SECOND REGULAR SESSION
HOUSE BILL NO. 1620
94TH GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVES JONES (117) (Sponsor), TILLEY, POLLOCK, McCLANAHAN, MUNZLINGER, LeVOTA, QUINN (7), GRISAMORE, QUINN (9), HARRIS (110), DEEKEN, PARSON, RUZICKA, BRUNS, BAKER (25), FAITH, MEADOWS, ROBB, WHORTON, WRIGHT, FARES, HODGES, FISHER, WETER, MOORE, SCHIEFFER, LOWE (44), SKAGGS, SCHARNHORST, WILSON (119), THRELKELD, BRANDOM, SCHOELLER, SMITH (150), DENISON, STEVENSON, SCHAD, COOPER (120), LEMBKE, MEINERS, WILDBERGER, TODD, LOW (39), DARROUGH, AULL, DOUGHERTY, SCHOEMEHL, WALSH, SALVA, FRAME, FALLERT, LOEHNER, CHAPPELLE-NADAL, HUNTER, DIXON, MAY, THOMSON, McGHEE, KUESSNER AND ICET (Co-sponsors).
Read 1st time January 10, 2008 and copies ordered printed.
D. ADAM CRUMBLISS, Chief Clerk
To repeal sections 195.070, 195.100, 334.104, and 335.016, RSMo, and to enact in lieu thereof five 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Section A. Sections 195.070, 195.100, 334.104, and 335.016, RSMo, are repealed and five new sections enacted in lieu thereof, to be known as sections 195.070, 195.100, 334.104, 335.016, and 335.019, to read as follows:
195.070. 1. A physician, podiatrist, dentist, or a registered optometrist certified to administer pharmaceutical agents as provided in section 336.220, RSMo, 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, RSMo, who holds a certificate of controlled substance prescriptive authority from the board of nursing pursuant to section 335.019, RSMo, and who is delegated the authority to prescribe controlled substances under a controlled substance collaborative practice agreement pursuant to section 334.104, RSMo, may prescribe any controlled substances listed in Schedules II, III, IV, and V of section 195.017, RSMo. However, no such certified advanced practice registered nurse shall ever, under any circumstances, prescribe controlled substance for his or her own self or family.
3. A veterinarian, in good faith and in the course of his professional practice only, and not for use by a human being, may prescribe, administer, and dispense controlled substances and he may cause them to be administered by an assistant or orderly under his direction and supervision.
[3.] 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.
[4.] 5. An individual practitioner may not prescribe or dispense a controlled substance for such practitioner's personal use except in a medical emergency.
195.100. 1. It shall be unlawful to distribute any controlled substance in a commercial container unless such container bears a label containing an identifying symbol for such substance in accordance with federal laws.
2. It shall be unlawful for any manufacturer of any controlled substance to distribute such substance unless the labeling thereof conforms to the requirements of federal law and contains the identifying symbol required in subsection 1 of this section.
3. The label of a controlled substance in Schedule II, III or IV shall, when dispensed to or for a patient, contain a clear, concise warning that it is a criminal offense to transfer such narcotic or dangerous drug to any person other than the patient.
4. Whenever a manufacturer sells or dispenses a controlled substance and whenever a wholesaler sells or dispenses a controlled substance in a package prepared by him, he shall securely affix to each package in which that drug is contained, a label showing in legible English the name and address of the vendor and the quantity, kind, and form of controlled substance contained therein. No person except a pharmacist for the purpose of filling a prescription under sections 195.005 to 195.425, shall alter, deface, or remove any label so affixed.
5. Whenever a pharmacist or practitioner sells or dispenses any controlled substance on a prescription issued by a physician, dentist, podiatrist [or] veterinarian, or advanced practice registered nurse, he shall affix to the container in which such drug is sold or dispensed, a label showing his own name and address of the pharmacy or practitioner for whom he is lawfully acting; the name of the patient or, if the patient is an animal, the name of the owner of the animal and the species of the animal; the name of the physician, dentist, podiatrist [or] , veterinarian, or advanced practice registered nurse by whom the prescription was written; the name of the collaborating physician if the prescription is written by an advanced practice registered nurse, and such directions as may be stated on the prescription. No person shall alter, deface, or remove any label so affixed.
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. 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 nurse as defined in subdivision (2) of section 335.016, RSMo. 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.
3. Controlled substance collaborative practice arrangements may delegate to an advanced practice registered nurse, as defined in section 335.016, RSMo, the authority to administer, dispense, or prescribe controlled substances listed in Schedules II, III, IV, and V of section 195.017, RSMo. Such controlled substance collaborative practice agreements shall be in writing and shall also set forth provisions for the type of collaboration between the advanced practice registered nurse and the collaborating physician. The written controlled substance collaborative practice agreement 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, a prominently displayed disclosure statement informing patients that they may be seen by an advanced practice registered nurse;
(4) All specialty or board certifications of the collaborating physician and 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; and
(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, and 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; and
(8) The duration of the written practice agreement between the collaborating physician and the advanced practice registered nurse.
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, RSMo, may jointly promulgate rules regulating the use of collaborative practice arrangements and controlled substance collaborative practice arrangements. Such rules shall be limited to specifying geographic areas to be covered, 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 collaborative practice arrangements delegating the authority to prescribe controlled substances. 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. 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, RSMo.
[4.] 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 actions as described in this section which have been submitted to the National Practitioner Data Bank. In subsequent applications or representations relating to his 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.
[5.] 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 agreement, including collaborative practice arrangements delegating the authority to prescribe controlled substances, or physician assistant agreement and also report to the board the name of each licensed professional with whom the physician has entered into such agreement. The board may make this information available to the public. The board shall track the reported information and may routinely conduct random reviews of such agreements to ensure that agreements are carried out for compliance under this chapter.
[6.] 7. Notwithstanding anything to the contrary in this section, a registered nurse who has graduated from a school of nurse anesthesia accredited by the Council on Accreditation of Educational Programs of Nurse Anesthesia or its predecessor and has been certified or is eligible for certification as a nurse anesthetist by the Council on Certification of Nurse Anesthetists 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.
8. A collaborating physician shall not enter into a collaborative practice arrangement with more than three full-time equivalent advanced practice registered nurses.
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.
10. It shall be unlawful to require any physician to enter into any contract or other agreement to serve as a collaborating physician for any advanced practice registered nurse. A physician shall have the right to refuse to collaborate, without penalty, with a particular advanced practice registered nurse. No contract or other agreement shall limit the collaborating physician's ultimate authority regarding protocols or standing orders or in the delegation of the physician's authority to any advanced practice registered nurse.
11. It shall be unlawful to require any advanced practice registered nurse to enter into any contract or other agreement to serve as a collaborating advanced practice registered nurse for any collaborating physician. An advanced practice registered nurse shall have the right to refuse to collaborate, without penalty, with a particular physician.
335.016. As used in this chapter, unless the context clearly requires otherwise, the following words and terms mean:
(1) "Accredited", the official authorization or status granted by an agency for a program through a voluntary process;
(2) "Advanced practice registered nurse", a nurse who has [had] education beyond the basic nursing education and is certified by a nationally recognized professional organization [as having a nursing specialty, or who meets criteria for advanced practice nurses established by the board of nursing. The board of nursing may promulgate rules specifying which professional nursing organization certifications are to be recognized as advanced practice nurses, and may set standards for education, training and experience required for those without such specialty certification to become advanced practice nurses] as an advanced registered nurse practitioner, certified nurse midwife, certified registered nurse anesthetist, or a certified clinical nurse specialist. The board shall have the authority to approve any nationally recognized professional organization for the purposes of this section. Advanced practice nurses and only such individuals may use the title "Advanced Practice Registered Nurse" and the abbreviation "APRN";
(3) "Advanced registered nurse practitioner", a registered nurse who is currently certified as a nurse practitioner by a nationally recognized certifying body approved by the board of nursing;
(4) "Approval", official recognition of nursing education programs which meet standards established by the board of nursing;
[(4)] (5) "Board" or "state board", the state board of nursing;
(6) "Certified clinical nurse specialist", a registered nurse who is currently certified as a clinical nurse specialist by a nationally recognized certifying board approved by the board of nursing;
(7) "Certified nurse midwife", a registered nurse who is currently certified as a nurse midwife by the American College of Nurse Midwives, or other nationally recognized certifying body approved by the board of nursing;
(8) "Certified registered nurse anesthetist", a registered nurse who is currently certified as a nurse anesthetist by the Council on Certification of Nurse Anesthetists, the Council on Recertification of Nurse Anesthetists, or other nationally recognized body approved by the board of nursing;
[(5)] (9) "Executive director", a qualified individual employed by the board as executive secretary or otherwise to administer the provisions of this chapter under the board's direction. Such person employed as executive director shall not be a member of the board;
[(6)] (10) "Inactive nurse", as defined by rule pursuant to section 335.061;
[(7)] (11) "Lapsed license status", as defined by rule under section 335.061;
[(8)] (12) "Licensed practical nurse" or "practical nurse", a person licensed pursuant to the provisions of this chapter to engage in the practice of practical nursing;
[(9)] (13) "Licensure", the issuing of a license to practice professional or practical nursing to candidates who have met the specified requirements and the recording of the names of those persons as holders of a license to practice professional or practical nursing;
[(10)] (14) "Practical nursing", the performance for compensation of selected acts for the promotion of health and in the care of persons who are ill, injured, or experiencing alterations in normal health processes. Such performance requires substantial specialized skill, judgment and knowledge. All such nursing care shall be given under the direction of a person licensed by a state regulatory board to prescribe medications and treatments or under the direction of a registered professional nurse. For the purposes of this chapter, the term "direction" shall mean guidance or supervision provided by a person licensed by a state regulatory board to prescribe medications and treatments or a registered professional nurse, including, but not limited to, oral, written, or otherwise communicated orders or directives for patient care. When practical nursing care is delivered pursuant to the direction of a person licensed by a state regulatory board to prescribe medications and treatments or under the direction of a registered professional nurse, such care may be delivered by a licensed practical nurse without direct physical oversight;
[(11)] (15) "Professional nursing", the performance for compensation of any act which requires substantial specialized education, judgment and skill based on knowledge and application of principles derived from the biological, physical, social and nursing sciences, including, but not limited to:
(a) Responsibility for the teaching of health care and the prevention of illness to the patient and his or her family;
(b) Assessment, nursing diagnosis, nursing care, and counsel of persons who are ill, injured or experiencing alterations in normal health processes;
(c) The administration of medications and treatments as prescribed by a person licensed by a state regulatory board to prescribe medications and treatments;
(d) The coordination and assistance in the delivery of a plan of health care with all members of a health team;
(e) The teaching and supervision of other persons in the performance of any of the foregoing;
[(12)] (16) A "registered professional nurse" or "registered nurse", a person licensed pursuant to the provisions of this chapter to engage in the practice of professional nursing;
[(13)] (17) "Retired license status", any person licensed in this state under this chapter who retires from such practice. Such person shall file with the board an affidavit, on a form to be furnished by the board, which states the date on which the licensee retired from such practice, an intent to retire from the practice for at least two years, and such other facts as tend to verify the retirement as the board may deem necessary; but if the licensee thereafter reengages in the practice, the licensee shall renew his or her license with the board as provided by this chapter and by rule and regulation.
335.019. The board of nursing may grant a certificate of controlled substance prescriptive authority to an advanced practice nurse who:
(1) Submits proof of successful completion of a board-approved 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) Has a controlled substance prescribing authority delegated in the collaborative practice agreement pursuant to section 334.104, RSMo, 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.