SB 1016

SECOND REGULAR SESSION
  SENATE BILL NO. 1016
  103RD GENERAL ASSEMBLY
  INTRODUCED BY SENATOR LEWIS.
 4987S.01I  KRISTINA MARTIN, Secretary
  AN ACT
 To repeal sections 195.070, 334.104, and 335.019, RSMo, and to enact in lieu thereof three new
  sections relating to advanced practice registered nurses.
 Be it enacted by the General Assembly of the State of Missouri, as follows:
1Section A.  Sections 195.070, 334.104, and 335.019, RSMo,
2  are repealed and three new sections enacted in lieu thereof, to
3  be known as sections 195.070, 334.104, and 335.019, to read as
4  follows:
1195.070.  1. A physician, podiatrist, dentist, a
2  registered optometrist certified to administer
3  pharmaceutical agents as provided in section 336.220, or an
4  assistant physician in accordance with section 334.037 or a
5  physician assistant in accordance with section 334.747 in
6  good faith and in the course of his or her professional
7  practice only, may prescribe, administer, and dispense
8  controlled substances or he or she may cause the same to be
9  administered or dispensed by an individual as authorized by
10  statute.
112. An advanced practice registered nurse, as defined
12  in section 335.016, but not a certified registered nurse
13  anesthetist as defined in subdivision (8) of section
14  335.016, who holds a certificate of controlled substance
15  prescriptive authority from the board of nursing under
16  section 335.019 and who is delegated the authority to
 EXPLANATION-Matter enclosed in bold-faced brackets [thus] in this bill is not enacted
 and is intended to be omitted in the law.
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17 prescribe controlled substances under a collaborative
18 practice arrangement under section 334.104 may prescribe any
19 controlled substances listed in Schedules III, IV, and V of
20 section 195.017, and may have restricted authority in
21 Schedule II. Prescriptions for Schedule II medications
22 prescribed by an advanced practice registered nurse who has
23 a certificate of controlled substance prescriptive authority
24 are restricted to only those medications containing
25 hydrocodone [and], Schedule II controlled substances for
26 hospice patients, and Schedule II stimulants for behavioral
27 health patients pursuant to the provisions of section
28 334.104. However, no such certified advanced practice
29 registered nurse shall prescribe controlled substance for
30 his or her own self or family.   Schedule III narcotic
31 controlled substance and Schedule II - hydrocodone
32 prescriptions shall be limited to a one hundred twenty-hour
33 supply without refill.
343. A veterinarian, in good faith and in the course of
35 the veterinarian's professional practice only, and not for
36 use by a human being, may prescribe, administer, and
37 dispense controlled substances and the veterinarian may
38 cause them to be administered by an assistant or orderly
39 under his or her direction and supervision.
404. A practitioner shall not accept any portion of a
41 controlled substance unused by a patient, for any reason, if
42 such practitioner did not originally dispense the drug,
43 except:
44(1) When the controlled substance is delivered to the
45 practitioner to administer to the patient for whom the
46 medication is prescribed as authorized by federal law.
47 Practitioners shall maintain records and secure the
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48 medication as required by this chapter and regulations
49 promulgated pursuant to this chapter; or
50(2) As provided in section 195.265.
515. An individual practitioner shall not prescribe or
52 dispense a controlled substance for such practitioner's
53 personal use except in a medical emergency.
1334.104.   1. A physician may enter into collaborative
2 practice arrangements with registered professional nurses.
3 Collaborative practice arrangements shall be in the form of
4 written agreements, jointly agreed-upon protocols, or
5 standing orders for the delivery of health care services.
6 Collaborative practice arrangements, which shall be in
7 writing, may delegate to a registered professional nurse the
8 authority to administer or dispense drugs and provide
9 treatment as long as the delivery of such health care
10 services is within the scope of practice of the registered
11 professional nurse and is consistent with that nurse's
12 skill, training and competence.
132. (1) Collaborative practice arrangements, which
14 shall be in writing, may delegate to a registered
15 professional nurse the authority to administer, dispense or
16 prescribe drugs and provide treatment if the registered
17 professional nurse is an advanced practice registered nurse
18 as defined in subdivision (2) of section 335.016.
19 Collaborative practice arrangements may delegate to an
20 advanced practice registered nurse, as defined in section
21 335.016, the authority to administer, dispense, or prescribe
22 controlled substances listed in Schedules III, IV, and V of
23 section 195.017, [and] Schedule II - hydrocodone, and for
24 behavioral health patients, Schedule II stimulants; except
25 that, the collaborative practice arrangement shall not
26 delegate the authority to administer any controlled
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27 substances listed in Schedules III, IV, and V of section
28 195.017, or Schedule II - hydrocodone for the purpose of
29 inducing sedation or general anesthesia for therapeutic,
30 diagnostic, or surgical procedures.   Schedule III narcotic
31 controlled substance and Schedule II - hydrocodone
32 prescriptions shall be limited to a one hundred twenty-hour
33 supply without refill.
34(2) Notwithstanding any other provision of this
35 section to the contrary, a collaborative practice
36 arrangement may delegate to an advanced practice registered
37 nurse the authority to administer, dispense, or prescribe
38 Schedule II controlled substances for hospice patients;
39 provided, that the advanced practice registered nurse is
40 employed by a hospice provider certified pursuant to chapter
41 197 and the advanced practice registered nurse is providing
42 care to hospice patients pursuant to a collaborative
43 practice arrangement that designates the certified hospice
44 as a location where the advanced practice registered nurse
45 is authorized to practice and prescribe.
46(3) Such collaborative practice arrangements shall be
47 in the form of written agreements, jointly agreed-upon
48 protocols or standing orders for the delivery of health care
49 services.
50(4) An advanced practice registered nurse may
51 prescribe buprenorphine for up to a thirty-day supply
52 without refill for patients receiving medication-assisted
53 treatment for substance use disorders under the direction of
54 the collaborating physician.
553. The written collaborative practice arrangement
56 shall contain at least the following provisions:
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57(1) Complete names, home and business addresses, zip
58 codes, and telephone numbers of the collaborating physician
59 and the advanced practice registered nurse;
60(2) A list of all other offices or locations besides
61 those listed in subdivision (1) of this subsection where the
62 collaborating physician authorized the advanced practice
63 registered nurse to prescribe;
64(3) A requirement that there shall be posted at every
65 office where the advanced practice registered nurse is
66 authorized to prescribe, in collaboration with a physician,
67 a prominently displayed disclosure statement informing
68 patients that they may be seen by an advanced practice
69 registered nurse and have the right to see the collaborating
70 physician;
71(4) All specialty or board certifications of the
72 collaborating physician and all certifications of the
73 advanced practice registered nurse;
74(5) The manner of collaboration between the
75 collaborating physician and the advanced practice registered
76 nurse, including how the collaborating physician and the
77 advanced practice registered nurse will:
78(a) Engage in collaborative practice consistent with
79 each professional's skill, training, education, and
80 competence;
81(b) Maintain geographic proximity, except as specified
82 in this paragraph.   The following provisions shall apply
83 with respect to this requirement:
84a. Until August 28, 2025, an advanced practice
85 registered nurse providing services in a correctional
86 center, as defined in section 217.010, and his or her
87 collaborating physician shall satisfy the geographic
88 proximity requirement if they practice within two hundred
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89  miles by road of one another.    An incarcerated patient who
90  requests or requires a physician consultation shall be
91  treated by a physician as soon as appropriate;
92b. The collaborative practice arrangement may allow
93  for geographic proximity to be waived for a maximum of
94  twenty-eight days per calendar year for rural health clinics
95  as defined by Pub.L. 95-210 (42 U.S.C. Section 1395x, as
96  amended), as long as the collaborative practice arrangement
97  includes alternative plans as required in paragraph (c) of
98  this subdivision.   This exception to geographic proximity
99  shall apply only to independent rural health clinics,
100 provider-based rural health clinics where the provider is a
101 critical access hospital as provided in 42 U.S.C. Section
102 1395i-4, and provider-based rural health clinics where the
103 main location of the hospital sponsor is greater than fifty
104 miles from the clinic;
105c. The collaborative practice arrangement may allow
106 for geographic proximity to be waived when the arrangement
107 outlines the use of telehealth, as defined in section
108 191.1145;
109d. In addition to the waivers and exemptions provided
110 in this subsection, an application for a waiver for any
111 other reason of any applicable geographic proximity shall be
112 available if a physician is collaborating with an advanced
113 practice registered nurse in excess of any geographic
114 proximity limit.    The board of nursing and the state board
115 of registration for the healing arts shall review each
116 application for a waiver of geographic proximity and approve
117 the application if the boards determine that adequate
118 supervision exists between the collaborating physician and
119 the advanced practice registered nurse.    The boards shall
120 have forty-five calendar days to review the completed
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121 application for the waiver of geographic proximity.     If no
122 action is taken by the boards within forty-five days after
123 the submission of the application for a waiver, then the
124 application shall be deemed approved.   If the application is
125 denied by the boards, the provisions of section 536.063 for
126 contested cases shall apply and govern proceedings for
127 appellate purposes; and
128e. The collaborating physician is required to maintain
129 documentation related to this requirement and to present it
130 to the state board of registration for the healing arts when
131 requested; and
132(c) Provide coverage during absence, incapacity,
133 infirmity, or emergency by the collaborating physician;
134(6) A description of the advanced practice registered
135 nurse's controlled substance prescriptive authority in
136 collaboration with the physician, including a list of the
137 controlled substances the physician authorizes the nurse to
138 prescribe and documentation that it is consistent with each
139 professional's education, knowledge, skill, and competence;
140(7) A list of all other written practice agreements of
141 the collaborating physician and the advanced practice
142 registered nurse;
143(8) The duration of the written practice agreement
144 between the collaborating physician and the advanced
145 practice registered nurse;
146(9) A description of the time and manner of the
147 collaborating physician's review of the advanced practice
148 registered nurse's delivery of health care services.     The
149 description shall include provisions that the advanced
150 practice registered nurse shall submit a minimum of ten
151 percent of the charts documenting the advanced practice
152 registered nurse's delivery of health care services to the
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153 collaborating physician for review by the collaborating
154 physician, or any other physician designated in the
155 collaborative practice arrangement, every fourteen days;
156(10) The collaborating physician, or any other
157 physician designated in the collaborative practice
158 arrangement, shall review every fourteen days a minimum of
159 twenty percent of the charts in which the advanced practice
160 registered nurse prescribes controlled substances.     The
161 charts reviewed under this subdivision may be counted in the
162 number of charts required to be reviewed under subdivision
163 (9) of this subsection; and
164(11) If a collaborative practice arrangement is used
165 in clinical situations where a collaborating advanced
166 practice registered nurse provides health care services that
167 include the diagnosis and initiation of treatment for
168 acutely or chronically ill or injured persons, then the
169 collaborating physician or any other physician designated in
170 the collaborative practice arrangement shall be present for
171 sufficient periods of time, at least once every two weeks,
172 except in extraordinary circumstances that shall be
173 documented, to participate in a chart review and to provide
174 necessary medical direction, medical services,
175 consultations, and supervision of the health care staff.
1764. The state board of registration for the healing
177 arts pursuant to section 334.125 and the board of nursing
178 pursuant to section 335.036 may jointly promulgate rules
179 regulating the use of collaborative practice arrangements.
180 Such rules shall be limited to the methods of treatment that
181 may be covered by collaborative practice arrangements and
182 the requirements for review of services provided pursuant to
183 collaborative practice arrangements including delegating
184 authority to prescribe controlled substances.    Any rules
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185 relating to geographic proximity shall allow a collaborating
186 physician and a collaborating advanced practice registered
187 nurse to practice within two hundred miles by road of one
188 another until August 28, 2025, if the nurse is providing
189 services in a correctional center, as defined in section
190 217.010. Any rules relating to dispensing or distribution
191 of medications or devices by prescription or prescription
192 drug orders under this section shall be subject to the
193 approval of the state board of pharmacy.   Any rules relating
194 to dispensing or distribution of controlled substances by
195 prescription or prescription drug orders under this section
196 shall be subject to the approval of the department of health
197 and senior services and the state board of pharmacy.    In
198 order to take effect, such rules shall be approved by a
199 majority vote of a quorum of each board.   Neither the state
200 board of registration for the healing arts nor the board of
201 nursing may separately promulgate rules relating to
202 collaborative practice arrangements.    Such jointly
203 promulgated rules shall be consistent with guidelines for
204 federally funded clinics.   The rulemaking authority granted
205 in this subsection shall not extend to collaborative
206 practice arrangements of hospital employees providing
207 inpatient care within hospitals as defined pursuant to
208 chapter 197 or population-based public health services as
209 defined by 20 CSR 2150-5.100 as of April 30, 2008.
2105. The state board of registration for the healing
211 arts shall not deny, revoke, suspend or otherwise take
212 disciplinary action against a physician for health care
213 services delegated to a registered professional nurse
214 provided the provisions of this section and the rules
215 promulgated thereunder are satisfied.   Upon the written
216 request of a physician subject to a disciplinary action
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217 imposed as a result of an agreement between a physician and
218 a registered professional nurse or registered physician
219 assistant, whether written or not, prior to August 28, 1993,
220 all records of such disciplinary licensure action and all
221 records pertaining to the filing, investigation or review of
222 an alleged violation of this chapter incurred as a result of
223 such an agreement shall be removed from the records of the
224 state board of registration for the healing arts and the
225 division of professional registration and shall not be
226 disclosed to any public or private entity seeking such
227 information from the board or the division.   The state board
228 of registration for the healing arts shall take action to
229 correct reports of alleged violations and disciplinary
230 actions as described in this section which have been
231 submitted to the National Practitioner Data Bank.    In
232 subsequent applications or representations relating to his
233 or her medical practice, a physician completing forms or
234 documents shall not be required to report any actions of the
235 state board of registration for the healing arts for which
236 the records are subject to removal under this section.
2376. Within thirty days of any change and on each
238 renewal, the state board of registration for the healing
239 arts shall require every physician to identify whether the
240 physician is engaged in any collaborative practice
241 arrangement, including collaborative practice arrangements
242 delegating the authority to prescribe controlled substances,
243 or physician assistant collaborative practice arrangement
244 and also report to the board the name of each licensed
245 professional with whom the physician has entered into such
246 arrangement. The board shall make this information
247 available to the public.   The board shall track the reported
248 information and may routinely conduct random reviews of such
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249 arrangements to ensure that arrangements are carried out for
250 compliance under this chapter.
2517. Notwithstanding any law to the contrary, a
252 certified registered nurse anesthetist as defined in
253 subdivision (8) of section 335.016 shall be permitted to
254 provide anesthesia services without a collaborative practice
255 arrangement provided that he or she is under the supervision
256 of an anesthesiologist or other physician, dentist, or
257 podiatrist who is immediately available if needed.    Nothing
258 in this subsection shall be construed to prohibit or prevent
259 a certified registered nurse anesthetist as defined in
260 subdivision (8) of section 335.016 from entering into a
261 collaborative practice arrangement under this section,
262 except that the collaborative practice arrangement may not
263 delegate the authority to prescribe any controlled
264 substances listed in Schedules III, IV, and V of section
265 195.017, or Schedule II - hydrocodone.
2668. A collaborating physician shall not enter into a
267 collaborative practice arrangement with more than six full-
268 time equivalent advanced practice registered nurses, full-
269 time equivalent licensed physician assistants, or full-time
270 equivalent assistant physicians, or any combination
271 thereof. This limitation shall not apply to collaborative
272 arrangements of hospital employees providing inpatient care
273 service in hospitals as defined in chapter 197 or population-
274 based public health services as defined by 20 CSR 2150-5.100
275 as of April 30, 2008, or to a certified registered nurse
276 anesthetist providing anesthesia services under the
277 supervision of an anesthesiologist or other physician,
278 dentist, or podiatrist who is immediately available if
279 needed as set out in subsection 7 of this section.
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2809. It is the responsibility of the collaborating
281 physician to determine and document the completion of at
282 least a one-month period of time during which the advanced
283 practice registered nurse shall practice with the
284 collaborating physician continuously present before
285 practicing in a setting where the collaborating physician is
286 not continuously present.   This limitation shall not apply
287 to collaborative arrangements of providers of population-
288 based public health services, as defined by 20 CSR 2150-
289 5.100 as of April 30, 2008, or to collaborative practice
290 arrangements between a primary care physician and a primary
291 care advanced practice registered nurse or a behavioral
292 health physician and a behavioral health advanced practice
293 registered nurse, where the collaborating physician is new
294 to a patient population to which the advanced practice
295 registered nurse is familiar.
29610. No agreement made under this section shall
297 supersede current hospital licensing regulations governing
298 hospital medication orders under protocols or standing
299 orders for the purpose of delivering inpatient or emergency
300 care within a hospital as defined in section 197.020 if such
301 protocols or standing orders have been approved by the
302 hospital's medical staff and pharmaceutical therapeutics
303 committee.
30411. No contract or other term of employment shall
305 require a physician to act as a collaborating physician for
306 an advanced practice registered nurse against the
307 physician's will.   A physician shall have the right to
308 refuse to act as a collaborating physician, without penalty,
309 for a particular advanced practice registered nurse.      No
310 contract or other agreement shall limit the collaborating
311 physician's ultimate authority over any protocols or
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312 standing orders or in the delegation of the physician's
313 authority to any advanced practice registered nurse, but
314 this requirement shall not authorize a physician in
315 implementing such protocols, standing orders, or delegation
316 to violate applicable standards for safe medical practice
317 established by hospital's medical staff.
31812. No contract or other term of employment shall
319 require any advanced practice registered nurse to serve as a
320 collaborating advanced practice registered nurse for any
321 collaborating physician against the advanced practice
322 registered nurse's will.     An advanced practice registered
323 nurse shall have the right to refuse to collaborate, without
324 penalty, with a particular physician.
32513.   (1)   The provisions of this section shall not
326 apply to an advanced practice registered nurse who has been
327 in a collaborative practice arrangement for a cumulative two
328 thousand documented hours with a collaborating physician and
329 whose license is in good standing.      Any such advanced
330 practice registered nurse shall not be required to enter
331 into or remain in an arrangement in order to practice in
332 this state.    Any other provisions of law requiring a
333 collaborative practice arrangement or delegation shall not
334 be required for an advanced practice registered nurse
335 described in this subsection.
336(2)   The provisions of this subsection shall not apply
337 to certified registered nurse anesthetists.
338(3)   Notwithstanding any provision of this section to
339 the contrary, an advanced practice registered nurse applying
340 for licensure by endorsement may demonstrate to the state
341 board of nursing completion of a cumulative two thousand
342 documented hours of practice.      Such advanced practice
343 registered nurses shall not be required to enter into a
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344 collaborative practice arrangement in order to practice in
345 this state.
1335.019.   1. An advanced practice registered nurse's
2  prescriptive authority shall include authority to:
3(1) Prescribe, dispense, and administer medications
4  and nonscheduled legend drugs, as defined in section
5  338.330, and controlled substances, as provided in
6  subsection 2 of section 195.070, within such APRN's practice
7  and specialty; and
8(2) Notwithstanding any other provision of this
9  chapter to the contrary, receive, prescribe, administer, and
10  provide nonscheduled legend drug samples from pharmaceutical
11  manufacturers to patients at no charge to the patient or any
12  other party.
132. In addition to advanced practice registered nurses
14  who have a collaborative practice arrangement, the
15  provisions of subsection 1 of this section shall apply to an
16  advanced practice registered nurse who meets the
17  requirements described in subsection 13 of section 334.104
18  and is no longer required to hold a collaborative practice
19  arrangement.
203. The board of nursing may grant a certificate of
21  controlled substance prescriptive authority to an advanced
22  practice registered nurse who:
23(1) Submits proof of successful completion of an
24  advanced pharmacology course that shall include preceptorial
25  experience in the prescription of drugs, medicines, and
26  therapeutic devices; and
27(2) Provides documentation of a minimum of three
28  hundred clock hours preceptorial experience in the
29  prescription of drugs, medicines, and therapeutic devices
30  with a qualified preceptor; and
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31(3) Provides evidence of a minimum of one thousand
32 hours of practice in an advanced practice nursing category
33 prior to application for a certificate of prescriptive
34 authority. The one thousand hours shall not include
35 clinical hours obtained in the advanced practice nursing
36 education program.   The one thousand hours of practice in an
37 advanced practice nursing category may include transmitting
38 a prescription order orally or telephonically or to an
39 inpatient medical record from protocols developed in
40 collaboration with and signed by a licensed physician; and
41(4) (a)   Has a controlled substance prescribing
42 authority delegated in the collaborative practice
43 arrangement under section 334.104 with a physician who has
44 an unrestricted federal Drug Enforcement Administration
45 registration number and who is actively engaged in a
46 practice comparable in scope, specialty, or expertise to
47 that of the advanced practice registered nurse; or
48(b)   Provides documentation of a minimum of two
49 thousand hours of practice in advanced practice nursing, as
50 provided in subsection 13 of section 334.104.
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