Chapter 59A-18- Nurse Registries Standards and Licensing.

CHAPTER 59A-18

NURSE REGISTRIES STANDARDS AND LICENSING

59A-18.001 Purpose (Repealed)

59A-18.002 Definitions

59A-18.004 Licensure Requirements, Procedures, and Fees

59A-18.005 Registration Policies

59A-18.006 Administrator

59A-18.007 Registered Nurse and Licensed Practical Nurse

59A-18.0081 Certified Nursing Assistant and Home Health Aide

59A-18.009 Homemakers or Companions

59A-18.010 Acceptance of Patients or Clients

59A-18.011 Medical Plan of Treatment 

59A-18.012 Clinical Records

59A-18.013 Administration of Drugs and Biologicals

59A-18.015 Surveys and Inspections (Repealed)

59A-18.016 Penalties (Repealed)

59A-18.017 Supplemental Staffing for Health Care Facilities

59A-18.018 Emergency Management Plans

59A-18.001 Purpose.

Rulemaking Authority 400.497, 400.506 FS. Law Implemented 400.497, 400.506 FS. History–New 2-9-93, Amended 12-24-00, Repealed 5-14-12.

59A-18.002 Definitions.

When used in this rule chapter, unless the context otherwise requires, the term:

(1) “AHCA” means Agency for Health Care Administration.

(2) “Assistance with activities of daily living” means a certified nursing assistant or a home health aide providing an individual assistance with activities promoting self-care and independence, to include the following:

(a) Ambulation. Providing physical support to enable the patient to move about within or outside of the patient’s place of residence. Physical support includes holding the patient’s hand, elbow, under the arm, or holding on to a support belt worn by the patient to assist in providing stability or direction while the patient ambulates.

(b) Bathing. Helping the patient in and out of the bathtub or shower, adjusting water temperatures, washing and drying portions of the body which are difficult for the patient to reach, and being available while the patient is bathing. Can also include washing and drying the patient who is bed-bound.

(c) Dressing. Helping the patient put on and remove clothing.

(d) Eating. Helping with feeding patients who require assistance with feeding themselves.

(e) Personal hygiene. Helping the patient with shaving and with oral, hair, skin and nail care.

(f) Toileting. Reminding the patient about using the toilet, assisting to the bathroom, helping to undress, positioning on the commode, and helping with related personal hygiene, including assistance with changing of an adult brief. Also includes assisting with positioning the patient on the bedpan, and helping with related personal hygiene.

(g) Assistance with physical transfer. Providing verbal and physical cueing, physical assistance, or both while the patient moves from one position to another, for example between the following: a bed, chair, wheelchair, commode, bathtub or shower, or a standing position. Transfer can also include use of a mechanical lift, if a home health aide or CNA is trained in its use.

(3) “Caregiver” means a registered nurse, licensed practical nurse, certified nursing assistant, home health aide, homemaker or companion that is referred by a nurse registry to provide services to patients.

(4) “Entity” means a partnership, corporation, or other business organization.

(5) “Financial instability” means the nurse registry cannot meet its financial obligation. The issuance of bad checks or an accumulation of delinquent bills or liens or failure to pay any outstanding fines unless the fine has been appealed is evidence of financial instability.

(6) “Geographic Service Area” means one or more of the counties within the health service planning district, as specified on the license, in which the nurse registry may refer its independent contractors to provide services to patients or clients in their homes or to provide staffing in facilities.

(7) “Independent Contractor” means a person who contracts through a referral from a nurse registry. The independent contractor maintains control over the method and means of delivering the services provided, and is responsible for the performance of such services. An independent contractor is not an employee of the nurse registry.

(8) “Licensed Practical Nurse,” as defined in section 464.003(16), F.S., means a person who is currently licensed to practice nursing pursuant to chapter 464, F.S.

(9) “Main Office” means the primary office established in a geographic service area which houses all components of the nurse registry operational site including the administration, fiscal management, service provision and supplies.

(10) “Nurse registry services” means referral of independent contractors to provide health care related services to a patient or client in the person’s home or place of residence or through staffing in a health care facility by an independent contractor referred through a nurse registry. Such services shall be limited to:

(a) Nursing care provided by licensed registered nurses or licensed practical nurses, or

(b) Care and services provided by certified nursing assistants or home health aides, or

(c) Homemaker or companion services.

(11) “Plan of treatment” means written plan of care and treatment, including a medical plan of treatment, signed within 30 days by the physician, advanced practice registered nurse, or physician assistant to assure the delivery of safe and adequate care provided by a licensed nurse to a patient in the home.

(12) “Registered Nurse,” as defined in section 464.003(22), F.S., means a person who is currently licensed to practice pursuant to chapter 464, F.S.

Rulemaking Authority 400.497, 400.506 FS. Law Implemented 400.497, 400.506 FS. History–New 2-9-93, Amended 1-27-94, 12-24-00, 3-15-07, 5-4-15, 8-9-16.

59A-18.004 Licensure Requirements, Procedures, and Fees.

(1) In order to operate a nurse registry as defined under section 400.462, F.S., the owner shall make application for a license on the Health Care Licensing Application, Nurse Registry, AHCA Form 3110-7004, March 2016, incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-07162, and the Health Care Licensing Application Addendum prescribed in subsection 59A-35.060(1), F.A.C. Applicants for renewal of a nurse registry license may submit the Health Care Licensing Online Application, Nurse Registry, AHCA Form 3110-7004OL, March 2016, incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-07163. The application forms are available online at: http://ahca.myflorida.com/HQAlicensureforms or, for online renewal submissions, at: http://apps.ahca.myflorida.com/SingleSignOnPortal. The application shall be accompanied by a $2,000 licensure fee. The application and other pertinent information can be obtained at the AHCA website: http://ahca.myflorida.com/HQAlicensureforms. The receipt of a license from AHCA shall be based upon compliance with all applicable rules and laws, as evidenced by a signed application and upon the results of a survey conducted by AHCA representatives.

(2) For renewal and change of ownership licensure, the application forms and licensure fee in subsection (1) must be submitted as required in section 408.806(2), F.S.

(3) A license shall not be granted to anyone under 18 years of age.

(4) Evidence of financial ability to operate for initial licensure and change of ownership applications must be submitted with the application, which shall consist of the completion of the financial schedules contained in a form as prescribed in subsection 59A-35.062(2), F.A.C.

(5) Satellite offices – A satellite office shares administration, fiscal management, and services with the main operational site; it is not separately licensed and is exempt from the requirements in paragraphs 59A-18.004(9)(a) and (b), F.A.C. A satellite office must be listed on the license of the nurse registry operational site. A nurse registry that operates a satellite office must:

(a) Maintain a system of communication and integration of services between the nurse registry operational site and the satellite office;

(b) Provide access to patient records at the satellite office;

(c) Ensure periodic onsite visits to each satellite office by the nurse registry’s administrator;

(d) Make the satellite office’s hours of operation available to the public if different than the hours of operation maintained by the nurse registry operational site.

(6) Evidence of compliance with local zoning authorities for the main operational site of the nurse registry and any satellite offices must be submitted with the application.

(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 health services planning district, pursuant to sections 408.032(5) and 400.497(9), F.S., in which the main operational site is located. However, any agency holding a current nurse registry license from AHCA, as of December 24, 2000, may continue to serve patients or clients in those counties listed on its current license.

(8) If a change of address is to occur, or if a nurse registry intends to change the counties served within the geographic service area, or open or close a satellite office, the nurse registry must complete and submit the Health Care Licensing Application, Nurse Registry, AHCA Form 3110-7004, March 2016, within the timeframe prescribed in paragraph 59A-35.040(2)(b), F.A.C. For changes of address and addition of satellite offices, the nurse registry must submit, with the application, evidence that the location is zoned for a nurse registry for the new address and evidence of legal right to occupy the property in accordance with sections 400.506(1)(c) and 408.810(6), F.S.

(9) A nurse registry has the following responsibility in terms of hours of operation:

(a) The nurse registry administrator, or his alternate, must be available to the public for any eight consecutive hours between 7:00 a.m. and 6:00 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 paragraph 59A-18.004(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 telecommunications during the designated business hours. This individual can be a clerical staff person.

(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.

(d) The nurse registry shall provide to the patient or the patient’s representative a list of telephone numbers to be called if a replacement caregiver is needed along with local emergency numbers as determined by the nurse registry.

Rulemaking Authority 400.497, 400.506, 408.810(8), 408.819 FS. Law Implemented 400.497, 400.506, 400.512, 408.806, 408.809, 408.810, 408.811 FS. History–New 2-9-93, Amended 1-27-94, 12-24-00, 8-10-06, 3-15-07, 5-4-15, 8-9-16.

59A-18.005 Registration Policies.

(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 email or other means of electronic communication.

(a) Registered nurses and licensed practical nurses shall receive for their use and reference:

1. Rule 59A-18.005, F.A.C., Registration Policies.
2. Rule 59A-18.007, F.A.C., Registered Nurses and Licensed Practical Nurses.
3. Rule 59A-18.011, F.A.C., Medical Plan of Treatment.
4. Rule 59A-18.012, F.A.C., Clinical Records.
5. Rule 59A-18.013, F.A.C., Administration of Biologicals.
6. Sections 400.506, 408.809, 400.484, 400.462, 400.488 and 408.810(5), F.S., with the telephone numbers referred to in the law.
7. Rule 59A-18.018, F.A.C., Emergency Management Plans.

(b) Certified nursing assistants and home health aides shall receive for their use and reference:

1. Rule 59A-18.005, F.A.C., Registration Policies.
2. Rule 59A-18.0081, F.A.C., Certified Nursing Assistant and Home Health Aide.
3. Sections 400.506, 408.809, 400.484, 400.462, 400.488 and 408.810(5), F.S., with the telephone numbers referred to in the law.
4. Rule 59A-18.018, F.A.C., Emergency Management Plans.

(c) Homemakers and Companions shall receive for their use and reference:

1. Rule 59A-18.009, F.A.C., Homemakers or Companions.
2. Sections 400.506, 408.809, 400.484, 400.462 and 408.810(5), F.S., with the telephone numbers referred to in the law.
3. Rule 59A-18.018, F.A.C., Emergency Management Plans.
4. Rule 59A-18.005, F.A.C., Registration Policies.

(2) Each nurse registry shall establish written procedures for the selection, documentation, screening and verification of credentials for each independent contractor referred by the registry.

(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 website 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 400.506(19), F.S. This includes reporting the individual to the Florida Board of Nursing, Department of Health as specified at its website: http://www.floridahealth.gov/licensing-and-regulation/enforcement/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.

(6) 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 chapters 458 or 459, F.S., a physician’s assistant, or an advanced practice registered nurse 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.

(7) Registration folders on each independent contractor must contain the information required in section 400.506(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 408.809(4), F.S.; and,

(8) Each nurse registry shall establish a system for the recording complaints involving individuals they refer. If the complaints are violations of state law, the nurse registry shall take the actions specified in section 400.506(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.

Rulemaking Authority 400.497, 400.506 FS. Law Implemented 400.497, 400.506 FS. History–New 2-9-93, Amended 1-27-94, 12-24-00, 8-10-06, 3-15-07, 5-4-15.

59A-18.006 Administrator.

The administrator of the nurse registry shall:

(1) Be a licensed physician, an advanced practice registered nurse, 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;

(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-18.004(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-18.006(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 400.506(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 400.506(6)(c), F.S.

Rulemaking Authority 400.497, 400.506 FS. Law Implemented 400.497, 400.506 FS. History–New 2-9-93, Amended 1-27-94, 12-24-00, 5-4-15.

59A-18.007 Registered Nurse and Licensed Practical Nurse.

The registered nurse and the licensed practical nurse shall:

(1) Be responsible for the clinical records for their patients. 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.

Rulemaking Authority 400.497, 400.506 FS. Law Implemented 400.497, 400.506 FS. History–New 2-9-93, Amended 1-27-94, 12-24-00, 5-4-15.

59A-18.0081 Certified Nursing Assistant and Home Health Aide.

The certified nursing assistant (C.N.A.) and the home health aide shall:

(1) Be limited to assisting a patient in accordance with section 400.506(6)(b), F.S.;

(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.

(7) For every CNA, a nurse registry shall have on file a copy of the person’s State of Florida certification.

(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 least forty hours of home health aide training, pursuant to section 400.506(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.

(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 chapter 464, part II, F.S.

(10) Home health aides registered with the nurse registry since the effective date of this rule 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.

(11) CNAs and home health aides referred by nurse registries must maintain a current cardiopulmonary resuscitation (CPR) certification from an instructor or training provider that is approved to provide training by the American Heart Association, the American Red Cross, or the Health and Safety Institute, and that provides CPR training in which the student is required to demonstrate, in person, that he or she is able to perform cardiopulmonary resuscitation.

(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.

(14) C.N.A.s and home health aides referred by nurse registries may assist with self-administration of medication as described in section 400.488, F.S.

(a) Home health aides and C.N.A.s assisting with self-administered medication, as described in section 400.488, 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 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-8.0095(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 assisted living facility staff in compliance with section 429.52(6), F.S.;
3. A training certificate for at least 2 hours of training from a career education school licensed pursuant to chapter 1005, F.S., and 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.

(d) In cases where a home health aide or a C.N.A. will provide assistance with self-administered medications as described in section 400.488, 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 400.488(2), F.S.

(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 400.488, 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.

(15) The nurse registry is not obligated to monitor, manage or supervise a certified nursing assistant or home health aide pursuant to section 400.506(19), F.S. The nurse registry is not obligated to review patient or client records per section 400.506(20), F.S., but the nurse registry is not prohibited from reviewing records and may do so. In the event of violation of section 400.488, F.S., or other state laws that comes to the attention of the nurse registry, the nurse registry shall take the actions specified in section 400.506(19), F.S.

Rulemaking Authority 400.488, 400.497, 400.506 FS. Law Implemented 400.488, 400.497, 400.506 FS. History–New 1-27-94, Amended 12-24-00, 8-10-06, 3-15-07, 5-4-15, 2-8-16.

59A-18.009 Homemakers or Companions.

(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.

(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;

(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.

(3) Homemakers and 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 section 400.506(20), F.S., but the nurse registry is not prohibited from reviewing the records and may do so.

Rulemaking Authority 400.497, 400.506 FS. Law Implemented 400.497, 400.506 FS. History–New 2-9-93, Amended 1-27-94, 12-24-00, 5-4-15.

59A-18.010 Acceptance of Patients or Clients.

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 practice registered nurse’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.

Rulemaking Authority 400.497, 400.506 FS. Law Implemented 400.497, 400.506 FS. History–New 2-9-93, Amended 12-24-00, 3-15-07, 5-4-15.

59A-18.011 Medical Plan of Treatment.

(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 practice registered nurse 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 practice registered nurse, 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 practice registered nurse 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 practice registered nurse.

(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 clinical notes must be filed in the office of the nurse registry, pursuant to section 400.506(13)(b), F.S., within 30 days, pursuant to Section 400.497(8), F.S.

(6) The nurse registry shall inform nurse registrants that the shift nurse that communicates with the physician’s office, the physician assistant or the advanced practice registered nurse about any changes in the orders should update the plan of treatment.

(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.

Rulemaking Authority 400.497, 400.506 FS. Law Implemented 400.497, 400.506 FS. History–New 2-9-93, Amended 1-27-94, 12-24-00, 8-10-06, 5-4-15.

59A-18.012 Clinical Records.

The licensed nurse responsible for the delivery of skilled patient care shall maintain a clinical record, pursuant to section 400.497(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 400.506(13), F.S.;

(4) Clinical and service notes, signed and dated by the nurse providing the service which shall include:

(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.

(7) 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.

(8) The nurse registry is not obligated to review patient or client records per section 400.506(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 400.506(19), F.S.

Rulemaking Authority 400.497, 400.506 FS. Law Implemented 400.497, 400.506 FS. History–New 2-9-93, Amended 1-27-94, 12-24-00, 8-10-06, 5-4-15.

59A-18.013 Administration of Drugs and Biologicals.

(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:

(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 practice registered nurse as required in section 400.506(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 practice registered nurse 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 practice registered nurse 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 practice registered nurse 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.

Rulemaking Authority 400.497, 400.506 FS. Law Implemented 400.497, 400.506 FS. History–New 2-9-93, Amended 1-27-94, 12-24-00, 3-15-07, 5-4-15.

59A-18.015 Surveys and Inspections.

Rulemaking Authority 400.497, 400.506 FS. Law Implemented 400.481, 400.484, 400.506 FS. History–New 2-9-93, Amended 1-27-94, 12-24-00, 3-15-07, Repealed 5-14-12.

59A-18.016 Penalties.

Rulemaking Authority 400.497, 400.506 FS. Law Implemented 400.497, 400.506 FS. History–New 2-9-93, Amended 1-27-94, 12-24-00, 3-15-07, Rpealed 5-14-12.

59A-18.017 Supplemental Staffing for Health Care Facilities.

(1) Each nurse registry may provide staffing services as defined in section 400.462(29), F.S.

(2) Each independent contractor shall carry their professional license or certification with them at all times during their working hours at a health care facility, and shall produce such a record for review by the health care facility, upon request.

(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 400.506(20), F.S., but the nurse registry is not prohibited from reviewing records and may do so.

(4) Each nurse registry shall provide to the independent contractor, the name of the appropriate person at the health care facility who will be responsible for orientation to the facility.

(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 maintain files in an organized manner and such files will be made available for inspection by the agency during the hours the registry is in operation. The nurse registry is not obligated to review patient or client records per section 400.506(20), F.S., but the nurse registry is not prohibited from reviewing records and may do so.

(8) The nurse registry is not obligated to monitor, manage or supervise a referred independent contractor pursuant to Section 400.506(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 400.506(19), F.S.

Rulemaking Authority 400.497, 400.506 FS. Law Implemented 400.497, 400.506 FS. History–New 2-9-93, Amended 1-27-94, 12-24-00, 8-10-06, 5-4-15.

59A-18.018 Emergency Management Plans.

(1) Pursuant to section 400.506(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 3110-1017, May 2015, incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-05234. This document is available from the Agency for Health Care Administration at http://ahca.myflorida.com/MCHQ/Emergency_Activities/index.shtml. 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 400.506(12), F.S.

(2) The nurse registry shall review its emergency management plan on an annual basis and make any substantive changes. Plans with any substantive changes will be forwarded for review to the entities identified in subsection (1).

(3) Changes in the 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).

(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 plans to the reviewing entity in subsection (1).

(5) In the event of an emergency, the nurse registry shall implement the nurse registry’s emergency management plan pursuant to section 400.506(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 400.506(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.

(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 400.506(11), F.S.

(a) Upon initial contract for services, and at a minimum on an annual basis, each nurse registry shall, pursuant to sections 400.506(12) and 252.355, 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 400.506(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.

(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 400.506(12), F.S., to the county emergency management office.

(7) The person referred for contract to a patient registered with the special needs registry, which shall include special needs registry patients being served in assisted living facilities and adult family care homes, shall ensure that the same type and quantity of continuous care is provided in the special needs shelter that was provided prior to the emergency as specified in section 400.506(12), F.S., unless circumstances beyond the control of the independent contractor as described in section 400.506(12)(d), F.S., make it impossible to continue services.

(8) When a nurse registry is unable to continue services to special needs patients registered under section 252.355, 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 400.506(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.

(9) When a state of emergency has been declared by executive order or proclamation of the Governor, pursuant to section 252.36(2), F.S., the nurse registry must contact those patients needing ongoing services pursuant to section 400.506(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.

(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 400.506(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 400.506(12), F.S.

(11) During emergency situations, when there is not a mandatory evacuation order issued by the local county emergency management office, some patients, registered pursuant to section 252.355, F.S., may decide not to evacuate and will stay in their homes. The nurse registry must establish procedures, prior to the time of an emergency, which will delineate to what extent the registry will continue to arrange for care during and immediately following an emergency pursuant to section 400.506(12)(a), F.S. The registry shall also contact the patients who need continuing services by calling the patient at home or calling the assisted living facility or adult family care home the patient resides in to determine if the patient still needs services from the registry and which patients have plans to receive care from their family or other persons. If the assisted living facility or adult family care home does relocate the residents to another assisted living facility or adult family care home in the geographic area served by the nurse registry, the registry will continue to provide services to the residents. If the patients relocated outside the area served by the registry, the registry will assist the assisted living facility and adult family care home in obtaining the services of another registry already licensed for that area until the patient returns back to their original location.

(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 400.506(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.

(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 400.506(12)(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 assistant, or advanced practice registered nurse and the physician, physician assistant or advanced practice registered nurse’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 400.506(12)(a) and (b), F.S.

Rulemaking Authority 400.506, 408.821(4) FS. Law Implemented 400.506 FS. History–New 8-10-06, Amended 3-15-07, 5-4-15.