HOUSE OF REPRESENTATIVES STAFF ANALYSIS BILL #: CS/HB 295 Substance Abuse Service Providers SPONSOR(S): Children, Families & Seniors Subcommittee, Caruso and others TIED BILLS: IDEN./SIM. BILLS: SB 210 REFERENCE ACTION ANALYST STAFF DIRECTOR or BUDGET/POLICY CHIEF 1) Children, Families & Seniors Subcommittee 13 Y, 0 N, As CS Curry Brazzell 2) Health & Human Services Committee 20 Y, 0 N Curry Calamas SUMMARY ANALYSIS The Department of Children and Families (DCF) administers a statewide system of safety-net services for substance abuse and mental health (SAMH) prevention, treatment, and recovery. It serves children and adults who are otherwise unable to obtain these services. DCF licenses substance abuse treatment facilities, such as addiction receiving facilities and intensive inpatient and outpatient treatment. The bill requires applicants applying for licensure as a substance abuse service provider to provide proof that the provider will prohibit the use of alcohol, medical marijuana, illegal drugs, and prescribed medications used by an individual other than whom the medication is prescribed. DCF is authorized to enter and inspect a licensed provider at any time to determine statutory and regulatory compliance and may, with permission or warrant, inspect suspected unlicensed providers. Inspections may be announced or unannounced. If a violation is found, DCF is required to issue a citation to the provider noting the violation classification and impose an administrative fine. The bill requires DCF to establish a mechanism for imposing and collecting fines for violations related to the inspections. A certified recovery residence with a DCF-approved discharge policy may immediately discharge or transfer a resident in accordance with the approved policy under certain circumstances. The bill makes willful refusal to leave the recovery residence after discharge, or after being warned to leave by the owner or employee of the residence, a second degree misdemeanor. Current law prohibits licensed substance abuse service providers from referring patients to a recovery residence unless the residence holds a valid certificate of compliance and is actively managed by a certified recovery residence administrator. Violators are subject to an administrative fine of $1,000 per occurrence. The bill requires DCF to establish a mechanism for imposing and collecting fines for referral violations. The bill prohibits the referral of a patient, to or from, a recovery residence that allows the use of alcohol, medical marijuana, illegal drugs, or the use of prescribed medication by an individual other than the individual for whom the medication is prescribed on the premises. The bill also requires a referral to include the placement of a patient by a licensed service provider into the licensed community housing component of the provider’s day or night treatment program, regardless of whether the community housing component is affiliated with the licensed service provider. The bill has an insignificant, indeterminate, negative fiscal impact on DCF and no fiscal impact on local governments. The bill provides an effective date of July 1, 2023. FULL ANALYSIS This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives . STORAGE NAME: h0295c.HHS DATE: 3/17/2023 I. SUBSTANTIVE ANALYSIS A. EFFECT OF PROPOSED CHANGES: Background Substance Abuse Approximately 1.1 million Floridians have a substance use disorder. 1 Substance abuse refers to the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs. 2 Substance use disorders occur when the chronic use of alcohol or drugs causes significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. 3 Repeated drug use leads to changes in the brain’s structure and function that can make a person more susceptible to developing a substance use disorder. 4 Brain imaging studies of persons with substance use disorders show physical changes in areas of the brain that are critical to judgment, decision making, learning and memory, and behavior control.5 According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, a diagnosis of substance use disorder is based on evidence of impaired control, social impairment, risky use, and pharmacological criteria.6 The most common substance use disorders in the United States are from the use of alcohol, tobacco, cannabis, stimulants, hallucinogens, and opioids.7 Substance Abuse Treatment in Florida DCF administers a statewide system of safety-net services for substance abuse and mental health (SAMH) prevention, treatment, and recovery. DCF provides treatment for substance abuse through a community-based provider system that offers detoxification, treatment and recovery support for adolescents and adults affected by substance misuse, abuse or dependence: 8 Detoxification Services: Detoxification services use medical and clinical procedures to assist individuals and adults as they withdraw from the physiological and psychological effects of substance abuse.9 Treatment Services: Treatment services 10 include a wide array of assessment, counseling, case management, and support services that are designed to help individuals who have lost their abilities to control their substance use on their own and require formal, structured intervention and support. Some of these services may also be offered to the family members of the individual in treatment.11 Recovery Support: Recovery support services, including transitional housing, life skills training, parenting skills, and peer-based individual and group counseling, are offered during 1 Substance Abuse and Mental Health Administration, Behavioral Health Barometer, Florida, Volume 6, (2020), https://www.samhsa.gov/data/sites/default/files/reports/rpt32826/Florida-BH-Barometer_Volume6.pdf (last visited February 10, 2023). 2 World Health Organization, Sub stance Ab use, https://www.afro.who.int/health-topics/substance-abuse (last visited February 11, 2023). 3 Substance Abuse and Mental Health Services Adminis tration, Sub stance Use Disorders https://www.samhsa.gov/find-help/disorders (last visited February 11, 2023). 4 National Institute on Drug Abuse, Drugs, Brains, and Behavior: The Science of Addiction, https://nida.nih.gov/sites/default/files/soa.pdf (last visited February 11, 2023). 5 Id. 6 NYSDOHA AI Substance Use Screening and Risk Assessment in Adults, Table 3: DSM-5 Diagnostic Criteria for Diagnosing and Classifying Substance Use Disorders, https://www.ncb i.nlm.nih.gov/books/NBK565474/pdf/Bookshelf_NBK565474.pdf. (last visited February 11, 2023). 7 The Rural Health Information Hub, Defining Substance Abuse and Substance Use Disorders, available at https://www.ruralhealthinfo.org/toolkits/substance-abuse/1/definition (last visited February 13, 2023). 8 Department of Children and Families, Treatment for Sub stance Ab use, https://www2.myflfamilies.com/service-programs/samh/ substance-abuse.shtml (last visited March 15, 2023). 9 Id. 10 Id. Research indicates that persons who successfully complete substance abuse treatment have better post-treatment outcomes related to future abstinence, reduced use, less involvement in the criminal justice system, reduced involvement in the child protective system, employment, increased earnings, and better health. 11 Supra, note 8. STORAGE NAME: h0295c.HHS PAGE: 2 DATE: 3/17/2023 and following treatment to further assist individuals in their development of the knowledge and skills necessary to maintain their recovery.12 Licensure of Substance Abuse Service Providers DCF regulates substance abuse treatment establishing licensure requirements and licensing service providers and individual service components under ch. 397, F.S., and rule 65D-30, F.A.C. Licensed service components include a continuum of substance abuse prevention, 13 intervention,14 and clinical treatment services.15 DCF uses a tier-based system of classifying violations and may issue administrative fines of up to $500 for violations committed by a licensee. 16 Clinical treatment is a professionally directed, deliberate, and planned regimen of services and interventions that are designed to reduce or eliminate the misuse of drugs and alcohol and promote a healthy, drug-free lifestyle.17 “Clinical treatment services” include, but are not limited to, the following licensable service components: 18 Addictions receiving facility; Day or night treatment; Day or night treatment with community housing; Detoxification; Intensive inpatient treatment; Intensive outpatient treatment; Medication-assisted treatment for opiate addiction; Outpatient treatment; and Residential treatment. Licensure Requirements DCF is required to establish the minimum licensure requirements and rules to address noncompliance. Licensure requirements must include, but are not limited to: 19 Standards and procedures for the administrative management of the licensed service component, including procedures for recordkeeping, referrals, and financial management; Standards consistent with clinical and treatment best practices that ensure the provision of quality treatment for individuals receiving substance abuse treatment services; The number and qualifications of all personnel, including, but not limited to, management, nursing, and qualified professionals, having responsibility for any part of an individual’s clinical treatment. These requirements must include, but are not limited to: o Education; credentials, such as licensure or certification, if appropriate; training; and supervision of personnel providing direct clinical treatment; o Minimum staffing ratios to provide adequate safety, care, and treatment; o Hours of staff coverage; 12 Id. 13 Section 397.311(26)(c), F.S. Prevention is a process involving strategies that are aimed at the individual, family, community, or substance and that preclude, forestall, or impede the development of substance use problems and promote responsible lifestyle s. See also, Department of Children and Families, Sub stance Ab use: Prevention, https://www.myflfamilies.com/service- programs/samh/prevention/index.shtml (last visited February 11, 2023). Substance abuse prevention is best accomplished through the use of ongoing strategies such as increasing public awareness and education, community-based processes and evidence-based practices. These prevention programs are focused primarily on youth, and, in recent years, have shifted to the l ocal level, giving individual communities the opportunity to identify their own unique prevention needs and develop action plans in response. Th is community focus allows prevention strategies to have a greater impact on behavioral change by shifting social , cultural and community environments. 14 Section 397.311(26)(b), F.S. Intervention is structured services directed toward individuals or groups at risk of substance a buse and focused on reducing or impeding those factors associated with the onset or the e arly stages of substance abuse and related problems. 15 Section 397.311(26), F.S. 16 Section 397.415, F.S. 17 Section 397.311(25)(a), F.S. 18 Id. 19 Section 397.410, F.S. STORAGE NAME: h0295c.HHS PAGE: 3 DATE: 3/17/2023 o The maximum number of individuals who may receive clinical services together in a group setting; and o The maximum number of licensed service providers for which a physician may serve as medical director and the total number of individuals he or she may treat in that capacity. Service provider facility standards, including, but not limited to: o Safety and adequacy of the facility and grounds; o Space, furnishings, and equipment for each individual served; o Infection control, housekeeping, sanitation, and facility maintenance; and o Meals and snacks. Disaster planning policies and procedures. Application for Licensure Applicants for licensure as a substance abuse service provider must submit an application to DCF and include, at a minimum:20 Information establishing the name and address of the applicant service provider and its director, and also of each member, owner, officer, and shareholder, if any; Information establishing the competency and ability of the applicant service provider and its director to carry out the requirements of ch. 397, F.S.; Proof satisfactory to the DCF of the applicant service provider’s financial ability and organizational capability to operate in accordance with ch. 397, F.S.; Proof of liability insurance coverage in amounts set by the DCF by rule; Sufficient information to conduct background screening for all owners, directors, chief financial officers, and clinical supervisors as provided in s. 397.4073, F.S.; Proof of satisfactory fire, safety, and health inspections, and compliance with local zoning ordinances;21 A comprehensive outline of the proposed services, including sufficient detail to evaluate compliance with clinical and treatment best practices, for: o Any new applicant; or o Any licensed service provider adding a new licensable service component. Proof of the ability to provide services in accordance with the DCF rules; and Any other information that the DCF finds necessary to determine the applicant’s ability to carry out its duties under this chapter and applicable rules. Names and locations of any recovery residences to which the applicant service provider plans to refer patients or from which the provider plans to accept patients. Inspections DCF is authorized to conduct announced or unannounced inspections, at any time, of a licensed provider to determine statutory and regulatory compliance. DCF may inspect suspected unlicensed providers with permission from the provider or with a warrant. 22 DCF must schedule periodic inspections of licensed service providers in order to minimize costs and the disruption of services; these inspections are done annually, unless a provider is accredited, in which case they are done triennially. 23 Violations found during inspection are classified according to the nature of the violation and the gravity of its probable effect on the individuals receiving substance abuse treatment. The classification of the violation must be indicated and provided on written notice to the provider. DCF is required to issue a citation for violations and impose an administrative fine, notwithstanding correction of the violation. 24 20 Section 397.403, F.S. 21 Service providers operating under a regular annual license shall have 18 months from the expiration date of their regular license within which to meet local zoning requirements. Applicants for a new license must demonstrate proof of compliance with zoning requirements prior to the department issuing a probationary license. 22 Section 397.411, F.S. 23 Rule 65D-30.0036, F.A.C 24 Section 397.411, F.S. STORAGE NAME: h0295c.HHS PAGE: 4 DATE: 3/17/2023 Following licensing inspections, regional offices may prepare and distribute to providers a report that includes a list of noncompliance issues, if any, with rule or statutory references and a request that the provider submit a plan for corrective action, including required completion dates. 25 DCF Remedies for Noncompliance Under current law, if DCF determines that an applicant, licensed service provider, or a licensed service component is not operating in compliance with all statutory and regulatory requirements, DCF may deny, suspend, revoke, or impose reasonable restrictions or penalties on the license or any portion of the license.26 In 2017, DCF’s authority to take action against service providers operating in noncompliance was expanded.27 DCF adopted rules to classify violations and establish the basis for issuing administrative fines in 2019. The rules also established a uniform system of procedures to impose disciplinary sanctions.28 Despite having the statutory authority and established rules and procedures in place to impose fines, DCF reported that between July 1, 2017, and December 1, 2022, the agency did not issue any fines for inspection violations 29or other statutory violations pursuant to section 397.415, F.S.30