HB 3099

                                SECOND REGULAR SESSION
                   HOUSE BILL NO. 3099
                          103RD GENERAL ASSEMBLY
                          INTRODUCED BY REPRESENTATIVE MURRAY.
6880H.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         Section A. Sections 195.070 and 334.104, RSMo, are repealed and two new sections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.
72. 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 II, 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 pursuant to the provisions of section 334.104].
17 However, no such certified advanced practice registered nurse shall prescribe controlled
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.
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18 substance for his or her own self or family. Schedule III narcotic controlled substance and
19 Schedule II - hydrocodone prescriptions shall be limited to a one hundred twenty-hour supply
20 without refill.
213. 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.
254. 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.
325. 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.
92. (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 II, III, IV, and
15 V of section 195.017, [and Schedule II - hydrocodone;] except that[,] the collaborative
16 practice arrangement shall not delegate the authority to administer any controlled substances
17 listed in Schedules II, III, IV, and V of section 195.017[, or Schedule II - hydrocodone] for the
18 purpose of inducing sedation or general anesthesia for therapeutic, diagnostic, or surgical
19 procedures. Schedule III narcotic controlled substance and Schedule II - hydrocodone
20 prescriptions shall be limited to a one hundred twenty-hour supply without refill.
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21(2) [Notwithstanding any other provision of this section to the contrary, a
22 collaborative practice arrangement may delegate to an advanced practice registered nurse the
23 authority to administer, dispense, or prescribe Schedule II controlled substances for hospice
24 patients; provided, that the advanced practice registered nurse is employed by a hospice
25 provider certified pursuant to chapter 197 and the advanced practice registered nurse is
26 providing care to hospice patients pursuant to a collaborative practice arrangement that
27 designates the certified hospice as a location where the advanced practice registered nurse is
28 authorized to practice and prescribe.
29(3)] Such collaborative practice arrangements shall be in the form of written
30 agreements, jointly agreed-upon protocols or standing orders for the delivery of health care
31 services.
32[(4)] (3) An advanced practice registered nurse may prescribe buprenorphine for up to
33 a thirty-day supply without refill for patients receiving medication-assisted treatment for
34 substance use disorders under the direction of the collaborating physician.
353. The written collaborative practice arrangement shall contain at least the following
36 provisions:
37(1) Complete names, home and business addresses, zip codes, and telephone numbers
38 of the collaborating physician and the advanced practice registered nurse;
39(2) A list of all other offices or locations besides those listed in subdivision (1) of this
40 subsection where the collaborating physician authorized the advanced practice registered
41 nurse to prescribe;
42(3) A requirement that there shall be posted at every office where the advanced
43 practice registered nurse is authorized to prescribe, in collaboration with a physician, a
44 prominently displayed disclosure statement informing patients that they may be seen by an
45 advanced practice registered nurse and have the right to see the collaborating physician;
46(4) All specialty or board certifications of the collaborating physician and all
47 certifications of the advanced practice registered nurse;
48(5) The manner of collaboration between the collaborating physician and the
49 advanced practice registered nurse, including how the collaborating physician and the
50 advanced practice registered nurse will:
51(a) Engage in collaborative practice consistent with each professional's skill, training,
52 education, and competence;
53(b) Maintain geographic proximity, except as specified in this paragraph. The
54 following provisions shall apply with respect to this requirement:
55a. Until August 28, 2025, an advanced practice registered nurse providing services in
56 a correctional center, as defined in section 217.010, and his or her collaborating physician
57 shall satisfy the geographic proximity requirement if they practice within two hundred miles
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58 by road of one another. An incarcerated patient who requests or requires a physician
59 consultation shall be treated by a physician as soon as appropriate;
60b. The collaborative practice arrangement may allow for geographic proximity to be
61 waived for a maximum of twenty-eight days per calendar year for rural health clinics as
62 defined by Pub.L. 95-210 (42 U.S.C. Section 1395x, as amended), as long as the collaborative
63 practice arrangement includes alternative plans as required in paragraph (c) of this
64 subdivision. This exception to geographic proximity shall apply only to independent rural
65 health clinics, provider-based rural health clinics where the provider is a critical access
66 hospital as provided in 42 U.S.C. Section 1395i-4, and provider-based rural health clinics
67 where the main location of the hospital sponsor is greater than fifty miles from the clinic;
68c. The collaborative practice arrangement may allow for geographic proximity to be
69 waived when the arrangement outlines the use of telehealth, as defined in section 191.1145;
70d. In addition to the waivers and exemptions provided in this subsection, an
71 application for a waiver for any other reason of any applicable geographic proximity shall be
72 available if a physician is collaborating with an advanced practice registered nurse in excess
73 of any geographic proximity limit. The board of nursing and the state board of registration
74 for the healing arts shall review each application for a waiver of geographic proximity and
75 approve the application if the boards determine that adequate supervision exists between the
76 collaborating physician and the advanced practice registered nurse. The boards shall have
77 forty-five calendar days to review the completed application for the waiver of geographic
78 proximity. If no action is taken by the boards within forty-five days after the submission of
79 the application for a waiver, then the application shall be deemed approved. If the application
80 is denied by the boards, the provisions of section 536.063 for contested cases shall apply and
81 govern proceedings for appellate purposes; and
82e. The collaborating physician is required to maintain documentation related to this
83 requirement and to present it to the state board of registration for the healing arts when
84 requested; and
85(c) Provide coverage during absence, incapacity, infirmity, or emergency by the
86 collaborating physician;
87(6) A description of the advanced practice registered nurse's controlled substance
88 prescriptive authority in collaboration with the physician, including a list of the controlled
89 substances the physician authorizes the nurse to prescribe and documentation that it is
90 consistent with each professional's education, knowledge, skill, and competence;
91(7) A list of all other written practice agreements of the collaborating physician and
92 the advanced practice registered nurse;
93(8) The duration of the written practice agreement between the collaborating
94 physician and the advanced practice registered nurse;
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95(9) A description of the time and manner of the collaborating physician's review of
96 the advanced practice registered nurse's delivery of health care services. The description shall
97 include provisions that the advanced practice registered nurse shall submit a minimum of ten
98 percent of the charts documenting the advanced practice registered nurse's delivery of health
99 care services to the collaborating physician for review by the collaborating physician, or any
100 other physician designated in the collaborative practice arrangement, every fourteen days;
101(10) The collaborating physician, or any other physician designated in the
102 collaborative practice arrangement, shall review every fourteen days a minimum of twenty
103 percent of the charts in which the advanced practice registered nurse prescribes controlled
104 substances. The charts reviewed under this subdivision may be counted in the number of
105 charts required to be reviewed under subdivision (9) of this subsection; and
106(11) If a collaborative practice arrangement is used in clinical situations where a
107 collaborating advanced practice registered nurse provides health care services that include the
108 diagnosis and initiation of treatment for acutely or chronically ill or injured persons, then the
109 collaborating physician or any other physician designated in the collaborative practice
110 arrangement shall be present for sufficient periods of time, at least once every two weeks,
111 except in extraordinary circumstances that shall be documented, to participate in a chart
112 review and to provide necessary medical direction, medical services, consultations, and
113 supervision of the health care staff.
1144. The state board of registration for the healing arts pursuant to section 334.125 and
115 the board of nursing pursuant to section 335.036 may jointly promulgate rules regulating the
116 use of collaborative practice arrangements. Such rules shall be limited to the methods of
117 treatment that may be covered by collaborative practice arrangements and the requirements
118 for review of services provided pursuant to collaborative practice arrangements including
119 delegating authority to prescribe controlled substances. Any rules relating to geographic
120 proximity shall allow a collaborating physician and a collaborating advanced practice
121 registered nurse to practice within two hundred miles by road of one another until August 28,
122 2025, if the nurse is providing services in a correctional center, as defined in section 217.010.
123 Any rules relating to dispensing or distribution of medications or devices by prescription or
124 prescription drug orders under this section shall be subject to the approval of the state board
125 of pharmacy. Any rules relating to dispensing or distribution of controlled substances by
126 prescription or prescription drug orders under this section shall be subject to the approval of
127 the department of health and senior services and the state board of pharmacy. In order to take
128 effect, such rules shall be approved by a majority vote of a quorum of each board. Neither the
129 state board of registration for the healing arts nor the board of nursing may separately
130 promulgate rules relating to collaborative practice arrangements. Such jointly promulgated
131 rules shall be consistent with guidelines for federally funded clinics. The rulemaking
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132 authority granted in this subsection shall not extend to collaborative practice arrangements of
133 hospital employees providing inpatient care within hospitals as defined pursuant to chapter
134 197 or population-based public health services as defined by 20 CSR 2150-5.100 as of April
135 30, 2008.
1365. The state board of registration for the healing arts shall not deny, revoke, suspend
137 or otherwise take disciplinary action against a physician for health care services delegated to a
138 registered professional nurse provided the provisions of this section and the rules
139 promulgated thereunder are satisfied. Upon the written request of a physician subject to a
140 disciplinary action imposed as a result of an agreement between a physician and a registered
141 professional nurse or registered physician assistant, whether written or not, prior to August
142 28, 1993, all records of such disciplinary licensure action and all records pertaining to the
143 filing, investigation or review of an alleged violation of this chapter incurred as a result of
144 such an agreement shall be removed from the records of the state board of registration for the
145 healing arts and the division of professional registration and shall not be disclosed to any
146 public or private entity seeking such information from the board or the division. The state
147 board of registration for the healing arts shall take action to correct reports of alleged
148 violations and disciplinary actions as described in this section which have been submitted to
149 the National Practitioner Data Bank. In subsequent applications or representations relating to
150 his or her medical practice, a physician completing forms or documents shall not be required
151 to report any actions of the state board of registration for the healing arts for which the
152 records are subject to removal under this section.
1536. Within thirty days of any change and on each renewal, the state board of
154 registration for the healing arts shall require every physician to identify whether the physician
155 is engaged in any collaborative practice arrangement, including collaborative practice
156 arrangements delegating the authority to prescribe controlled substances, or physician
157 assistant collaborative practice arrangement and also report to the board the name of each
158 licensed professional with whom the physician has entered into such arrangement. The board
159 shall make this information available to the public. The board shall track the reported
160 information and may routinely conduct random reviews of such arrangements to ensure that
161 arrangements are carried out for compliance under this chapter.
1627. Notwithstanding any law to the contrary, a certified registered nurse anesthetist as
163 defined in subdivision (8) of section 335.016 shall be permitted to provide anesthesia services
164 without a collaborative practice arrangement provided that he or she is under the supervision
165 of an anesthesiologist or other physician, dentist, or podiatrist who is immediately available if
166 needed. Nothing in this subsection shall be construed to prohibit or prevent a certified
167 registered nurse anesthetist as defined in subdivision (8) of section 335.016 from entering into
168 a collaborative practice arrangement under this section, except that the collaborative practice
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169 arrangement may not delegate the authority to prescribe any controlled substances listed in
170 Schedules II, III, IV, and V of section 195.017[, or Schedule II - hydrocodone].
1718. A collaborating physician shall not enter into a collaborative practice arrangement
172 with more than six full-time equivalent advanced practice registered nurses, full-time
173 equivalent licensed physician assistants, or full-time equivalent assistant physicians, or any
174 combination thereof. This limitation shall not apply to collaborative arrangements of hospital
175 employees providing inpatient care service in hospitals as defined in chapter 197 or
176 population-based public health services as defined by 20 CSR 2150-5.100 as of April 30,
177 2008, or to a certified registered nurse anesthetist providing anesthesia services under the
178 supervision of an anesthesiologist or other physician, dentist, or podiatrist who is immediately
179 available if needed as set out in subsection 7 of this section.
1809. It is the responsibility of the collaborating physician to determine and document
181 the completion of at least a one-month period of time during which the advanced practice
182 registered nurse shall practice with the collaborating physician continuously present before
183 practicing in a setting where the collaborating physician is not continuously present. This
184 limitation shall not apply to collaborative arrangements of providers of population-based
185 public health services, as defined by 20 CSR 2150-5.100 as of April 30, 2008, or to
186 collaborative practice arrangements between a primary care physician and a primary care
187 advanced practice registered nurse or a behavioral health physician and a behavioral health
188 advanced practice registered nurse, where the collaborating physician is new to a patient
189 population to which the advanced practice registered nurse is familiar.
19010. No agreement made under this section shall supersede current hospital licensing
191 regulations governing hospital medication orders under protocols or standing orders for the
192 purpose of delivering inpatient or emergency care within a hospital as defined in section
193 197.020 if such protocols or standing orders have been approved by the hospital's medical
194 staff and pharmaceutical therapeutics committee.
19511. No contract or other term of employment shall require a physician to act as a
196 collaborating physician for an advanced practice registered nurse against the physician's will.
197 A physician shall have the right to refuse to act as a collaborating physician, without penalty,
198 for a particular advanced practice registered nurse. No contract or other agreement shall limit
199 the collaborating physician's ultimate authority over any protocols or standing orders or in the
200 delegation of the physician's authority to any advanced practice registered nurse, but this
201 requirement shall not authorize a physician in implementing such protocols, standing orders,
202 or delegation to violate applicable standards for safe medical practice established by hospital's
203 medical staff.
20412. No contract or other term of employment shall require any advanced practice
205 registered nurse to serve as a collaborating advanced practice registered nurse for any
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206 collaborating physician against the advanced practice registered nurse's will. An advanced
207 practice registered nurse shall have the right to refuse to collaborate, without penalty, with a
208 particular physician.
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