Bill Summary – FastDemocracy

SECOND REGULAR SESSION
                        HOUSE BILL NO. 1989
                               103RD GENERAL ASSEMBLY


                               INTRODUCED BY REPRESENTATIVE HINMAN.

     4605H.01I                                                                    JOSEPH ENGLER, Chief Clerk


                                                AN ACT
     To repeal sections 195.070, 334.104, 335.016, and 335.019, RSMo, and to enact in lieu
            thereof four 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             Section A. Sections 195.070, 334.104, 335.016, and 335.019, RSMo, are repealed
 and four new sections enacted in lieu thereof, to be known as sections 195.070, 334.104,
 335.016, 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 either delegated the authority to prescribe controlled
 substances under a collaborative practice arrangement under section 334.104 or exempt from
 the requirement to work in a collaborative practice arrangement under the provisions of
 subsection 13 of 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 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

     EXPLANATION — Matter enclosed in bold-faced brackets [thus] in the above bill is not enacted and is
     intended to be omitted from the law. Matter in bold-face type in the above bill is proposed language.
HB 1989                                             2

 medications containing hydrocodone and Schedule II controlled substances for hospice
 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.
             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; 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.
HB 1989                                               3

 Schedule III narcotic controlled substance and Schedule II - hydrocodone prescriptions shall
 be limited to a one hundred twenty-hour supply without refill.
         (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, 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; and
         (b) [Maintain geographic proximity, except as specified in this paragraph. The
 following provisions shall apply with respect to this requirement:
HB 1989                                            4

         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, 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
         (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;
 HB 1989                                              5

         (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
         (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.]
 The state board of registration for the healing arts and the board of nursing shall not
 promulgate rules to enforce any geographic proximity restrictions, including any
 mileage or distance restrictions for advanced practice registered nurses or physicians,
 for collaborative practice arrangements. Any rules governing geographic proximity in
 effect before August 28, 2026, shall no longer be effective. Any collaborative practice
 HB 1989                                             6

 arrangements that contain provisions relating to geographic proximity requirements
 shall be deemed unenforceable. 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 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 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
 HB 1989                                             7

 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 physicia