The Agency for Health Care Administration (AHCA) has issued a Notice of Change to its proposed rule governing training requirements for home health aides for medically fragile children (AMFC). While the overall framework remains intact, the revisions refine several key areas, including supervision, training structure, clinical expectations, and administrative requirements.

Supervisory Visits — Alignment With Federal Standards

The requirement for registered nurse (RN) supervisory visits at least every 60 days remains unchanged. However, AHCA added language clarifying that federally certified agencies must comply with more frequent supervisory requirements under the federal Conditions of Participation (CoPs) at Title 42 of the Code of Federal Regulations (C.F.R. § 484.80).

This reinforces that the 60-day standard is a baseline, while Medicare-certified providers remain subject to stricter federal expectations.

Training Requirements Refined: Federal Alignment and Competency Focus

AHCA added language confirming that Medicare- and Medicaid-certified agencies may be required to demonstrate compliance with additional training requirements under the federal CoPs.

More significantly, the rule now explicitly requires agencies to:

• Evaluate each AMFC competency
• Identify learning needs based on the patient’s individualized plan of care
• Ensure AMFCs are trained to safely and effectively perform all delegated tasks

This shifts the focus from completing a fixed curriculum to demonstrating competency and readiness in practice, specifically as it relates to the medically fragile child and the provider’s plan of care.

The rule also removes prior language requiring training accommodations for non-English speakers. While broader legal obligations remain, this specific directive has been eliminated from the rule.

Greater Flexibility in Training Delivery

Training may now be conducted by or under the general supervision of a registered nurse, rather than strictly by an RN.

This provides additional operational flexibility while maintaining clinical oversight.

Expanded and Clarified Expectations in Clinical Skills and Competency

AHCA refined and expanded required skills training to better align with the care needs of medically fragile children and Florida law.

A key addition requires agencies to ensure all training aligns with the nurse delegation statute (section 464.0156, Florida Statutes), reinforcing that AMFCs may only be trained on tasks that can be legally delegated.

Updates to training content include:

• Clearer expectations for assistance with non-invasive elimination devices
• Expanded intravenous-related support, including total parenteral nutrition (TPN)
• Broader dietary support, including prescribed and special diets
• More explicit expectations for observing and reporting physical and behavioral changes

The rule also updates competency validation requirements. Agencies must continue to provide at least 16 hours of hands-on validation with an actual patient, supervised by a qualified RN. Revisions clarify that:

• Competency must include IV- and TPN-related assistive care, where applicable
• Validation emphasizes intake and output monitoring, with less focus on a standalone vital signs requirement

Overall, the revisions place greater emphasis on demonstrated competency in real-world settings — not just completion of training hours.

Medication Administration: Removal of Controlled Substance Language

AHCA removed language that explicitly prohibited RNs from delegating the administration of controlled substances.

The rule continues to allow medication administration when:

• Delegated by an RN in accordance with Florida law
• The AMFC has completed required training
• All regulatory requirements are met

Importantly, this change does not expand delegation authority. Nurse delegation remains governed by section 464.0156, Florida Statutes. Any expansion — particularly involving controlled substances — would require statutory change.

This revision appears to remove duplicative or potentially conflicting language while deferring to existing law and standards of practice.

HCAF led an effort during this year’s Legislative Session to incrementally expand RN delegation to allow delegation of rectal rescue seizure medications to AMFCs. While the bill did not pass due to end-of-session disagreements between the House and Senate, HCAF intends to continue pursuing RN delegation changes to help meet the needs of medically fragile children.

Adverse Incident Reporting: Definition Clarified

AHCA added a definition of “adverse incident” consistent with statute, clarifying that such events:

• Are within the control of agency personnel
• Are associated with medical intervention
• Are not solely attributable to the patient’s condition

This does not create new reporting requirements but provides clearer guidance for compliance and consistency.

Providers must report all adverse incidents within 48 hours using the AHCA Incident Reporting System (AIRS). Click here to view the draft report.

Bottom Line for Providers

The Notice of Change reflects a more refined and operationally grounded approach:

• Clearer alignment with federal requirements for Medicare- and Medicaid-certified agencies
• Shift to competency-based training tied to patient-specific needs
• Expanded and clarified clinical expectations for AMFCs
• Greater flexibility in training delivery
• Reduced administrative burden in certain areas
• No expansion of delegation authority, despite removal of restrictive language

For providers, the takeaway is straightforward: compliance will increasingly depend on the ability to demonstrate that staff are properly trained, supervised, and capable of delivering safe, appropriate care — not just that minimum training requirements have been met.

HCAF is closely monitoring this rulemaking process and will continue to provide updates and guidance as additional developments occur.