HOUSE BILL NO. 2067 103RD GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVE CASTEEL.
5322H.01I JOSEPH ENGLER, Chief Clerk
AN ACT To repeal sections 195.070 and 334.104, RSMo, and to enact in lieu thereof two new sections relating to the prescriptive authority of advanced practice registered nurses.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Sections 195.070 and 334.104, RSMo, are repealed and two new sections 2 enacted in lieu thereof, to be known as sections 195.070 and 334.104, to read as follows: 195.070. 1. A physician, podiatrist, dentist, a registered optometrist certified to 2 administer pharmaceutical agents as provided in section 336.220, or an assistant physician in 3 accordance with section 334.037 or a physician assistant in accordance with section 334.747 4 in good faith and in the course of his or her professional practice only, may prescribe, 5 administer, and dispense controlled substances or he or she may cause the same to be 6 administered or dispensed by an individual as authorized by statute. 7 2. An advanced practice registered nurse, as defined in section 335.016, but not a 8 certified registered nurse anesthetist as defined in subdivision (8) of section 335.016, who 9 holds a certificate of controlled substance prescriptive authority from the board of nursing 10 under section 335.019 and who is delegated the authority to prescribe controlled substances 11 under a collaborative practice arrangement under section 334.104 may prescribe any 12 controlled substances listed in Schedules III, IV, and V of section 195.017, and may have 13 restricted authority in Schedule II. Prescriptions for Schedule II medications prescribed by an 14 advanced practice registered nurse who has a certificate of controlled substance prescriptive 15 authority are restricted to only those medications containing hydrocodone [and], Schedule II 16 controlled substances for hospice patients, and Schedule II stimulants pursuant to the 17 provisions of section 334.104. However, no such certified advanced practice registered nurse
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 2067 2
18 shall prescribe controlled substance for his or her own self or family. Schedule III narcotic 19 controlled substance and Schedule II - hydrocodone prescriptions shall be limited to a one 20 hundred twenty-hour supply without refill. 21 3. A veterinarian, in good faith and in the course of the veterinarian's professional 22 practice only, and not for use by a human being, may prescribe, administer, and dispense 23 controlled substances and the veterinarian may cause them to be administered by an assistant 24 or orderly under his or her direction and supervision. 25 4. A practitioner shall not accept any portion of a controlled substance unused by a 26 patient, for any reason, if such practitioner did not originally dispense the drug, except: 27 (1) When the controlled substance is delivered to the practitioner to administer to the 28 patient for whom the medication is prescribed as authorized by federal law. Practitioners 29 shall maintain records and secure the medication as required by this chapter and regulations 30 promulgated pursuant to this chapter; or 31 (2) As provided in section 195.265. 32 5. An individual practitioner shall not prescribe or dispense a controlled substance for 33 such practitioner's personal use except in a medical emergency. 334.104. 1. A physician may enter into collaborative practice arrangements with 2 registered professional nurses. Collaborative practice arrangements shall be in the form of 3 written agreements, jointly agreed-upon protocols, or standing orders for the delivery of 4 health care services. Collaborative practice arrangements, which shall be in writing, may 5 delegate to a registered professional nurse the authority to administer or dispense drugs and 6 provide treatment as long as the delivery of such health care services is within the scope of 7 practice of the registered professional nurse and is consistent with that nurse's skill, training 8 and competence. 9 2. (1) Collaborative practice arrangements, which shall be in writing, may delegate to 10 a registered professional nurse the authority to administer, dispense or prescribe drugs and 11 provide treatment if the registered professional nurse is an advanced practice registered nurse 12 as defined in subdivision (2) of section 335.016. Collaborative practice arrangements may 13 delegate to an advanced practice registered nurse, as defined in section 335.016, the authority 14 to administer, dispense, or prescribe controlled substances listed in Schedules III, IV, and V of 15 section 195.017[, and]; Schedule II - hydrocodone; and Schedule II stimulants; except that, 16 the collaborative practice arrangement shall not delegate the authority to administer any 17 controlled substances listed in Schedules III, IV, and V of section 195.017[, or]; Schedule II - 18 hydrocodone; or Schedule II stimulants for the purpose of inducing sedation or general 19 anesthesia for therapeutic, diagnostic, or surgical procedures. Schedule III narcotic controlled 20 substance and Schedule II - hydrocodone prescriptions shall be limited to a one hundred 21 twenty-hour supply without refill. HB 2067 3
22 (2) Notwithstanding any other provision of this section to the contrary, a collaborative 23 practice arrangement may delegate to an advanced practice registered nurse the authority to 24 administer, dispense, or prescribe Schedule II controlled substances for hospice patients; 25 provided, that the advanced practice registered nurse is employed by a hospice provider 26 certified pursuant to chapter 197 and the advanced practice registered nurse is providing care 27 to hospice patients pursuant to a collaborative practice arrangement that designates the 28 certified hospice as a location where the advanced practice registered nurse is authorized to 29 practice and prescribe. 30 (3) Such collaborative practice arrangements shall be in the form of written 31 agreements, jointly agreed-upon protocols or standing orders for the delivery of health care 32 services. 33 (4) An advanced practice registered nurse may prescribe buprenorphine for up to a 34 thirty-day supply without refill for patients receiving medication-assisted treatment for 35 substance use disorders under the direction of the collaborating physician. 36 3. The written collaborative practice arrangement shall contain at least the following 37 provisions: 38 (1) Complete names, home and business addresses, zip codes, and telephone numbers 39 of the collaborating physician and the advanced practice registered nurse; 40 (2) A list of all other offices or locations besides those listed in subdivision (1) of this 41 subsection where the collaborating physician authorized the advanced practice registered 42 nurse to prescribe; 43 (3) A requirement that there shall be posted at every office where the advanced 44 practice registered nurse is authorized to prescribe, in collaboration with a physician, a 45 prominently displayed disclosure statement informing patients that they may be seen by an 46 advanced practice registered nurse and have the right to see the collaborating physician; 47 (4) All specialty or board certifications of the collaborating physician and all 48 certifications of the advanced practice registered nurse; 49 (5) The manner of collaboration between the collaborating physician and the 50 advanced practice registered nurse, including how the collaborating physician and the 51 advanced practice registered nurse will: 52 (a) Engage in collaborative practice consistent with each professional's skill, training, 53 education, and competence; 54 (b) Maintain geographic proximity, except as specified in this paragraph. The 55 following provisions shall apply with respect to this requirement: 56 a. Until August 28, 2025, an advanced practice registered nurse providing services in 57 a correctional center, as defined in section 217.010, and his or her collaborating physician 58 shall satisfy the geographic proximity requirement if they practice within two hundred miles HB 2067 4
59 by road of one another. An incarcerated patient who requests or requires a physician 60 consultation shall be treated by a physician as soon as appropriate; 61 b. The collaborative practice arrangement may allow for geographic proximity to be 62 waived for a maximum of twenty-eight days per calendar year for rural health clinics as 63 defined by Pub.L. 95-210 (42 U.S.C. Section 1395x, as amended), as long as the collaborative 64 practice arrangement includes alternative plans as required in paragraph (c) of this 65 subdivision. This exception to geographic proximity shall apply only to independent rural 66 health clinics, provider-based rural health clinics where the provider is a critical access 67 hospital as provided in 42 U.S.C. Section 1395i-4, and provider-based rural health clinics 68 where the main location of the hospital sponsor is greater than fifty miles from the clinic; 69 c. The collaborative practice arrangement may allow for geographic proximity to be 70 waived when the arrangement outlines the use of telehealth, as defined in section 191.1145; 71 d. In addition to the waivers and exemptions provided in this subsection, an 72 application for a waiver for any other reason of any applicable geographic proximity shall be 73 available if a physician is collaborating with an advanced practice registered nurse in excess 74 of any geographic proximity limit. The board of nursing and the state board of registration 75 for the healing arts shall review each application for a waiver of geographic proximity and 76 approve the application if the boards determine that adequate supervision exists between the 77 collaborating physician and the advanced practice registered nurse. The boards shall have 78 forty-five calendar days to review the completed application for the waiver of geographic 79 proximity. If no action is taken by the boards within forty-five days after the submission of 80 the application for a waiver, then the application shall be deemed approved. If the application 81 is denied by the boards, the provisions of section 536.063 for contested cases shall apply and 82 govern proceedings for appellate purposes; and 83 e. The collaborating physician is required to maintain documentation related to this 84 requirement and to present it to the state board of registration for the healing arts when 85 requested; and 86 (c) Provide coverage during absence, incapacity, infirmity, or emergency by the 87 collaborating physician; 88 (6) A description of the advanced practice registered nurse's controlled substance 89 prescriptive authority in collaboration with the physician, including a list of the controlled 90 substances the physician authorizes the nurse to prescribe and documentation that it is 91 consistent with each professional's education, knowledge, skill, and competence; 92 (7) A list of all other written practice agreements of the collaborating physician and 93 the advanced practice registered nurse; 94 (8) The duration of the written practice agreement between the collaborating 95 physician and the advanced practice registered nurse; HB 2067 5
96 (9) A description of the time and manner of the collaborating physician's review of 97 the advanced practice registered nurse's delivery of health care services. The description shall 98 include provisions that the advanced practice registered nurse shall submit a minimum of ten 99 percent of the charts documenting the advanced practice registered nurse's delivery of health 100 care services to the collaborating physician for review by the collaborating physician, or any 101 other physician designated in the collaborative practice arrangement, every fourteen days; 102 (10) The collaborating physician, or any other physician designated in the 103 collaborative practice arrangement, shall review every fourteen days a minimum of twenty 104 percent of the charts in which the advanced practice registered nurse prescribes controlled 105 substances. The charts reviewed under this subdivision may be counted in the number of 106 charts required to be reviewed under subdivision (9) of this subsection; and 107 (11) If a collaborative practice arrangement is used in clinical situations where a 108 collaborating advanced practice registered nurse provides health care services that include the 109 diagnosis and initiation of treatment for acutely or chronically ill or injured persons, then the 110 collaborating physician or any other physician designated in the collaborative practice 111 arrangement shall be present for sufficient periods of time, at least once every two weeks, 112 except in extraordinary circumstances that shall be documented, to participate in a chart 113 review and to provide necessary medical direction, medical services, consultations, and 114 supervision of the health care staff. 115 4. The state board of registration for the healing arts pursuant to section 334.125 and 116 the board of nursing pursuant to section 335.036 may jointly promulgate rules regulating the 117 use of collaborative practice arrangements. Such rules shall be limited to the methods of 118 treatment that may be covered by collaborative practice arrangements and the requirements 119 for review of services provided pursuant to collaborative practice arrangements including 120 delegating authority to prescribe controlled substances. Any rules relating to geographic 121 proximity shall allow a collaborating physician and a collaborating advanced practice 122 registered nurse to practice within two hundred miles by road of one another until August 28, 123 2025, if the nurse is providing services in a correctional center, as defined in section 217.010. 124 Any rules relating to dispensing or distribution of medications or devices by prescription or 125 prescription drug orders under this section shall be subject to the approval of the state board 126 of pharmacy. Any rules relating to dispensing or distribution of controlled substances by 127 prescription or prescription drug orders under this section shall be subject to the approval of 128 the department of health and senior services and the state board of pharmacy. In order to take 129 effect, such rules shall be approved by a majority vote of a quorum of each board. Neither the 130 state board of registration for the healing arts nor the board of nursing may separately 131 promulgate rules relating to collaborative practice arrangements. Such jointly promulgated 132 rules shall be consistent with guidelines for federally funded clinics. The rulemaking HB 2067 6
133 authority granted in this subsection shall not extend to collaborative practice arrangements of 134 hospital employees providing inpatient care within hospitals as defined pursuant to chapter 135 197 or population-based public health services as defined by 20 CSR 2150-5.100 as of April 136 30, 2008. 137 5. The state board of registration for the healing arts shall not deny, revoke, suspend 138 or otherwise take disciplinary action against a physician for health care services delegated to a 139 registered professional nurse provided the provisions of this section and the rules 140 promulgated thereunder are satisfied. Upon the written request of a physician subject to a 141 disciplinary action imposed as a result of an agreement between a physician and a registered 142 professional nurse or registered physician assistant, whether written or not, prior to August 143 28, 1993, all records of such disciplinary licensure action and all records pertaining to the 144 filing, investigation or review of an alleged violation of this chapter incurred as a result of 145 such an agreement shall be removed from the records of the state board of registration for the 146 healing arts and the division of professional registration and shall not be disclosed to any 147 public or private entity seeking such information from the board or the division. The state 148 board of registration for the healing arts shall take action to correct reports of alleged 149 violations and disciplinary actions as described in this section which have been submitted to 150 the National Practitioner Data Bank. In subsequent applications or representations relating to 151 his or her medical practice, a physician completing forms or documents shall not be required 152 to report any actions of the state board of registration for the healing arts for which the 153 records are subject to removal under this section. 154 6. Within thirty days of any change and on each renewal, the state board of 155 registration for the healing arts shall require every physician to identify whether the physician 156 is engaged in any collaborative practice arrangement, including collaborative practice 157 arrangements delegating the authority to prescribe controlled substances, or physician 158 assistant collaborative practice arrangement and also report to the board the name of each 159 licensed professional with whom the physician has entered into such arrangement. The board 160 shall make this information available to the public. The board shall track the reported 161 information and may routinely conduct random reviews of such arrangements to ensure that 162 arrangements are carried out for compliance under this chapter. 163 7. Notwithstanding any law to the contrary, a certified registered nurse anesthetist as 164 defined in subdivision (8) of section 335.016 shall be permitted to provide anesthesia services 165 without a collaborative practice arrangement provided that he or she is under the supervision 166 of an anesthesiologist or other physician, dentist, or podiatrist who is immediately available if 167 needed. Nothing in this subsection shall be construed to prohibit or prevent a certified 168 registered nurse anesthetist as defined in subdivision (8) of section 335.016 from entering into 169 a collaborative practice arrangement under this section, except that the collaborative practice HB 2067 7
170 arrangement may not delegate the authority to prescribe any controlled substances listed in 171 Schedules III, IV, and V of section 195.017[, or]; Schedule II - hydrocodone; or Schedule II 172 stimulants. 173 8. A collaborating physician shall not enter into a collaborative practice arrangeme