Ron DeSantis, Governor Joseph A. Ladapo, MD, PhD, State Surgeon General Fiscal Year 2022-23 Florida Department of Health DIVISION OF MEDICAL QUALITY ASSURANCE ANNUAL REPORT and Long-Range Plan
2 HOW WE WORK: LICENSE, ENFORCE, INFORM The Division of Medical Quality Assurance regulates health care practitioners and facilities through professional licensure, facility permitting, and administrative enforcement in order to preserve the health, safety, and welfare of the public. MISSION, VISION, VALUES We search for creative solutions and manage resources wisely. INNOVATION We use teamwork to achieve common goals and solve problems. COLLABORATION We perform with integrity and respect. ACCOUNTABILITY We achieve our mission by serving our customers and engaging our partners. RESPONSIVENESS We promote quality outcomes through learning and continuous performance improvement. EXCELLENCE MISSION: To protect, promote, and improve the health of all people in Florida through integrated state, county, and community efforts. VISION: To be the healthiest state in the nation.
3 Annual Report and Long-Range Plan | Fiscal Year 2022-23 Mission, Vision, Values 2 Introduction 4 State Surgeon General Message 4 Division Director Message 5 Executive Summary 6 About Medical Quality Assurance 8 Purpose 8 Composition 9 Organizational Structure 9 Boards and Councils 10 Department Regulated Professions and Facilities 10 Program Areas 11 Prescription Drug Monitoring Program 11 Veteran Licensure Services 12 Unlicensed Activity Program 13 Long-Range Planning 14 Purpose 14 Strategy Map 15 Annual Performance Results 16 Reduction of Year-Old Cases 21 Disciplinary Guidelines 22 Appendix 26 Table 1: Summary of Licensed Practitioners 26 Table 2: Summary of Licensed Facilities and Establishments 31 Table 3: Recognized Continuing Education Providers 32 Table 4: Initial Applications Received and Initial Licenses Issued 34 Table 5: Upgrade Applications Received and Initial Licenses Issued 38 Table 6: Online Renewals 39 Table 7: Emergency Orders Issued 42 Table 8: Reports Received, Complaints Received, and Investigations Completed 47 Table 9: Probable Cause Actions 53 Table 10: Disciplinary Cases 58 Table 11: Medical Malpractice Claims 66 Table 12: Hospital Annual Report Claims 72 Table 13: Unlicensed Activity 72 Table 14: Student Loan Defaults 77 Table 15: Revenues, Expenditures, and Cash Balances 78 Table 16: Projected Cash Balances 79 Table 17: Review of the Adequacy of Renewal Fees 80 CONTENTS
Annual Report and Long-Range Plan | Fiscal Year 2022-23 4 INTRODUCTION Message from the State Surgeon General Joseph A. Ladapo, MD, PhD State Surgeon General As Florida’s State Surgeon General, it gives me great pleasure to present this annual report on behalf of the Division of Medical Quality Assurance (MQA), which captures its purpose, achievements, and impact on the landscape of health care regulation in Florida during FY 2022-23. Every day, the health care practitioners and facilities we regulate, and the consumers who receive their services, rely on us to fulfill the purpose of our regulations. These regulations help uphold the safety and quality expected by each Floridian and visitor when receiving health care services. The success of these regulations relies on awareness, education, and compliance by the practitioners, facilities, and consumers and supporting resources to implement enforcement and programmatic activities. I am proud that MQA is one of many divisions at the Department of Health (Department) contributing to the mission to protect, promote, and improve the health of all Floridians. MQA works hard to sustain and improve a regulatory structure that supports the state’s priorities related to global competitiveness and economic growth. This year, MQA issued over 128,000 initial licenses, upgraded more than 26,000 licenses, and renewed over 610,000 licenses. These efforts are supported by dedicated employees who collaborate with 22 regulatory boards and four councils to effectively regulate 364 health care professions and adapt strategies to help the state respond to emergencies like hurricanes. In the wake of Hurricane Ian in October 2022, MQA effectively deployed 10 percent of its workforce, promptly delivered urgent notifications about emergency directives affecting professions, responded in partnership with Volunteer Florida to promote an online portal for licensed practitioners to volunteer in impacted areas, and redirected resources to maintain critical licensure processes for priority professions. MQA’s Board of Nursing was one unit that demonstrated this agility and focus on expediting licensure, as its initial applications for licensure were processed in under 24 hours. In addition to managing its daily operations, I am proud of MQA for its enforcement and programmatic activities. My visit to one of MQA’s 11 investigative field offices showed me the importance of statewide investigative work taking place with law enforcement partners. Health care facility inspectors, investigators, program liaisons, compliance managers, and attorneys work together with the boards, councils, and Office of the General Counsel to produce an effective enforcement and compliance model for Florida’s practitioners and facilities that are often looked to by other states when enacting legislation affecting health care professions. This year, MQA completed 5,249 investigations and issued 561 cease-and-desist orders, fulfilling its commitment to the safety of health care consumers in Florida. These regulations help uphold the safety and quality expected by each Floridian and visitor when receiving health care services. We have much to celebrate as we reflect on the impact our work has had in FY 2022-23. Whether educating the public about the dangers of unlicensed medical practice, offering licensure support services for veterans, or encouraging safer prescribing of controlled substances, it is clear that MQA takes seriously its commitment to protecting the public.
5 Annual Report and Long-Range Plan | Fiscal Year 2022-23 As you’ll see in the coming pages, we firmly believe that the success of MQA comes from the passionate people who share our mission, embody our core values, and seek our vision every day. I am proud of MQA’s work in streamlining the licensing, enforcement, and information processes to benefit Florida’s health care applicants, practitioners, and consumers. Together, we are making a meaningful difference for the Floridians we serve. Jennifer L. Wenhold, MSW, CPM Division Director Since 2021, I have been honored to serve the state of Florida as the Director of MQA, where we strive to ensure excellence, efficiency, responsiveness, and innovation for its health care applicants, practitioners, and consumers. From introducing e-licensing as a new licensure experience for practitioners to delivering an AI-powered renewal process for nurses, I am proud to report that MQA combined the dedication of many talented employees to pursue forward-thinking, practitioner-focused innovations. This operational excellence helps MQA carry its commitment to Florida’s practitioners and allows them to focus attention on the delivery of care. In addition to conducting licensure and enforcement duties, practitioners and consumers rely on MQA to be informed on the changing dynamics of evolving professions. Throughout the year, MQA staff participated in the exchange of information and best practices with various partners, ranging from law enforcement officials and health care associations to board and council members, licensure compact states, and other state agencies. These expectations underscore the importance of our work and the opportunities we have to make a difference in the lives of Floridians and the communities where they live and work. To build on our successes and ensure MQA remains a leader in health care regulation, it is vital that we inspire our talent to be innovative and intentional in addressing existing and future challenges. With this sentiment, MQA began revisiting its strategic plan, which was last established in 2019, to better reflect strategies informed by current regulatory trends, board and council member feedback, and employee input. MQA distributed an online survey to solicit board and council member feedback, hosted a long-range planning meeting with Board and Council Chairs, Vice Chairs, and industry partners, conducted an environmental scan of the strengths, weaknesses, opportunities, and threats impacting MQA, and drafted new strategic goals and objectives that propel us to achieve our vision of becoming the healthiest state in the nation. Message from the Division Director
Annual Report and Long-Range Plan | Fiscal Year 2022-23 6 EXECUTIVE SUMMARY Florida’s population has increased by 1.9 percent since 2021, which makes it the fastest-growing state in the nation. With a population that is rapidly expanding, MQA is tasked with ensuring that the 1.4 million Florida health care practitioners can get to work and stay working with little delay in credentialing. In FY 2022-23, MQA not only met but exceeded its key performance measures. MQA issued 128,184 initial licenses to health care practitioners and processed over 610,000 renewal applications for licensure. The Bureau of Enforcement received 45,352 complaints and issued 200 emergency orders in response to serious violations. Finally, as a leading state agency harnessing artificial intelligence (AI) technology in service to its customers, MQA’s Virtual Agent, ELI, has fielded over 509,000 voice calls and more than 224,000 web chats. 5,361 5,246 19,441 1,104 561 Florida’s population has increased by 1.9 percent since 2021, which makes it the fastest-growing state in the nation.
7 Annual Report and Long-Range Plan | Fiscal Year 2022-23 With a population that is rapidly expanding, MQA is tasked with ensuring that the 1.4 million Florida health care practitioners can get to work and stay working with little delay in credentialing. 6.5% 4.4% 30,137 3% 6.6% 96.9% 3.4% 3.2% 3.1% 3.1%
Annual Report and Long-Range Plan | Fiscal Year 2022-23 8 ABOUT MQA Purpose While the regulatory landscape is complex and ever-changing, the primary purpose of MQA remains consistent: to protect health care consumers. Section 456.003, Florida Statutes, provides MQA with the authority to regulate. It is the Legislature’s intent that health care professions should be regulated for the preservation of the health, safety, and welfare of the public and such professions should be regulated when: a) Their unregulated practice can harm or endanger the health, safety, and welfare of the public, and when the potential for such harm is recognizable and clearly outweighs any anticompetitive impact which may result from regulation. b) The public is not effectively protected by other means, including, but not limited to, other state statutes, local ordinances, or federal legislation. c) Less restrictive means of regulation are not available.
9 Annual Report and Long-Range Plan | Fiscal Year 2022-23 Composition MQA contributes to the mission of the Department by upholding a regulatory system that promotes a safe working environment for health care practitioners and ensures that public health and welfare are served through its licensure, enforcement, and information activities. MQA comprises three bureaus that collaborate with the Office of the General Counsel’s Prosecution Services Unit and 22 boards and four councils to license health care practitioners who meet statutory standards and enforce laws and rules governing health care practitioners. Organizational Structure THE BUREAU OF HEALTH CARE PRACTICTIONER REGULATION THE BUREAU OF OPERATIONS THE BUREAU OF ENFORCEMENT DIRECTOR’S OFFICE Human Resources Budget Strategic Planning Services Board Offices Veteran Licensure Services Prescription Drug Monitoring Program Operational Support Services Licensure Support Services System Support Services Background Sreening and Practitioner Notification Services Four Councils 22 Regulatory Boards Prosecution Services Unit Unlicensed Activity Program Investigative Services Unit Compliance Management Unit Consumer Services Unit • The Director’s Office facilitates cross-functional processes so that strategy is integrated, executed, and evaluated across MQA. Key functions include human resource management, budget development, and strategic planning services. • The Bureau of Health Care Practitioner Regulation consists of seven board offices that work with the regulatory boards and four councils, implementing rules into policy and procedure and advising on budget matters. Applications for licensure are reviewed, disciplinary hearings are conducted, and rules are promulgated in partnerships with the boards and councils. • The Bureau of Operations provides operation and infrastructure support to MQA and the boards and councils through the functions of four main units. Key functions range from document, contract, asset, and database management to license maintenance and renewal, background screening services, and voice, email, and AI-powered customer contact. • The Bureau of Enforcement acts as the compliance and investigative arm of MQA, where complaints about practitioners are received and investigated and violations and administrative actions are established according to Florida Statutes or rules. The 11 field offices throughout the state facilitate the investigations of complaints and inspections of facilities.
Annual Report and Long-Range Plan | Fiscal Year 2022-23 10 Boards and Councils While states may organize regulatory functions through a collective umbrella or by a series of independent and autonomous boards, Florida’s regulatory work is accomplished through a combination of the two. The composition of Florida’s 22 boards and four councils varies but typically includes members representing individual practitioners from the profession being regulated, public members to represent the consumer, and other members, like from a complementary profession. Boards and councils are staffed by an Executive Director who carries out the work as directed by the board or council. While board members are appointed by the Governor, the council members serve in an advisory capacity to their respective boards and are appointed by the State Surgeon General or the board under which the council operates. Members serve to conduct disciplinary hearings, promulgate rules, develop proposed legislation, approve CE providers and courses, and review licensure applications. The 22 boards and four councils are shown below. Interested in an appointment to a health care regulatory board or council? We welcome you to complete the Gubernatorial Appointments Questionnaire at FLgov.com/ Appointments for interest serving on a board, or the Florida Department of Health Questionnaire for interest serving on a council at FL-Appointment.AzureWebsites.net. Department Regulated Professions and Facilities MQA’s health care regulatory system helps keep track of how well the practitioners and facilities are complying with legal requirements. MQA inspects Department regulated facilities prior to opening to ensure compliance, and facilities are subject to inspection prior to permitting and licensing, after receipt of an application for a change in location or ownership, and routinely to ensure compliance and patient safety. BOARDS: Acupuncture Athletic Trainers Chiropractic Medicine Clinical Laboratory Personnel Clinical Social Work, Marriage and Family Therapy, and Mental Health Counseling Dentistry Hearing Aid Specialists Massage Therapy Medicine Nursing Nursing Home Administrators Occupational Therapy Opticianry Optometry Orthotists and Prosthetists Osteopathic Medicine Pharmacy Physical Therapy Podiatric Medicine Psychology Respiratory Care Speech-Language Pathology and Audiology COUNCILS: Dietetics and Nutrition Practice Electrolysis Licensed Midwifery Physician Assistants Interested in an appointment to a health care regulatory board or council? We welcome you to complete the Gubernatorial Appointments Questionaire at www.FLgov.com/appointments for interest serving on a board, or the Florida Department of Health Questionnaire for interest serving on a council at FL-Appointment.AzureWebsites.net.
11 Annual Report and Long-Range Plan | Fiscal Year 2022-23 Program Areas MQA’s programs and activities provide value by supporting regulatory work and ensuring that high standards of performance are maintained. Three of these program areas are highlighted below. Prescription Drug Monitoring Program The Prescription Drug Monitoring Program (PDMP), also known as E-FORSCE® (Electronic-Florida Online Reporting of Controlled Substance Evaluation Program), was created in 2009 to encourage safer prescribing of controlled substances and reduce drug abuse and diversion within the state of Florida. Under the leadership of the Director’s Office, the PDMP facilitates the collection, storage, maintenance, and analysis of controlled substance dispensing data reported by pharmacies and dispensing health care practitioners. The information is available to health care practitioners to view before prescribing or dispensing controlled substances, serving as a promising tool that can inform clinical practice with a comprehensive view of patients’ prescribing histories and inform clinical practice and prescribing decisions. For more information about the PDMP, please visit FLHealthSource.gov/FloridaTakeControl/PDMP. A list of Department regulated facilities and professions are as follows. Professions • Certified Master Social Workers • Emergency Medical Technicians • Genetic Counselors • Medical Physicists • Paramedics • Radiologic Technologists • School Psychologists Facilities • Dental Laboratories • Office Surgery Registration • Optical Establishments • Massage Establishments • Pain Management Clinics
Annual Report and Long-Range Plan | Fiscal Year 2022-23 12 Licensing for Military Members, Veterans, and Spouses MQA offers licensure support services to qualified military families as part of our commitment to supporting nearly 1.5 million military veterans that call Florida home. By implementing special fee waivers and expediting licensing, MQA can better assist service members as they grow in their careers, wish to practice while stationed in the state, or settle in Florida at the end of their service. The Department is sensitive to the unique challenges military families face when required to relocate and strives to offer a more seamless licensing process that eliminates additional financial burdens on service members and their loved ones. House Bill 139 (2022) was signed by Governor DeSantis on May 26, 2023, establishing MQA’s new Office of Veteran Licensure Services which will provide information, guidance, direction, and assistance with health care licensure processes for all veterans and their spouses. The Office will also include a referral program partnership with Veterans Florida to assist veterans and their spouses with access, training, education, and employment in Florida’s health care professions. For more information about licensing for military members and spouses, visit https://flhealthsource.gov/valor/.
Annual Report and Long-Range Plan | Fiscal Year 2022-23 13 Unlicensed Activity The Department’s Unlicensed Activity (ULA) Program protects Florida residents and visitors from the potentially serious and dangerous consequences of receiving medical and health care services from an unlicensed person. MQA investigates and refers for prosecution all unlicensed health care activity complaints and allegations. In many instances, unlicensed activity is a felony-level criminal offense. More importantly, receiving health care from unlicensed people is dangerous and could result in further injury, disease, or even death. The ULA Program works in conjunction with law enforcement and the state attorney’s offices to prosecute individuals practicing without a license. Program staff also proactively conduct public outreach but help by licensed health care practitioners and partnering organizations is crucial to educating others. The Department has several resources to combat unlicensed activity. • Consumers are encouraged to use the Department’s website FLHealthSource.gov where they can conveniently view the license information of their health care practitioner. • Complaints may be filed anonymously by completing and mailing the complaint form on the Department’s website, or by calling 1-877-HALT-ULA (425-8852).
Annual Report and Long-Range Plan | Fiscal Year 2022-23 14 LONG-RANGE POLICY PLANNING Purpose Priorities for improving public health in Florida are addressed through various plans at the Department, including collaboration with partners and internal agency priorities. MQA supports the Department’s strategic planning efforts by developing and implementing a longrange policy planning and monitoring process to facilitate efficient and cost-effective regulation, per section 456.005, Florida Statutes. During FY 2022-23, MQA operated under the strategies contained within the 2016-23 MQA Strategic Plan while updating this approach for the new reporting period (2023-2027). MQA embraces the value of reasonable regulation as a means of public protection and supports the state’s priorities for economic growth. Consumers esteem care from licensed practitioners and are protected by MQA’s established system that regulates practitioners’ education, examination, and experience standards just as practitioners value fast and accessible credentialing to begin, maintain, and improve health care delivery to patients. Through its strategic delivery of licensure, enforcement, and information services, MQA is positioned to create lasting change for health care applicants, practitioners, and consumers. With this focus on public protection and regulatory efficiency, MQA continued to collaborate with regulatory partners to uphold the standards that protect consumers and communities while reducing regulatory burdens for practitioners wherever possible. MQA relies on its robust and agile technological infrastructure and informationsharing with partners to assess, adapt, and respond to changes in the environment that can impact goal attainment. Agency for Health Care Administration Agency for Persons with Disabilities Bureau of Insurance Fraud Department of Business and Professional Regulation Department of Children and Families Department of Elder Affairs Department of Financial Services Department of Law Enforcement Department of Revenue Department of Veterans’ Affairs Greater Palm Beach County Task Force Governor-appointed boards Local law enforcement Metropolitan Bureau of Investigation North Florida Task Force Office of the Attorney General State Surgeon General-appointed councils University of Florida Chain Pharmacies Continuing Education Compliance Organizations Federation of Health Care Regulatory Boards Federation of State Medical Boards Florida PDMP Foundation, Inc. Florida Society of Health System Pharmacists Florida Society of Interventional Pain Physicians Impaired Practitioner Monitoring Programs Insurance Companies Licensing Verification Companies National Association of Drug Diversion Investigators National Council of State Boards of Nursing National Insurance Crime Bureau Professional health care associations Testing companies Private Drug Enforcement Administration Department of Health and Human Services Department of Justice Federal Bureau of Investigation Food and Drug Administration Office of Justice Programs Substance Abuse and Mental Health Services Administration Federal MAJOR PARTNERS PRIVATE FEDERAL STATE
15 Annual Report and Long-Range Plan | Fiscal Year 2022-23 A Establish a regulatory structure that supports the state’s strategic priorities related to global competitiveness and economic growth. A1 Enforce health care standards through timely discipline of individuals and facilities found in violation of the law. A2 License health care practitioners in a more timely and efficient manner. B Demonstrate readiness for emerging health threats. B1 Increase telehealth capacity to support direct service delivery. • Decrease the average time to register qualified out-of-state telehealth providers. Regulatory Efficiency Readiness for Emerging Health Threats STRATEGIES GOALS MEASURES • Increase the percentage of Priority 1 (P1) investigations completed within 12 days. • Reduce the average time to issue a license to a qualified applicant. Priorities Strategy Map Percentage of P1 Investigations Completed within 12 Days Average Time to Register Qualified Out-of-State Telehealth Providers (Days) Average Time to Issue a License to a Qualified Applicant (Days)
Annual Report and Long-Range Plan | Fiscal Year 2022-23 16 Figure 1: Total Number of Licensed Health Care Practitioners Figure 2: Largest Number of Licensed Health Care Practitioners Licensure Florida’s population has increased by 1.9 percent since 2021, which makes it the fastest-growing state in the nation. With a population that is expanding so rapidly, MQA is charged with ensuring that the 1.4 million Florida health care practitioners can get to work and stay working with little delay in licensing. In FY 2022-23, MQA licensed over 128,000 new health care practitioners with an average processing time of 0.09 days per license. Total licensure for practitioners has increased 3.4% over the past six years from 1,245,454 to 1,478,142 (Figure 1). This year, 152,581 initial applications were received, and 128,167 initial licenses were issued. Also, 610,818 renewal licenses were issued, which is the highest number of renewals for the reporting period. The professions with the greatest number of licensed practitioners are registered nurses, certified nursing assistants (CNAs), medical doctors, licensed practical nurses, and registered pharmacy technicians (Figure 2). Over the past five years, the number of registered nurses increased at a rate of 4.3%, making it the fastest-growing health care profession in Florida. Medical doctors and pharmacy technicians are also growing at fast rates, with six-year growth rates of 3.6% and 2.4%, respectively. While registered nurses and medical doctors are also two of the most popular professions among licensed military practitioners, certified nursing assistants and massage therapists accounted for the largest increase in military practitioners at 4.9% and 3.5%, respectively. By contrast, professions with the highest declines in practitioners are licensed practical nursing and certified nursing assistants, but the declines are marginal; the number of licensed practical nurses declined at a rate of 0.006% while the number of CNAs declined at a rate of 0.26%. Figure 3 illustrates the top 10 largest and smallest professions in Florida. In Thousands 1,245,454 1,299,305 1,345,417 1,417,072 1,431,063 1,478,142
17 Annual Report and Long-Range Plan | Fiscal Year 2022-23 REGISTERED NURSE 404,463 RADIOLOGIC TECHNOLOGY 46,929 MASSAGE THERAPIST 46,443 PARAMEDIC 40,113 CERTIFIED NURSING ASSISTANT 185,197 LICENSED PRACTICAL NURSE 78,977 REGISTERED PHARMACY TECHNICIAN 61,402 EMERGENCY MEDICAL TECHNICIAN 53,398 MEDICAL DOCTOR 93,221 ADVANCED PRACTICE REGISTERED NURSE 56,005 0 MEDICAL DOCTOR LIMITED TO CLEVELAND CLINIC 0 MEDICAL DOCTOR PUBLIC PSYCHIATRY CENTER 0 OSTEOPATHIC FACULTY CERTIFICATE 1 MEDICAL DOCTOR LIMITED TO MAYO CLINIC 1 MEDICAL DOCTOR PUBLIC HEALTH CERTIFICATION 1 TEMPORARY AREA OF CRITICAL NEED – OSTEOPATHIC 2 OSTEOPATHIC LIMITED LICENSE 3 RESPIRATORY CARE PRACTITIONER NON-CRITICAL 6 CERTIFIED MASTER SOCIAL WORKER 9 ORTHOTIC – PROSTHETIC RESIDENT 10 LARGEST 10 SMALLEST In addition to licensing health care practitioners, MQA also licenses health care facilities and continuing education (CE) providers. In FY 2022-23, MQA licensed 24,460 facilities, which is 4.6% more than last year – an anticipated increase knowing that the trend of facility licensure is influenced by the biennial renewal cycle (Figure 4). While the number of licensed facilities in Florida has remained constant over the last six years (1.4%), the CE application rate grew by 3.1%. Figure 3: The Top 10 Largest and Smallest Populated Health Care Professions in FY 2022-23 Figure 4: Licensed Facilities and Establishments 22851 24,602 23,360 24,151 24,460 23,392
Annual Report and Long-Range Plan | Fiscal Year 2022-23 18 Designed to keep health care workers up-to-date on medical advances, CE credits are an educational requirement for professionals with health care careers as they fill the gap between current care and optimal care. In FY 2022-23, MQA received 566 and approved 553 applications for CE providers to be able to offer courses pursuant to Florida laws and statutes (Figure 5). Another way to keep up with the latest advancements, improve skills, and advance patient outcomes is by upgrading health care licensure and certifications after an initial license is issued. As shown by Figure 6, MQA received and issued the highest number of upgrade applications in FY 2022-23 (30,137 and 26,655, respectively). In fact, 73.1% more licenses were upgraded this year than were issued five years ago (26,655 in FY 2022-23 compared to 15,394 in FY 2018-19). Of all the professions to upgrade, nursing accounted for the most upgrade licenses (52.5%), followed by pharmacy (43.7%). That is 14,002 nurses (Advanced Practice Registered Nurses/ APRN, Licensed Practical Nurses, and Registered Nurses) upgraded to either autonomous practice APRN or the Nurse Licensure Compact, while 11,652 pharmacies and registered pharmacy technicians received certifications to administer immunizations, collaboratively practice with a physician, and/or conduct point-of-care testing and diagnostic services for minor, nonchronic health conditions (test and treat).. What are Autonomous APRNs and the Nurse Licensure Compact? APRNs are eligible to practice autonomously if they meet certain legislatively mandated eligibility criteria per section 464.0123, Florida Statutes. Autonomous APRNs (A-APRNs) are permitted to practice in primary care settings including family medicine, general pediatrics, and general internal medicine, as defined by the Florida Board of Nursing’s rule. The Nurse Licensure Compact (NLC) is an interstate compact that allows a Registered Nurse or Licensed Practical Nurse to have a multistate license in the primary state of residency, permitting the nurse to practice in other member states subject to each state’s practice laws. Figure 5: CE Applications Received vs. Approved Figure 6: Upgrade Applications Received vs. Issued
19 Annual Report and Long-Range Plan | Fiscal Year 2022-23 Enforcement The Consumer Services Unit (CSU), Investigative Services Unit (ISU), and Compliance Management Unit (CMU) investigate complaints involving regulated health care practitioners. Together, these units comprise the Bureau of Enforcement, which collaborates with the Prosecution Services Unit (PSU) to enforce appropriate Florida Statutes, rules, and laws (Figure 7). Figure 7: Enforcement Process Explained Informal Board Hearing (No Dispute) Board Hearing Waived (No Dispute) DOAH Hearing Settlement for Board Approval Full Board Action and Deposition Administrative Complaint Filed Final Order Imposing Discipline Filed Election of Rights Appeal Procedures Compliance Monitoring Complaints Received Analysis Citation Issued Attorney Review Probable Cause Review Complaint Closed Mediation Referral Investigation Prosecution Disputed Emergency Action Dismissal (No Probable Cause) Non-Disputed Final Order Probable Cause Legally Non- Sufficient
Annual Report and Long-Range Plan | Fiscal Year 2022-23 20 CSU represents the first step in the enforcement process, receiving all complaints submitted to MQA and determining if there is legal sufficiency for further review. In other words, if the allegations made in the written and signed complaint are found to be true and in violation of recognized standards of practice, the complaint will be deemed legally sufficient, and the subject of the complaint (or their attorney) will be provided with a copy of the complaint. Complaints with legal sufficiency indicate a potential violation of Florida Statutes or administrative rules, and are forwarded to ISU for investigation. MQA received 45,352 complaints in FY 2022-23, which is among the greatest number of complaints recorded when compared to other years (Figure 8). More than onethird of the complaints received were against registered nurses (or 30.3%), and over 5,000 cases were deemed to be legally sufficient. As the investigative arm of MQA, staff within ISU’s 11 investigative services regions serve the public by investigating legally sufficient complaints against health care practitioners and facilities, conducting routine facility inspections, and stopping unlicensed activity. MQA completed 5,246 investigations in FY 2022-23, found 1,577 cases of probable cause (compared to the 3,165 cases of no probable cause), and received the greatest number of unlicensed activity complaints over the last five years at 1,186. Figure 9: Investigative Services Regions Figure 8: Total of Complaints Received As the investigative arm of MQA, staff within ISU’s 11 investigative services regions serve the public by investigating legally sufficient complaints against health care practitioners and facilities, conducting routine facility inspections, and stopping unlicensed activity. MQA completed 5,246 investigations in FY 2022-23, found 1,577 cases of probable cause (compared to the 3,165 cases of no probable cause), and received the greatest number of unlicensed activity complaints over the last five years at 1,186.
21 Annual Report and Long-Range Plan | Fiscal Year 2022-23 Reduction of Year-Old Cases In FY 2022-23, PSU faced significant staffing issues and a swell of new priority cases, both of which impacted its ability to reduce aging cases. Nearly half of PSU’s attorney positions were vacant at the start of the fiscal year (41%) and, of the 5,137 new cases that were received, 27.1% were priority cases (or 1,391). Despite the staffing shortage and influx of priority cases, PSU ended the fiscal year with a total of 4,940 cases and reduced its attorney vacancy rate by 34%. Of the 4,940 cases remaining at the end of the fiscal year, 34.0% (or 1,679) were over one year old as compared to the 26.5% at close of FY 2021-22 (Figure 10). To reduce the year and older cases, PSU concentrated its efforts on resolving the oldest cases in its inventory. The oldest cases typically have aged due to complexities in the case, which require more effort to bring to a final resolution. By eliminating the oldest cases, PSU attorneys can allocate more time to resolving more recent complaints. For this fiscal year, 81.1% of the cases that were over one year old were from 2021 to 2022, meaning those cases were two or less years old. Truly complex, fully contested cases often will not be resolved within one year; referral to the Division of Administrative Hearings (DOAH) is essential to bringing about timely resolution. As such, PSU has emphasized the importance of referring cases to DOAH through performance expectations. As a result, PSU referred 100 cases in FY 2022-23 to DOAH for assignment to an Administrative Law Judge. Figure 10: Total Cases Compared to Year and Older Cases* *At the close of the fiscal year.
Annual Report and Long-Range Plan | Fiscal Year 2022-23 22 Disciplinary Guidelines MQA, in partnership with the boards and councils, reviews disciplinary guidelines for compliance with the legislative intent set forth in section 456.079, Florida Statutes. Per section 456.026(9), Florida Statutes, the MQA Annual Report and Long-Range Plan must provide a status of the development and implementation of rules providing disciplinary guidelines. BOARD/COUNCIL Rule Number Description Rule Development Published Notice Published Adopted Effective Acupuncture 64B1-9.001 Disciplinary Guidelines 07/09/2021 07/26/2021 9/02/2021 9/22/2021 Athletic Trainers 64B33-5.001 Disciplinary Guidelines 08/10/2021 08/25/2021 09/24/2021 10/04/2021 Chiropractic Medicine 64B2-16.003 Disciplinary Guidelines 10/01/2021 10/18/2021 11/19/2021 *filed date 12/09/2021 Clinical Social Work, Marriage and Family Therapy, and Mental Health Counseling 64B4-5.001 Disciplinary Guidelines 09/24/2021 10/15/2021 11/18/2021 12/08/2021 Clinical Laboratory Personnel 64B3-12.001 Disciplinary Guidelines 03/10/2021 04/14/2021 (proposed) 09/10/2021 (change) 10/18/2021 11/07/2021 Dentistry 64B5-13.005 Disciplinary Guidelines 09/13/2021 09/28/2021 10/20/2022 11/09/2022 Dietetics and Nutrition 64B8-44.003 Disciplinary Guidelines 11/01/2021 11/16/2021 12/14/2021 01/03/2022 Electrolysis 64B8-55.001 Disciplinary Guidelines 04/23/2021 05/03/2022 11/02/2022 11/22/2022 Hearing Aid Specialists 64B6-7.002 Guidelines for Disposition of Disciplinary Cases 02/24/2023 03/13/2023 04/17/2023 05/07/2023 Massage Therapy 64B7-30.002 Disciplinary Guidelines 09/20/2022 10/05/2022 11/14/2022 12/04/2022 Medical Physicists 64B23-6.001 PenaltyGuidelines 02/09/2022 04/27/2023 (proposed) 07/26/2023 (change) Pending Pending Medicine 64B8-8.001 Disciplinary Guidelines 06/28/2022 07/13/2022 08/23/2022 09/12/2022 Medicine 64B8-30.015 Disciplinary Guidelines 09/21/2021 10/06/2021 11/16/2021 12/06/2021 Medicine 64B8-31.010 Disciplinary Guidelines 09/16/2021 10/01/2021 11/01/2021 11/21/2021 Midwifery 64B24-8.002 Disciplinary Guidelines 08/12/2015 12/22/2015 03/02/2016 03/22/2016
23 Annual Report and Long-Range Plan | Fiscal Year 2022-23 BOARD/COUNCIL Rule Number Description Rule Development Published Notice Published Adopted Effective Nursing 64B9-8.006 Disciplinary Guidelines 05/19/2023 06/05/2023 07/18/2023 08/07/2023 Nursing 64B9-15.009 Disciplinary Guidelines 12/29/2020 01/13/2021 08/02/2021 08/22/2021 Nursing Home Administrator 64B10-14.004 Disciplinary Guidelines; Range of Penalties; Aggravating and Mitigating Circumstances 09/08/2021 09/23/2021 11/10/2021 11/30/2021 Occupational Therapy 64B11-4.003 Standards of Practice; Discipline 09/24/2021 10/08/2021 11/09/2021 11/29/2021 Opticianry 64B12-8.020 Disciplinary Guidelines 09//09/2021 09/23/2021 10/25/2021 11/14/2021 Optometry 64B13-15.005 Designation of Administrative Violations; Major; Minor 09/09/2021 10/07/2021 11/16/2021 12/06/2021 Optometry 64B13-15.006 Designation of Patient Care Violations; Major; Minor 09/09/2021 10/07/2021 11/16/2021 12/06/2021 Orthotists and Prosthetists 64B14-7.003 Disciplinary Guidelines 06/17/2021 07/12/2021 10/12/2021 11/01/2021 Osteopathic Medicine 64B15-19.002 Violations and Penalties 12/28/2022 01/12/2023 03/02/2023 03/22/2023 Podiatric Medicine 64B18-14.002 Disciplinary Guidelines 08/31/2021 09/14/2021 12/09/2021 12/29/2021 Pharmacy 64B16-30.001 Disciplinary Guidelines 09/09/2021 10/04/2021 02/21/2022 03/13/2022 Psychology 64B19-17.002 Disciplinary Guidelines 12/02/2021 12/20/2021 01/19/2022 02/08/2022 Physical Therapy 64B17-7.001 Disciplinary Guidelines 09/08/2021 09/23/2021 10/28/2021 11/17/2021 Respiratory Care 64B32-5.001 Disciplinary Guidelines 08/25/2021 09/09/2021 12/01/2021 12/21/2021 School Psychology 64B21504.002 Disciplinary Guidelines 05/23/2022 09/01/2022 12/09/2022 12/29/2022 Speech-Language Pathology 64B20-7.001 Disciplinary Guidelines 08/12/2021 08/26/2021 09/29/2021 10/19/2021
Annual Report and Long-Range Plan | Fiscal Year 2022-23 24 All About ELI MQA’s Virtual Agent, ELI, is an artificial intelligent chatbot that provides real-time customer service on MQA’s board web pages. ELI is available after hours, during the weekend, and on holidays, which allows practitioners to manage licensure applications and receive assistance at times that are convenient for them. With this streamlined process of responding to practitioner inquiries, MQA agents are empowered to redirect their attention to complex inquiries, which decreases wait times, increases the number of channels through which practitioners can interact with MQA, and provides an overall improved experience for customers. Applicants and licensees can use ELI for assistance with the following: • Check workforce survey status. • Provide exam results and status. • Assist with name and address changes. • Verify licenses. • Process payments to renew. • Renew license statuses. • Learn about licensure and renewal requirements and fees. • Check initial application status. • Learn about the background screening processes. • Learn about public records requests. • Learn about filing a complaint. ELI handled 224,097 web chats and 509,079 voice conversations in FY 2022-23. MQA works diligently to track the usage of ELI across the board and MQA websites to stay informed of the patterns and needs of practitioners. Collected data from each conversation are used to update ELI’s library of questions and answers and ensure that ELI remains relevant for practitioners. MQA is proud to report the successful launch of an ELI-assisted internet application tool for two high-volume professions: Registered Nursing and Licensed Practical Nursing. As a result, Registered Nurses seeking licensure by exam and endorsement were able to complete their initial applications online using ELI. The ELI project team will continue to evaluate trends and needs, and work with the boards to identify the next phase in ELI functionality.
25 Annual Report and Long-Range Plan | Fiscal Year 2022-23 In the future, health care licensure applicants, practitioners, and consumers can expect the following features from ELI: ■ MQA boards will test and share feedback about ELI’s ability to respond to customers, providing greater insights to the ELI project team and guaranteeing that ELI remains a relevant, personal, and customer-focused champion for all practitioners looking to do business with MQA. ■ ELI will link inquirers to pertinent resources existing on board websites based on the questions they ask. For instance, if a practitioner asks a question on the Board of Medicine website but the question is relevant to the Board of Osteopathic Medicine, ELI will redirect that user to the Board of Osteopathic website as appropriate. To learn more or access ELI, visit FLHealthSource. gov/ELI or find ELI at the bottom of any respective board website. Board of Pharmacy 7.0% Board of Medicine 9.3% Board of Clinical Social Work, Marriage and Family Therapy, and Mental Health Counseling 11.5% TOP FIVE ELI WEB CHAT VOLUMES in FY 2022-23 Background Screening 5.3% Board of Nursing 37.9% All Other 29%
Annual Report and Long-Range Plan | Fiscal Year 2022-23 26 Table 1: Summary of Licensed Practitioners Over 1.4 million health care practitioners were licensed by the end of FY 2022-23, which is a 3.3% increase from the previous year. The Department is committed to improving technology and processes regarding licensure, so practitioners can get to work quickly. PROFESSION In State Out of State Military Active Retired TOTAL Active Inactive Delinquent Active Inactive Delinquent ACUPUNCTURE Acupuncturist 2,342 31 95 280 41 47 5 120 2,961 ATHLETIC TRAINING Athletic Trainer 2,515 5 422 349 3 115 15 74 3,498 CERTIFIED SOCIAL WORKER Certified Master Social Worker 4 0 1 0 0 1 0 0 6 CHIROPRACTIC MEDICINE Certified Chiropractic Physician's Assistant 360 7 82 2 0 0 0 4 455 Chiropractic Faculty Certificate 8 0 6 3 0 0 0 0 17 Chiropractic Physician 6,396 52 197 804 167 147 15 497 8,275 CLINICAL LABORATORY PERSONNEL Clinical Laboratory Personnel 14,719 144 1,241 2,725 111 604 38 947 20,529 Clinical Laboratory Trainee 562 0 0 10 0 0 0 0 572 Clinical Laboratory Training Program 35 0 0 16 0 0 0 0 51 CLINICAL SOCIAL WORKER Licensed Clinical Social Worker 12,785 67 422 2,348 97 227 19 572 16,537 Provisional Clinical Social Worker Licensee 153 0 0 9 0 0 0 0 162 Registered Clinical Social Worker Intern 4,677 0 0 113 0 0 0 0 4,790 DENTISTRY Dental Expert Witness Certificate 9 0 0 64 0 0 0 0 73 Dental Hygienist 14,886 79 597 2,047 142 215 97 960 19,023 Dental Radiographer 31,749 0 0 264 0 0 0 0 32,013 Dental Residency Permits 380 0 0 9 0 0 0 0 389 Dental Teaching Permits 212 0 0 0 0 0 0 0 212 Dental Temporary Certificate 39 0 12 4 0 0 0 0 55 Dental-Health Access Dental 43 0 3 12 1 3 0 7 69 Dentist 13,887 44 350 2,891 175 222 68 1,223 18,860 DIETETICS AND NUTRITION Dietetics/Nutritionist 5,013 18 569 1,046 9 428 12 164 7,259
27 Annual Report and Long-Range Plan | Fiscal Year 2022-23 PROFESSION In State Out of State Military Active Retired TOTAL Active Inactive Delinquent Active Inactive Delinquent Nutrition Counselor 43 2 6 7 0 1 0 20 79 ELECTROLYSIS Electrologist 2,487 20 325 47 3 11 2 60 2,955 EMERGENCY MEDICAL SERVICES Emergency Allergy Treatment Licensee 68 0 0 3 0 0 0 0 71 Emergency Medical Technician 37,465 118 13,241 1,214 22 1,149 189 0 53,398 Paramedic 32,907 180 3,977 1,810 23 1,142 74 0 40,113 GENETIC COUNSELING Genetic Counselor 131 0 0 523 0 0 0 0 654 Temporary Genetic Counselor 14 0 0 1 0 0 0 0 15 HEARING AID SPECIALIST Hearing Aid Specialist 923 4 118 65 2 15 1 79 1,207 Hearing Aid Specialist Trainee 207 117 0 4 0 0 0 0 328 MARRIAGE AND FAMILY THERAPY Licensed Marriage and Family Therapist 2,573 16 88 417 12 36 1 124 3,267 Provisional Marriage and Family Therapist Licensee 54 0 0 2 0 0 0 0 56 Registered Marriage and Family Therapist Intern 687 0 0 29 0 0 0 0 716 MASSAGE THERAPY Approved Massage School 191 0 0 0 0 0 0 0 191 Massage Therapist 34,515 282 3,685 5,164 105 961 174 1,557 46,443 Massage Therapy Apprentice 0 0 0 0 0 0 0 0 0 MEDICAL PHYSICIST Diagnostic Radiological Physicist 48 0 2 68 1 7 0 4 130 Medical Health Physicist 27 0 0 10 0 1 0 4 42 Medical Nuclear Radiological Physicist 28 0 2 27 1 1 0 5 64 Medical Physicist In Training 52 0 0 14 0 0 0 0 66 Therapeutic Radiological Physicist 311 1 20 183 6 35 0 9 565 MEDICINE Anesthesiologist Assistants 616 0 15 54 2 13 0 4 704 House Physician 379 0 0 40 0 0 0 0 419 Limited License Medical Doctor 92 0 36 10 0 3 0 29 170 Medical Doctor 59,144 88 1,738 23,389 495 2,592 122 5,653 93,221
Annual Report and Long-Range Plan | Fiscal Year 2022-23 28 PROFESSION In State Out of State Military Active Retired TOTAL Active Inactive Delinquent Active Inactive Delinquent Medical Doctor Expert Witness Certificate 38 0 0 2,028 0 0 0 0 2,066 Medical Doctor Limited to Cleveland Clinic 0 0 0 0 0 0 0 0 0 Medical Doctor Limited to Mayo Clinic 0 0 0 0 0 0 0 1 1 Medical Doctor Public Health Certificate 0 0 0 0 0 0 0 1 1 Medical Doctor Public Psychiatry Certificate 0 0 0 0 0 0 0 0 0 Medical Doctor Visiting Faculty Certificate 1 0 0 11 0 0 0 0 12 Medical Faculty Certificate 62 0 0 8 0 0 0 0 70 Physician Assistant (PA) 11,504 28 424 1,977 65 269 72 299 14,638 Resident Registration 7,461 0 20 1,953 0 0 0 0 9,434 Temporary Area of Critical Need- Med. Doctor 912 2 48 122 2 22 1 20 1,129 MENTAL HEALTH COUNSELING Licensed Mental Health Counselor 14,823 64 416 1,676 69 122 12 609 17,791 Provisional Mental Health Counselor Licensee 224 0 0 22 0 0 0 0 246 Registered Mental Health Counselor Intern 4,976 0 0 110 0 0 1 0 5,087 MIDWIFERY Midwife 209 6 16 15 1 3 1 28 279 NURSING Advanced Practice Registered Nurse 43,063 78 1,166 8,466 134 1,827 71 1,200 56,005 Certified Nursing Assistant 142,448 0 34,093 5,051 0 3,447 158 0 185,197 Certified Nursing Assistant Programs 200 0 0 0 0 0 0 0 200 Licensed Practical Nurse 63,103 302 7,281 4,686 117 1,121 158 2,209 78,977 Nursing Education Program – Practical Nurse 196 0 0 0 0 0 0 0 196 Nursing - Nursing Education Program- Registered Nurse 323 0 0 1 0 0 0 0 324 Registered Nurse 326,416 1,060 14,173 35,470 892 11,871 539 14,042 404,463
29 Annual Report and Long-Range Plan | Fiscal Year 2022-23 PROFESSION In State Out of State Military Active Retired TOTAL Active Inactive Delinquent Active Inactive Delinquent NURSING HOME ADMINISTRATOR Nursing Home Administrator 1,574 9 105 191 7 36 5 201 2,128 OCCUPATIONAL THERAPY Occupational Therapist 9,901 35 546 1,314 50 672 40 342 12,900 Occupational Therapy Assistant 5,823 42 782 375 21 262 10 133 7,448 OTD Capstone Exemption Registration 78 0 0 8 0 0 0 0 86 OPTICIANRY Apprentice Optician 1,338 0 0 8 0 0 0 0 1,346 Optician 3,660 36 282 171 28 41 6 153 4,377 OPTOMETRY Optometric Faculty Certificate 19 0 0 0 0 0 0 0 19 Optometrist 3,054 16 63 576 78 101 37 187 4,112 ORTHOTISTS AND PROSTHETISTS Orthotic Fitter 98 0 15 1 0 0 0 11 125 Orthotic Fitter Assistant 40 0 17 0 0 0 0 9 66 Orthotic Resident 19 0 0 5 0 0 0 0 24 Orthotic-Prosthetic Resident 9 0 0 0 0 0 0 0 9 Orthotist 87 0 28 13 0 3 0 20 151 Pedorthist 85 1 12 2 0 0 0 13 113 Prosthetic Residents 15 0 0 1 0 0 0 0 16 Prosthetist 64 0 12 9 0 0 0 15 100 Prosthetist-Orthotist 257 0 13 19 1 3 0 32 325 OSTEOPATHIC MEDICINE Osteopathic Faculty Certificate 0 0 0 0 0 0 0 0 0 Osteopathic Limited License 0 0 0 0 0 0 0 2 2 Osteopathic Physician 8,452 13 193 2,764 106 256 52 451 12,287 Osteopathic Physician Expert Witness Certificate 0 0 0 43 0 0 0 0 43 Osteopathic Resident Registration 1,660 0 1 227 0 0 0 0 1,888 Temporary Area of Critical Need 1 0 0 0 0 0 0 0 1 PHARMACY Consultant Pharmacist 3,115 64 411 185 12 40 1 246 4,074 Nuclear Pharmacist 157 0 4 50 2 10 0 17 240 Pharmacist 27,061 52 577 9,256 222 660 96 1,413 39,337
Annual Report and Long-Range Plan | Fiscal Year 2022-23 30 PROFESSION In State Out of State Military Active Retired TOTAL Active Inactive Delinquent Active Inactive Delinquent Pharmacist Intern 6,908 0 0 6,655 0 0 0 0 13,563 Registered Pharmacy Technician 46,618 117 13,066 1,014 6 508 52 21 61,402 PHYSICAL THERAPY Physical Therapist 17,566 92 530 2,958 376 558 92 527 22,699 Physical Therapist Assistant 11,983 107 575 773 70 182 53 204 13,947 PODIATRIC MEDICINE Certified Pod X-Ray Assistant 554 0 283 1 0 0 0 4 842 Podiatric Physician 1,604 11 59 302 41 60 4 201 2,282 Podiatric Resident Registration 135 0 0 42 0 0 0 0 177 PSYCHOLOGY Limited License Psychologist 8 0 1 1 0 1 0 2 13 Provisional Psychologist 36 0 0 0 0 0 0 0 36 Psychologist 5,417 10 128 1,103 32 67 13 493 7,263 RADIOLOGIC TECHNOLOGY Radiologic Technology 26,582 9 12,042 3,733 5 4,526 32 0 46,929 Radiologist Assistant 38 0 4 8 0 6 0 0 56 RESPIRATORY CARE Certified Respiratory Therapist 2,069 18 274 313 8 388 11 103 3,184 Registered Respiratory Therapist 9,709 56 591 2,266 43 2,460 19 297 15,441 Respiratory Care Practitioner Critical Care 14 1 2 0 0 0 0 3 20 Respiratory Care Practitioner Non-Critical Care 1 0 0 1 0 0 0 1 3 SCHOOL PSYCHOLOGY School Psychologist 1,037 4 45 60 0 8 2 55 1,211 SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY Audiologist 1,239 3 64 299 2 32 2 32 1,673 Audiology Assistant 190 1 93 1 0 3 0 1 289 Provisional Audiologist 26 0 0 5 0 0 0 0 31 Provisional SpeechLanguage Pathologist 859 0 0 69 0 0 0 0 928 Speech-Language Pathologist 11,731 23 565 1,779 15 399 20 219 14,751 Speech-Language Pathology Assistant 2,635 10 557 127 0 35 0 29 3,393 TELEHEALTH PROVIDER Out of State 0 0 0 19,996 0 0 0 0 19,996 TOTAL 3,545 116,827 164,397 3,823 37,975 2,392 35,962 1,113,221 1,478,142
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