SB 979

5116S.02C
  SENATE COMMITTEE SUBSTITUTE
  FOR
  SENATE BILLS NOS. 979 & 1016
  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:
  Section A.     Sections 195.070, 334.104, and 335.019, RSMo,
   are repealed and three new sections enacted in lieu thereof, to
   be known as sections 195.070, 334.104, and 335.019, to read as
   follows:
  195.070.    1. A physician, podiatrist, dentist, a
   registered optometrist certified to administer
   pharmaceutical agents as provided in section 336.220, or an
   assistant physician in accordance with section 334.037 or a
   physician assistant in accordance with section 334.747 in
   good faith and in the course of his or her professional
   practice only, may prescribe, administer, and dispense
   controlled substances or he or she may cause the same to be
   administered or dispensed by an individual as authorized by
   statute.
  2. An advanced practice registered nurse, as defined
   in section 335.016, but not a certified registered nurse
   anesthetist as defined in subdivision (8) of section
   335.016, who holds a certificate of controlled substance
   prescriptive authority from the board of nursing under
   section 335.019 and who is delegated the authority to
   prescribe controlled substances under a collaborative
   practice arrangement under section 334.104 may prescribe any
   controlled substances listed in Schedules III, IV, and V of
   section 195.017, and may have restricted authority in
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Schedule II. Prescriptions for Schedule II medications
prescribed by an advanced practice registered nurse who has
a certificate of controlled substance prescriptive authority
are restricted to only those medications containing
hydrocodone [and], Schedule II controlled substances for
hospice patients, and Schedule II stimulants for behavioral
health patients pursuant to the provisions of section
334.104. However, no such certified advanced practice
registered nurse shall prescribe controlled substance for
his or her own self or family.   Schedule III narcotic
controlled substance and Schedule II - hydrocodone
prescriptions shall be limited to a one hundred twenty-hour
supply without refill.
    3. A veterinarian, in good faith and in the course of
the veterinarian's professional practice only, and not for
use by a human being, may prescribe, administer, and
dispense controlled substances and the veterinarian may
cause them to be administered by an assistant or orderly
under his or her direction and supervision.
    4. A practitioner shall not accept any portion of a
controlled substance unused by a patient, for any reason, if
such practitioner did not originally dispense the drug,
except:
    (1) When the controlled substance is delivered to the
practitioner to administer to the patient for whom the
medication is prescribed as authorized by federal law.
Practitioners shall maintain records and secure the
medication as required by this chapter and regulations
promulgated pursuant to this chapter; or
    (2) As provided in section 195.265.
    5. An individual practitioner shall not prescribe or
dispense a controlled substance for such practitioner's
personal use except in a medical emergency.
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    334.104.   1. A physician may enter into collaborative
practice arrangements with registered professional nurses.
Collaborative practice arrangements shall be in the form of
written agreements, jointly agreed-upon protocols, or
standing orders for the delivery of health care services.
Collaborative practice arrangements, which shall be in
writing, may delegate to a registered professional nurse the
authority to administer or dispense drugs and provide
treatment as long as the delivery of such health care
services is within the scope of practice of the registered
professional nurse and is consistent with that nurse's
skill, training and competence.
    2. (1) Collaborative practice arrangements, which
shall be in writing, may delegate to a registered
professional nurse the authority to administer, dispense or
prescribe drugs and provide treatment if the registered
professional nurse is an advanced practice registered nurse
as defined in subdivision (2) of section 335.016.
Collaborative practice arrangements may delegate to an
advanced practice registered nurse, as defined in section
335.016, the authority to administer, dispense, or prescribe
controlled substances listed in Schedules III, IV, and V of
section 195.017, [and] Schedule II - hydrocodone, and for
behavioral health patients, Schedule II stimulants; except
that, the collaborative practice arrangement shall not
delegate the authority to administer any controlled
substances listed in Schedules III, IV, and V of section
195.017, or Schedule II - hydrocodone for the purpose of
inducing sedation or general anesthesia for therapeutic,
diagnostic, or surgical procedures.   Schedule III narcotic
controlled substance and Schedule II - hydrocodone
prescriptions shall be limited to a one hundred twenty-hour
supply without refill.
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    (2) Notwithstanding any other provision of this
section to the contrary, a collaborative practice
arrangement may delegate to an advanced practice registered
nurse the authority to administer, dispense, or prescribe
Schedule II controlled substances for hospice patients;
provided, that the advanced practice registered nurse is
employed by a hospice provider certified pursuant to chapter
197 and the advanced practice registered nurse is providing
care to hospice patients pursuant to a collaborative
practice arrangement that designates the certified hospice
as a location where the advanced practice registered nurse
is authorized to practice and prescribe.
    (3) Such collaborative practice arrangements shall be
in the form of written agreements, jointly agreed-upon
protocols or standing orders for the delivery of health care
services.
    (4) An advanced practice registered nurse may
prescribe buprenorphine for up to a thirty-day supply
without refill for patients receiving medication-assisted
treatment for substance use disorders under the direction of
the collaborating physician.
    3. The written collaborative practice arrangement
shall contain at least the following provisions:
    (1) Complete names, home and business addresses, zip
codes, and telephone numbers of the collaborating physician
and the advanced practice registered nurse;
    (2) A list of all other offices or locations besides
those listed in subdivision (1) of this subsection where the
collaborating physician authorized the advanced practice
registered nurse to prescribe;
    (3) A requirement that there shall be posted at every
office where the advanced practice registered nurse is
authorized to prescribe, in collaboration with a physician,
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a prominently displayed disclosure statement informing
patients that they may be seen by an advanced practice
registered nurse and have the right to see the collaborating
physician;
    (4) All specialty or board certifications of the
collaborating physician and all certifications of the
advanced practice registered nurse;
    (5) The manner of collaboration between the
collaborating physician and the advanced practice registered
nurse, including how the collaborating physician and the
advanced practice registered nurse will:
    (a) Engage in collaborative practice consistent with
each professional's skill, training, education, and
competence;
    (b) Maintain geographic proximity, except as specified
in this paragraph.   The following provisions shall apply
with respect to this requirement:
    a. Until August 28, 2025, an advanced practice
registered nurse providing services in a correctional
center, as defined in section 217.010, and his or her
collaborating physician shall satisfy the geographic
proximity requirement if they practice within two hundred
miles by road of one another.   An incarcerated patient who
requests or requires a physician consultation shall be
treated by a physician as soon as appropriate;
    b. The collaborative practice arrangement may allow
for geographic proximity to be waived for a maximum of
twenty-eight days per calendar year for rural health clinics
as defined by Pub.L. 95-210 (42 U.S.C. Section 1395x, as
amended), as long as the collaborative practice arrangement
includes alternative plans as required in paragraph (c) of
this subdivision.    This exception to geographic proximity
shall apply only to independent rural health clinics,
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provider-based rural health clinics where the provider is a
critical access hospital as provided in 42 U.S.C. Section
1395i-4, and provider-based rural health clinics where the
main location of the hospital sponsor is greater than fifty
miles from the clinic;
    c. The collaborative practice arrangement may allow
for geographic proximity to be waived when the arrangement
outlines the use of telehealth, as defined in section
191.1145;
    d. In addition to the waivers and exemptions provided
in this subsection, an application for a waiver for any
other reason of any applicable geographic proximity shall be
available if a physician is collaborating with an advanced
practice registered nurse in excess of any geographic
proximity limit.   The board of nursing and the state board
of registration for the healing arts shall review each
application for a waiver of geographic proximity and approve
the application if the boards determine that adequate
supervision exists between the collaborating physician and
the advanced practice registered nurse.   The boards shall
have forty-five calendar days to review the completed
application for the waiver of geographic proximity.   If no
action is taken by the boards within forty-five days after
the submission of the application for a waiver, then the
application shall be deemed approved.   If the application is
denied by the boards, the provisions of section 536.063 for
contested cases shall apply and govern proceedings for
appellate purposes; and
    e. The collaborating physician is required to maintain
documentation related to this requirement and to present it
to the state board of registration for the healing arts when
requested; and
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    (c) Provide coverage during absence, incapacity,
infirmity, or emergency by the collaborating physician;
    (6) A description of the advanced practice registered
nurse's controlled substance prescriptive authority in
collaboration with the physician, including a list of the
controlled substances the physician authorizes the nurse to
prescribe and documentation that it is consistent with each
professional's education, knowledge, skill, and competence;
    (7) A list of all other written practice agreements of
the collaborating physician and the advanced practice
registered nurse;
    (8) The duration of the written practice agreement
between the collaborating physician and the advanced
practice registered nurse;
    (9) A description of the time and manner of the
collaborating physician's review of the advanced practice
registered nurse's delivery of health care services.    The
description shall include provisions that the advanced
practice registered nurse shall submit a minimum of ten
percent of the charts documenting the advanced practice
registered nurse's delivery of health care services to the
collaborating physician for review by the collaborating
physician, or any other physician designated in the
collaborative practice arrangement, every fourteen days;
    (10) The collaborating physician, or any other
physician designated in the collaborative practice
arrangement, shall review every fourteen days a minimum of
twenty percent of the charts in which the advanced practice
registered nurse prescribes controlled substances.    The
charts reviewed under this subdivision may be counted in the
number of charts required to be reviewed under subdivision
(9) of this subsection; and
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    (11) If a collaborative practice arrangement is used
in clinical situations where a collaborating advanced
practice registered nurse provides health care services that
include the diagnosis and initiation of treatment for
acutely or chronically ill or injured persons, then the
collaborating physician or any other physician designated in
the collaborative practice arrangement shall be present for
sufficient periods of time, at least once every two weeks,
except in extraordinary circumstances that shall be
documented, to participate in a chart review and to provide
necessary medical direction, medical services,
consultations, and supervision of the health care staff.
    4. The state board of registration for the healing
arts pursuant to section 334.125 and the board of nursing
pursuant to section 335.036 may jointly promulgate rules
regulating the use of collaborative practice arrangements.
Such rules shall be limited to the methods of treatment that
may be covered by collaborative practice arrangements and
the requirements for review of services provided pursuant to
collaborative practice arrangements including delegating
authority to prescribe controlled substances. Any rules
relating to geographic proximity shall allow a collaborating
physician and a collaborating advanced practice registered
nurse to practice within two hundred miles by road of one
another until August 28, 2025, if the nurse is providing
services in a correctional center, as defined in section
217.010. Any rules relating to dispensing or distribution
of medications or devices by prescription or prescription
drug orders under this section shall be subject to the
approval of the state board of pharmacy.   Any rules relating
to dispensing or distribution of controlled substances by
prescription or prescription drug orders under this section
shall be subject to the approval of the department of health
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and senior services and the state board of pharmacy.    In
order to take effect, such rules shall be approved by a
majority vote of a quorum of each board.   Neither the state
board of registration for the healing arts nor the board of
nursing may separately promulgate rules relating to
collaborative practice arrangements.    Such jointly
promulgated rules shall be consistent with guidelines for
federally funded clinics.   The rulemaking authority granted
in this subsection shall not extend to collaborative
practice arrangements of hospital employees providing
inpatient care within hospitals as defined pursuant to
chapter 197 or population-based public health services as
defined by 20 CSR 2150-5.100 as of April 30, 2008.
    5. The state board of registration for the healing
arts shall not deny, revoke, suspend or otherwise take
disciplinary action against a physician for health care
services delegated to a registered professional nurse
provided the provisions of this section and the rules
promulgated thereunder are satisfied.   Upon the written
request of a physician subject to a disciplinary action
imposed as a result of an agreement between a physician and
a registered professional nurse or registered physician
assistant, whether written or not, prior to August 28, 1993,
all records of such disciplinary licensure action and all
records pertaining to the filing, investigation or review of
an alleged violation of this chapter incurred as a result of
such an agreement shall be removed from the records of the
state board of registration for the healing arts and the
division of professional registration and shall not be
disclosed to any public or private entity seeking such
information from the board or the division. The state board
of registration for the healing arts shall take action to
correct reports of alleged violations and disciplinary
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actions as described in this section which have been
submitted to the National Practitioner Data Bank.    In
subsequent applications or representations relating to his
or her medical practice, a physician completing forms or
documents shall not be required to report any actions of the
state board of registration for the healing arts for which
the records are subject to removal under this section.
    6. Within thirty days of any change and on each
renewal, the state board of registration for the healing
arts shall require every physician to identify whether the
physician is engaged in any collaborative practice
arrangement, including collaborative practice arrangements
delegating the authority to prescribe controlled substances,
or physician assistant collaborative practice arrangement
and also report to the board the name of each licensed
professional with whom the physician has entered into such
arrangement. The board shall make this information
available to the public.   The board shall track the reported
information and may routinely conduct random reviews of such
arrangements to ensure that arrangements are carried out for
compliance under this chapter.
    7. Notwithstanding any law to the contrary, a
certified registered nurse anesthetist as defined in
subdivision (8) of section 335.016 shall be permitted to
provide anesthesia services without a collaborative practice
arrangement provided that he or she is under the supervision
of an anesthesiologist or other physician, dentist, or
podiatrist who is immediately available if needed.    Nothing
in this subsection shall be construed to prohibit or prevent
a certified registered nurse anesthetist as defined in
subdivision (8) of section 335.016 from entering into a
collaborative practice arrangement under this section,
except that the collaborative practice arrangement may not
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delegate the authority to prescribe any controlled
substances listed in Schedules III, IV, and V of section
195.017, or Schedule II - hydrocodone.
    8. A collaborating physician shall not enter into a
collaborative practice arrangement with more than six full-
time equivalent advanced practice registered nurses, full-
time equivalent licensed physician assistants, or full-time
equivalent assistant physicians, or any combination
thereof. This limitation shall not apply to collaborative
arrangements of hospital employees providing inpatient care
service in hospitals as defined in chapter 197 or population-
based public health services as defined by 20 CSR 2150-5.100
as of April 30, 2008, or to a certified registered nurse
anesthetist providing anesthesia services under the
supervision of an anesthesiologist or other physician,
dentist, or podiatrist who is immediately available if
needed as set out in subsection 7 of this section.
    9. It is the responsibility of the collaborating
physician to determine and document the completion of at
least a one-month period of time during which the advanced
practice registered nurse shall practice with the
collaborating physician continuously present before
practicing in a setting where the collaborating physician is
not continuously present.   This limitation shall not apply
to collaborative arrangements of providers of population-
based public health services, as defined by 20 CSR 2150-
5.100 as of April 30, 2008, or to collaborative practice
arrangements between a primary care physician and a primary
care advanced practice registered nurse or a behavioral
health physician and a behavioral health advanced practice
registered nurse, where the collaborating physician is new
to a patient population to which the advanced practice
registered nurse is familiar.
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    10. No agreement made under this section shall
supersede current hospital licensing regulations governing
hospital medication orders under protocols or standing
orders for the purpose of delivering inpatient or emergency
care within a hospital as defined in section 197.020 if such
protocols or standing orders have been approved by the
hospital's medical staff and pharmaceutical therapeutics
committee.
    11. No contract or other term of employment shall
require a physician to act as a collaborating physician for
an advanced practice registered nurse against the
physician's will.   A physician shall have the right to
refuse to act as a collaborating physician, without penalty,
for a particular advanced practice registered nurse.      No
contract or other agreement shall limit the collaborating
physician's ultimate authority over any protocols or
standing orders or in the delegation of the physician's
authority to any advanced practice registered nurse, but
this requirement shall not authorize a physician in
implementing such protocols, standing orders, or delegation
to violate applicable standards for safe medical practice
established by hospital's medical staff.
    12. No contract or other term of employment shall
require any advanced practice registered nurse to serve as a
collaborating advanced practice registered nurse for any
collaborating physician against the advanced practice
registered nurse's will.   An advanced practice registered
nurse shall have the right to refuse to collaborate, without
penalty, with a particular physician.
    13. (1)   The provisions of this section shall not
apply to an advanced practice registered nurse who has been
in a collaborative practice arrangement for a cumulative two
thousand documented hours with a collaborating physician and
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whose license is in good standing.   Any such advanced
practice registered nurse shall not be required to enter
into or remain in an arrangement in order to practice in
this state. Any other provisions of law requiring a
collaborative practice arrangement or delegation shall not
be required for an advanced practice registered nurse
described in this subsection.
    (2) The provisions of this subsection shall not apply
to certified registered nurse anesthetists.
    (3) Notwithstanding any provision of this section to
the contrary, an advanced practice registered nurse applying
for licensure by endorsement may demonstrate to the state
board of nursing completion of a cumulative two thousand
documented hours of practice.   Such advanced practice
registered nurses shall not be required to enter into a
collaborative practice arrangement in order to practice in
this state.
    335.019.   1. An advanced practice registered nurse's
prescriptive authority shall include authority to:
    (1) Prescribe, dispense, and administer medications
and nonscheduled legend drugs, as defined in section
338.330, and controlled substances, as provided in
subsection 2 of section 195.070, within such APRN's practice
and specialty; and
    (2) Notwithstanding any other provision of this
chapter to the contrary, receive, prescribe, administer, and
provide nonscheduled legend drug samples from pharmaceutical
manufacturers to patients at no charge to the patient or any
other party.
    2. In addition to advanced practice registered nurses
who have a collaborative practice arrangement, the
provisions of subsection 1 of this section shall apply to an
advanced practice registered nurse who meets the
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requirements described in subsection 13 of section 334.104
and is no longer required to hold a collaborative practice
arrangement.
    3. The board of nursing may grant a certificate of
controlled substance prescriptive authority to an advanced
practice registered nurse who:
    (1) Submits proof of successful completion of an
advanced pharmacology course that shall include preceptorial
experience in the prescription of drugs, medicines, and
therapeutic devices; and
    (2) Provides documentation of a minimum of three
hundred clock hours preceptorial experience in the
prescription of drugs, medicines, and therapeutic devices
with a qualified preceptor; and
    (3) Provides evidence of a minimum of one thousand
hours of practice in an advanced practice nursing category
prior to application for a certificate of prescriptive
authority. The one thousand hours shall not include
clinical hours obtained in the advanced practice nursing
education program.   The one thousand hours of practice in an
advanced practice nursing category may include transmitting
a prescription order orally or telephonically or to an
inpatient medical record from protocols developed in
collaboration with and signed by a licensed physician; and
    (4) (a)    Has a controlled substance prescribing
authority delegated in the collaborative practice
arrangement under section 334.104 with a physician who has
an unrestricted federal Drug Enforcement Administration
registration number and who is actively engaged in a
practice comparable in scope, specialty, or expertise to
that of the advanced practice registered nurse; or
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    (b) Provides documentation of a minimum of two
thousand hours of practice in advanced practice nursing, as
provided in subsection 13 of section 334.104.
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