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 Appropriations Committee on Health and Human Services
BILL: CS/SB 170
INTRODUCER: Health Policy Committee and Senator Burton
SUBJECT: Quality of Care in Nursing Homes
DATE: March 25, 2025
ANALYST STAFF DIRECTOR REFERENCE ACTION
1. Looke Brown HP Fav/CS
2. Barr McKnight AHS Pre-meeting
3. AP
Please see Section IX. for Additional Information:
COMMITTEE SUBSTITUTE - Technical Changes
I. Summary:
CS/SB 170 amends several sections related to the regulation of nursing homes. Specifically, the
bill:
• Requires the Agency for Health Care Administration (AHCA) to develop user-friendly
consumer satisfaction surveys to capture resident and family member satisfaction with the
care provided by nursing homes;
• Requires each nursing home’s medical director to be certified by the American Medical
Directors Association or have a similar credential recognized by the AHCA;
• Requires each nursing home to conduct a patient safety culture survey at least biennially and
to include the results in the facilities Nursing Home Guide;
• Provides that each nursing home that maintains electronic health records must make available
all admission, transfer, and discharge data to the Florida Health Information Exchange
program;
• Requires the AHCA to impose a $10,000 fine against a nursing home or the home office of a
nursing home that fails to submit financial data to the Florida Nursing Home Uniform
Reporting System (FNHURS); and
• Requires the AHCA to report to the Governor and the Legislature on payments made under
the Medicaid Quality Incentive Program (QIP). The report must include trends in the
improvement of the quality of care that may be attributable to the payments made under the
QIP.
REVISED: BILL: CS/SB 170 Page 2
The bill has a significant, negative impact on state expenditures and an indeterminate positive
impact on state revenues. See Section V. Fiscal Impact Statement
The bill takes effect July 1, 2025.
II. Present Situation:
Nursing Homes
Nursing homes in Florida are licensed under Part II of ch. 400, F.S., and provide 24-hour-a-day
nursing care, case management, health monitoring, personal care, nutritional meals and special
diets, physical, occupational, and speech therapy, social activities and respite care for those who
are ill or physically infirm.
1
Currently, there are 696 nursing homes licensed in Florida.
2
Of the
696 licensed nursing homes, 668 are certified to accept Medicare or Medicaid and consequently
must follow federal Centers for Medicare & Medicaid Services (CMS) requirements for nursing
homes.
3
Nursing Home Medical Directors
Florida administrative code requires that each nursing home have only one physician, who is
licensed under ch. 458 or ch. 459, F.S., that is designated as its medical director.
4
If the medical
director does not have hospital privileges, he or she is required to be certified or credentialed
through a recognized certifying or credentialing body, such as The Joint Commission, the
American Medical Directors Association, the Healthcare Facilities Accreditation Program of the
American Osteopathic Association, the Bureau of Osteopathic Specialists of the American
Osteopathic Association, the Florida Medical Directors Association or a health maintenance
organization licensed in Florida.
5
One physician may be the medical director of up to 10 nursing
homes at any one time and must have his or her principal office within 60 miles of all facilities
for which he or she serves as medical director.
6
The medical director is required to visit each facility at least once a month, meet quarterly with
the risk management and quality assurance committee of each facility, and must review for each
facility:
• All new policies and procedures;
• All new incident and accident reports to identify clinic risk and safety hazards;
• The most recent grievance logs for any complains or concerns related to clinical issues.
7
1
Agency for Health Care Administration webpage, nursing homes, available at
https://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Long_Term_Care/Nursing_Homes.shtml (last visited
Feb. 28, 2025).
2
Florida Health Finder Report, available at https://www.floridahealthfinder.gov/facilitylocator/ListFacilities.aspx (last visited
Feb. 28, 2025).
3
Id. Search for nursing homes that accept Medicaid or Medicare as payment.
4
Fla. Admin. Code R. 59A-4.1075 (2015).
5
Id.
6
Id. Note: if the facility is a rural nursing home, the AHCA may approve a request to waive the distance requirement.
7
Id. BILL: CS/SB 170 Page 3
Additionally, the medical director must participate in the development of the comprehensive care
plan for any resident for whom he or she is the attending physician.
8
Nursing Home Financial Reports
Nursing homes are required to submit financial data to the AHCA pursuant to
s. 408.061 (5)-(6), F.S. These provisions were added in 2021 by SB 2518 (ch. 2021-41, L.O.F.)
and mirror provisions in current law that require other health care facilities to submit such data.
9
Prior to July 1, 2021, nursing homes were exempt from this reporting requirement.
A nursing home must report, within 120 days after the end of its fiscal year, its actual financial
experience for that fiscal year, including expenditures, revenues, and statistical measures. Such
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. This actual experience must be audited and must
include the fiscal year-end balance sheet, income statement, statement of cash flow, and
statement of retained earnings and must be submitted to the AHCA in addition to the information
filed in the Florida Nursing Home Uniform Reporting System (FNHURS).
The final rule for implementation of the FNHURS became effective November 1, 2023, and
required nursing homes to begin submitting data to the FNHURS 30 days after that date in
accordance with the end of each nursing home’s fiscal year.
10
As of March 17, 2025, at least 536
of the 696 nursing homes had submitted to the AHCA.
11
Medicaid Quality Incentive Program
The Medicaid Quality Incentive Program (QIP) was established to ensure continued quality of
care in nursing home facilities.
12
Nursing homes providers submit quality data directly to the
federal Centers for Medicare and Medicaid Services, and the AHCA uses this information to
rank all providers by 16 quality measures.
13
The quality metrics used include
14
:
• Process Measures, which include flu vaccine, antipsychotic medication, and restraint quality
metrics.
o Providers whose fourth quarter measure score is at or above the 90th percentile for a
particular measure will be awarded 3 points, those scoring from the 75th up to 90th
percentiles will be awarded 2 points, and those scoring from the 50th up to 75th
percentiles will receive 1 point.
o Providers who score below the 50th percentile and achieve a 20 percent improvement
from the previous year will receive 0.5 points.
8
Fla. Admin. Code R. 59A-4.1075 (2015).
9
See s. 408.061(4), F.S.
10
Fla. Admin. Code R. 59E-4.102 (2023).
11
Email from Jim Browne, Legislative Affairs Director, Agency for Health Care Administration, to Cynthia Barr, Chief
Legislative Analyst, Senate Appropriations Committee on Health and Human Services (Mar. 18, 2025) (on file with the
Senate Appropriations Committee on Health and Human Services).
12
ch. 2017-129, s. 8, Laws of Fla.
13
Email from Jim Browne, Legislative Affairs Director, Agency for Health Care Administration, to Cynthia Barr, Chief
Legislative Analyst, Senate Appropriations Committee on Health and Human Services (Feb. 25, 2025) (on file with the
Senate Appropriations Committee on Health and Human Services).
14
Fla. Admin. Code R. 59G-6.010(2)(y)(2021). BILL: CS/SB 170 Page 4
• Outcome Measures, which include urinary tract infections, pressure ulcers, falls,
incontinence, and decline in activities of daily living quality metrics.
o Outcome Measures are scored and percentiles are calculated using the same methodology
as Process Measures.
• Structure Measures, which include direct care staffing from the Medicaid cost report
received by the rate setting cutoff date and social work and activity staff.
o Structure Measures are scored and percentiles are calculated using the same methodology
as Process Measures and Outcome Measures.
• Credentialing Measures which include CMS Overall 5-Star, Florida Gold Seal, Joint
Commission Accreditation, and American Health Care Association National Quality Award.
o Facilities assigned a rating of 3, 4, or 5 stars in the CMS 5- Star program will receive
1, 3, or 5 points, respectively.
o Facilities that have either a Florida Gold Seal, Joint Commission Accreditation, or the
silver or gold American Health Care Association National Quality Award on May 31 of
the current year will be awarded 5 points.
By statute, nursing homes must meet the minimum threshold of the 20 percentile of included
facilities to receive a quality incentive add-on payment, which is set at 10 percent of the 2016
non-property related payments of included facilities.
15
In the 2023-2024 federal fiscal year, the
incentive pool totaled $316 million with 534 of the 655 active providers receiving a quality
incentive add-on to their rate.
16
Patient Safety Culture Surveys
Patient safety culture refers to the values, beliefs, and norms that are shared by health care
practitioners and other staff throughout the organization that influence their actions and
behaviors to support and promote patient safety. Patient safety culture can be measured by
determining the values, beliefs, norms, and behaviors related to patient safety that are rewarded,
supported, expected, and accepted in an organization. Culture exists at multiple levels, from the
unit level to the department, organization, and system levels.
17
The federal Agency for Health Care Research and Quality (AHRQ) has developed a “Survey on
Patient Safety Culture” (SOPS) program which develops and supports surveys of providers and
staff that assess the extent to which their organizational culture supports patient safety and safe
practices. All the SOPS surveys include a standard set of core items with comparable survey
content across facilities and have been developed for the following settings of care:
• Hospitals.
• Medical Offices.
• Nursing Homes.
• Community Pharmacies.
• Ambulatory Surgery Centers.
15
Sections 409.908(2)(b)1.e. and f.
16
Email from Jim Browne, Legislative Affairs Director, Agency for Health Care Administration, to Cynthia Barr, Chief
Legislative Analyst, Senate Appropriations Committee on Health and Human Services (Feb. 25, 2025) (on file with the
Senate Appropriations Committee on Health and Human Services).
17
What is Patient Safety Culture?, ARHQ, June 2024, available at https://www.ahrq.gov/sops/about/patient-safety-
culture.html, (last visited Feb. 28, 2025). BILL: CS/SB 170 Page 5
The SOPS Program also offers optional supplemental item sets that can be added to the core
surveys to assess additional content areas focusing on health information technology, patient
safety, workplace safety, value and efficiency, and diagnostic safety.
SOPS surveys and supplemental item sets undergo a rigorous development and testing process.
Because the surveys ask questions that have been developed and pilot tested using a consistent
methodology across a large sample of respondents, they are standardized and validated measures
of patient safety culture.
18
The areas that are assessed by the SOPS include:
• Communication About Error.
• Communication Openness.
• Organizational Learning—Continuous Improvement.
• Overall Rating on Patient Safety.
• Response to Error.
• Staffing.
• Supervisor and Management Support for Patient Safety.
• Teamwork.
• Work Pressure and Pace.
19
Research has shown that significant relationships exist between SOPS patient safety culture
scores and important health care delivery measures and outcomes. Some key findings based on
studies that administered SOPS surveys include the following:
• Hospital units with more positive SOPS scores had:
o Fewer hospital-acquired pressure ulcers and patient falls.
o Lower surgical site infection rates.
• Hospitals with more positive SOPS scores had:
o Lower rates of in-hospital complications or adverse events as measured by AHRQ’s
patient safety indicators (PSIs).
o Patients who reported more positive experiences with care.
• Nursing homes with more positive SOPS scores had:
o Higher Centers for Medicare & Medicaid Services (CMS) Nursing Home Five-Star
Quality ratings.
o Lower risks of resident falls, long-stay urinary tract infections, and short stay ulcers.
20
Florida law requires hospitals and ambulatory surgical centers (ASC) to conduct, at least
biennially, a patient safety culture survey using the SOPS.
21
In order to implement the
requirement, the AHCA has customized the AHRQ’s patient safety survey instruments, and
18
What is Patient Safety Culture?, ARHQ, June 2024, available at https://www.ahrq.gov/sops/about/patient-safety-
culture.html, (last visited Feb. 28, 2025).
19
Id.
20
Id.
21
Section 395.1012(4), F.S. BILL: CS/SB 170 Page 6
developed a database application to facilitate the required submission of patient safety culture
survey data from Florida hospitals and ASCs to the agency as statutorily mandated.
22
Florida’s Health Information Exchange Program
Founded in 2011, the Florida Health Information Exchange (FHIE) facilitates the secure
statewide exchange of health information between health care providers, hospital systems, and
payers. The AHCA governs the FHIE by establishing policy, convening stakeholders, providing
oversight, engaging federal partners, and promoting the benefits of health information
technology.
The FHIE electronically makes patient health information available to doctors, nurses, hospitals,
and health care organizations when needed for patient care. The exchange of patient information
is protected through strict medical privacy and confidential procedures. The FHIE is designed to
improve the speed, quality, safety, and cost of patient care.
As part of the FHIE Services, Florida has developed an Encounter Notification Service (ENS)
that delivers real-time notifications based off of Admit, Discharge, and Transfer (ADT) data
from participating health care facilities. This data is provided to authorize health care entities to
improve patient care coordination.
23
III. Effect of Proposed Changes:
Section 1 reenacts and amends s. 400.0225, F.S., to require the Agency for Health Care
Administration (AHCA) to develop user-friendly consumer satisfaction surveys to capture
resident and family member satisfaction with care provided by nursing home facilities. The
surveys must be based on a core set of consumer satisfaction questions to allow for consistent
measurement and must be administered annually to a random sample of long-stay and short-stay
residents of each facility and their family members. The survey tool must be based on an agency-
validated survey instrument whose measures have received an endorsement by the National
Quality Forum. The AHCA is required under the bill to:
• Specify the protocols for conducting the consumer satisfaction surveys, ensuring survey
validity, reporting survey results, and protecting the identity of individual respondents; and
• Make aggregated survey data available to consumers on the agency’s website in a manner
that allows for comparison between nursing home facilities.
The bill allows family members, guardians, or other resident designees to assist a resident in
completing the survey and also prohibits employees and volunteers of the nursing home, or of a
corporation or business entity with and ownership interest in the nursing home, from attempting
to influence a resident’s responses to the survey.
22
Patient Safety Survey System User Guide, 2024, available at
https://ahca.myflorida.com/content/download/25680/file/PSCS%20System%20Guide_2022%2824%29EP.pdf, (last visited
Feb. 28, 2025).
23
Agency for Health Care Administration, Senate Bill 7016 (2024) Analysis. (on file with the Senate Committee on Health
Policy). BILL: CS/SB 170 Page 7
Section 2 amends s. 400.141, F.S., to require the medical director of each nursing home facility
to obtain designation as a certified medical director by the American Medical Directors
Association, hold a similar credential bestowed by an organization recognized by the AHCA, or
be in the process of seeking such designation or credentialing, according to parameters adopted
by agency rule, by January 1, 2026. The bill also requires the AHCA to include the name of each
nursing home’s medical director on the facility’s provider profile published on the AHCA’s
website.
The bill also requires each nursing home to conduct, at least biennially, a patient safety culture
survey using the applicable survey on patient culture developed by the federal Agency for Health
Care Research and Quality. The bill requires each facility to conduct the survey anonymously
and allows facilities to contract with a third party to administer the survey. The survey data,
including participation rates, must be submitted to the AHCA biennially and each facility must
develop an internal action plan between surveys to improve survey results and submit the plan to
the AHCA.
Section 3 amends s. 400.191, F.S., to require the AHCA to include the results of the consumer
satisfaction surveys in its Nursing Home Guide.
Section 4 amends s. 408.051, F.S., to require each nursing home that maintains certified
electronic health records technology to make available all admit, transfer, and discharge data to
the FHIE. The bill allows the AHCA to adopt rules to implement this subsection.
Section 5 amends s. 408.061, F.S., to specify that, beginning January 1, 2026, the AHCA is
required to impose an administrative fine of $10,000 per violation
24
against a nursing home or
the home office of a nursing home that fails to comply with the requirement to submit specified
audited financial data to the Florida Nursing Home Uniform Reporting System (FNHURS).
Additionally, the bill specifies that failing to file the report during any subsequent 10-day period
occurring after the due date constitutes a separate violation until the report has been submitted.
The bill requires the AHCA to adopt rules to implement the fine and requires the rules to include
provisions for a home office to present factors in mitigation of the imposition of the fine’s full
dollar amount. The AHCA may determine not to impose the fine’s full dollar amount upon a
demonstration that the full fine is inappropriate under the circumstances.
Section 6 clarifies that a facility that is fined under s. 408.061, F.S., for an FNHURS violation,
as described above, may not also be fined for such violation under s. 408.08, F.S.
Section 7 amends s. 409.908, F.S., to require the AHCA to, by October 1, 2025, and each year
thereafter, submit a report to the Governor and the Legislature on each Medicaid Quality
Incentive Program (QIP) payment made. The report must, at a minimum, include:
• The name of each facility that received a QIP payment and the dollar amount of such
payment each facility received.
24
The bill, for purposes of this fine, defines “violation” to mean failing to file the financial report required on or before the
report’s due date. BILL: CS/SB 170 Page 8
• The total number of quality incentive metric points awarded by the agency to each facility
and the number of points awarded by the agency for each individual quality metric measured.
• An examination of any trends in the improvement of the quality of care provided to nursing
home residents which may be attributable to incentive payments received under the QIP. The
AHCA is required to include an examination of trends both for the program as a whole as
well as for each individual quality metric used by the AHCA to award program payments.
Section 8 provides that the bill takes effect July 1, 2025.
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.
B. Private Sector Impact:
CS/SB 170 may have an indeterminate, negative fiscal impact on nursing homes that are
required to conduct surveys, meet additional requirements, or that are fined for not
submitting Florida Nursing Home Uniform Reporting System data as required.
The bill may have an indeterminate, negative fiscal impact on nursing home medical
directors who are required to obtain certification under the bill’s requirements. BILL: CS/SB 170 Page 9
C. Government Sector Impact:
The Agency for Health Care Administration (AHCA) estimates the bill will have a
significant negative fiscal impact on state expenditures. The AHCA estimates a cost of
$356,500 to implement the Nursing Home Patient Satisfaction Survey and the Nursing
Home Patient Safety Culture Survey required in this bill. The agency will also require
$140,500 annually to maintain, enhance, and secure endorsements for these surveys.
25
New fines created under this bill for nursing homes that fail to submit required data will
have an indeterminate positive fiscal impact on state revenues and could offset a portion
of the expenditure impact.
VI. Technical Deficiencies:
None.
VII. Related Issues:
None.
VIII. Statutes Affected:
This bill substantially amends the following sections of the Florida Statutes: 400.0225, 400.141,
400.191, 408.051, 408.061, 408.08, and 409.908.
IX. Additional Information:
A. Committee Substitute – Statement of Changes:
(Summarizing differences between the Committee Substitute and the prior version of the bill.)
CS by Health Policy on March 4, 2025:
The CS applies the bill’s fine for a Florida Nursing Home Uniform Reporting System
(FNHURS) violation to individual nursing homes as well as the home office of a nursing
home, instead of solely to home offices as in the underlying bill. Both are required to file
FNHURS reports under current law in s. 408.061(5) and (6), F.S.
B. Amendments:
None.
This Senate Bill Analysis does not reflect the intent or official position of the bill’s introducer or the Florida Senate.
25
Agency for Health Care Administration, Senate Bill 170 Analysis (Feb. 28, 2025) (on file with Senate Committee on
Health Policy).