The Florida Senate BILL ANALYSIS AND FISCAL IMPACT STATEMENT (This document is based on the provisions contained in the legislation as of the latest date listed below.) Prepared By: The Professional Staff of the Committee on Health Policy BILL: CS/SB 1572 INTRODUCER: Health Policy Committee and Senator Baxley SUBJECT: Dementia-related Staff Training DATE: February 10, 2022 ANALYST STAFF DIRECTOR REFERENCE ACTION 1. Looke Brown HP Fav/CS 2. AHS 3. AP Please see Section IX. for Additional Information: COMMITTEE SUBSTITUTE - Substantial Changes I. Summary: CS/SB 1572 creates the Florida Alzheimer’s Disease and Dementia Training and Education Act. The bill requires each covered provider (CP) 1 to: Provide each of its employees 2 with basic written information about interacting with patients who have Alzheimer’s disease or related dementia (ADRD) upon beginning employment and to provide each employee who provides direct care 3 and who is in regular contact 4 with participants, patients, or residents with one hour of ADRD related training within 30 days of beginning employment. 5 1 As defined in the bill a “covered provider” includes nursing homes, home health agencies, nurse registries, companion homemaker services, assisted living facilities, adult family-care homes, and adult day care centers. 2 As defined in the bill a “employee” includes any staff member, contracted staff, or independent contractor employed or referred by a covered provider who is required to undergo a level 2 background screening as required by s. 408.809, F.S., and ch. 435, F.S. The term includes, but is not limited to, direct care workers; staff responsible for housekeeping, the front desk, and other administrative functions; and companions or homemakers. 3 Defines as providing, through in-person contact, assistance with the activities of daily living; assistance with the self- administration of medication; homemaker or companion services; nursing services; or other services that promote the physical, mental, and psychosocial well-being of participants, patients, and residents of covered providers. The term does not include administrative functions or maintenance of the physical environment of a licensed facility, including grounds maintenance, building maintenance, housekeeping, laundry, or food preparation. 4 Defined as the performance of duties other than direct care which may require employees to interact in person on a daily basis with participants, patients, or residents. 5 The employee is not required to take the one hour of training if he or she has already completed the one hour of training as an employee of a different covered provider. REVISED: BILL: CS/SB 1572 Page 2 Require each of its employees who provides direct care to complete two or three additional hours of ADRD training, depending on the CP’s license type, within the first seven months after beginning employment. If the CP advertises that it provides special care for persons with ADRD, require each of its employees who provide direct to care or have regular contact with residents or participants to complete an additional three hours of training within the first three months after beginning employment and employees who provide direct care to complete an additional four hours of training within the first six months after beginning employment. Additionally, an employee who provides direct care must participate in a minimum of four contact hours of continuing education each year. The bill specifies the Department of Elder Affairs (DOEA) may adopt training curriculum guidelines for specified training and approve training providers. The training may be in a variety of formats. The bill specifies what qualifications a training provider must possess in order to be able to provide training without DOEA approval and requires the DOEA to provide the one hour training course at no cost to CPs and must make it available online. The bill allows certified nursing assistants (CNA) and health care practitioners to apply the training taken under the bill to the training requirements for their license types. The bill adds to the licensure statutes for nursing homes, home health agencies, nurse registries, companion homemaker services, assisted living facilities, adult family-care homes, and adult day care centers a requirement for each facility to meet the training requirements established by the bill as a condition of licensure. Additionally, if the licensure statutes for any CP already includes ADRD-specific training requirements, the bill removes those requirements in favor of the requirements established by the bill. The bill provides an effective date of July 1, 2022. II. Present Situation: Dementia and Alzheimer’s Disease Dementia is the loss of cognitive functioning—thinking, remembering, and reasoning—and behavioral abilities to such an extent that it interferes with a person’s daily life and activities. These functions include memory, language skills, visual perception, problem solving, self- management, and the ability to focus and pay attention. Some people with dementia cannot control their emotions, and their personalities may change. Dementia ranges in severity from the mildest stage, when it is just beginning to affect a person’s functioning, to the most severe stage, when the person must depend completely on others for basic activities of living. 6 Alzheimer’s disease is the most common type of dementia. It is a progressive disease that begins with mild memory loss and can lead to loss of the ability to carry on a conversation and respond to one’s environment. Alzheimer’s disease affects parts of the brain that control thought, 6 National Institute on Aging, What is Dementia? Symptoms, Types, and Diagnosis, available at https://www.nia.nih.gov/health/what-dementia-symptoms-types-and-diagnosis, (last visited on Jan. 28, 2022). BILL: CS/SB 1572 Page 3 memory, and language. It can seriously affect a person’s ability to carry out daily activities. Although scientists are studying the disease, what causes Alzheimer’s disease is unknown. 7 There are an estimated 580,000 individuals living with Alzheimer’s disease in the state of Florida. 8 By 2025, it is projected that 720,000 Floridians will have Alzheimer’s disease. 9 Most individuals with Alzheimer’s can live in the community with support, often provided by spouses or other family members. In the late stages of the disease, many patients require care 24 hours per day and are often served in long-term care facilities. Dementia and Alzheimer’s Disease Training Providers not Currently Required to Provide Specific ADRD Training. Nurse registries are prohibited from training a registered nurse, licensed practical nurse, certified nursing assistant, companion or homemaker, or home health aide that it refers for contract. 10 However, depending on his or her license type, an individual referred by the nurse registry may have ADRD-specific training required by his or her practice act. Companion and homemaker service providers are not required to train the companions or homemakers they provide. Adult family-care home providers are required to undergo 12 hours of training, some of which must be related to identifying and meeting the special needs of disabled adults and frail elders. However, these providers are not currently required to undergo training specific to ADRD. 11 Overview of ADRD Training Requirements by Facility Type All Employees Employees with Expected or Required Direct Contact Employees Providing Direct Care Health Care Practitioner Continuing Education Sufficient? Training Approved? Exemptions Nursing Homes Provided with basic written information about interacting with persons with ADRD upon beginning employment. 1 hour of training within the first 3 months of employment. Additional 3 hours of training within the first 9 months of employment. Yes By DOEA. Home Health Agencies Not specified. 2 hours of training within the first 9 months of employment. Yes By DOEA. HHA’s that serve 90% individuals under age 21 are exempt. 7 Centers for Disease Control and Prevention, Alzheimer’s Disease and Healthy Aging, available at https://www.cdc.gov/aging/aginginfo/alzheimers.htm#AlzheimersDisease, (last visited Jan. 28, 2022). 8 Alzheimer’s Association, Alzheimer’s Statistics Florida, available at https://www.alz.org/media/Documents/florida- alzheimers-facts-figures-2018.pdf, (last visited Jan. 28, 2022). 9 Id. 10 Section 400.506(19), F.S. 11 See s. 429.75, F.S., and Fla. Admin. Code R. 59A-37.007 (2020). BILL: CS/SB 1572 Page 4 All Employees Employees with Expected or Required Direct Contact Employees Providing Direct Care Health Care Practitioner Continuing Education Sufficient? Training Approved? Exemptions ALFs 12 Employees with incidental contact must be given information within 3 months. 4 hours within 3 months of employment 4 additional hours within 9 months of employment + 4 hours CE annually Not specified. By DOEA Adult Day Care Centers Same as nursing homes, home health agencies, and Hospice. 1 hour of training within the first 3 months of employment. Additional 3 hours of training within the first 9 months of employment. Yes By DOEA Details for each facility type are below: Nursing Homes Section 400.1755, F.S., requires each nursing home to provide the following training: Provide each of its employees basic written information about interacting with persons with ADRD upon beginning employment. All employees who are expected to, or whose responsibilities require them to, have direct contact with residents with ADRD must also have an initial training of at least one hour completed in the first three months after beginning employment. This training must include, but is not limited to, an overview of dementias and must provide basic skills in communicating with persons with dementia. An individual who provides direct care must complete the required initial training and an additional three hours of training within nine months after beginning employment. This training must include, but is not limited to, managing problematic behaviors, promoting the resident’s independence in activities of daily living, and skills in working with families and caregivers. Health care practitioners’ continuing education can be counted toward the required training hours. The DOEA or its designee must approve the initial and continuing training provided in the facilities. The DOEA must approve training offered in a variety of formats, including, but not limited to, Internet-based training, videos, teleconferencing, and classroom instruction. The DOEA must keep a list of current providers who are approved to provide initial and continuing training. The DOEA must adopt rules to establish standards for the trainers and the training required in this section of statute. Upon completing any training listed in the section, the employee or direct caregiver must be issued a certificate that includes the name of the training provider, the topic covered, and the date and signature of the training provider. The certificate is evidence of completion of training in the identified topic, and the employee or direct caregiver is not required to repeat training in that topic if the employee or direct caregiver changes employment to a different facility or to an assisted living facility, home health agency, adult day care center, or adult 12 Training is required if the ALF advertises that it provides special care for persons with Alzheimer’s disease or related disorders. Section 429.178, F.S. BILL: CS/SB 1572 Page 5 family-care home. The direct caregiver must comply with other applicable continuing education requirements. Home Health Agencies Section 400.4785, F.S., requires a home health agency to provide the following staff training: Upon beginning employment with the agency, each employee must receive basic written information about interacting with participants who have ADRD. Newly-hired home health agency personnel who will be providing direct care to patients must complete two hours of training in ADRD within nine months after beginning employment with the agency. This training must include, but is not limited to, an overview of dementia, a demonstration of basic skills in communicating with persons who have dementia, the management of problematic behaviors, information about promoting the client’s independence in activities of daily living, and instruction in skills for working with families and caregivers. For certified nursing assistants, the required two hours of training are part of the total hours of training required annually. For a health care practitioner, as defined in s. 456.001, F.S., 13 continuing education hours taken as required by that practitioner’s licensing board are counted toward the total of two hours. For an employee who is a licensed health care practitioner, training that is sanctioned by that practitioner’s licensing board must be considered to be approved by the DOEA. The DOEA, or its designee, must approve the required training. The DOEA must consider for approval training offered in a variety of formats. The DOEA must keep a list of current providers who are approved to provide the two-hour training. The DOEA must adopt rules to establish standards for the employees who are subject to this training, for the trainers, and for the training required in this section of statute. Upon completing the training listed in the section, the employee must be issued a certificate stating that the training mandated under the section has been received. The certificate must be dated and signed by the training provider. The certificate is evidence of completion of this training, and the employee is not required to repeat this training if the employee changes employment to a different home health agency. A licensed home health agency whose unduplicated census during the most recent calendar year was composed of at least 90 percent of individuals aged 21 years or younger at the date of admission, is exempt from the training requirements in this section of statute. Assisted Living Facilities Section 429.178, F.S., requires an ALF that advertises it provides special care for persons with ADRD to provide the following training: An employee who has regular contact with such residents must complete up to four hours of initial dementia-specific training developed or approved by the DOEA. The training must be 13 Section 456.001(4), F.S., defines “health care practitioner” as any person licensed under ch. 457, F.S.; ch. 458, F.S.; ch. 459, F.S.; ch. 460, F.S.; ch. 461, F.S.; ch. 462, F.S.; ch. 463, F.S.; ch. 464, F.S.; ch. 465, F.S.; ch. 466, F.S.; ch. 467, F.S.; part I, part II, part III, part V, part X, part XII, or part XIV of ch. 468, F.S.; ch. 478, F.S.; ch. 480, F.S.; part I or part II of ch. 483, F.S.; ch. 484, F.S.; ch. 486, F.S.; ch. 490, F.S.; or ch. 491, F.S. BILL: CS/SB 1572 Page 6 completed within three months after beginning employment and satisfy the core training requirements of s. 429.52(3)(g), F.S. A direct caregiver who provides direct care to such residents must complete the required initial training and four additional hours of training developed or approved by the DOEA. The training must be completed within nine months after beginning employment and satisfy the core training requirements of s. 429.52(3)(g), F.S. An individual who is employed by a facility that provides special care for residents with ADRD, but who only has incidental contact with such residents, must be given, at a minimum, general information on interacting with individuals with ADRD, within three months after beginning employment. A direct caregiver must also participate in a minimum of four contact hours of continuing education each calendar year. The continuing education must include one or more topics included in the dementia-specific training, developed or approved by the DOEA, in which the caregiver has not received previous training. Upon completing any specified training, the employee or direct caregiver must be issued a certificate that includes the name of the training provider, the topic covered, and the date and signature of the training provider. The certificate is evidence of completion of training in the identified topic, and the employee or direct caregiver is not required to repeat training in that topic if the employee or direct caregiver changes employment to a different facility. The employee or direct caregiver must comply with other applicable continuing education requirements. The DOEA, or its designee, must approve the initial and continuing education courses and providers. The DOEA must keep a current list of providers who are approved to provide initial and continuing education for staff of facilities that provide special care for persons with ADRD. Adult Day Care Centers Section 429.917, F.S., requires an adult day care center to provide the following staff training: Upon beginning employment with the facility, each employee must receive basic written information about interacting with participants who have ADRD. In addition to the information provided, newly-hired adult day care center personnel who are expected to, or whose responsibilities require them to, have direct contact with participants who have ADRD must complete initial training of at least one hour within the first three months after beginning employment. The training must include an overview of dementias and must provide instruction in basic skills for communicating with persons who have dementia. In addition to the previous requirements, an employee who will be providing direct care to a participant who has ADRD must complete an additional three hours of training within nine months after beginning employment. This training must include, but is not limited to, the management of problem behaviors, information about promoting the participant's independence in activities of daily living, and instruction in skills for working with families and caregivers. For certified nursing assistants, the required four hours of training is part of the total hours of training required annually. For a health care practitioner as defined in s. 456.001, F.S., continuing education hours taken as required by that practitioner’s licensing board are counted toward the total of four hours. BILL: CS/SB 1572 Page 7 For an employee who is a licensed health care practitioner as defined in s. 456.001, F.S., training that is sanctioned by that practitioner’s licensing board is considered to be approved by the DOEA. The DOEA or its designee must approve the one-hour and three-hour training provided to employees and direct caregivers under this section of statute. The DOEA must consider for approval training offered in a variety of formats. The DOEA must keep a list of current providers who are approved to provide the one-hour and three-hour training. The DOEA must adopt rules to establish standards for the employees who are subject to this training, for the trainers, and for the training required in this section of statute. Upon completing any training described in the section, the employee or direct caregiver must be issued a certificate that includes the name of the training provider, the topic covered, and the date and signature of the training provider. The certificate is evidence of completion of training in the identified topic, and the employee or direct caregiver is not required to repeat training in that topic if the employee or direct caregiver changes employment to a different adult day care center or to an assisted living facility, nursing home, home health agency, or hospice. The direct caregiver must comply with other applicable continuing education requirements. Current Administration of ADRD Training The DOEA has authority for administering the existing ADRD training 14 and currently does so through a contract with the University of South Florida (USF). 15 USF, through its Training Academy on Aging, reviews and approves ADRD Training Providers and Training Curriculum Programs for the DOEA. The mission of the ADRD training program is to improve the care of individuals with ADRDs who receive services from nursing homes, assisted living facilities, home health agencies, adult day care centers, and hospice care facilities. The ADRD training program is designed to ensure that agency and facility staff members who have regular contact with or provide direct care to, persons with ADRD receive the relevant ADRD training. 16 III. Effect of Proposed Changes: CS/SB 1572 creates s. 430.5025, F.S., entitled the Florida Alzheimer’s Disease and Dementia Training and Education Act. The bill defines the following terms: “Covered provider” means a nursing home facility, a home health agency, a nurse registry, a companion or homemaker service provider, an assisted living facility, an adult family-care home, or an adult day care center licensed or registered under chapter 400, F.S., or ch. 429, F.S. “Department” means the Department of Elder Affairs. “Direct care” means providing, through in-person contact, assistance with the activities of daily living; assistance with the self-administration of medication; homemaker or companion services; nursing services; or other services that promote the physical, mental, and psychosocial well-being of participants, patients, and residents of covered providers. The term does not include administrative functions or maintenance of the physical environment of 14 Fla. Admin. Code R. 58A-5.0194 (2020). 15 Contract XQ092.A3, effective July 1, 2021. 16 Department of Elder Affairs, DOEA Bill Analysis of SB 1572 (Jan. 13, 2022) (on file with the Senate Committee on Health Policy). BILL: CS/SB 1572 Page 8 a licensed facility, including grounds maintenance, building maintenance, housekeeping, laundry, or food preparation. “Employee” means any staff member, contracted staff, or independent contractor hired or referred by a CP who is required to undergo a level 2 background screening as required by s. 408.809(1)(e), F.S. The term includes, but is not limited to, direct care workers; staff responsible for housekeeping, the front desk, and other administrative functions; and companions or homemakers. “Regular contact” means the performance of duties other than direct care which may require employees to interact in person on a daily basis with participants, patients, or residents. The bill allows the DOEA or its designee to adopt training curriculum guidelines for training other than continuing education and specifies that the training may be in a variety of in-person or electronic formats. Additionally, the bill requires the DOEA or its designee to offer training to the general public which includes basic information about the most common forms of dementia, how to identify the signs and symptoms of dementia, skills for coping with and responding to changes as a result of the onset of dementia symptoms, planning for the future, and how to access additional resources about dementia. The bill specifies that any training curriculum on ADRD approved by the DOEA or its designee before July 1, 2022, remains in effect until the curriculum’s expiration date. The bill specifies that training providers who have the following qualifications may provide training under the section without being approved by the DOEA: An individual approved by a board of the Department of Health to provide training who is registered with the electronic tracking system established in s. 456.025, F.S.; An individual with a master’s or doctorate degree in health care, social services, or gerontology from an accredited college or university; or A training provider approved by the department or its designee before July 1, 2022. Training providers other than those who were approved by the DOEA before July 1, 2022, must also have: At least one year of teaching experience as an educator for caregivers of individuals with ADRD; At least one year of practical experience in a program providing care to individuals with ADRD; or Completed a specialized training program in the subject matter of ADRD from an accredited health care, human services, or gerontology education provider. When an employee completes the required training, the training provider must provide a record of completion of the training which includes the name of the employee, the name of the training provider, the topics covered, and the date of completion. The record is evidence of completion of training in the identified topic, and the employee is not required to repeat training in that topic if the employee changes employment to a different covered provider. BILL: CS/SB 1572 Page 9 Required Training and Information Basic Information The bill requires CPs to provide each employee, upon beginning employment, with basic written information about interacting with patients who have Alzheimer’s disease or related dementia. Training for All Employees The bill requires each employee who provides direct care and who is in regular contact with participants, patients, or residents to complete one hour of dementia-related training within 30 days after employment begins. Covered providers must maintain in its records a copy of the employee’s certificate of completion. The bill specifies that an employee who completes the training is not required to retake the training when switching employment. The bill specifies that the DOEA or its designee must provide the one hour ADRD training at no cost and the training must include basic information about the most common forms of dementia and instruction on methods for identifying warning signs and symptoms of dementia and skills for communicating and interacting with individuals who have Alzheimer’s disease or related dementia. The DOEA must also provide certificates of completion for each employee who completes the course which includes the name of the training and training provider, the name of the employee, and the date of completion. Training for Employees with Direct Contact and/or with Regular Contact In addition to the one hour of training, the bill requires CPs to require all employees who provide direct care to receive additional training as follows: Two hours of additional training if the CP is a home health agency, nurse registry, or a companion or homemaker service provider; Three hours of additional training if the CP is a nursing home, ALF, adult-family care home, or adult day care center. The training must be completed within the first seven months after employment begins and must include, but is not limited to, information related to management of problematic behaviors, promotion of independence in activities of daily living, and instruction on skills for working with family members and caregivers of patients. If the employee works for a ALF, adult family-care home, or adult day care center that advertises special care for individuals with ADRD, an employee who provides direct care or has regular contact must complete three additional hours of training within three months after beginning employment. In addition, an employee who provides direct care must complete four more hours of training which must include, but need not be limited to, information related to understanding ADRD, the stages of Alzheimer’s disease, communication strategies, medical information, and stress management within six months of beginning employment. Afterwards, each employee who provides direct care must participate in a minimum of four contact hours of continuing education annually. The continuing education must cover at least one of the topics included in the dementia-specific training in which the employee has not received previous training. BILL: CS/SB 1572 Page 10 The bill specifies that the training required under the bill qualifies as training that a CNA or health care worker may count towards any continuing education required to maintain his or her license or certification. The bill specifies that individuals employed, contracted, or referred before July 1, 2022, must complete the training by July 1, 2025, or provide proof of equivalent training received before July 1, 2022. The bill grants the DOEA rulemaking authority to create training curriculum guidelines, to establish requirements for the approval of qualified training providers, and to conduct sampling of training or training curricula as necessary to monitor for compliance with curriculum guidelines. Additionally, the bill amends and creates ss. 400.511, 400.1755, 400.4785, 429.178, 429.52, 429.75, 429.83, 429.917, and 429.918, F.S., to eliminate existing ADRD training requirements from the licensure statutes for all CPs and to add a requirement that each license type meet the training requirements established by the bill. The bill provides and effective date of July 1, 2022. IV. Constitutional Issues: A. Municipality/County Mandates Restrictions: None. B. Public Records/Open Meetings Issues: None. C. Trust Funds Restrictions: None. D. State Tax or Fee Increases: None. E. Other Constitutional Issues: None. V. Fiscal Impact Statement: A. Tax/Fee Issues: None. BILL: CS/SB 1572 Page 11 B. Private Sector Impact: SB 1572 may have an indeterminate fiscal impact on license types that must require employees to receive ADRD training under the bill if those license types are not currently required to provide such training or if the training required by the bill is greater than the training currently required. C. Government Sector Impact: None. VI. Technical Deficiencies: None. VII. Related Issues: SB 1572 includes nurse registries under the definition of CP and creates s. 400.511, F.S., to require that each individual employed, contracted, or referred by a nurse registry must complete the training established in the bill. The bill requires CPs to “provide” one hour of training to all employees (as defined) and to “require all employees who are direct care workers to receive” additional training as specified in the bill. However, s. 400.506(19), F.S., states that a nurse registry may not “monitor, supervise, manage, or train a registered nurse, licensed practical nurse, certified nursing assistant, companion or homemaker, or home health aide referred for contract under this chapter.” Section 400.511, F.S., as created by the bill, does not provide an exemption from this prohibition, and it is unclear whether the training required by the bill would violate this provision. The bill should be amended to provide an exemption from s. 400.506(19), F.S., for the training required related to nurse registries under the bill. VIII. Statutes Affected: This bill substantially amends the following sections of the Florida Statutes: 400.1755, 400.4785, 429.178, 429.52, 429.75, 429.83, 429.917, and 429.918. This bill creates the following sections of the Florida Statutes: 430.5025 and 400.511. IX. Additional Information: A. Committee Substitute – Statement of Substantial Changes: (Summarizing differences between the Committee Substitute and the prior version of the bill.) CS by Health Policy on February 10, 2022: The CS: Replaces the definition of “direct care worker” with definitions for “direct care” and “regular contact;” Replaces the requirement that the DOEA or its designee approve or develop all the training required by the bill with provisions that authorize that the DOEA to adopt training curriculum guidelines and approve training providers; BILL: CS/SB 1572 Page 12 Allows training providers to provide training under the section without being approved by the DOEA if the training provider meets specified qualifications. Narrows who must receive the one hour of training from all employees to employees who provide direct care and who are in regular contact with residents, patients, or participants; Requires the additional two or three hours of training for employees providing direct care to be completed within seven months of employment, rather than four months. Specifies that if an ALF, adult family-care home, or adult day care center advertises it provides specialized Alzheimer’s care certain of the facility’s employees must receive additional training. The bill originally required additional training for all of the covered providers who advertise as such. Increases the required initial training for employees of the facilities specified above: o Requires three additional hours of training for employees who have regular contact or provide direct care within three months of employment; and o Requires four additional hours of training for employees who provide direct care within six months of beginning employment. Allows training taken under the section to count toward a CNA’s or a health care provider’s total hours of required continuing education required for licensure or certification. Removes provisions that allow a health care provider’s training for his or her licensure to count toward the required hours under the bill. Specifies that training curricula approved by the DOEA prior to July 1, 2022, remains in effect until such curricula expires. Requires employees who are hired prior to July 1, 2022, to receive the necessary training by July 1, 2025, or to provide proof that they have already received equivalent training prior to July 1, 2022. Narrows DOEA rulemaking authority to areas related to approving curriculum guidelines, approving training providers, and overseeing compliance with the curriculum guidelines B. Amendments: None. This Senate Bill Analysis does not reflect the intent or official position of the bill’s introducer or the Florida Senate.