HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: CS/HB 891 Health Care Provider Accountability
SPONSOR(S): Select Committee on Health Innovation, Giallombardo and others
TIED BILLS: IDEN./SIM. BILLS: SB 952
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
1) Select Committee on Health Innovation 22 Y, 0 N, As CS Guzzo Calamas
2) Health & Human Services Committee 18 Y, 0 N Guzzo Calamas
SUMMARY ANALYSIS
Nursing homes provide 24-hour a day nursing care, case management, health monitoring, personal care,
social activities, respite care, and physical, occupational, and speech therapy to those who are ill or physically
infirm. Nursing homes are regulated by the Agency for Health Care Administration (AHCA) under the Health
Care Licensing Procedures Act in part II of chapter 408, F.S., and under the individual authorizing statutes for
nursing homes in part II of chapter 400, F.S.,
CS/HB 891 requires nursing homes to report to AHCA any common ownership the facility or its parent
company shares with a staffing or management company, a vocational or physical rehabilitation company, or
any other entity that conducts business within the facility. Common ownership means, in relevant part, an
ownership interest of 5 percent or more held by the entity in the facility or by the facility in the entity. The bill
requires facilities to report this information electronically as an element of the data required to be reported in
the Florida Nursing Home Uniform Reporting System. AHCA must annually publish on its website all common
ownership reported in the preceding year.
The bill also requires AHCA to submit an annual report to the Governor and the Legislature on the success of
the Personal Care Attendant (PCA) training program, which was created by the Legislature in 2021, to create
an additional path for an individual to become a certified nursing assistant (CNA). The report must include:
The number of PCAs who take and subsequently pass the CNA exam after the four months of initial
employment with a facility;
Any adverse actions related to patient care involving PCAs; and
The number of new CNAs employed and remaining each year after being employed as PCAs.
The bill has no fiscal impact on state or local government.
The bill provides an effective date of July 1, 2024.
This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives .
STORAGE NAME: h0891b.HHS
DATE: 2/15/2024
FULL ANALYSIS
I. SUBSTANTIVE ANALYSIS
A. EFFECT OF PROPOSED CHANGES:
Background
Nursing Homes
Nursing homes are regulated by the Agency for Health Care Administration (AHCA) under the Health
Care Licensing Procedures Act (Act) in part II of chapter 408, F.S., which contains uniform licensing
standards for all 29 types of facilities and providers licensed by AHCA. In addition, nursing homes must
comply with the requirements contained in the individual authorizing statutes of part II of chapter 400,
F.S., which includes unique provisions beyond the uniform criteria.
Nursing Home Uniform Reporting System
Nursing homes are required to annually submit actual audited, financial experience including
expenditures, revenues, and statistical measures to AHCA’s Florida Nursing Home Uniform Reporting
System (NHURS).1 The data may be based on internal financial reports that are certified to be
complete and accurate by the chief financial officer of the nursing home, and must include the fiscal
year-end balance sheet, income statement, statement of cash flow, and statement of retained
earnings.2
Disclosure of Ownership Interest (State)
The Act requires applicants for licensure, including applicants for nursing home licensure, to submit to
AHCA the name, address, and social security number, or individual taxpayer identification number if a
social security number cannot be legally obtained, of: 3
The applicant;
The administrator or a similarly titled person who is responsible for the day-to-day operation of
the facility;
The financial officer or similarly titled person who is responsible for the financial operation of
the licensee or provider;
Each person or entity that serves as an officer of, is on the board of directors of, or has a 5-
percent or greater ownership interest in the applicant or licensee; and
Each person or entity that serves as an officer of, is on the board of directors of, or has a 5-
percent or greater ownership interest in the management company or other entity, related or
unrelated, with which the applicant or licensee contracts to manage the provider.
Current Florida law does not require nursing homes to report to AHCA any common ownership the
facility or its parent company shares with staffing or management companies, vocational or physical
rehabilitation companies, or any other companies that conduct business within the facility.
Disclosure of Ownership Interest (Federal)
The federal Centers for Medicare and Medicaid Services (CMS) recently published a final rule
implementing additional disclosure requirements for nursing homes certified to provide Medicare or
Medicaid.4 According to CMS, “over the years CMS has become increasingly concerned about the
quality of care at nursing homes, especially those owned by private equity companies and other types
of investment firms. Academic research suggests that ownership of nursing homes by private equity
1 S. 408.061(5), F.S.
2 Id.
3 Ss. 408.806(1), F.S., and 408.803(7), F.S.
4 42 C.F.R., § 424.502 (Nov. 17, 2023).
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companies and other types of investment firms can be associated with worse resident outcomes, and
merits closer scrutiny.”5
The rule requires all Medicare and Medicaid certified nursing homes to report to CMS and the relevant
state Medicaid agencies additional information about their ownership and management structures.
Specifically, nursing homes must submit certain information with their application for initial enrollment
and upon revalidation, including information on any person or entity who does any of the following: 6
Exercises operational, financial, or managerial control over the facility or a part thereof;
Provides policies or procedures for any of the operations of the facility;
Provides financial or cash management services to the facility;
Leases or subleases real property to the facility;
Owns a whole or part interest equal to or exceeding five percent of the total value of such real
property;
Provides management or administrative services;
Provides management or clinical consulting services; or
Provides accounting or financial services to the facility.
For each disclosable party above, the nursing facilities must report the organizational structure of such
entity. This requirement varies by business structure, as follows: 7
For a corporation – the officers, directors, and shareholders of the corporation who have an
ownership interest in the corporation which is equal to or exceeds five percent.
For a limited liability company – the members and managers of the limited liability company
including, as applicable, what percentage each member and manager has of the ownership
interest in the limited liability company.
For a general partnership – The partners of the general partnership.
For a limited partnership – The general partners and any limited partners of the limited
partnership who have an ownership interest in the limited partnership which is equal to or
exceeds 10 percent.
For a trust – The trustees of the trust.
Personal Care Attendant Training Program
In the initial stages of the COVID-19 pandemic, nursing homes struggled to maintain adequate staffing
levels.8 To address the staffing challenges caused by the pandemic, AHCA temporarily approved the
creation of the personal care attendant (PCA) training program.9 A PCA is an individual who has not
fulfilled the necessary requirements to become a certified nursing assistant (CNA), but may assist
nursing home residents with certain tasks after completion of required training. 10 This allows them to
develop the skills to become a CNA while receiving on the job experience. Like all applicants for
certification as a CNA, a PCA is required to pass the CNA competency exam, but their PCA training
5 Centers for Medicare & Medicaid Services, Disclosures of Ownership and Additional Disclosable Parties Information for Skilled
Nursing Facilities and Nursing Facilities; Definitions of Private Equity Companies and Real Estate Investment Trusts for Medi care
Providers and Suppliers (Nov. 15, 2023), available at https://www.cms.gov/newsroom/fact-sheets/disclosures-ownership-and-
additional-disclosable-parties-information-skilled-nursing-facilities-and-0 (last visited January 30, 2024).
6 42 C.F.R., § 424.502 “Additional Disclosable Party” (1)-(3).
7 42 C.F.R., § 424.502 “Organizational Structure”
8 Noelle Denny-Brown, Denise Stone, Burke Hays, and Dayna Gallaghe/U.S. Department of Health & Human Services, Office of the
Assistant Secretary for Planning and Evaluation, COVID-19 Intensifies Nursing Home Workforce Challenges (Oct. 19, 2020), available
at https://aspe.hhs.gov/basic-report/covid-19-intensifies-nursing-home-workforce-challenges (last visited January 30, 2024).
9 Memorandum from the Agency for Health Care Administration to the Florida Health Care Association and Florida Leading Age (Mar .
28, 2020), available at https://www.fhca.org/images/uploads/pdf/Personal_Care_Attendent.pdf (last visited January 30, 2024). See also
Memorandum from the Agency for Health Care Administration to the Florida Health Care Association and Florida Leading Age (Sep . 9,
2020), available at https://www.fhca.org/images/uploads/pdf/PCA_letter_9-8-20_1.pdf (last visited January 30, 2024).
10 S. 400.211(2)(d), F.S.
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substitutes for the 120-hour CNA training program.11 A PCA must become certified within four months
of initial employment.12
In 2021, the Legislature codified the temporary PCA training program, with modifications to align it with
current practice for CNAs.13 The goal of the PCA training program is to enable the PCA to further
obtain skills and training from their employer toward successfully passing the CNA exam. 14 The PCA
must attain certification as a CNA within four months of initial employment. 15
Completion of all training and documentation requirements for PCA candidates is the ultimate
responsibility of the nursing home.16 Training must consist of 16 hours of classroom instruction and
eight hours of supervised simulation in which the PCA candidate is required to demonstrate
competency in all areas of training.17 The facility must maintain a record of all PCA candidates who
complete training and must provide the names of all PCAs working in the facility to AHCA upon
request.18
Effect of the Bill
CS/HB 891 requires nursing homes to report to AHCA any common ownership the facility or its parent
company shares with a staffing or management company, a vocational or physical rehabilitation
company, or any other entity that conducts business within the facility. Common ownership means, in
relevant part, an ownership interest of 5 percent or more held by the entity in the facility or by the
facility in the entity. The bill requires facilities to report this information electronically as an element of
the data required to be reported in the NHURS. AHCA must annually publish on its website all
common ownership reported in the preceding year.
The bill also requires AHCA to submit an annual report to the Governor and the Legislature on the
success of the PCA training program, which must include:
The number of PCAs who take and subsequently pass the CNA exam after the four months of
initial employment with a facility;
Any adverse actions related to patient care involving PCAs; and
The number of new CNAs employed and remaining each year after being employed as PCAs.
The bill provides an effective date of July 1, 2024.
B. SECTION DIRECTORY:
Section 1: Amends s. 400.141, F.S., relating to administration and management of nursing home
facilities.
Section 2: Amends s. 400.211, F.S., relating to persons employed as nursing assistants; certification
requirements; qualified medication aide designation and requirements.
Section 3: Provides an effective date of July 1, 2024.
II. FISCAL ANALYSIS & ECONOMIC IMPACT STATEMENT
A. FISCAL IMPACT ON STATE GOVERNMENT:
1. Revenues:
None.
11 S. 400.141(1)(w), F.S., and rule 59A-4.1081, F.A.C.
12 S. 400.211(2)(d), F.S.
13 Chapter 2021-163, Laws of Fla.
14 Rule 59A-4.1081(2), F.A.C.
15 S.400.211(2)(d), F.S.
16 Rule 59A-4.1081(6), F.A.C.
17 Id.
18 Id.
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2. Expenditures:
None.
B. FISCAL IMPACT ON LOCAL GOVERNMENTS:
1. Revenues:
None.
2. Expenditures:
None.
C. DIRECT ECONOMIC IMPACT ON PRIVATE SECTOR:
None.
D. FISCAL COMMENTS:
None.
III. COMMENTS
A. CONSTITUTIONAL ISSUES:
1. Applicability of Municipality/County Mandates Provision:
Not applicable. The bill does not appear to affect county or municipal governments.
2. Other:
None.
B. RULE-MAKING AUTHORITY:
The bill does not necessitate rule-making for implementation.
C. DRAFTING ISSUES OR OTHER COMMENTS:
None.
IV. AMENDMENTS/COMMITTEE SUBSTITUTE CHANGES
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Statutes affected: H 891 Filed: 400.211, 409.908
H 891 c1: 400.211