readily available on the premises or by telecommunications during the above operating hours; (5) Designate in writing a qualified individual to serve as the alternate administrator during absences of the administrator. During such absences, the on-site alternate administrator will have the responsibility and authority for the daily operation of the registry. The alternate administrator must meet qualifications as stated in subsection 59A (1), F.A.C.; (6) Be responsible for the completion, maintenance and submission of such reports and records as required by AHCA; (7) Be responsible for making sure that the nurse registry advises the patient, the patient ' s family, or any other person acting on behalf of the patient at the time the referral is made that: (a) The caregiver is an independent contractor and that it is not the obligation of a nurse registry to monitor, supervise, manage or train the caregiver as required in Section (6)(e), F.S.; and (b) Registered nurses are available to make visits to the patient ' s home for an additional cost when a certified nursing assistant or home health aide is referred as required in Section (6)(c), F.S.

11 Page 11 of 80 ST - G Home Infusion Title Home Infusion Statute or Rule (3) FS; (17-18) FS Home Infusion Therapy , F.S. (3) A home infusion therapy provider must be licensed as a home health agency or nurse registry , F.S. (17) "Home infusion therapy provider" means an organization that employs, contracts with, or refers a licensed professional who has received advanced training and experience in intravenous infusion therapy and who administers infusion therapy to a patient in the patient's home or place of residence. (18) "Home infusion therapy" means the administration of intravenous pharmacological or nutritional products to a patient in his or her home. Nurse registries can refer nurses to patients to provide home infusion therapy. A registered nurse can provide home infusion therapy. Only license practical nurses that have met the education and competency requirement in state nursing rules at 64B9-12, FAC, can provide infusion therapy within the scope permitted in this regulation. ST - G RN and LPN Title RN and LPN Statute or Rule 59A (1-3), F.A.C. RN and LPN 59A , F.A.C. The registered nurse and the licensed practical nurse shall: (1) Be responsible for the clinical records for their patients. The surveyor reviews a sample of clinical records to determine if the nurse is maintaining the record and the plan of treatment with progress notes, and changes in the plan or orders. Performance of services in the medical plan of treatment signed by a physician, physician's assistant or ARNP shall

12 Page 12 of 80 The clinical records shall be filed with the nurse registry, for each patient or client to whom they are giving care in the home or place of residence. Clinical notes and clinical records related to care given under a staffing arrangement are maintained by the facility where the staffing contract is arranged; (2) Be responsible for maintaining the medical plan of treatment with clinical notes and filing the initial medical plan of treatment, any amendments to the plan, any additional order or change in orders, and a copy of the clinical notes at the office of the nurse registry; suffice as meeting the requirement for working under the direction of a physician. ST - G Homemaker Title Homemaker Statute or Rule 59A (1&3) FAC; (16&24) FS Homemaker 59A , F.A.C. (1) The homemaker shall have the following responsibilities: (a) To maintain the home in the optimum state of cleanliness and safety depending upon the client ' s and the caregiver ' s resources; (b) To perform the functions generally undertaken by the natural homemaker, including such duties as preparation of meals, laundry, and shopping; (c) To perform casual, cosmetic assistance, such as brushing the client ' s hair, assisting with make-up, filing and polishing nails, with the exception of clipping nails for diabetic patients; (d) To stabilize the client when walking, as needed, by holding the client ' s arm or hand; and (e) To report any unusual incidents or changes in the patient ' s or client ' s behavior to the person(s) designated by the client. (3) Homemakers and companions shall be responsible for The surveyor samples and reviews files of patients receiving homemaker services to see if (1) they performs appropriate tasks as stated in the standard and (2) there is documentation in the file of services provided.

13 Page 13 of 80 providing to patient and nurse registry copies of any documentation which reflects the services provided. This will be stored by the nurse registry in the client ' s file. The nurse registry is not obligated to review patient or client records per subsection (20), F.S., but the nurse registry is not prohibited from reviewing the records and may do so. s , F.S. (16) "Homemaker" means a person who performs household chores that include housekeeping, meal planning and preparation, shopping assistance, and routine household activities for an elderly, handicapped, or convalescent individual. A homemaker may not provide hands-on personal care to a client. (24) "Personal care" means assistance to a patient in the activities of daily living, such as dressing, bathing, eating, or personal hygiene, and assistance in physical transfer, ambulation, and in administering medications as permitted by rule. ST - G Companions Title Companions Statute or Rule 59A (2-3) FAC; (7 &24) FS (2) The companion shall have the following responsibilities: (a) To provide companionship for the patient or client; (b) To provide escort services such as taking the patient or client to the health care provider (c) To provide light housekeeping tasks such as preparation of a meal or laundering the client ' s personal garments; (d) To perform casual, cosmetic assistance, such as brushing the client ' s hair, assisting with make-up, filing and polishing nails, with the exception of clipping nails for diabetic patients; The surveyor samples and reviews files of patients receiving companion services to see if the companion performs appropriate tasks as stated in the standard. The surveyor reviews review client records to verify documentation of services.

14 Page 14 of 80 and (e) To stabilize the client when walking, as needed, by holding the client ' s arm or hand; and (f) To report any unusual incidents or changes in the patient ' s or client ' s behavior to the person(s) designated by the client nurse registry to the caregiver. (3)...companions shall be responsible for providing to patient and nurse registry copies of any documentation which reflects the services provided. This will be stored by the nurse registry in the client ' s file. The nurse registry is not obligated to review patient or client records per subsection (20), F.S., but the nurse registry is not prohibited from reviewing the records and may do so. s , F.S. (7) "Companion" or "sitter" means a person who cares for an elderly, handicapped, or convalescent individual and accompanies such individual on trips and outings and may prepare and serve meals to such individual. A companion may not provide hands-on personal care to a client. (24) "Personal care" means assistance to a patient in the activities of daily living, such as dressing, bathing, eating, or personal hygiene, and assistance in physical transfer, ambulation, and in administering medications as permitted by rule. ST - G Access to Files Title Access to Files Statute or Rule 59A (8)(c); 59A (7) FAC

15 Page 15 of 80 59A (8) (c), F.A.C. If an AHCA surveyor arrives on the premises to conduct a survey and the administrator, or a person authorized to give access to patient records, is not available on the premises he, or his alternate, must be available on the premises within two hours. 59A (7), FAC Each nurse registry shall keep clinical records received from the independent contractor licensed nurse for 5 years following the termination of service. Retained records can be stored as hard paper copy, microfilm, computer disks or tapes and must be retrievable for use during unannounced surveys. If 59A (9) (c) is not met, (2), F.S., provides legal authority for a classed deficiency with a fine; and the license may be denied or revoked per (1)(c), F.S. The surveyor must have access to patient records within 2 hours of his/her arrival at the nurse registry. Any other files requested by the surveyor need to be provided to surveyor during the survey. ST - G Hours of Operation Title Hours of Operation Statute or Rule 59A (9), F.A.C. Hours of Operation 59A (8), F.A.C. (a) The nurse registry administrator, or his alternate, must be available to the public for any eight consecutive hours between 7 a.m. and 6 p.m., Monday through Friday of each week, excluding legal and religious holidays. Available to the public means being readily available on the premises or by telecommunications. (b) When the administrator, or the designated alternate, are not on the premises during designated business hours, pursuant to Rule 59A (8)(a), F.A.C., a staff person must be available to answer the phone and the door and must be able to contact the administrator, or the alternate, by If 59A (9) (a) or (b) are not met, the surveyor should cite the standard as not met and require correction. The standard is classed and fined as specified in (2), F.S. This would typically be a class III deficiency.

16 Page 16 of 80 telecommunications during the designated business hours. This individual can be a clerical staff person. ST - G Acceptance of Patients Title Acceptance of Patients Statute or Rule 59A , F.A.C. Policies for acceptance of patients or clients and termination of services to patients or clients shall include, for example, the following conditions: (1) No patient or client shall be refused service because of age, race, color, sex or national origin, pursuant to Chapter 760, F.S.; (2) When a patient or client is accepted for referrals of independent contractors, there shall be a reasonable expectation that the requested services can be provided adequately and safely in their residence. The responsibility of the registry is to refer independent contractors capable of delivering services as defined in a specific medical plan of treatment for a patient or services requested by a client, including all visits; (3) When medical treatments or medications are administered, physician ' s, advanced registered nurse practitioner ' s, or physician assistant ' s orders in writing that are signed and dated shall be included in the clinical record; and (4) When services are to be terminated, the patient or client, or the person designated by the patient or client shall be notified of the date of termination and the reason for termination, and these shall be documented in the patient or client ' s record. The surveyor reviews the policies regarding acceptance of patients, civil rights compliance, and termination of services. The surveyor reviews patient records to verify that the policies required in the standard are being complied with.

17 Page 17 of 80 ST - G Plan of Treatment Title Plan of Treatment Statute or Rule (13) FS; 59A (1-6) FAC (13) FS All persons referred for contract in private residences by a nurse registry must comply with the following requirements for plan of treatment: (a) When, in accordance with the privileges and restrictions imposed upon a nurse under part I of chapter 464, the delivery of care to a patient is under the direction or supervision of a physician or when a physician is responsible for the medical care of the patient, a medical plan of treatment must be established for each patient receiving care or treatment provided by a licensed nurse in the home. The original medical plan of treatment must be timely signed by the physician, physician assistant, or advanced registered nurse practitioner, acting within his or her respective scope of practice, and reviewed in consultation with the licensed nurse at least every 2 months. Any additional order or change in orders must be obtained from the physician, physician assistant, or advanced registered nurse practitioner. The delivery of care under a medical plan of treatment must be substantiated by the appropriate nursing notes or documentation made by the nurse in compliance with nursing practices established under part I of chapter 464. (b) Whenever a medical plan of treatment is established for a patient, the initial medical plan of treatment, any amendment to the plan, additional order or change in orders, and copy of nursing notes must be filed in the office of the nurse registry. The surveyor should sample records of patients receiving a nursing service to see if the standard is being met. Is the information in (13)(b) maintained at the NR office within the time frame in 59A (5). The surveyor reviews the medical orders in the clinical records and verifies the plan of treatment. The surveyor reviews the clinical records to verify signed plans of treatment within 30 days of initiation of services and reviewed by the physician, physician assistant or advanced registered nurse practitioner in consultation with the licensed nurse at least every 2 months. The surveyor reviews the nurse's notes to determine whether the nurse documented the patient's progress. Do the patient records show that the patient is receiving care in accordance with the plan of treatment? 59A , F.A.C.

18 Page 18 of 80 (1) When the delivery of skilled care to a patient in the home is under the direction or supervision of a physician or when a physician, physician ' s assistant or advanced registered nurse practitioner is responsible for the medical care of the patient, a medical plan of treatment must be established for each patient receiving care or treatment provided by the licensed nurse in the home or residence. (2) The licensed nurse providing care to the patient is responsible for having the medical plan of treatment signed by the physician, physician assistant, or advanced registered nurse practitioner, acting within his or her respective scope of practice, within 30 days from the initiation of services and reviewed by the physician, physician assistant, or advanced registered nurse practitioner in consultation with the licensed nurse at least every 2 months. (3) The licensed nurse responsible for delivering care to the patient is responsible for the medical plan of treatment which shall include, at a minimum, the following: (a) Diagnoses; (b) Activities permitted when indicated; (c) Diet when indicated; (d) Medication, treatments, and equipment required; and (e) Dated signature of physician, physician assistant, or advanced registered nurse practitioner. (4) The delivery of care pursuant to a medical plan of treatment must be substantiated by the nursing notes or documentation made by the nurse in compliance with nursing practices established under Chapter 464, F.S. (5) The initial medical plan of treatment, any amendment to the plan, additional orders or change in orders, and copy of nursingclinical notes must be filed in the office of the nurse registry, pursuant to s.section (13)(b), F.S., within 30 days, pursuant to Section (8)F.S. (6) The nurse registry shall inform nurse registrants that the

19 Page 19 of 80 shift nurse that communicates with the physician ' s office, the physician assistant or the advanced registered practitioner about any changes in the orders should update the plan of treatment. ST - G Patient Rights Title Patient Rights Statute or Rule 59A (7), F.A.C. (7) The patient, caregiver or guardian must be informed by independent contractors of the nurse registry that: (a) They have the right to be informed of the medical plan of treatment; (b) They have the right to participate in the development of the medical plan of treatment; (c) They may have a copy of the medical plan of treatment if requested; and (d) The caregiver being referred is an independent contractor of the registry. Is the patient, caregiver or guardian being informed of his rights as stated in the standard? Interview at least one independent contractor to find out if they are informing these persons of their rights. As time permits, make a telephone interview of a patient or caregiver to determine if they are informed of their rights. ST - G Abuse and Neglect Title Abuse and Neglect Statute or Rule (1) FS; (7) FS Abuse and Neglect (1) In addition to the grounds provided in authorizing statutes, grounds that may be used by the agency for denying and revoking a license...include any of the following actions When an intentional or negligent act that materially affects the health or safety of a client is found, the surveyor would cite this standard. The Home Care Unit will submit a Recommendation for Sanction to the AHCA General Counsel's office to revoke the license of the nurse registry.

20 Page 20 of 80 by a controlling interest:... (b) An intentional or negligent act materially affecting the health or safety of a client of the provider (7) "Controlling interest" means: (a) The applicant or licensee; (b) A person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the applicant or licensee; or (c) A person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the management company or other entity, related or unrelated, with which the applicant or licensee contracts to manage the provider. ST - G Clinical Records Title Clinical Records Statute or Rule 59A (1-6 & 8), F.A.C. The licensed nurse responsible for the delivery of skilled patient care shall maintain a clinical record, pursuant to Section (8), F.S., for each patient receiving nursing services in the home that shall include, at a minimum, the following: (1) Identification sheet containing the patient ' s name, address, telephone number, date of birth, sex, and caregiver or guardian; (2) Before information can be released, an authorization for such release must be dated and signed by the patient, caregiver, or guardian; (3) Plan of treatment as required in Section (13), F.S.; (4) Clinical and service notes, signed and dated by the nurse providing the service which shall include: The surveyor reviews the documentation in a sampling of clinical records verifying that they are completed and current according to the requirements in the standard. The surveyor reviews the termination summary to see if all items in the standard are included. Are records kept for 5 years following the termination of Services.

21 Page 21 of 80 (a) Any assessments by a registered nurse; (b) Progress notes with changes in the person ' s condition; (c) Services provided; (d) Observations; and (e) Instructions to the patient and caregiver; (5) Reports to physicians; (6) Termination summary including: (a) The date of the first and last visit; (b) The reason for termination of services; (c) An evaluation of established goals at time of termination; (d) The condition of the patient at the time of termination of services; and (e) The referral for additional services when the patient requires continuing services. (8) The nurse registry is not obligated to review patient or client records per Section (20), F.S., but the nurse registry is not prohibited from reviewing records and may do so. In the event of violation of state law which comes to the attention of the nurse registry, the nurse registry shall take the actions specified in Section (19), F.S. ST - G Administration of Drugs and Biologicals Title Administration of Drugs and Biologicals Statute or Rule 59A , F.A.C. Administration of Drugs and Biologicals 59A , F.A.C. (1) Each nurse registry shall disseminate to its independent contractor nurses the procedures required by Chapter 464, F.S. and the rules of the Agency for Health Care Administration governing the administration of drugs and biologicals to patients. (2) The procedures shall include the following: The surveyor reviews the NR procedures governing the administration of drugs and biological to patients. The procedure must include the items in the standard. Review a sampling of records for nursing patients to determine if procedures are being followed.

22 Page 22 of 80 (a) An order for medications to be administered by the licensed nurse shall be dated and signed by the attending physician, physician assistant, or advanced registered nurse practitioner as required in Section (13), F.S.; (b) An order for medications shall contain the name of the patient, the name of the drug, dosage, frequency, method or site of injection, and order from the physician, physician assistant, or advanced registered nurse practitioner if the patient or caregiver are to be taught to give the medication; and (c) A verbal order for medication or change in the medication orders from the physician, physician assistant, or advanced registered nurse practitioner shall be taken by a licensed registered nurse, reduced to writing, to include the patient's name, the date, time, order received, signature and title. The physician, physician assistant, or advanced registered nurse practitioner shall acknowledge the telephone order within 30 days by signing and dating the orders. A verbal order or change in medication order shall be on file in the clinical record at the nurse registry within 30 days. ST - G Procedures for Contractors Title Procedures for Contractors Statute or Rule 59A (2), F.A.C. Each nurse registry shall establish written procedures for the selection, documentation, screening and verification of credentials for each independent contractor referred by the registry. The surveyor reviews written procedures on initial licensure survey and on subsequent surveys if procedures have changed, to determine if the items required in the standard are included.

23 Page 23 of 80 ST - G Confirming Licensure Title Confirming Licensure Statute or Rule 59A (3-5), F.A.C. (3) Each nurse registry shall confirm a new independent contractor ' s licensure or certification with the issuing board or department. A screen print from the Department of Health web site that shows a clear and active license or certification for each nurse and certified nursing assistant is sufficient for documentation. (4) Each nurse registry shall, at least annually, reconfirm the licensure or certification of all of its independent contractors who are licensed or certified. If the nurse registry cannot confirm the licensure of any registered nurse, licensed practical nurse or certification of any certified nursing assistant, the nurse registry shall take the actions specified in Section (19), F.S. This includes reporting the individual to the Florida Board of Nursing, Department of Health as specified at its web site: ment/report-unlicensed-activity/file-a-complaint.html. (5) Each nurse registry shall confirm the identity of the independent contractor prior to referral. Identification shall be verified by using the individual's current driver's license or other photo identification, including the professional license or certificate. Files of independent contractors shall be sampled by the surveyor to verify licensure or certification for nurses and CNAs.

24 Page 24 of 80 ST - G Supplemental Staffing Title Supplemental Staffing Statute or Rule 59A (3) & (5-8), FAC (3) Each nurse registry shall establish a system for the recording complaints involving individuals they referred to health care facilities or other business entity, and such records shall be kept in the individual ' s registration file. The nurse registry is not obligated to review records per Section (20), F.S., but the nurse registry is not prohibited from reviewing records and may do so. (5) Each nurse registry shall, upon receiving licensure and certification information, inform the health care facility or other business entity, if a licensed or certified individual being referred to the facility is on probation with their professional licensing board or certifying agency or has any other restrictions placed on their license or certification. The registry shall also advise the licensed or certified individual that this information has been given to the health care facility or other business entity and keep a copy of this information in the independent contractor ' s file. (6) Each nurse registry shall maintain on file the name and address of facilities to whom the independent contractor is referred for contract, the amount of the fee charged, the title of the position, and the amount of the fee received by the registry. (7) Each nurse registry shall, at least annually, reconfirm the licensure or certification of all of its independent contractors who are licensed or certified. The nurse registry is not obligated to review patient or client records per Section (20), F.S., but the nurse registry is not prohibited from reviewing records and may do so. The surveyor should request that the administrator show the system for recording complaints. Do the contractor records show complaints as required in the standard? Does the contractor file show any restrictions on the contractor's license or certification? If so, does the file indicate that the facility was notified? Does the contractor file include the information required in (7) of the standard? If a contractor is referred for staffing in nursing homes, does the contractor file of an independent contractor whom has not maintained continuous residency in Florida for 5 years preceding the staffing referral include evidence that the individual completed a level 2 background screening? Are the files available for inspection by the surveyor?

25 Page 25 of 80 (8) The nurse registry is not obligated to monitor, manage or supervise a referred independent contractor pursuant to Section (19), F.S. In the event of violation of state law which comes to the attention of the nurse registry, the nurse registry shall take the actions specified in Section (19), F.S. ST - G Certified Nursing Assistant Title Certified Nursing Assistant Statute or Rule 59A (7) & (9), F.A.C. Certified Nursing Assistant 59A , F.A.C. (7) For every CNA, a nurse registry shall have on file a copy of the person's State of Florida certification. (9) Individuals who earn their CNA certificate in another state must contact the Florida Certified Nursing Assistant office at the Department of Health to inquire about taking the written examination prior to working as a CNA in Florida, pursuant to Part II of Chapter 464, F.S. Moved C.N.A. certificate requirement from G 277. Review CNA personnel files to see if certification is included. ST - G HH Aide Qualifications Title HH Aide Qualifications Statute or Rule 59A (8 & 10 & 12-13), FAC (8) For every home health aide registered with the nurse registry since May 4, 2015, a nurse registry shall have on file a certificate or documentation of successful completion of at Review files of sample of new home health aides registered since May 4, 2015 to see if there is a certificate or evidence of at least 40 hours of home health aide training from a public vocational technical school or a licensed non-public career education school.

26 Page 26 of 80 least forty hours of home health aide training, pursuant to Section (6)(a), F.S., from a public vocational technical school or a non-public postsecondary career school licensed by the Commission on Independent Education, Florida Department of Education. (10) Home health aides registered with the nurse registry since May 4, 2015 who complete their training in another state must provide a certificate of completion of home health aide training from a public vocational technical school or a career education school that is licensed in that state. (12) Licensed practical nurses and registered nurses that are licensed in Florida or another state may work as home health aides. Also, persons who have completed the licensed practical nurse or registered nurse training from a public school, college, or university or a licensed nonpublic career education school or college in Florida who are not yet licensed may work as home health aides. (13) A certified nursing assistant may work as a home health aide. ST - G C.N.A. & Home Health Aide - CPR Title C.N.A. & Home Health Aide - CPR Statute or Rule 59A (11), F.A.C. CNAs and home health aides referred by nurse registries must maintain a current CPR certification from an instructor that is approved to provide training by the American Heart Association or the American Red Cross.; Review a sample of C.N.A. and home health aides to ensure that CPR certification is current.

27 Page 27 of 80 ST - G Evidence of HIV Training Title Evidence of HIV Training Statute or Rule (8)(e), F.S. (8) Each nurse registry must require every applicant for contract to complete an application form providing the following information:... (e) Proof of completion of a continuing educational course on modes of transmission, infection control procedures, clinical management, and prevention of human immunodeficiency virus and acquired immune deficiency syndrome with an emphasis on appropriate behavior and attitude change. Such instruction shall include information on current Florida law and its effect on testing, confidentiality of test results, and treatment of patients and any protocols and procedures applicable to human immunodeficiency virus counseling and testing, reporting, offering HIV testing to pregnant women, and partner notification issues pursuant to ss and Review a sample of independent contractors to ensure a course on HIV/AIDS has been completed. This requirement was added by the 2008 Legislature. (Note: this is a one-time only course. In the past the training was biennial.) ST - G C.N.A. & Home Health Aide - Physician Title C.N.A. & Home Health Aide - Physician Statute or Rule (6)(b), F.S (b) A certified nursing assistant or home health aide may be referred for a contract to provide care to a patient in his home only if that patient is under a doctor's care. The surveyor reviews a sampling of the records of those patients receiving CNA and home health aide to: (1.) determine if CNAs and HH aides are performing appropriate tasks. (This can also be checked on a home visit or telephone interview as time permits.); and

28 Page 28 of 80 A CNA or home health aide referred for contract in a private residence shall be limited to assisting a patient with bathing, dressing, toileting, grooming, eating, physical transfer, and those normal daily routines the patient could perform for himself were he physically able. A CNA or home health aide may not provide medical or other health care services that require specialized training and that may be performed only by licensed health care professionals. The nurse registry shall obtain the name and address of the attending physician and send written notification to physician within 48 hours after a contract is concluded that a CNA or home health aide will be providing care for that patient. (2.) determine whether the attending physician has been notified that a CNA and home health aide will be providing care for the patients. ST - G CNA and HH Aide - RN Available Title CNA and HH Aide - RN Available Statute or Rule (6)(c), F.S. (c) When a certified nursing assistant or home health aide is referred to a patient's home by a nurse registry, the nurse registry shall advise the patient, the patient's family or any other person acting on behalf of the patient at the time the contract for services is made that registered nurses are available to make visits to the patient's home for an additional cost. The surveyor reviews how the information is provided to the patient or family or other person on behalf of the patient that RNs are available to make visits. ST - G CNA and Home Health Aide - Responsibilities Title CNA and Home Health Aide - Responsibilities Statute or Rule 59A (2-6), F.A.C.

29 Page 29 of 80 (2) Be responsible for documenting services provided to the patient or client and for filing said documentation with the nurse registry on a regular basis. These service logs will be stored by the nurse registry in the client ' s file. The service logs shall include the name of the patient or client and a listing of the services provided; (3) Be responsible for observing appearance and gross behavioral changes in the patient and reporting these changes to the patient's health care surrogate or other person designated by the patient and the nurse registry or to the responsible facility employee if staffing in a facility; (4) Be responsible to maintain a clean, safe and healthy environment, which may include light cleaning and straightening of the bathroom, straightening the sleeping and living areas, washing the patient's dishes or laundry, and such tasks to maintain cleanliness and safety for the patient; (5) Perform other activities as taught and documented by a registered nurse, concerning activities for a specific patient and restricted to the following: (a) Assisting with the change of a colostomy bag, reinforcement of dressing; (b) Assisting with the use of devices for aid to daily living such as a wheelchair or walker; (c) Assisting with prescribed range of motion exercises; (d) Assisting with prescribed ice cap or collar; (e) Doing simple urine tests for sugar, acetone or albumin; (f) Measuring and preparing special diets,; (g) Measuring intake and output of fluids; and (h) Measuring temperature, pulse, respiration or blood pressure. (6) Be prohibited from changing sterile dressings, irrigating body cavities such as giving an enema, irrigating a colostomy or wound, performing gastric irrigation or enteral feeding, catheterizing a patient, administering medications, applying heat by any method, or caring for a tracheotomy tube. Sample records of patients receiving CNAs and home health aides to determine whether services are documented and whether appearance and behavioral changes are noted and reported. Review duties performed by the CNA and home health aide as reported in the file to determine if appropriate as per items (4) through (6) of the standard. Review CNA personnel files to see if certification is included.

30 Page 30 of 80 ST - G Assistance with Medications Title Assistance with Medications Statute or Rule FS; 59A (14)(d-e) FAC Assistance with Medications s , F.S. (1) For purposes of this section, the term: (a) "Informed consent" means advising the patient, or the patient's surrogate, guardian or attorney in fact, that the patient may be receiving assistance with self-administration of medication from an unlicensed person. (b) "Unlicensed person" means an individual not currently licensed to practice nursing or medicine who is employed by or under contract to a home health agency and who has received training with respect to assisting with the self-administration of medication as provided by agency rule. (2) Patients who are capable of self-administering their own medications without assistance shall be encouraged and allowed to do so. However, an unlicensed person may, consistent with a dispensed prescription's label or the package directions of an over-the-counter medication, assist a patient whose condition is medically stable with the self-administration of routine, regularly scheduled medications that are intended to be self-administered. Assistance with self-medication by an unlicensed person may occur only upon a documented request by, and the written informed consent of, a patient or the patient's surrogate, guardian, or attorney in fact. For purposes of this section, self-administered medications include both legend and over-the-counter oral dosage forms, topical dosage forms, and topical ophthalmic, otic, and nasal dosage forms, including solutions, suspensions, Identify and review files of patients receiving assistance with medications to determine compliance with these provisions. If the surveyor makes a home visit to a patient that is receiving assistance with their medication, the surveyor should ask what the home health aide or CNA does to assist the patient with his or her medications. If the assistance is more than what is permitted under this standard, the nurse registry is not in compliance with this standard and should be cited. Check the sample of patient records to see if the patients that receive such assistance are medically stable and have regularly scheduled medications that are intended to be self-administered. When reviewing sampled patient files, look for documentation of consent in the patient's record for those patients that are getting assistance for medication as permitted in the law. Was a review of the medications for which assistance is to be provided conducted by a registered nurse or licensed practical nurse to ensure the HHA or CNA was able to assist in accordance with training and the medication prescription?

31 Page 31 of 80 sprays, and inhalers. (3) Assistance with self-administration of medication includes: (a) Taking the medication, in its previously dispensed, properly labeled container, from where it is stored and bringing it to the patient. (b) In the presence of the patient, reading the label, opening the container, removing a prescribed amount of medication from the container, and closing the container. (c) Placing an oral dosage in the patient's hand or placing the dosage in another container and helping the patient by lifting the container to his or her mouth. (d) Applying topical medications. (e) Returning the medication container to proper storage. (f) Keeping a record of when a patient receives assistance with self-administration under this section. (4) Assistance with self-administration does not include: (a) Mixing, compounding, converting, or calculating medication doses, except for measuring a prescribed amount of liquid medication or breaking a scored tablet or crushing a tablet as prescribed. (b) The preparation of syringes for injection or the administration of medications by any injectable route. (c) Administration of medications through intermittent positive pressure breathing machines or a nebulizer. (d) Administration of medications by way of a tube inserted in a cavity of the body. (e) Administration of parenteral preparations. (f) Irrigations or debriding agents used in the treatment of a skin condition. (g) Rectal, urethral, or vaginal preparations. (h) Medications ordered by the physician or health care professional with prescriptive authority to be given "as needed," unless the order is written with specific parameters

32 Page 32 of 80 that preclude independent judgment on the part of the unlicensed person, and at the request of a competent patient. (i) Medications for which the time of administration, the amount, the strength of dosage, the method of administration, or the reason for administration requires judgment or discretion on the part of the unlicensed person. (5) Assistance with the self-administration of medication by an unlicensed person as described in this section does not constitute administration as defined in s (6) The agency may by rule establish procedures and interpret terms as necessary to administer this section. 59A , F.A.C. (14) (d) In cases where a home health aide or a C.N.A. will provide assistance with self-administered medications as described in Section , F.S., and paragraph (e) below, a review of the medications for which assistance is to be provided shall be conducted by a registered nurse or licensed practical nurse to ensure the C.N.A. and home health aide are able to assist in accordance with their training and with the medication prescription. and the medication is not required to be administered by a nurse. If the patient will not consent to a visit by the nurse to review the medications, a written list with the dosage, frequency and route of administration shall be provided by the patient or the patient ' s health care surrogate, family member, or person designated by the patient to the home health aide or CNA to have reviewed by the nurse. The patient or the patient ' s surrogate, guardian, or attorney in fact must give written consent for a home health aide or C.N.A. to provide assistance with self-administered medications, as required in Section (2), F.S.

33 Page 33 of 80 (e) The trained home health aide and C.N.A. may also provide the following assistance with self-administered medication, as needed by the patient and as described in Section , F.S.: 1. Prepare necessary items such as juice, water, cups, or spoons to assist the patient in the self-administration of medication; 2. Open and close the medication container or tear the foil of prepackaged medications; 3. Assist the resident in the self-administration process. Examples of such assistance include the steadying of the arm, hand, or other parts of the patient's body so as to allow the self-administration of medication; 4. Assist the patient by placing unused doses of solid medication back into the medication container. ST - G Training on Assistance With Medications Title Training on Assistance With Medications Statute or Rule 59A (14), F.A.C. (14) C.N.A.s and home health aides referred by nurse registries may assist with self-administration of medication as described in Section , F.S. (a) Home health aides and C.N.A.s assisting with self-administered medication, as described in Section , F.S.., shall have received a minimum of 2 hours of training covering the following content: 1. Training shall cover state law and rule requirements with respect to the assistance with self-administration of medications in the home, procedures for assisting the resident with self-administration of medication, common medications, recognition of side effects and adverse reactions and procedures to follow when patients appear to be experiencing Identify and review files of patients receiving assistance with medications. Verify that the file for the HHA or CNA independent contractor providing the assistance with medications for the patient file reviewed by the surveyor contains documentation of a minimum of 2 hours of training. Does the training documentation meet the types of acceptable training listed in the standard?

34 Page 34 of 80 side effects and adverse reactions. Training must include verification that each C.N.A. and home health aide can read the prescription label and any instructions. 2. Individuals who cannot read shall not be permitted to assist with prescription medications. (b) Documentation of training on assistance with self-administered medication from one of the following sources is acceptable: 1. Documentation of 2 hours of training in compliance with subsection 59A (5), F.A.C., from a home health agency if the home health aide or C.N.A. previously worked for the home health agency; 2. A training certificate for 4 hours of training for assisted living facility staff in compliance with subsection 58A (5), F.A.C. 3. A training certificate for at least 2 hours of training from a career education school licensed pursuant to Chapter 1005, F.S., and Chapter Rule Division 6E, F.A.C., by the Department of Education, Commission for Independent Education. 4. Documentation of at least 2 hours of training by a provider approved by the Florida Board of Nursing, Department of Health. (c) Documentation of the training must be maintained in the file of each home health aide and C.N.A. who assists patients with self-administered medication. ST - G Assisted Living Facilities & Other Title Assisted Living Facilities & Other Statute or Rule (15)(a) Assisted Living Facilities & Other s (15)(a) The agency may deny, suspend, or revoke "Fair market value" means the value in arms length transactions, consistent with the price that an asset would bring as the result of bona fide bargaining between well informed buyers and sellers who are not otherwise in a position to

35 Page 35 of 80 the license of a nurse registry and shall impose a fine of $5,000 against a nurse registry that: 1. Provides services to residents in an assisted living facility for which the nurse registry does not receive fair market value remuneration. 2. Provides staffing to an assisted living facility for which the nurse registry does not receive fair market value remuneration. 3. Fails to provide the agency, upon request, with copies of all contracts with assisted living facilities which were executed within the last 5 years. (b) The agency shall also impose an administrative fine of $15,000 if the nurse registry refers nurses, certified nursing assistants, home health aides, or other staff without charge to a facility licensed under chapter 429 [assisted living facility, adult family care home, adult day care] in return for patient referrals from the facility. generate business for the other party, or the compensation that would be included in a service agreement as the result of bona fide bargaining between well-informed parties to the agreement who are not otherwise in a position to generate business for the other party, on the date of acquisition of the asset or at the time of the service agreement. (s (11), F.S.) ALFs: Check contracts the Nurse Registry may have with ALFs for staffing, referrals and/or space. Failure to provide copies of all contracts with ALFs is a fine of $5,000 and may result in denial, revocation or suspension of the license. Are the NR personnel working in ALFs under contract with specific residents to provide services in their rooms? Does the NR staff the ALF and/or operate a resident drop-in office at the facility? Is this NR the only NR that sees its residents? ALF, Adult Day Care, Adult Family Care Home: Any HHA that provides nurses, CNAs, HH aides or other staff without charge to an ALF, adult day care center, or adult family care home in return for patient referrals is to be fined ( (4), F.S.). The Field Office submits a Recommendation for Sanction to General Counsel's office. ST - G Remuneration for referrals Title Remuneration for referrals Statute or Rule (15)(a)4. & 5. & (27) Remuneration for referrals s (15) (a) The agency may deny, suspend, or revoke the license of a nurse registry and shall impose a fine of $5,000 against a nurse registry that: Gives remuneration to a case manager, discharge planner, facility-based staff member, or third-party vendor who is involved in the discharge-planning process of a facility licensed under chapter 395 or this chapter and from whom the nurse registry receives referrals. A nurse registry is exempt from this subparagraph if it does not bill the Florida Medicaid program or the Medicare program or share a controlling interest with any entity licensed, registered, or certified under This applies to nurse registries that bill the Florida Medicaid program, including Medicaid Waivers, or the Medicare program - or share controlling interests (5% or more ownership, officers, and board members) with any facility that is licensed, registered or certified by AHCA that does such billing as follows: 1. Any payment or other benefit provided by a Nurse Registry to a case manager, discharge planner or facility - based staff member or 3rd party vendor, from whom the NR receives referrals for following kinds of facilities: Facilities licensed under chapter 395 are: hospitals, ambulatory surgical centers, and mobile surgical facilities. Facilities licensed under chapter 400 are: skilled nursing facilities, home health agencies, nurse registries, hospices, intermediate care facilities, prescribed pediatric extended care centers, transitional living facilities, and health care services pools.

36 Page 36 of 80 part II of chapter 408 that bills the Florida Medicaid program or the Medicare program. 5. Gives remuneration to a physician, a member of the physician's office staff, or an immediate family member of the physician, and the nurse registry received a patient referral in the last 12 months from that physician or the physician's office staff. A nurse registry is exempt from this subparagraph if it does not bill the Florida Medicaid program or the Medicare program or share a controlling interest with any entity licensed, registered, or certified under part II of chapter 408 that bills the Florida Medicaid program or the Medicare program. 2. Any payment or other benefit to a physician, physician's office staff, or immediate family of a physician who has made a referral to the nurse registry. The Field Office submits Recommendation for Sanction to General Counsel's Office. s (27) " Remuneration " means any payment or other benefit made directly or indirectly, overtly or covertly, in cash or in kind. However, if the term is used in any provision of law relating to health care providers, the term does not apply to an item that has an individual value of up to $15, including, but not limited to, a plaque, a certificate, a trophy, or a novelty item that is intended solely for presentation or is customarily given away solely for promotional, recognition, or advertising purposes. ST - G Special needs registration Title Special needs registration Statute or Rule (11); (1&6); 59A (6) Special needs registration s , F.S. (11) Nurse registries shall assist persons who would need assistance and sheltering during evacuations because of Is there evidence that the NR has recieved the information necessary to assist special needs patients with registration through the local emergency management agency? The NR should have contacted the local Emergency Management Agency in each county to find out what information needs to be submitted. Review the procedure used at intake by the NR to identify and assist special needs patients with registration.

37 Page 37 of 80 physical, mental, or sensory disabilities in registering with the appropriate local emergency management agency pursuant to s s , F.S. (1) In order to meet the special needs of persons who would need assistance during evacuations and sheltering because of physical, mental, cognitive impairment, or sensory disabilities, each local emergency management agency in the state shall maintain a registry of persons with special needs located within the jurisdiction of the local agency. The registration shall identify those persons in need of assistance and plan for resource allocation to meet those identified needs. To assist the local emergency management agency in identifying such persons...nurse registries...shall provide registration information to all of their special needs clients and to all persons with special needs who receive services. The registry shall be updated annually. The registration program shall give persons with special needs the option of preauthorizing emergency response personnel to enter their homes during search and rescue operations if necessary to assure their safety and welfare following disasters. Verify that the procedure allows for an annual review of the registered patients and the specific steps taken to determine if the special needs patient continues to need ongoing registration with the local Emergency Management Agency. Review the NR's emergency management plan to verify that procedures for registering special needs patients are included. Verify that special needs registration information has been sent to the county emergency management office. s , F.S. (6) All appropriate agencies and community-based service providers, including...nurse registries...shall assist emergency management agencies by collecting registration information for persons with special needs as part of program intake processes, establishing programs to increase the awareness of the registration process, and educating clients about the procedures that may be necessary for their safety during disasters. Clients of state or federally funded service programs with physical, mental, cognitive impairment, or

38 Page 38 of 80 sensory disabilities who need assistance in evacuating, or when in shelters, must register as persons with special needs. 59A , F.A.C. (6) Nurse registries shall assist patients who would need assistance and sheltering during evacuations because of physical, mental, or sensory disabilities in registering with the local emergency management agency, as required in Section (11), F.S. (a) Upon initial contract for services, and at a minimum on an annual basis, each nurse registry shall, pursuant to Sections (11) and , F.S., inform the patient and the patient ' s family member or other person acting on behalf of the patient, by the best method possible as it pertains to the person's disability, of the special needs registry and procedures for registration at the special needs registry maintained by their county emergency management office. (b) If the patient is to be registered at the special needs registry, the nurse registry shall assist the patient with registering pursuant to Sections (12), F.S., and must document in the patient's file if the patient plans to evacuate or remain at home; if the patient ' s family or other person that provides care to the patient can take responsibility during the emergency for services normally provided by independent contractors referred by the registry; or if the registry needs to make referrals in order for services to continue. If the patient has a case manager through the Community Care for the Elderly or the Medicaid Waiver programs or any other state funded program designated in law to help patients and clients register with the special needs registry, then the nurse registry will check with the case manager to verify if the patient has already been registered. If so, a note will be made in the patient's file by the nurse registry that the patient's need for registration has already been reviewed and handled by the

39 Page 39 of 80 other program's case manager. (c) The independent contractors referred by the nurse registry, or registry staff, shall inform patients registered with the special needs registry that special needs shelters are an option of last resort and that services may not be equal to what they have received in their homes. (d) This registration information, when collected, shall be submitted, pursuant to Section (11), F.S., to the county emergency management office ST - G Emergency Management Plan Title Emergency Management Plan Statute or Rule (12) FS; 59A (1) FAC Emergency Management Plan s , F.S. (12) Each nurse registry shall prepare and maintain a comprehensive emergency management plan that is consistent with the criteria in this subsection and with the local special needs plan.... The plan shall include the means by which the nurse registry will continue to provide the same type and quantity of services to its patients who evacuate to special needs shelters which were being provided to those patients prior to evacuation. The plan shall specify how the nurse registry shall facilitate the provision of continuous care by persons referred for contract to persons who are registered pursuant to s during an emergency that interrupts the provision of care or services in private residencies. Nurse registries may establish links to local emergency operations centers to determine a mechanism by which to approach specific areas within a disaster area in order for a provider to Does the NR have an emergency management plan? A comprehensive emergency management plan format, AHCA Form , December 2006, has been adopted. PLEASE NOTE The form number on the format may be AHCA Form or Both are acceptable. The Department of Health has provided contact information for nurse registry plan reviews. Nurse registries will need to send a separate plan to each of the counties that appear on their license. Plans are to be sent electronically to the county health department contacts. The AHCA website links to the Department of Health ' s county health department contact information at. The document entitled Emergency Management Plan Review Contacts contains the and the phone number for the county health department reviewer for each of the 67 counties in the state. The nurse registry staff should check with the reviewer before sending the plan and make sure they get a confirmation from the county reviewer that the plan was received. Some of the counties may not be reviewing plans as there was no funding allocated for reviewer positions. However, the nurse registry still needs to complete a plan and send it to the reviewer and get confirmation that it was received. If the NR submitted a plan, and it has been over 90 days and no response by the designated reviewer has been received by the NR, then ask to see the reviewer's initial response and the NR's response if the reviewer requested revisions to the plan. The NR must do any revisions requested by the county health department reviewer and return it for approval. A deficiency should only be cited if the NR did not revise the plan as instructed and did not return the

40 Page 40 of 80 reach its clients.... (e) The comprehensive emergency management plan required by this subsection is subject to review and approval by the county health department. During its review, the county health department shall contact state and local health and medical stakeholders when necessary. The county health department shall complete its review to ensure that the plan complies with the criteria in the Agency for Health Care Administration rules within 90 days after receipt of the plan and shall either approve the plan or advise the nurse registry of necessary revisions. If a nurse registry fails to submit a plan or fails to submit requested information or revisions to the county health department within 30 days after written notification from the county health department, the county health department shall notify the Agency for Health Care Administration. The agency shall notify the nurse registry that its failure constitutes a deficiency, subject to a fine of $5,000 per occurrence. If the plan is not submitted, information is not provided, or revisions are not made as requested, the agency may impose the fine. 59A , F.A.C. (1) Pursuant to Section (12), F.S., each nurse registry shall prepare and maintain a written comprehensive emergency management plan, in accordance with the Comprehensive Emergency Management Plan for Nurse Registries, AHCA Form , May 2015, incorporated by reference. and available at < 34>. This document is available from the Agency for Health Care Administration at < ex.shtml%20>. The plan shall describe how the nurse registry establishes and maintains an effective response to emergencies and disasters. The plan, once completed, will be sent electronically to the contact designated by the Department of Health as required in Section (12), F.S. plan to the county health department reviewer for a second review. A deficiency should be cited if there is no emergency management plan. If the plan is not done on the required format this is also a deficiency. If the county health department has notified AHCA that a NR has failed to submit a plan or requested revisions within 30 days after notification from the county health department, this is a deficiency and subject to a $5,000 fine. If not corrected, a Recommendation for Sanction (the $5,000 fine) is prepared and submitted by the Home Care Unit to AHCA General Counsel's office. Plan Contents: Has the NR included items III A in their emergency management plan regarding plan implementation? Has the NR included in their emergency management plan item III C 3 and 4 how independent contractors responsible for special needs patient's will be notified and continue the same type and quantity of services to patients evacuating to the special needs shelters? Has the NR included in their emergency management plan item III C 5 and 6 how the NR will contact special needs patients in the event of an emergency? Has the NR included in their emergency management plan item III D 1 how independent contractors will continue services to special needs patients when evacuation is not ordered? Has the NR included in their emergency management plan III E 4 what other resources they will utilize to continue services to special needs shelter patients in the event their independent contractors cannot continue the same type and quantity of services in the shelter?

41 Page 41 of 80 ST - G Emergency Management Plan Updates Title Emergency Management Plan Updates Statute or Rule (12), FS; 59A (2-3) FAC Emergency Management Plan Updates s , F.S. (12) Each nurse registry shall prepare and maintain a comprehensive emergency management plan that is consistent with the criteria in this subsection and with the local special needs plan. The plan shall be updated annually... Check for annual updates to the plan or documentation that it was reviewed and changes made. If no changes were needed, check to see that the NR documented the review was done but no changes were needed. Some of the county health departments reviewing the plans may require that a plan update be sent annually for review. Were changes to the applicable county emergency management offices and local county health department? 59A , F.A.C. (2) The nurse registry shall review its emergency management plan on an annual basis and make any substantive changes. (3) Changes in telephone numbers of those administrative staff who are coordinating the nurse registry's emergency response must be reported to the county emergency management office and to the county health department. For nurse registries with multiple counties on their license, the changes must be reported to each county health department and each county emergency management office. The telephone numbers must include numbers where the coordinating staff can be contacted outside of the nurse registry's regular office hours. All nurse registries must report these changes, whether their plan has been previously reviewed or not as defined in subsection (1).

42 Page 42 of 80 ST - G Emergency Management Plan - CHOW Title Emergency Management Plan - CHOW Statute or Rule 59A (4), FAC (4) When a nurse registry goes through a change of ownership, the new owner shall review the registry's emergency management plan and make any substantive changes, including changes noted in subsection (3). Those nurse registries will need to report any substantive changes in their plan to the reviewing entity in subsection (1). If the agency changed ownership since the last survey, were changes to the comprehensive emergency management plan made and reported to the reviewing entity and the local county emergency management offices and local county health departments? ST - G EM Plan and Patient Records Title EM Plan and Patient Records Statute or Rule (12)(a) FS; 59A (6b &7 &10) EM Plan and Patient Records s , F.S. (12)(a) All persons referred for contract who care for persons registered pursuant to s must include in the patient record a description of how care will be continued during a disaster or emergency that interrupts the provision of care in the patient's home. It shall be the responsibility of the person referred for contract to ensure that continuous care is provided. When sampling patient records, including records for patients in assisted living facilities and adult family care homes, is the patient's plan for evacuation and continuing the same type and quantity of services in a special needs shelter during an emergency documented? If the emergency does not require evacuation does the patient record indicate how services will be continued? Did the NR collect the special needs registration information for the patient and submit it to the county emergency management office?

43 Page 43 of 80 59A , F.A.C. (6)(b) If the patient is to be registered at the special needs registry, the nurse registry shall assist the patient with registering, pursuant to Sections (12), F.S., and must document in the patient ' s file if the patient plans to evacuate or remain at home; if the patient ' s family or other person that provides care to the patient can take responsibility during the emergency for services normally provided by independent contractors referred by the registry; or if the registry needs to make referrals in order for services to continue. If the patient has a case manager through the Community Care for the Elderly or the Medicaid Waiver programs or any other state funded program designated in law to help patients and clients register with the special needs registry, then the nurse registry will check with the case manager to verify if the patient has already been registered. If so, a note will be made in the patient ' s file by the nurse registry that the patient ' s need for registration has already been reviewed and handled by the other program ' s case manager. (10) If the independent contractor is unable to provide services to special needs registry patients, including any assisted living facility and adult family care home special needs registry patients, due to circumstances beyond their control pursuant to Section (12)(d), F.S., then the nurse registry will contact the independent contractors it has available for referral to find another independent contractor for the patient, pursuant to Section (1612), F.S. ST - G Emergency Management - Prioritized List Title Emergency Management - Prioritized List Statute or Rule (12)(b) FS; 59A (12) FAC

44 Page 44 of 80 Emergency Management - Prioritized List s , F.S. (12) (b) Each nurse registry shall maintain a current prioritized list of patients in private residences who are registered pursuant to s and are under the care of persons referred for contract and who need continued services during an emergency. This list shall indicate, for each patient, if the client is to be transported to special needs shelter and if the patient is receiving skilled nursing services. Nurse registries shall make this list available to County health departments and to local emergency management agencies upon request. Ask the Administrator how the NR maintains and keeps the prioritized list current. Has the NR included in their emergency management plan item III C 7 on how the NR will maintain and keep current a prioritized list of special needs registry patients? 59A , F.A.C. (12) The prioritized list of registered special needs patients maintained by the nurse registry shall be kept current and shall include information, as defined in Sections (12) (b) and (c), F.S. This list also shall be furnished to county health departments and to the county emergency management office, upon request. ST - G Emergency Management and List of Meds Title Emergency Management and List of Meds Statute or Rule (12)(c) FS; 59A (13 &14) Emergency Management and List of Meds Review a special needs registry patient record to verify the presence of the list of items described in (16)(c) s , F.S.

45 Page 45 of 80 (12)(c) Each person referred for contract who is caring for a patient who is registered pursuant to s shall provide a list of the patient's medication and equipment needs to the nurse registry. Each person referred for contract shall make this information available to county health departments and to local emergency management agencies upon request. 59A , F.A.C. (13) The independent contractor from the nurse registry is required to maintain in the home of the special needs patient a list of patient-specific medications, supplies and equipment required for continuing care and service should the patient be evacuated as per Section (1612)(c), F.S. The list must include the names of all medications, their dose, frequency, route, time of day and any special considerations for administration. The list must also include any allergies; the name of the patient ' s physician physician, physician assistant, or advanced registered nurse practitioner and the physician, physician assistant or advanced registered nurse practitioner ' s phone number; and the name, phone number and address of the patient ' s pharmacy. If the patient permits, the list can also include the patient ' s diagnosis. (14) The patient record for each person registered as a special needs patient shall include the list described in subsection (13) above and information as listed in Sections (12)(a) and (b), F.S. ST - G Emergency Mgmt Plan and Contacting Patients Title Emergency Mgmt Plan and Contacting Patients Statute or Rule 59A (9), F.A.C.

46 Page 46 of 80 (9) When a state of emergency has been declared by executive order or proclamation of the Governor, pursuant to Section (2), F.S., the nurse registry must contact those patients needing ongoing services pursuant to Section (12)(a), F.S., and confirm each patient ' s plan during and immediately following an emergency. The nurse registry shall contact the assisted living facility and adult family care home patients and confirm their plans during and immediately following an emergency. If an emergency has occurred since the last survey verify through review of special needs patient records that the NR made contact and to confirm plans. ST - G Emergency Management Plan Implementation Title Emergency Management Plan Implementation Statute or Rule 59A (5) & (8) FAC; (12) 59A (5) In the event of an emergency, the nurse registry shall implement the nurse registry ' s emergency management plan pursuant to Section (12), F.S. Also, the registry must meet the following requirements: (a) All administrative staff shall be informed of responsibilities for implementing the emergency management plan. (b) If telephone service is not available during an emergency, the registry shall have a contingency plan to support communication, pursuant to Section (12)(f), F.S. A contingency plan may include cell phones, contact with a community based ham radio group, public announcements through radio or television stations, driving directly to the patient ' s home, and, in medical emergency situations, contact with police or emergency rescue services. If there has been an emergency or a complaint since the last survey does the patient record reflect that the same type and quantity of services was delivered to the patient? If not is there documentation in the patient record describing what steps the NR took to try and continue services to the special needs patient? Was another independent contractor referred to care for the patient in the special needs shelter? Review a sample of files of special needs patients that live in the home, assisted living facility and adult family care home, if applicable, to see if the file was documented with the efforts made by the NR to find an alternative provider for services. If there is no evidence that a good faith effort was made, the NR should be cited.

47 Page 47 of 80 (8) When a nurse registry is unable to continue services to special needs patients registered under Section , F.S., that patient ' s record must contain documentation of the efforts made by the registry to comply with their emergency management plan in accordance with Section (12), F.S. Documentation includes but is not limited to contacts made to the patient ' s family or other person that provides care, if applicable, contacts made to the assisted living facility and adult family care home if applicable; contacts made to local emergency operation centers to obtain assistance in reaching patients and contacts made to other agencies which may be able to provide temporary services (12), F.S....Nurse registries shall demonstrate a good faith effort to comply with the requirements of this subsection by documenting attempts of staff to follow procedures outlined in the nurse registry ' s comprehensive emergency management plan which support a finding that the provision of continuing care has been attempted for patients identified as needing care by the nurse registry and registered under s in the event of an emergency under this subsection. (d) Each person referred for contract shall not be required to continue to provide care to patients in emergency situations that are beyond the person ' s control and that make it impossible to provide services, such as when roads are impassable or when patients do not go to the location specified in their patient records. If there has been an emergency since the last survey, check for compliance with this standard. ST - GZ800 - Applicability; Definitions Title Applicability; Definitions Statute or Rule ; 59A ; 59A (1)

48 Page 48 of Applicability.- The provisions of this part apply to the provision of services that require licensure as defined in this part and to the following entities licensed, registered, or certified by the agency, as described in chapters 112, 383, 390, 394, 395, 400, 429, 440, 483, and 765: (1) Laboratories authorized to perform testing under the Drug-Free Workplace Act, as provided under ss and (2) Birth centers, as provided under chapter 383. (3) Abortion clinics, as provided under chapter 390. (4) Crisis stabilization units, as provided under parts I and IV of chapter 394. (5) Short-term residential treatment facilities, as provided under parts I and IV of chapter 394. (6) Residential treatment facilities, as provided under part IV of chapter 394. (7) Residential treatment centers for children and adolescents, as provided under part IV of chapter 394. (8) Hospitals, as provided under part I of chapter 395. (9) Ambulatory surgical centers, as provided under part I of chapter 395. (10) Mobile surgical facilities, as provided under part I of chapter 395. (11) Health care risk managers, as provided under part I of chapter 395. (12) Nursing homes, as provided under part II of chapter 400. (13) Assisted living facilities, as provided under part I of chapter 429. (14) Home health agencies, as provided under part III of chapter 400. (15) Nurse registries, as provided under part III of chapter 400. (16) Companion services or homemaker services providers, as

49 Page 49 of 80 provided under part III of chapter 400. (17) Adult day care centers, as provided under part III of chapter 429. (18) Hospices, as provided under part IV of chapter 400. (19) Adult family-care homes, as provided under part II of chapter 429. (20) Homes for special services, as provided under part V of chapter 400. (21) Transitional living facilities, as provided under part V of chapter 400. (22) Prescribed pediatric extended care centers, as provided under part VI of chapter 400. (23) Home medical equipment providers, as provided under part VII of chapter 400. (24) Intermediate care facilities for persons with developmental disabilities, as provided under part VIII of chapter 400. (25) Health care services pools, as provided under part IX of chapter 400. (26) Health care clinics, as provided under part X of chapter 400. (27) Clinical laboratories, as provided under part I of chapter 483. (28) Multiphasic health testing centers, as provided under part II of chapter 483. (29) Organ, tissue, and eye procurement organizations, as provided under part V of chapter Definitions.-As used in this part, the term: (1) "Agency" means the Agency for Health Care Administration, which is the licensing agency under this part. (2) "Applicant" means an individual, corporation, partnership, firm, association, or governmental entity that submits an application for a license to the agency.

50 Page 50 of 80 (3) "Authorizing statute" means the statute authorizing the licensed operation of a provider listed in s and includes chapters 112, 383, 390, 394, 395, 400, 429, 440, 483, and 765. (4) "Certification" means certification as a Medicare or Medicaid provider of the services that require licensure, or certification pursuant to the federal Clinical Laboratory Improvement Amendment (CLIA). (5) "Change of ownership" means: (a) An event in which the licensee sells or otherwise transfers its ownership to a different individual or entity as evidenced by a change in federal employer identification number or taxpayer identification number; or (b) An event in which 51 percent or more of the ownership, shares, membership, or controlling interest of a licensee is in any manner transferred or otherwise assigned. This paragraph does not apply to a licensee that is publicly traded on a recognized stock exchange. A change solely in the management company or board of directors is not a change of ownership. (6) "Client" means any person receiving services from a provider listed in s (7) "Controlling interest" means: (a) The applicant or licensee; (b) A person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the applicant or licensee; or (c) A person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the management company or other entity, related or unrelated, with which the applicant or licensee contracts to manage the provider. The term does not include a voluntary board member. (8) "License" means any permit, registration, certificate, or license issued by the agency.

51 Page 51 of 80 (9) "Licensee" means an individual, corporation, partnership, firm, association, governmental entity, or other entity that is issued a permit, registration, certificate, or license by the agency. The licensee is legally responsible for all aspects of the provider operation. (10) "Moratorium" means a prohibition on the acceptance of new clients. (11) "Provider" means any activity, service, agency, or facility regulated by the agency and listed in s (12) "Services that require licensure" means those services, including residential services, that require a valid license before those services may be provided in accordance with authorizing statutes and agency rules. (13) "Voluntary board member" means a board member or officer of a not-for-profit corporation or organization who serves solely in a voluntary capacity, does not receive any remuneration for his or her services on the board of directors, and has no financial interest in the corporation or organization. 59A Definitions. (1) "Address of record" means the location that is printed on the license and is the address at which the provider is licensed to operate. In the event a license displays multiple locations including branch offices, satellite offices, or off-site locations, the address of record is the main or principle office address. (2) "Agency notification" or "Agency request" means the Agency sends notification by: (a) Mail or personal delivery to the address of record for a licensee or applicant, (b) Mail to an alternative mailing address if requested by the licensee or applicant, or (c) Electronic mail if an electronic mail address has been provided. (3) "Days" means calendar days.

52 Page 52 of 80 (4) "Management company" means an entity retained by a licensee to administer or direct the operation of a provider. This does not include an entity that serves solely as a lender or lien holder. 59A Background Screening. (1) Definitions: (a) "Arrest Report" means the detailed narrative written by the arresting law enforcement officer explaining the circumstances of the arrest. (b) "Disposition" means the sentencing or other final settlement of a criminal case which shall include, regardless of adjudication, a plea of nolo contendere or guilty, or a conviction by a judge or jury. (c) "Disqualifying Offense" means any criminal offense prohibited in Section or (5), F.S. (d) "Exemption from Disqualification" means an exemption granted by the Agency following a review of the Application for Exemption, AHCA Form , September 2013, hereby incorporated by reference, and an informal hearing, if appropriate, during which the individual must present clear and convincing evidence to support a reasonable belief that he or she has been rehabilitated and does not present a danger to the health, safety, and welfare of the patient or individual as described in Section , F.S. (e) "FBI" means the Federal Bureau of Investigation. (f) "FDLE" means the Florida Department of Law Enforcement. (g) "Level 2 Screening" means an assessment of the criminal history record obtained through a fingerprint search through the FDLE and FBI to determine whether screened individuals have any disqualifying offenses pursuant to Section or (5), F.S. An analysis and review of court dispositions and arrest reports may be required to make a final determination. (h) "Livescan Service Provider" means an entity that scans fingerprints electronically and submits them to FDLE

53 Page 53 of 80 ST - GZ802 - License or application denial; revocation Title License or application denial; revocation Statute or Rule , FS License or application denial; revocation.- (1) In addition to the grounds provided in authorizing statutes, grounds that may be used by the agency for denying and revoking a license or change of ownership application include any of the following actions by a controlling interest: (a) False representation of a material fact in the license application or omission of any material fact from the application. (b) An intentional or negligent act materially affecting the health or safety of a client of the provider. (c) A violation of this part, authorizing statutes, or applicable rules. (d) A demonstrated pattern of deficient performance. (e) The applicant, licensee, or controlling interest has been or is currently excluded, suspended, or terminated from participation in the state Medicaid program, the Medicaid program of any other state, or the Medicare program. (2) If a licensee lawfully continues to operate while a denial or revocation is pending in litigation, the licensee must continue to meet all other requirements of this part, authorizing statutes, and applicable rules and file subsequent renewal applications for licensure and pay all licensure fees. The provisions of ss (1) and (3)(c) do not apply to renewal applications filed during the time period in which the litigation of the denial or revocation is pending until that litigation is final. (3) An action under s or denial of the license of the transferor may be grounds for denial of a change of ownership

54 Page 54 of 80 application of the transferee. (4) Unless an applicant is determined by the agency to satisfy the provisions of subsection (5) for the action in question, the agency shall deny an application for a license or license renewal based upon any of the following actions of an applicant, a controlling interest of the applicant, or any entity in which a controlling interest of the applicant was an owner or officer when the following actions occurred: (a) A conviction or a plea of guilty or nolo contendere to, regardless of adjudication, a felony under chapter 409, chapter 817, chapter 893, 21 U.S.C. ss , or 42 U.S.C. ss , Medicaid fraud, Medicare fraud, or insurance fraud, unless the sentence and any subsequent period of probation for such convictions or plea ended more than 15 years before the date of the application; or (b) Termination for cause from the Medicare program or a state Medicaid program, unless the applicant has been in good standing with the Medicare program or a state Medicaid program for the most recent 5 years and the termination occurred at least 20 years before the date of the application. ST - GZ803 - License Required; Display Title License Required; Display Statute or Rule , F.S License required; display.- (1) It is unlawful to provide services that require licensure, or operate or maintain a provider that offers or provides services that require licensure, without first obtaining from the agency a license authorizing the provision of such services or the operation or maintenance of such provider. (2) A license must be displayed in a conspicuous place readily visible to clients who enter at the address that appears on the - Check to see that the license is for the facility and location where it is displayed. Contact the appropriate licensure unit if there are questions about the license. - If applicable, check to make sure the category of testing being done is reflected on the license, the ownership given on the face of the license is accurate, that the location of the facility is the address printed on the license, and that the license is properly displayed. Look at Z0827 Unlicensed Activity , F.S. as unlicensed activity should be cited if there has been a change of ownership, or for clinical laboratories, testing outside of the specialty/subspecialties printed on the license are being performed. - Regarding Nursing Homes, refer to (2) which states:

55 Page 55 of 80 license and is valid only in the hands of the licensee to whom it is issued and may not be sold, assigned, or otherwise transferred, voluntarily or involuntarily. The license is valid only for the licensee, provider, and location for which the license is issued. (3) Any person who knowingly alters, defaces, or falsifies a license certificate issued by the agency, or causes or procures any person to commit such an offense, commits a misdemeanor of the second degree, punishable as provided in s or s Any licensee or provider who displays an altered, defaced, or falsified license certificate is subject to the penalties set forth in s and an administrative fine of $1,000 for each day of illegal display. Separate licenses shall be required for facilities maintained in separate premises, even though operated under the same management. However, a separate license shall not be required for separate buildings on the same grounds. - Regarding Labs, refer to 59A-7.021(3) which states: Separate licensure shall be required for all laboratories maintained on separate premises, as defined under subsection 59A-7.020(27), F.A.C., including mobile laboratory units, even though operated under the same management. Separate licensure shall not be required for separate buildings on the same or adjoining grounds. ST - GZ806 - Change of Address Title Change of Address Statute or Rule 59A (2-5), F.A.C. (2) Any request to amend a license must be received by the Agency in advance of the requested effective date as detailed below. Requests to amend a license are not authorized until the license is issued. (a) Requests to change the address of record must be received by the Agency 60 to 120 days in advance of the requested effective date for the following provider types: 1. Birth Centers, as provided under Chapter 383, F.S.; 2. Abortion Clinics, as provided under Chapter 390, F.S.; 3. Crisis Stabilization Units, as provided under Parts I and IV of Chapter 394, F.S.; 4. Short Term Residential Treatment Units, as provided under Parts I and IV of Chapter 394, F.S. 5. Residential Treatment Facilities, as provided under Part IV of Chapter 394, F.S.; - The licensure unit handles change of address, but surveyors may find that the provider has moved and therefore could cite this.

56 Page 56 of Residential Treatment Centers for Children and Adolescents, as provided under Part IV of Chapter 394, F.S.; 7. Hospitals, as provided under Part I of Chapter 395, F.S.; 8. Ambulatory Surgical Centers, as provided under Part I of Chapter 395, F.S.; 9. Nursing Homes, as provided under Part II of Chapter 400, F.S.; 10. Hospices, as provided under Part IV of Chapter 400, F.S.; 11. Homes for Special Services as provided under Part V of Chapter 400, F.S.; 12. Transitional Living Facilities, as provided under Part V of Chapter 400, F.S.; 13. Prescribed Pediatric Extended Care Centers, as provided under Part VI of Chapter 400, F.S.; 14. Intermediate Care Facilities for the Developmentally Disabled, as provided under Part VIII of Chapter 400, F.S.; 15. Assisted Living Facilities, as provided under Part I of Chapter 429, F.S.; 16. Adult Family-Care Homes, as provided under Part II of Chapter 429, F.S.; 17. Adult Day Care Centers, as provided under Part III of Chapter 429, F.S. (b) Requests to change the address of record must be received by the Agency 21 to 120 days in advance of the requested effective date for the following provider types: 1. Drug Free Workplace Laboratories as provided under Sections and , F.S.; 2. Mobile Surgical Facilities, as provided under Part I of Chapter 395, F.S.; 3. Health Care Risk Managers, as provided under Part I of Chapter 395, F.S.; 4. Home Health Agencies, as provided under Part III of Chapter 400, F.S.; 5. Nurse Registries, as provided under Part III of Chapter 400, F.S.;

57 Page 57 of Companion Services or Homemaker Services Providers, as provided under Part III of Chapter 400, F.S.; 7. Home Medical Equipment Providers, as provided under Part VII of Chapter 400, F.S.; 8. Health Care Services Pools, as provided under Part IX of Chapter 400, F.S.; 9. Health Care Clinics, as provided under Part X of Chapter 400, F.S., including certificate of exemption; 10. Clinical Laboratories, as provided under Part I of Chapter 483, F.S.; 11. Multiphasic Health Testing Centers, as provided under Part II of Chapter 483, F.S.; 12. Organ and Tissue Procurement Agencies, as provided under Chapter 381, F.S. (c) All other requests to amend a license including but not limited to services, licensed capacity, and other specifications which are required to be displayed on the license by authorizing statutes or applicable rules must be received by the Agency 60 to 120 days in advance of the requested effective date. This deadline does not apply to a request to amend hospital emergency services defined in Section (2), F.S. (3) Failure to submit a timely request shall result in a $500 fine. (4) A licensee is not authorized to operate in a new location until a license is obtained which specifies the new location. Failure to amend a license prior to a change of the address of record constitutes unlicensed activity. (5) The licensee shall return the license certificate to the Agency upon the rendition of a final order revoking, cancelling or denying a license, and upon the voluntary discontinuance of operation.

58 Page 58 of 80 ST - GZ809 - Proof of Financial Ability to Operate Title Proof of Financial Ability to Operate Statute or Rule 59A (3)(e)&(7); (7); A (3)(e) FAC Proof of Financial Ability to Operate. "Financial instability" means the provider cannot meet its financial obligations. Evidence such as the issuance of bad checks, an accumulation of delinquent bills, or inability to meet current payroll needs shall constitute prima facie evidence that the ownership of the provider lacks the financial ability to operate. Evidence shall also include the Medicare or Medicaid program's indications or determination of financial instability or fraudulent handling of government funds by the provider (7) FS Definitions. "Controlling interest" means: (a) The applicant or licensee; (b) A person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the applicant or licensee; or (c) A person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the management company or other entity, related or unrelated, with which the applicant or licensee contracts to manage the provider. The term does not include a voluntary board member FS (8) Upon application for initial licensure or change of ownership licensure, the applicant shall furnish satisfactory proof of the applicant's financial ability to operate in - This standard would be used by surveyors if evidence of financial instability is found and the licensee or any controlling interest in the licensee withholds information from the surveyor. - The financial schedules and documentation of correction of the financial instability are submitted to the AHCA Home Care Unit in the state office and reviewed by AHCA state office financial reviewers in the Financial Analysis Unit. Further administrative action may be taken by the state office. - This standard applies to the following provider types: Nursing Home Facilities, as specified in Part II, Chapter 400, F.S.; Assisted Living Facilities, as specified in Part I, Chapter 429, F.S.; Home Health Agencies, as specified in Part III, Chapter 400, F.S.; Hospices, as specified in Part IV, Chapter 400, F.S.; Adult Day Care Centers, as specified in Part III, Chapter 429, F.S.; Prescribed Pediatric Extended Care Centers, as specified in Part VI, Chapter 400, F.S.; Home Medical Equipment Providers, as specified in Part VII, Chapter 400, F.S.; Intermediate Care Facilities for the Developmentally Disabled, as specified in Part VIII, Chapter 400, F.S.; Health Care Clinics, as specified in Part X, Chapter 400, F.S.; - The standard applies to Nurse Registries as specified in 59A (7) which states: - An application for renewal of a license shall not be required to provide proof of financial ability to operate, unless the applicant has demonstrated financial instability at any time, pursuant to Section , F.S., in which case AHCA shall require the applicant for renewal to provide proof of financial ability to operate by submitting information as described in 59A (7)(b), F.A.C. and documentation of correction of the financial instability, to include evidence of the payment in full of any bad checks, delinquent bills or liens and all associated fees, costs, and changes related to the instability. If complete payment cannot be made, evidence must be submitted of partial payment along with a plan for payment of any liens or delinquent bills. If the lien is with a government agency or repayment is ordered by a federal, state, or district court, an accepted plan of repayment must be provided. If the licensed nurse registry has demonstrated financial instability as outlined above at any time the AHCA will request proof of financial ability to operate. - None of the Hospital Unit Programs nor the Lab Unit Programs would have this requirement.

59 Page 59 of 80 accordance with the requirements of this part, authorizing statutes, and applicable rules. The agency shall establish standards for this purpose, including information concerning the applicant's controlling interests. The agency shall also establish documentation requirements, to be completed by each applicant, that show anticipated provider revenues and expenditures, the basis for financing the anticipated cash-flow requirements of the provider, and an applicant's access to contingency financing. A current certificate of authority, pursuant to chapter 651, may be provided as proof of financial ability to operate. The agency may require a licensee to provide proof of financial ability to operate at any time if there is evidence of financial instability, including, but not limited to, unpaid expenses necessary for the basic operations of the provider. 59A FS (7) An applicant for renewal of a license shall not be required to provide proof of financial ability to operate, unless the licensee or applicant has demonstrated financial instability. If an applicant or licensee has shown signs of financial instability, as provided in Section (9), F.S., at any time, the Agency may require the applicant or licensee to provide proof of financial ability to operate by submission of: (a) AHCA Form , July 2009, Proof of Financial Ability Form, that includes a balance sheet and income and expense statement for the next 2 years of operation which provide evidence of having sufficient assets, credit, and projected revenues to cover liabilities and expenses, and (b) Documentation of correction of the financial instability, including but not limited to, evidence of the payment of any bad checks, delinquent bills or liens. If complete payment cannot be made, evidence must be submitted of partial payment along with a plan for payment of any liens or delinquent bills. If the lien is with a government agency or repayment is ordered by a federal or state court, an accepted plan of repayment must be provided.

60 Page 60 of 80 ST - GZ812 - Change of Ownership Title Change of Ownership Statute or Rule (5); F.S (5) FS "Change of ownership" means: (a) An event in which the licensee sells or otherwise transfers its ownership to a different individual or entity as evidenced by a change in federal employer identification number or taxpayer identification number; or (b) An event in which 51 percent or more of the ownership, shares, membership, or controlling interest of a licensee is in any manner transferred or otherwise assigned. This paragraph does not apply to a licensee that is publicly traded on a recognized stock exchange. A change solely in the management company or board of directors is not a change of ownership. - This tag may be cited for unreported changes of ownership Change of ownership.-whenever a change of ownership occurs: (1) The transferor shall notify the agency in writing at least 60 days before the anticipated date of the change of ownership. (2) The transferee shall make application to the agency for a license within the timeframes required in s (3) The transferor shall be responsible and liable for: (a) The lawful operation of the provider and the welfare of the clients served until the date the transferee is licensed by the agency. (b) Any and all penalties imposed against the transferor for violations occurring before the date of change of ownership. (4) Any restriction on licensure, including a conditional

61 Page 61 of 80 license existing at the time of a change of ownership, shall remain in effect until the agency determines that the grounds for the restriction are corrected. (5) The transferee shall maintain records of the transferor as required in this part, authorizing statutes, and applicable rules, including: (a) All client records. (b) Inspection reports. (c) All records required to be maintained pursuant to s , if applicable. ST - GZ815 - Background Screening; Prohibited Offenses Title Background Screening; Prohibited Offenses Statute or Rule ; (2); FS Background screening; prohibited offenses.- (1) Level 2 background screening pursuant to chapter 435 must be conducted through the agency on each of the following persons, who are considered employees for the purposes of conducting screening under chapter 435: (a) The licensee, if an individual. (b) The administrator or a similarly titled person who is responsible for the day-to-day operation of the provider. (c) The financial officer or similarly titled individual who is responsible for the financial operation of the licensee or provider. (d) Any person who is a controlling interest if the agency has reason to believe that such person has been convicted of any offense prohibited by s For each controlling interest who has been convicted of any such offense, the licensee shall submit to the agency a description and explanation of the conviction at the time of license application. (e) Any person, as required by authorizing statutes, seeking - Employees and independent contractors hired or contracted before August 1, 2010, must be screened according to the schedule in (5), F.S. included in this standard. - Persons already hired or under contract before August 1, 2010 would have received level 1 screening. - Employees and contractors who do not meet the background screening requirements cannot be retained in a direct care capacity, unless an exemption from disqualification has been approved by AHCA or the Department of Health (when a licensed or certified health care professional or certified nursing assistant). - The employee or contractor with a disqualifying offense must have a copy of an exemption [granted by either DOH or AHCA] in their personnel file before the employee or contractor can be hired. - There is a new staggered schedule: (a) Individuals for whom the last screening was conducted on or before December 31, 2004, must be rescreened by July 31, (b) Individuals for whom the last screening conducted was between January 1, 2005, and December 31, 2008, must be rescreened by July 31, (c) Individuals for whom the last screening conducted was between January 1, 2009, through July 31, 2011, must be rescreened by July 31, An employer may hire an employee to a position that requires background screening before the employee completes the screening process for training and orientation purposes. However, the employee may not have direct contact with vulnerable persons until the screening process is completed and the employee demonstrates that he or she exhibits no

62 Page 62 of 80 employment with a licensee or provider who is expected to, or whose responsibilities may require him or her to, provide personal care or services directly to clients or have access to client funds, personal property, or living areas; and any person, as required by authorizing statutes, contracting with a licensee or provider whose responsibilities require him or her to provide personal care or personal services directly to clients. Evidence of contractor screening may be retained by the contractor's employer or the licensee. (3) All fingerprints must be provided in electronic format. Screening results shall be reviewed by the agency with respect to the offenses specified in s and this section, and the qualifying or disqualifying status of the person named in the request shall be maintained in a database. The qualifying or disqualifying status of the person named in the request shall be posted on a secure website for retrieval by the licensee or designated agent on the licensee's behalf. (4) In addition to the offenses listed in s , all persons required to undergo background screening pursuant to this part or authorizing statutes must not have an arrest awaiting final disposition for, must not have been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, and must not have been adjudicated delinquent and the record not have been sealed or expunged for any of the following offenses or any similar offense of another jurisdiction: (a) Any authorizing statutes, if the offense was a felony. (b) This chapter, if the offense was a felony. (c) Section , relating to Medicaid provider fraud. (d) Section , relating to Medicaid fraud. (e) Section , relating to domestic violence. (f) Section , relating to attempts, solicitation, and conspiracy to commit an offense listed in this subsection. (g) Section , relating to fraudulent acts through mail, behaviors that warrant the denial or termination of employment. - Individuals may be provisionally employed in positions requiring background screening. They may be in training or orientation, but may NOT have access to residents/patients until the background screening process is completed. - An employer of persons subject to screening by a specified agency must register with the clearinghouse and maintain the employment status of all employees within the clearinghouse. Initial employment status and any changes in status must be reported within 10 business days. - If an individual is in the Clearinghouse and are working then they must be on that provider's employee roster within 10 days of their hire date. The same for once a person is no longer working for that provider. If they are in the Clearinghouse then their status in the employee roster must be updated within 10 days of a change. Surveyor Probes: - Level 2 includes FDLE and FBI screening. - Staff who do not have access to client property, funds, or living areas or who do not have contact with clients are not required to be screened. - If an employee or contractor's responsibility requires him or her to have contact with clients, a Level 2 background screening is required. - Was the employee or contractor hired on or after August 1, 2010? - Does the licensee have evidence of contractor and employee screening?

63 Page 63 of 80 wire, radio, electromagnetic, photoelectronic, or photooptical systems. (h) Section , relating to false and fraudulent insurance claims. (i) Section , relating to obtaining goods by using a false or expired credit card or other credit device, if the offense was a felony. (j) Section , relating to fraudulently obtaining goods or services from a health care provider. (k) Section , relating to patient brokering. (l) Section , relating to criminal use of personal identification information. (m) Section , relating to obtaining a credit card through fraudulent means. (n) Section , relating to fraudulent use of credit cards, if the offense was a felony. (o) Section , relating to forgery. (p) Section , relating to uttering forged instruments. (q) Section , relating to forging bank bills, checks, drafts, or promissory notes. (r) Section , relating to uttering forged bank bills, checks, drafts, or promissory notes. (s) Section , relating to fraud in obtaining medicinal drugs. (t) Section , relating to the sale, manufacture, delivery, or possession with the intent to sell, manufacture, or deliver any counterfeit controlled substance, if the offense was a felony. (u) Section , relating to racketeering and collection of unlawful debts. (v) Section , relating to the Florida Money Laundering Act. If, upon rescreening, a person who is currently employed or contracted with a licensee as of June 30, 2014, and was screened and qualified under ss and , has a

64 Page 64 of 80 disqualifying offense that was not a disqualifying offense at the time of the last screening, but is a current disqualifying offense and was committed before the last screening, he or she may apply for an exemption from the appropriate licensing agency and, if agreed to by the employer, may continue to perform his or her duties until the licensing agency renders a decision on the application for exemption if the person is eligible to apply for an exemption and the exemption request is received by the agency no later than 30 days after receipt of the rescreening results by the person. (5) A person who serves as a controlling interest of, is employed by, or contracts with a licensee on July 31, 2010, who has been screened and qualified according to standards specified in s or s must be rescreened by July 31, 2015, in compliance with the following schedule. If, upon rescreening, such person has a disqualifying offense that was not a disqualifying offense at the time of the last screening, but is a current disqualifying offense and was committed before the last screening, he or she may apply for an exemption from the appropriate licensing agency and, if agreed to by the employer, may continue to perform his or her duties until the licensing agency renders a decision on the application for exemption if the person is eligible to apply for an exemption and the exemption request is received by the agency within 30 days after receipt of the rescreening results by the person. The rescreening schedule shall be: (a) Individuals for whom the last screening was conducted on or before December 31, 2004, must be rescreened by July 31, (b) Individuals for whom the last screening conducted was between January 1, 2005, and December 31, 2008, must be rescreened by July 31, (c) Individuals for whom the last screening conducted was between January 1, 2009, through July 31, 2011, must be rescreened by July 31, 2015.

65 Page 65 of 80 (6) The costs associated with obtaining the required screening must be borne by the licensee or the person subject to screening. Licensees may reimburse persons for these costs. The Department of Law Enforcement shall charge the agency for screening pursuant to s (3). The agency shall establish a schedule of fees to cover the costs of screening. (7)(a) As provided in chapter 435, the agency may grant an exemption from disqualification to a person who is subject to this section and who: 1. Does not have an active professional license or certification from the Department of Health; or 2. Has an active professional license or certification from the Department of Health but is not providing a service within the scope of that license or certification. (b) As provided in chapter 435, the appropriate regulatory board within the Department of Health, or the department itself if there is no board, may grant an exemption from disqualification to a person who is subject to this section and who has received a professional license or certification from the Department of Health or a regulatory board within that department and that person is providing a service within the scope of his or her licensed or certified practice. (8) The agency and the Department of Health may adopt rules pursuant to ss (1) and to implement this section, chapter 435, and authorizing statutes requiring background screening and to implement and adopt criteria relating to retaining fingerprints pursuant to s (2). (9) There is no reemployment assistance or other monetary liability on the part of, and no cause of action for damages arising against, an employer that, upon notice of a disqualifying offense listed under chapter 435 or this section, terminates the person against whom the report was issued, whether or not that person has filed for an exemption with the Department of Health or the agency.

66 Page 66 of Exclusion from employment.- (1) If an employer or agency has reasonable cause to believe that grounds exist for the denial or termination of employment of any employee as a result of background screening, it shall notify the employee in writing, stating the specific record that indicates noncompliance with the standards in this chapter. It is the responsibility of the affected employee to contest his or her disqualification or to request exemption from disqualification. The only basis for contesting the disqualification is proof of mistaken identity. (2)(a) An employer may not hire, select, or otherwise allow an employee to have contact with any vulnerable person that would place the employee in a role that requires background screening until the screening process is completed and demonstrates the absence of any grounds for the denial or termination of employment. If the screening process shows any grounds for the denial or termination of employment, the employer may not hire, select, or otherwise allow the employee to have contact with any vulnerable person that would place the employee in a role that requires background screening unless the employee is granted an exemption for the disqualification by the agency as provided under s (b) If an employer becomes aware that an employee has been arrested for a disqualifying offense, the employer must remove the employee from contact with any vulnerable person that places the employee in a role that requires background screening until the arrest is resolved in a way that the employer determines that the employee is still eligible for employment under this chapter. (c) The employer must terminate the employment of any of its personnel found to be in noncompliance with the minimum standards of this chapter or place the employee in a position for which background screening is not required unless the employee is granted an exemption from disqualification pursuant to s

67 Page 67 of 80 (d) An employer may hire an employee to a position that requires background screening before the employee completes the screening process for training and orientation purposes. However, the employee may not have direct contact with vulnerable persons until the screening process is completed and the employee demonstrates that he or she exhibits no behaviors that warrant the denial or termination of employment. (3) Any employee who refuses to cooperate in such screening or refuses to timely submit the information necessary to complete the screening, including fingerprints if required, must be disqualified for employment in such position or, if employed, must be dismissed. (4) There is no reemployment assistance or other monetary liability on the part of, and no cause of action for damages against, an employer that, upon notice of a conviction or arrest for a disqualifying offense listed under this chapter, terminates the person against whom the report was issued or who was arrested, regardless of whether or not that person has filed for an exemption pursuant to this chapter Definitions.-For the purposes of this chapter, the term: (2) "Employee" means any person required by law to be screened pursuant to this chapter, including, but not limited to, persons who are contractors, licensees, or volunteers. ST - GZ816 - Background Screening-Compliance Attestation Title Background Screening-Compliance Attestation Statute or Rule (2)(a-c) FS (2) Every 5 years following his or her licensure, employment, or entry into a contract in a capacity that under subsection (1) would require level 2 background screening under chapter - Is AHCA Recommended Form , September 2013, Affidavit of Compliance with Background Screening Requirements, in the employee's personnel file? - Or, does the employee have a similar document attesting under penalty of perjury that they are in compliance with

68 Page 68 of , each such person must submit to level 2 background rescreening as a condition of retaining such license or continuing in such employment or contractual status. For any such rescreening, the agency shall request the Department of Law Enforcement to forward the person's fingerprints to the Federal Bureau of Investigation for a national criminal history record check unless the person's fingerprints are enrolled in the Federal Bureau of Investigation ' s national retained print arrest notification program. If the fingerprints of such a person are not retained by the Department of Law Enforcement under s (2)(g) and (h), the person must submit fingerprints electronically to the Department of Law Enforcement for state processing, and the Department of Law Enforcement shall forward the fingerprints to the Federal Bureau of Investigation for a national criminal history record check. The fingerprints shall be retained by the Department of Law Enforcement under s (2)(g) and (h) and enrolled in the national retained print arrest notification program when the Department of Law Enforcement begins participation in the program. The cost of the state and national criminal history records checks required by level 2 screening may be borne by the licensee or the person fingerprinted. Until a specified agency is fully implemented in the clearinghouse created under s , the agency may accept as satisfying the requirements of this section proof of compliance with level 2 screening standards submitted within the previous 5 years to meet any provider or professional licensure requirements of the agency, the Department of Health, the Department of Elderly Affairs, the Agency for Persons with Disabilities, the Department of Children and Families, or the Department of Financial Services for an applicant for a certificate of authority or provisional certificate of authority to operate a continuing care retirement community under chapter 651, provided that: (a) The screening standards and disqualifying offenses for the prior screening are equivalent to those specified in s Chapter 435, F.S.

69 Page 69 of 80 and this section; (b) The person subject to screening has not had a break in service from a position that requires level 2 screening for more than 90 days; and (c) Such proof is accompanied, under penalty of perjury, by an attestation of compliance with chapter 435 and this section using forms provided by the agency. ST - GZ817 - Minimum Licensure Requirement - Inform AHCA Title Minimum Licensure Requirement - Inform AHCA Statute or Rule (3-4) FS; 59A (1) FAC Minimum licensure requirements.-in addition to the licensure requirements specified in this part, authorizing statutes, and applicable rules, each applicant and licensee must comply with the requirements of this section in order to obtain and maintain a license. (3) Unless otherwise specified in this part, authorizing statutes, or applicable rules, any information required to be reported to the agency must be submitted within 21 calendar days after the report period or effective date of the information, whichever is earlier, including, but not limited to, any change of: (a) Information contained in the most recent application for licensure. (b) Required insurance or bonds. (4) Whenever a licensee discontinues operation of a provider: (a) The licensee must inform the agency not less than 30 days prior to the discontinuance of operation and inform clients of such discontinuance as required by authorizing statutes. Immediately upon discontinuance of operation by a provider, the licensee shall surrender the license to the agency and the - Refer to s , F.S. regarding the Exemptions for this regulation. - Regarding Nursing Homes, note that the closing of a nursing facility ( (4)(a)) must comply with (1), F.S. instead which states: (1) Whenever a licensee voluntarily discontinues operation, and during the period when it is preparing for such discontinuance, it shall inform the agency not less than 90 days prior to the discontinuance of operation. The licensee also shall inform the resident or the next of kin, legal representative, or agency acting on behalf of the resident of the fact, and the proposed time, of such discontinuance and give at least 90 days' notice so that suitable arrangements may be made for the transfer and care of the resident. In the event any resident has no such person to represent him or her, the licensee shall be responsible for securing a suitable transfer of the resident before the discontinuance of operation. The agency shall be responsible for arranging for the transfer of those residents requiring transfer who are receiving assistance under the Medicaid program.

70 Page 70 of 80 license shall be canceled. (b) The licensee shall remain responsible for retaining and appropriately distributing all records within the timeframes prescribed in authorizing statutes and applicable rules. In addition, the licensee or, in the event of death or dissolution of a licensee, the estate or agent of the licensee shall: 1. Make arrangements to forward records for each client to one of the following, based upon the client's choice: the client or the client's legal representative, the client's attending physician, or the health care provider where the client currently receives services; or 2. Cause a notice to be published in the newspaper of greatest general circulation in the county in which the provider was located that advises clients of the discontinuance of the provider operation. The notice must inform clients that they may obtain copies of their records and specify the name, address, and telephone number of the person from whom the copies of records may be obtained. The notice must appear at least once a week for 4 consecutive weeks. 59A Minimum Licensure Requirements. Provider location. A licensee must maintain proper authority for operation of the provider at the address of record. If such authority is denied, revoked or otherwise terminated by the local zoning or code enforcement authority, the Agency may deny or revoke an application or license, or impose sanctions. ST - GZ818 - Minimum Licensure Requirement - Client Notice Title Minimum Licensure Requirement - Client Notice Statute or Rule (5) FS Minimum licensure requirements. In addition to the licensure requirements specified in this part, - Refer to s , F.S. regarding the Exemptions for this regulation.

71 Page 71 of 80 authorizing statutes, and applicable rules, each applicant and licensee must comply with the requirements of this section in order to obtain and maintain a license. (5)(a) On or before the first day services are provided to a client, a licensee must inform the client and his or her immediate family or representative, if appropriate, of the right to report: 1. Complaints. The statewide toll-free telephone number for reporting complaints to the agency must be provided to clients in a manner that is clearly legible and must include the words: "To report a complaint regarding the services you receive, please call toll-free (phone number)." 2. Abusive, neglectful, or exploitative practices. The statewide toll-free telephone number for the central abuse hotline must be provided to clients in a manner that is clearly legible and must include the words: "To report abuse, neglect, or exploitation, please call toll-free (phone number)." 3. Medicaid fraud. An agency-written description of Medicaid fraud and the statewide toll-free telephone number for the central Medicaid fraud hotline must be provided to clients in a manner that is clearly legible and must include the words: "To report suspected Medicaid fraud, please call toll-free (phone number)." The agency shall publish a minimum of a 90-day advance notice of a change in the toll-free telephone numbers. (b) Each licensee shall establish appropriate policies and procedures for providing such notice to clients. ST - GZ819 - Minimum Licensure Req - Financial Viability Title Minimum Licensure Req - Financial Viability Statute or Rule (9) FS

72 Page 72 of FS (9) A controlling interest may not withhold from the agency any evidence of financial instability, including, but not limited to, checks returned due to insufficient funds, delinquent accounts, nonpayment of withholding taxes, unpaid utility expenses, nonpayment for essential services, or adverse court action concerning the financial viability of the provider or any other provider licensed under this part that is under the control of the controlling interest. A controlling interest shall notify the agency within 10 days after a court action to initiate bankruptcy, foreclosure, or eviction proceedings concerning the provider in which the controlling interest is a petitioner or defendant. Any person who violates this subsection commits a misdemeanor of the second degree, punishable as provided in s or s Each day of continuing violation is a separate offense. - Refer to s , F.S. regarding the Exemptions for this regulation. ST - GZ821 - Reporting Requirements; Electronic Submission Title Reporting Requirements; Electronic Submission Statute or Rule 59A , FAC 59A Reporting Requirements; Electronic Submission. (1) During the two year licensure period, any change or expiration of any information that is required to be reported under Chapter 408, Part II, F.S., or authorizing statutes for the provider type as specified in Section (3), F.S., during the license application process must be reported to the Agency within 21 days of occurrence of the change, including: (a) Insurance coverage renewal, (b) Bond renewal, - Regarding 59A (1)(f), this does not apply to Home Care Unit programs since there is a different process through the Department of Health in chapter 400 Part III & IV, F.S. - Regarding 59A (2), this only applies to nursing homes and assisted living facilities.

73 Page 73 of 80 (c) Change of administrator or the similarly titled person who is responsible for the day-to-day operation of the provider, (d) Annual sanitation inspections, (e) Fire inspections, (f) Approval of revisions to emergency management plans. (2) Electronic submission of information. (a) The following required information must be reported through the Agency's Internet site at 1. Nursing homes: a. Semi-annual staffing ratios required pursuant to Section (1)(o), F.S. and Rule 59A-4.103, F.A.C. b. Adverse incident reports required pursuant to Sections (7) and (8), F.S. and Rule 59A-4.123, F.A.C. c. Liability claim reports required pursuant to Section (10), F.S. and Rule 59A-4.123, F.A.C. 2. Assisted living facilities: a. Adverse incident reports required pursuant to Sections (3) and (4), F.S. and Rule 58A , F.A.C. b. Liability claim reports required pursuant to Section (5), F.S. and Rule 58A , F.A.C. (b) The licensee must retain the receipt issued from the Internet site indicating that their transaction was accepted. (c) If the Agency's Internet site is temporarily out of service, the required reports may be submitted by mail or facsimile as follows: 1. Semi-annual staffing ratios and liability claim reports are sent to the Agency for Health Care Administration, Central Systems Management Unit, 2727 Mahan Drive, MS #47, Tallahassee, FL or facsimile to (850) Adverse incident reports are sent to the Agency for Health Care Administration, Florida Center for Health Information and Policy Analysis, 2727 Mahan Drive, MS #16, Tallahassee, FL or facsimile to (850)

74 Page 74 of 80 ST - GZ824 - Right of Inspection; Inspection Reports Title Right of Inspection; Inspection Reports Statute or Rule , F.S., 59A , F.A.C Right of inspection; copies; inspection reports; plan for correction of deficiencies.- (1) An authorized officer or employee of the agency may make or cause to be made any inspection or investigation deemed necessary by the agency to determine the state of compliance with this part, authorizing statutes, and applicable rules. The right of inspection extends to any business that the agency has reason to believe is being operated as a provider without a license, but inspection of any business suspected of being operated without the appropriate license may not be made without the permission of the owner or person in charge unless a warrant is first obtained from a circuit court. Any application for a license issued under this part, authorizing statutes, or applicable rules constitutes permission for an appropriate inspection to verify the information submitted on or in connection with the application. (a) All inspections shall be unannounced, except as specified in s (b) Inspections for relicensure shall be conducted biennially unless otherwise specified by authorizing statutes or applicable rules. (2) Inspections conducted in conjunction with certification, comparable licensure requirements, or a recognized or approved accreditation organization may be accepted in lieu of a complete licensure inspection. However, a licensure inspection may also be conducted to review any licensure requirements that are not also requirements for certification. (3) The agency shall have access to and the licensee shall

75 Page 75 of 80 provide, or if requested send, copies of all provider records required during an inspection or other review at no cost to the agency, including records requested during an offsite review. (4) A deficiency must be corrected within 30 calendar days after the provider is notified of inspection results unless an alternative timeframe is required or approved by the agency. (5) The agency may require an applicant or licensee to submit a plan of correction for deficiencies. If required, the plan of correction must be filed with the agency within 10 calendar days after notification unless an alternative timeframe is required. (6)(a) Each licensee shall maintain as public information, available upon request, records of all inspection reports pertaining to that provider that have been filed by the agency unless those reports are exempt from or contain information that is exempt from s (1) and s. 24(a), Art. I of the State Constitution or is otherwise made confidential by law. Effective October 1, 2006, copies of such reports shall be retained in the records of the provider for at least 3 years following the date the reports are filed and issued, regardless of a change of ownership. (b) A licensee shall, upon the request of any person who has completed a written application with intent to be admitted by such provider, any person who is a client of such provider, or any relative, spouse, or guardian of any such person, furnish to the requester a copy of the last inspection report pertaining to the licensed provider that was issued by the agency or by an accrediting organization if such report is used in lieu of a licensure inspection. 59A Inspections. (1) When regulatory violations are identified by the Agency: (a) Deficiencies must be corrected within 30 days of the date the Agency sends the deficiency notice to the provider, unless an alternative timeframe is required or approved by the

76 Page 76 of 80 Agency. (b) The Agency may conduct an unannounced follow-up inspection or off-site review to verify correction of deficiencies at any time. (2) If an inspection is completed through off-site record review, any records requested by the Agency in conjunction with the review, must be received within 7 days of request and provided at no cost to the Agency. Each licensee shall maintain the records including medical and treatment records of a client and provide access to the Agency. (3) Providers that are exempt from Agency inspections due to accreditation oversight as prescribed in authorizing statutes must provide: (a) Documentation from the accrediting agency including the name of the accrediting agency, the beginning and expiration dates of the provider's accreditation, accreditation status and type must be submitted at the time of license application, or within 21 days of accreditation. (b) Documentation of each accreditation inspection including the accreditation organization's report of findings, the provider's response and the final determination must be submitted within 21 days of final determination or the provider is no longer exempt from Agency inspection. ST - GZ827 - Unlicensed Activity Title Unlicensed Activity Statute or Rule , F.S Unlicensed activity.- (1) A person or entity may not offer or advertise services that require licensure as defined by this part, authorizing statutes, or applicable rules to the public without obtaining a valid license from the agency. A licenseholder may not advertise or - This tag can be cited in conjunction with Z0803 License Required; Display, F.S. - License required when the provider is offering services not authorized and printed on the face of the license, when the licensed owner is not operating and it is being operated by another entity that is not licensed to operate. - It may also be cited if the Agency has notified the provider to cease unlicensed activity and the provider continues to operate.

77 Page 77 of 80 hold out to the public that he or she holds a license for other than that for which he or she actually holds the license. (2) The operation or maintenance of an unlicensed provider or the performance of any services that require licensure without proper licensure is a violation of this part and authorizing statutes. Unlicensed activity constitutes harm that materially affects the health, safety, and welfare of clients. The agency or any state attorney may, in addition to other remedies provided in this part, bring an action for an injunction to restrain such violation, or to enjoin the future operation or maintenance of the unlicensed provider or the performance of any services in violation of this part and authorizing statutes, until compliance with this part, authorizing statutes, and agency rules has been demonstrated to the satisfaction of the agency. (3) It is unlawful for any person or entity to own, operate, or maintain an unlicensed provider. If after receiving notification from the agency, such person or entity fails to cease operation and apply for a license under this part and authorizing statutes, the person or entity shall be subject to penalties as prescribed by authorizing statutes and applicable rules. Each day of continued operation is a separate offense. (4) Any person or entity that fails to cease operation after agency notification may be fined $1,000 for each day of noncompliance. (5) When a controlling interest or licensee has an interest in more than one provider and fails to license a provider rendering services that require licensure, the agency may revoke all licenses and impose actions under s and a fine of $1,000 per day, unless otherwise specified by authorizing statutes, against each licensee until such time as the appropriate license is obtained for the unlicensed operation. (6) In addition to granting injunctive relief pursuant to subsection (2), if the agency determines that a person or entity is operating or maintaining a provider without obtaining a

78 Page 78 of 80 license and determines that a condition exists that poses a threat to the health, safety, or welfare of a client of the provider, the person or entity is subject to the same actions and fines imposed against a licensee as specified in this part, authorizing statutes, and agency rules. (7) Any person aware of the operation of an unlicensed provider must report that provider to the agency. ST - GZ829 - Moratorium; Emergency Suspension Title Moratorium; Emergency Suspension Statute or Rule , FS Moratorium; emergency suspension.- (1) The agency may impose an immediate moratorium or emergency suspension as defined in s on any provider if the agency determines that any condition related to the provider or licensee presents a threat to the health, safety, or welfare of a client. (2) A provider or licensee, the license of which is denied or revoked, may be subject to immediate imposition of a moratorium or emergency suspension to run concurrently with licensure denial, revocation, or injunction. (3) A moratorium or emergency suspension remains in effect after a change of ownership, unless the agency has determined that the conditions that created the moratorium, emergency suspension, or denial of licensure have been corrected. (4) When a moratorium or emergency suspension is placed on a provider or licensee, notice of the action shall be posted and visible to the public at the location of the provider until the action is lifted.

79 Page 79 of 80 ST - GZ830 - Emergency Management Planning Title Emergency Management Planning Statute or Rule , F.S Emergency management planning; emergency operations; inactive license.- (1) A licensee required by authorizing statutes to have an emergency operations plan must designate a safety liaison to serve as the primary contact for emergency operations. (2) An entity subject to this part may temporarily exceed its licensed capacity to act as a receiving provider in accordance with an approved emergency operations plan for up to 15 days. While in an overcapacity status, each provider must furnish or arrange for appropriate care and services to all clients. In addition, the agency may approve requests for overcapacity in excess of 15 days, which approvals may be based upon satisfactory justification and need as provided by the receiving and sending providers. (3)(a) An inactive license may be issued to a licensee subject to this section when the provider is located in a geographic area in which a state of emergency was declared by the Governor if the provider: 1. Suffered damage to its operation during the state of emergency. 2. Is currently licensed. 3. Does not have a provisional license. 4. Will be temporarily unable to provide services but is reasonably expected to resume services within 12 months. (b) An inactive license may be issued for a period not to exceed 12 months but may be renewed by the agency for up to 12 additional months upon demonstration to the agency of progress toward reopening. A request by a licensee for an - Four of the Home Care programs have major state laws that have extensive emergency management requirements - home health agencies, hospices, nurse registries and home medical equipment providers - and their associated regulation sets have specific standards.

80 Page 80 of 80 inactive license or to extend the previously approved inactive period must be submitted in writing to the agency, accompanied by written justification for the inactive license, which states the beginning and ending dates of inactivity and includes a plan for the transfer of any clients to other providers and appropriate licensure fees. Upon agency approval, the licensee shall notify clients of any necessary discharge or transfer as required by authorizing statutes or applicable rules. The beginning of the inactive licensure period shall be the date the provider ceases operations. The end of the inactive period shall become the license expiration date, and all licensure fees must be current, must be paid in full, and may be prorated. Reactivation of an inactive license requires the prior approval by the agency of a renewal application, including payment of licensure fees and agency inspections indicating compliance with all requirements of this part and applicable rules and statutes. (4) The agency may adopt rules relating to emergency management planning, communications, and operations. Licensees providing residential or inpatient services must utilize an online database approved by the agency to report information to the agency regarding the provider's emergency status, planning, or operations.