HOUSE BILL NO. 2287 103RD GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVE BROWN.
5967H.01I JOSEPH ENGLER, Chief Clerk
AN ACT To repeal sections 195.070, 334.104, 334.735, and 334.747, RSMo, and to enact in lieu thereof four new sections relating to prescriptive authority for certain health care professionals.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Sections 195.070, 334.104, 334.735, and 334.747, RSMo, are repealed 2 and four new sections enacted in lieu thereof, to be known as sections 195.070, 334.104, 3 334.735, and 334.747, to read as follows: 195.070. 1.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
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 2287 2
16 controlled substances for hospice patients and patients of providers designated as 17 administrative entities by the department of mental health under section 630.407 18 pursuant to the provisions of section 334.104. However, no such certified advanced practice 19 registered nurse shall prescribe controlled substance for his or her own self or family. 20 Schedule III narcotic controlled substance and Schedule II - hydrocodone prescriptions shall 21 be limited to a one hundred twenty-hour supply without refill. 22 3. A veterinarian, in good faith and in the course of the veterinarian's professional 23 practice only, and not for use by a human being, may prescribe, administer, and dispense 24 controlled substances and the veterinarian may cause them to be administered by an assistant 25 or orderly under his or her direction and supervision. 26 4. A practitioner shall not accept any portion of a controlled substance unused by a 27 patient, for any reason, if such practitioner did not originally dispense the drug, except: 28 (1) When the controlled substance is delivered to the practitioner to administer to the 29 patient for whom the medication is prescribed as authorized by federal law. Practitioners 30 shall maintain records and secure the medication as required by this chapter and regulations 31 promulgated pursuant to this chapter; or 32 (2) As provided in section 195.265. 33 5. An individual practitioner shall not prescribe or dispense a controlled substance for 34 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; except that, the collaborative practice 16 arrangement shall not delegate the authority to administer any controlled substances listed in 17 Schedules III, IV, and V of section 195.017, or Schedule II - hydrocodone for the purpose of 18 inducing sedation or general anesthesia for therapeutic, diagnostic, or surgical procedures. HB 2287 3
19 Schedule III narcotic controlled substance and Schedule II - hydrocodone prescriptions shall 20 be limited to a one hundred twenty-hour supply without refill. 21 (2) Notwithstanding any other provision of this section to the contrary, a collaborative 22 practice arrangement may delegate to an advanced practice registered nurse the authority to 23 administer, dispense, or prescribe Schedule II controlled substances for hospice patients or 24 patients of providers designated as administrative entities by the department of mental 25 health under section 630.407; provided, that the advanced practice registered nurse is 26 employed by a hospice provider certified pursuant to chapter 197 or by a provider 27 designated as an administrative entity by the department of mental health under section 28 630.407 and the advanced practice registered nurse is providing care to hospice patients or 29 patients of the provider designated as an administrative entity by the department of 30 mental health under section 630.407 pursuant to a collaborative practice arrangement that 31 designates the certified hospice or the provider designated as an administrative entity by 32 the department of mental health under section 630.407 as a location where the advanced 33 practice registered nurse is authorized to practice and prescribe. 34 (3) Such collaborative practice arrangements shall be in the form of written 35 agreements, jointly agreed-upon protocols or standing orders for the delivery of health care 36 services. 37 (4) An advanced practice registered nurse may prescribe buprenorphine for up to a 38 thirty-day supply without refill for patients receiving medication-assisted treatment for 39 substance use disorders under the direction of the collaborating physician. 40 3. The written collaborative practice arrangement shall contain at least the following 41 provisions: 42 (1) Complete names, home and business addresses, zip codes, and telephone numbers 43 of the collaborating physician and the advanced practice registered nurse; 44 (2) A list of all other offices or locations besides those listed in subdivision (1) of this 45 subsection where the collaborating physician authorized the advanced practice registered 46 nurse to prescribe; 47 (3) A requirement that there shall be posted at every office where the advanced 48 practice registered nurse is authorized to prescribe, in collaboration with a physician, a 49 prominently displayed disclosure statement informing patients that they may be seen by an 50 advanced practice registered nurse and have the right to see the collaborating physician; 51 (4) All specialty or board certifications of the collaborating physician and all 52 certifications of the advanced practice registered nurse; 53 (5) The manner of collaboration between the collaborating physician and the 54 advanced practice registered nurse, including how the collaborating physician and the 55 advanced practice registered nurse will: HB 2287 4
56 (a) Engage in collaborative practice consistent with each professional's skill, training, 57 education, and competence; 58 (b) Maintain geographic proximity, except as specified in this paragraph. The 59 following provisions shall apply with respect to this requirement: 60 a. Until August 28, 2025, an advanced practice registered nurse providing services in 61 a correctional center, as defined in section 217.010, and his or her collaborating physician 62 shall satisfy the geographic proximity requirement if they practice within two hundred miles 63 by road of one another. An incarcerated patient who requests or requires a physician 64 consultation shall be treated by a physician as soon as appropriate; 65 b. The collaborative practice arrangement may allow for geographic proximity to be 66 waived for a maximum of twenty-eight days per calendar year for rural health clinics as 67 defined by Pub.L. 95-210 (42 U.S.C. Section 1395x, as amended), as long as the collaborative 68 practice arrangement includes alternative plans as required in paragraph (c) of this 69 subdivision. This exception to geographic proximity shall apply only to independent rural 70 health clinics, provider-based rural health clinics where the provider is a critical access 71 hospital as provided in 42 U.S.C. Section 1395i-4, and provider-based rural health clinics 72 where the main location of the hospital sponsor is greater than fifty miles from the clinic; 73 c. The collaborative practice arrangement may allow for geographic proximity to be 74 waived when the arrangement outlines the use of telehealth, as defined in section 191.1145; 75 d. In addition to the waivers and exemptions provided in this subsection, an 76 application for a waiver for any other reason of any applicable geographic proximity shall be 77 available if a physician is collaborating with an advanced practice registered nurse in excess 78 of any geographic proximity limit. The board of nursing and the state board of registration 79 for the healing arts shall review each application for a waiver of geographic proximity and 80 approve the application if the boards determine that adequate supervision exists between the 81 collaborating physician and the advanced practice registered nurse. The boards shall have 82 forty-five calendar days to review the completed application for the waiver of geographic 83 proximity. If no action is taken by the boards within forty-five days after the submission of 84 the application for a waiver, then the application shall be deemed approved. If the application 85 is denied by the boards, the provisions of section 536.063 for contested cases shall apply and 86 govern proceedings for appellate purposes; and 87 e. The collaborating physician is required to maintain documentation related to this 88 requirement and to present it to the state board of registration for the healing arts when 89 requested; and 90 (c) Provide coverage during absence, incapacity, infirmity, or emergency by the 91 collaborating physician; HB 2287 5
92 (6) A description of the advanced practice registered nurse's controlled substance 93 prescriptive authority in collaboration with the physician, including a list of the controlled 94 substances the physician authorizes the nurse to prescribe and documentation that it is 95 consistent with each professional's education, knowledge, skill, and competence; 96 (7) A list of all other written practice agreements of the collaborating physician and 97 the advanced practice registered nurse; 98 (8) The duration of the written practice agreement between the collaborating 99 physician and the advanced practice registered nurse; 100 (9) A description of the time and manner of the collaborating physician's review of 101 the advanced practice registered nurse's delivery of health care services. The description shall 102 include provisions that the advanced practice registered nurse shall submit a minimum of ten 103 percent of the charts documenting the advanced practice registered nurse's delivery of health 104 care services to the collaborating physician for review by the collaborating physician, or any 105 other physician designated in the collaborative practice arrangement, every fourteen days; 106 (10) The collaborating physician, or any other physician designated in the 107 collaborative practice arrangement, shall review every fourteen days a minimum of twenty 108 percent of the charts in which the advanced practice registered nurse prescribes controlled 109 substances. The charts reviewed under this subdivision may be counted in the number of 110 charts required to be reviewed under subdivision (9) of this subsection; and 111 (11) If a collaborative practice arrangement is used in clinical situations where a 112 collaborating advanced practice registered nurse provides health care services that include the 113 diagnosis and initiation of treatment for acutely or chronically ill or injured persons, then the 114 collaborating physician or any other physician designated in the collaborative practice 115 arrangement shall be present for sufficient periods of time, at least once every two weeks, 116 except in extraordinary circumstances that shall be documented, to participate in a chart 117 review and to provide necessary medical direction, medical services, consultations, and 118 supervision of the health care staff. 119 4. The state board of registration for the healing arts pursuant to section 334.125 and 120 the board of nursing pursuant to section 335.036 may jointly promulgate rules regulating the 121 use of collaborative practice arrangements. Such rules shall be limited to the methods of 122 treatment that may be covered by collaborative practice arrangements and the requirements 123 for review of services provided pursuant to collaborative practice arrangements including 124 delegating authority to prescribe controlled substances. Any rules relating to geographic 125 proximity shall allow a collaborating physician and a collaborating advanced practice 126 registered nurse to practice within two hundred miles by road of one another until August 28, 127 2025, if the nurse is providing services in a correctional center, as defined in section 217.010. 128 Any rules relating to dispensing or distribution of medications or devices by prescription or HB 2287 6
129 prescription drug orders under this section shall be subject to the approval of the state board 130 of pharmacy. Any rules relating to dispensing or distribution of controlled substances by 131 prescription or prescription drug orders under this section shall be subject to the approval of 132 the department of health and senior services and the state board of pharmacy. In order to take 133 effect, such rules shall be approved by a majority vote of a quorum of each board. Neither the 134 state board of registration for the healing arts nor the board of nursing may separately 135 promulgate rules relating to collaborative practice arrangements. Such jointly promulgated 136 rules shall be consistent with guidelines for federally funded clinics. The rulemaking 137 authority granted in this subsection shall not extend to collaborative practice arrangements of 138 hospital employees providing inpatient care within hospitals as defined pursuant to chapter 139 197 or population-based public health services as defined by 20 CSR 2150-5.100 as of April 140 30, 2008. 141 5. The state board of registration for the healing arts shall not deny, revoke, suspend 142 or otherwise take disciplinary action against a physician for health care services delegated to a 143 registered professional nurse provided the provisions of this section and the rules 144 promulgated thereunder are satisfied. Upon the written request of a physician subject to a 145 disciplinary action imposed as a result of an agreement between a physician and a registered 146 professional nurse or registered physician assistant, whether written or not, prior to August 147 28, 1993, all records of such disciplinary licensure action and all records pertaining to the 148 filing, investigation or review of an alleged violation of this chapter incurred as a result of 149 such an agreement shall be removed from the records of the state board of registration for the 150 healing arts and the division of professional registration and shall not be disclosed to any 151 public or private entity seeking such information from the board or the division. The state 152 board of registration for the healing arts shall take action to correct reports of alleged 153 violations and disciplinary actions as described in this section which have been submitted to 154 the National Practitioner Data Bank. In subsequent applications or representations relating to 155 his or her medical practice, a physician completing forms or documents shall not be required 156 to report any actions of the state board of registration for the healing arts for which the 157 records are subject to removal under this section. 158 6. Within thirty days of any change and on each renewal, the state board of 159 registration for the healing arts shall require every physician to identify whether the physician 160 is engaged in any collaborative practice arrangement, including collaborative practice 161 arrangements delegating the authority to prescribe controlled substances, or physician 162 assistant collaborative practice arrangement and also report to the board the name of each 163 licensed professional with whom the physician has entered into such arrangement. The board 164 shall make this information available to the public. The board shall track the reported HB 2287 7
165 information and may routinely conduct random reviews of such arrangements to ensure that 166 arrangements are carried out for compliance under this chapter. 167 7. Notwithstanding any law to the contrary, a certified registered nurse anesthetist as 168 defined in subdivision (8) of section 335.016 shall be permitted to provide anesthesia services 169 without a collaborative practice arrangement provided that he or she is under the supervision 170 of an anesthesiologist or other physician, dentist, or podiatrist who is immediately available if 171 needed. No