SECONDREGULARSESSION
HOUSEBILLNO.2434
101STGENERALASSEMBLY
INTRODUCEDBYREPRESENTATIVEGRIER.
5246H.01I DANARADEMANMILLER,ChiefClerk
ANACT
Torepealsections197.400,197.405,197.445,334.104,and335.175,RSMo,andtoenactin
lieuthereoffivenewsectionsrelatingtohealthcareprofessionals,withanemergency
clause.
BeitenactedbytheGeneralAssemblyofthestateofMissouri,asfollows:
SectionA.Sections197.400,197.405,197.445,334.104,and335.175,RSMo,are
2repealedandfivenewsectionsenactedinlieuthereof,tobeknownassections197.400,
3197.405,197.445,334.104,and335.175,toreadasfollows:
197.400.Asusedinsections197.400to197.475,unlessthecontextotherwise
2requires,thefollowingtermsmean:
3 (1)"Advancedpracticeregisterednurse",thesamemeaninggiventothetermin
4section335.016;
5 (2)"Council",thehomehealthservicesadvisorycouncilcreatedbysections197.400
6to197.475;
7 [(2)](3)"Department",thedepartmentofhealthandseniorservices;
8 [(3)](4)"Homehealthagency",apublicagencyorprivateorganizationora
9subdivisionorsubunitofanagencyororganizationthatprovidestwoormorehomehealth
10servicesattheresidenceofapatientaccordingtoa[physician's] written[andsigned] planof
11treatmentsignedbyaphysician,advancedpracticeregisterednurse,orphysician
12assistant;
13 [(4)](5)"Homehealthservices",anyofthefollowingitemsandservicesprovidedat
14theresidenceofthepatientonapart-timeorintermittentbasis:nursing,physicaltherapy,
15speechtherapy,occupationaltherapy,homehealthaid,ormedicalsocialservice;
EXPLANATION—Matterenclosedinbold-facedbrackets[thus] intheabovebillisnotenactedandis
intendedtobeomittedfromthelaw.Matterinbold-facetypeintheabovebillisproposedlanguage. 16 [(5)](6)"Part-timeorintermittentbasis",theprovidingofhomehealthservicesinan
17interruptedintervalsequenceontheaverageofnottoexceedthreehoursinanytwenty-four-
18hourperiod;
19 [(6)](7)"Patient'sresidence",theactualplaceofresidenceofthepersonreceiving
20homehealthservices,includinginstitutionalresidencesaswellasindividualdwellingunits;
21 [(7)](8)"Physician",apersonlicensedbythestateboardofregistrationforthe
22healingartspursuanttotheprovisionsofchapter334topracticeinthisstateasaphysician
23andsurgeon;
24 [(8)](9)"Physicianassistant",apersonlicensedbythestateboardof
25registrationforthehealingartsundertheprovisionsofchapter334topracticeinthis
26stateasaphysicianassistant;
27 (10)"Planoftreatment",aplanreviewedandsignedasoftenasmedicallynecessary
28byaphysician[or],podiatrist,advancedpracticeregisterednurse,orphysicianassistant,
29nottoexceedsixtydaysinduration,prescribingitemsandservicesforanindividualpatient's
30condition;
31 [(9)](11)"Podiatrist",apersonlicensedbythestateboardofpodiatrypursuanttothe
32provisionsofchapter330topracticeinthisstateasapodiatrist;
33 [(10)] (12)"Subunit"or"subdivision",anyorganizationalunitofalarger
34organizationwhichcanbeclearlydefinedasaseparateentitywithinthelargerstructure,
35whichcanmeetalloftherequirementsofsections197.400to197.475independentofthe
36largerorganization,whichcanbeheldaccountableforthecareofpatientsitisserving,and
37whichprovidestoallpatientscareandservicesmeetingthestandardsandrequirementsof
38sections197.400to197.475.
197.405.Nohomehealthagency,includingMedicareandMedicaidproviders,shall
2providetwoormoreofthehomehealthservicescoveredbysubdivision[(4)](5)ofsection
3197.400orshallholditselfoutasprovidingsuchhomehealthservicesorasahomehealth
4agencyunlessitislicensedandregisteredinaccordancewiththeprovisionsofsections
5197.400to197.475.
197.445.1.Thedepartmentmayadoptreasonablerulesandstandardsnecessaryto
2carryouttheprovisionsofsections197.400to197.477.Therulesandstandardsadopted
3shallnotbelessthanthestandardsestablishedbythefederalgovernmentforhomehealth
4agenciesunderTitleXVIIIoftheFederalSocialSecurityAct.Thereasonablerulesand
5standardsshallbeinitiallypromulgatedwithinoneyearofSeptember28,1983.
6 2.Therulesandstandardsadoptedbythedepartmentpursuanttotheprovisionsof
7sections197.400to197.477shallapplytoallhealthservicescoveredbysections197.400to
8197.477renderedtoanypatientbeingservedbyahomehealthagencyregardlessofsourceof
9paymentfortheservice,patient'scondition,orplaceofresidence,atwhichthehomehealth
HB2434 2 10servicesareorderedbythephysician[or],podiatrist, advancedpracticeregisterednurse,or
11physicianassistant. Noruleorportionofarulepromulgatedpursuanttotheauthorityof
12sections197.400to197.477shallbecomeeffectiveunlessithasbeenpromulgatedpursuant
13totheprovisionsofsection536.024.
334.104.1.Aphysicianmayenterintocollaborativepracticearrangementswith
2registeredprofessionalnurses.Collaborativepracticearrangementsshallbeintheformof
3writtenagreements,jointlyagreed-uponprotocols,orstandingordersforthedeliveryof
4healthcareservices.Collaborativepracticearrangements,whichshallbeinwriting,may
5delegatetoaregisteredprofessionalnursetheauthoritytoadministerordispensedrugsand
6providetreatmentaslongasthedeliveryofsuchhealthcareservicesiswithinthescopeof
7practiceoftheregisteredprofessionalnurseandisconsistentwiththatnurse'sskill,training
8andcompetence.
9 2.Collaborativepracticearrangements,whichshallbeinwriting,maydelegatetoa
10registeredprofessionalnursetheauthoritytoadminister,dispenseorprescribedrugsand
11providetreatmentiftheregisteredprofessionalnurseisanadvancedpracticeregisterednurse
12asdefinedinsubdivision(2)ofsection335.016.Collaborativepracticearrangementsmay
13delegatetoanadvancedpracticeregisterednurse,asdefinedinsection335.016,theauthority
14toadminister,dispense,orprescribecontrolledsubstanceslistedinSchedulesIII,IV,andVof
15section195.017,andScheduleII-hydrocodone;exceptthat,thecollaborativepractice
16arrangementshallnotdelegatetheauthoritytoadministeranycontrolledsubstanceslistedin
17SchedulesIII,IV,andVofsection195.017,orScheduleII-hydrocodoneforthepurposeof
18inducingsedationorgeneralanesthesiafortherapeutic,diagnostic,orsurgicalprocedures.
19ScheduleIIInarcoticcontrolledsubstanceandScheduleII-hydrocodoneprescriptionsshall
20belimitedtoaonehundredtwenty-hoursupplywithoutrefill.Suchcollaborativepractice
21arrangementsshallbeintheformofwrittenagreements,jointlyagreed-uponprotocolsor
22standingordersforthedeliveryofhealthcareservices.Anadvancedpracticeregisterednurse
23mayprescribebuprenorphineforuptoathirty-daysupplywithoutrefillforpatientsreceiving
24medication-assistedtreatmentforsubstanceusedisordersunderthedirectionofthe
25collaboratingphysician.
26 3.Thewrittencollaborativepracticearrangementshallcontainatleastthefollowing
27provisions:
28 (1)Completenames,homeandbusinessaddresses,zipcodes,andtelephonenumbers
29ofthecollaboratingphysicianandtheadvancedpracticeregisterednurse;
30 (2)Alistofallotherofficesorlocationsbesidesthoselistedinsubdivision(1)ofthis
31subsectionwherethecollaboratingphysicianauthorizedtheadvancedpracticeregistered
32nursetoprescribe;
HB2434 3 33 (3)Arequirementthatthereshallbepostedateveryofficewheretheadvanced
34practiceregisterednurseisauthorizedtoprescribe,incollaborationwithaphysician,a
35prominentlydisplayeddisclosurestatementinformingpatientsthattheymaybeseenbyan
36advancedpracticeregisterednurseandhavetherighttoseethecollaboratingphysician;
37 (4)Allspecialtyorboardcertificationsofthecollaboratingphysicianandall
38certificationsoftheadvancedpracticeregisterednurse;
39 (5)Themannerofcollaborationbetweenthecollaboratingphysicianandthe
40advancedpracticeregisterednurse,includinghowthecollaboratingphysicianandthe
41advancedpracticeregisterednursewill:
42 (a)Engageincollaborativepracticeconsistentwitheachprofessional'sskill,training,
43education,andcompetence;and
44 (b)[Maintaingeographicproximity,exceptthecollaborativepracticearrangement
45mayallowforgeographicproximitytobewaivedforamaximumoftwenty-eightdaysper
46calendaryearforruralhealthclinicsasdefinedbyP.L.95-210,aslongasthecollaborative
47practicearrangementincludesalternativeplansasrequiredinparagraph(c)ofthis
48subdivision.Thisexceptiontogeographicproximityshallapplyonlytoindependentrural
49healthclinics,provider-basedruralhealthclinicswheretheproviderisacriticalaccess
50hospitalasprovidedin42U.S.C.Section1395i-4,andprovider-basedruralhealthclinics
51wherethemainlocationofthehospitalsponsorisgreaterthanfiftymilesfromtheclinic.The
52collaboratingphysicianisrequiredtomaintaindocumentationrelatedtothisrequirementand
53topresentittothestateboardofregistrationforthehealingartswhenrequested;and
54 (c)]Providecoverageduringabsence,incapacity,infirmity,oremergencybythe
55collaboratingphysician;
56 (6)Adescriptionoftheadvancedpracticeregisterednurse'scontrolledsubstance
57prescriptiveauthorityincollaborationwiththephysician,includingalistofthecontrolled
58substancesthephysicianauthorizesthenursetoprescribeanddocumentationthatitis
59consistentwitheachprofessional'seducation,knowledge,skill,andcompetence;
60 (7)Alistofallotherwrittenpracticeagreementsofthecollaboratingphysicianand
61theadvancedpracticeregisterednurse;
62 (8)Thedurationofthewrittenpracticeagreementbetweenthecollaborating
63physicianandtheadvancedpracticeregisterednurse;
64 (9)Adescriptionofthetimeandmannerofthecollaboratingphysician'sreviewof
65theadvancedpracticeregisterednurse'sdeliveryofhealthcareservices[. Thedescription
66shallincludeprovisionsthattheadvancedpracticeregisterednurseshallsubmitaminimum
67oftenpercentofthechartsdocumentingtheadvancedpracticeregisterednurse'sdeliveryof
68healthcareservicestothecollaboratingphysicianforreviewbythecollaboratingphysician,
HB2434 4 69oranyotherphysiciandesignatedinthecollaborativepracticearrangement,everyfourteen
70days]; and
71 (10)Thecollaboratingphysician,oranyotherphysiciandesignatedinthe
72collaborativepracticearrangement,shallrevieweveryfourteendaysaminimumoftwenty
73percentofthechartsinwhichtheadvancedpracticeregisterednurseprescribescontrolled
74substances.[Thechartsreviewedunderthissubdivisionmaybecountedinthenumberof
75chartsrequiredtobereviewedundersubdivision(9)ofthissubsection.]
76 4.Thestateboardofregistrationforthehealingartspursuanttosection334.125and
77theboardofnursingpursuanttosection335.036mayjointlypromulgaterulesregulatingthe
78useofcollaborativepracticearrangements.Suchrulesshallbelimitedto[specifying
79geographicareastobecovered,] themethodsoftreatmentthatmaybecoveredby
80collaborativepracticearrangementsandtherequirementsforreviewofservicesprovided
81pursuanttocollaborativepracticearrangementsincludingdelegatingauthoritytoprescribe
82controlledsubstances.Anyrulesrelatingtodispensingordistributionofmedicationsor
83devicesbyprescriptionorprescriptiondrugordersunderthissectionshallbesubjecttothe
84approvalofthestateboardofpharmacy.Anyrulesrelatingtodispensingordistributionof
85controlledsubstancesbyprescriptionorprescriptiondrugordersunderthissectionshallbe
86subjecttotheapprovalofthedepartmentofhealthandseniorservicesandthestateboardof
87pharmacy.Inordertotakeeffect,suchrulesshallbeapprovedbyamajorityvoteofa
88quorumofeachboard.Neitherthestateboardofregistrationforthehealingartsnorthe
89boardofnursingmayseparatelypromulgaterulesrelatingtocollaborativepractice
90arrangements.Suchjointlypromulgatedrulesshallbeconsistentwithguidelinesfor
91federallyfundedclinics.Therulemakingauthoritygrantedinthissubsectionshallnotextend
92tocollaborativepracticearrangementsofhospitalemployeesprovidinginpatientcarewithin
93hospitalsasdefinedpursuanttochapter197orpopulation-basedpublichealthservicesas
94definedby20CSR2150-5.100asofApril30,2008.
95 5.Thestateboardofregistrationforthehealingartsshallnotdeny,revoke,suspend
96orotherwisetakedisciplinaryactionagainstaphysicianforhealthcareservicesdelegatedtoa
97registeredprofessionalnurseprovidedtheprovisionsofthissectionandtherules
98promulgatedthereunderaresatisfied.Uponthewrittenrequestofaphysiciansubjecttoa
99disciplinaryactionimposedasaresultofanagreementbetweenaphysicianandaregistered
100professionalnurseorregisteredphysicianassistant,whetherwrittenornot,priortoAugust
10128,1993,allrecordsofsuchdisciplinarylicensureactionandallrecordspertainingtothe
102filing,investigationorreviewofanallegedviolationofthischapterincurredasaresultof
103suchanagreementshallberemovedfromtherecordsofthestateboardofregistrationforthe
104healingartsandthedivisionofprofessionalregistrationandshallnotbedisclosedtoany
105publicorprivateentityseekingsuchinformationfromtheboardorthedivision.Thestate
HB2434 5 106boardofregistrationforthehealingartsshalltakeactiontocorrectreportsofalleged
107violationsanddisciplinaryactionsasdescribedinthissectionwhichhavebeensubmittedto
108theNationalPractitionerDataBank.Insubsequentapplicationsorrepresentationsrelatingto
109hisorhermedicalpractice,aphysiciancompletingformsordocumentsshallnotberequired
110toreportanyactionsofthestateboardofregistrationforthehealingartsforwhichthe
111recordsaresubjecttoremovalunderthissection.
112 6.Withinthirtydaysofanychangeandoneachrenewal,thestateboardof
113registrationforthehealingartsshallrequireeveryphysiciantoidentifywhetherthephysician
114isengagedinanycollaborativepracticeagreement,includingcollaborativepractice
115agreementsdelegatingtheauthoritytoprescribecontrolledsubstances,orphysician
116assistantagreementandalsoreporttotheboardthenameofeachlicensedprofessional
117withwhomthephysicianhasenteredintosuchagreement.Theboardmaymakethis
118informationavailabletothepublic.Theboardshalltrackthereportedinformationandmay
119routinelyconductrandomreviewsofsuchagreementstoensurethatagreementsarecarried
120outforcomplianceunderthischapter.
121 7.Notwithstandinganylawtothecontrary,acertifiedregisterednurseanesthetistas
122definedinsubdivision(8)ofsection335.016shallbepermittedtoprovideanesthesiaservices
123withoutacollaborativepracticearrangementprovidedthatheorsheisunderthesupervision
124ofananesthesiologistorotherphysician,dentist,orpodiatristwhoisimmediatelyavailableif
125needed.Nothinginthissubsectionshallbeconstruedtoprohibitorpreventacertified
126registerednurseanesthetistasdefinedinsubdivision(8)ofsection335.016fromenteringinto
127acollaborativepracticearrangementunderthissection,exceptthatthecollaborativepractice
128arrangementmaynotdelegatetheauthoritytoprescribeanycontrolledsubstanceslistedin
129SchedulesIII,IV,andVofsection195.017,orScheduleII-hydrocodone.
130 8.Acollaboratingphysicianshallnotenterintoacollaborativepracticearrangement
131withmorethansixfull-timeequivalentadvancedpracticeregisterednurses,full-time
132equivalentlicensedphysicianassistants,orfull-timeequivalentassistantphysicians,orany
133combinationthereof.Thislimitationshallnotapplytocollaborativearrangementsofhospital
134employeesprovidinginpatientcareserviceinhospitalsasdefinedinchapter197or
135population-basedpublichealthservicesasdefinedby20CSR2150-5.100asofApril30,
1362008,ortoacertifiedregisterednurseanesthetistprovidinganesthesiaservicesunderthe
137supervisionofananesthesiologistorotherphysician,dentist,orpodiatristwhoisimmediately
138availableifneededassetoutinsubsection7ofthissection.
139 9.Itistheresponsibilityofthecollaboratingphysiciantodetermineanddocument
140thecompletionof[atleastaone-month] aperiodoftimeduringwhichtheadvancedpractice
141registerednurseshallpracticewiththecollaboratingphysiciancontinuouslypresentbefore
142practicinginasettingwherethecollaboratingphysicianisnotcontinuouslypresent.This
HB2434 6 143limitationshallnotapplytocollaborativearrangementsofprovidersofpopulation-based
144publichealthservicesasdefinedby20CSR2150-5.100asofApril30,2008.
145 10.Noagreementmadeunderthissectionshallsupersedecurrenthospitallicensing
146regulationsgoverninghospitalmedicationordersunderprotocolsorstandingordersforthe
147purposeofdeliveringinpatientoremergencycarewithinahospitalasdefinedinsection
148197.020ifsuchprotocolsorstandingordershavebeenapprovedbythehospital'smedical
149staffandpharmaceuticaltherapeuticscommittee.
150 11.Nocontractorotheragreementshallrequireaphysiciantoactasacollaborating
151physicianforanadvancedpracticeregisterednurseagainstthephysician'swill.Aphysician
152shallhavetherighttorefusetoactasacollaboratingphysician,withoutpenalty,fora
153particularadvancedpracticeregisterednurse.Nocontractorotheragreementshalllimitthe
154collaboratingphysician'sultimateauthorityoveranyprotocolsorstandingordersorinthe
155delegationofthephysician'sauthoritytoanyadvancedpracticeregisterednurse,butthis
156requirementshallnotauthorizeaphysicianinimplementingsuchprotocols,standingorders,
157ordelegationtoviolateapplicablestandardsforsafemedicalpracticeestablishedbyhospital's
158medicalstaff.
159 12.Nocontractorotheragreementshallrequireanyadvancedpracticeregistered
160nursetoserveasacollaboratingadvancedpracticeregisterednurseforanycollaborating
161physicianagainsttheadvancedpracticeregisterednurse'swill.Anadvancedpractice
162registerednurseshallhavetherighttorefusetocollaborate,withoutpenalty,withaparticular
163physician.
335.175.1.NolaterthanJanuary1,2014,thereisherebyestablishedwithinthestate
2boardofregistrationforthehealingartsandthestateboardofnursingthe"Utilizationof
3TelehealthbyNurses".[Anadvancedpracticeregisterednurse(APRN)providingnursing
4servicesunderacollaborativepracticearrangementundersection334.104mayprovidesuch
5servicesoutsidethegeographicproximityrequirementsofsection334.104ifthe
6collaboratingphysicianandadvancedpracticeregisterednurseutilizetelehealthinthecare
7ofthepatientandiftheservicesareprovidedinaruralareaofneed.] Telehealthproviders
8shallberequiredtoobtainpatientconsentbeforetelehealthservicesareinitiatedandensure
9confidentialityofmedicalinformation.
10 2.Asusedinthissection,"telehealth"shallhavethesamemeaningassuchtermis
11definedinsection191.1145.
12 3.(1)Theboardsshalljointlypromulgaterulesgoverningthepracticeoftelehealth
13underthissection.Suchrulesshalladdress,butnotbelimitedto,appropriatestandardsfor
14theuseoftelehealth.
15 (2)Anyruleorportionofarule,asthattermisdefinedinsection536.010,thatis
16createdundertheauthoritydelegatedinthissectionshallbecomeeffectiveonlyifitcomplies
HB2434 7 17withandissubjecttoalloftheprovisionsofchapter536and,ifapplicable,section536.028.
18Thissectionandchapter536arenonseverableandifanyofthepowersvestedwiththe
19generalassemblypursuanttochapter536toreview,todelaytheeffectivedate,orto
20disapproveandannularulearesubsequentlyheldunconstitutional,thenthegrantof
21rulemakingauthorityandanyruleproposedoradoptedafterAugust28,2013,shallbeinvalid
22andvoid.
23 [4.Forpurposesofthissection,"ruralareaofneed"meansanyruralareaofthisstate
24whichislocatedinahealthprofessionalshortageareaasdefinedinsection354.650.]
SectionB.Becauseimmediateactionisnecessarytoincreasetheindependenceof
2certainhealthcareprofessionalsinordertoensuretheresidentsofthisstatehaveaccessto
3healthcareduringtheongoingCOVID-19pandemic,sectionAofthisactisdeemed
4necessaryfortheimmediatepreservationofthepublichealth,welfare,peace,andsafety,and
5isherebydeclaredtobeanemergencyactwithinthemeaningoftheconstitution,andsection
6Aofthisactshallbeinfullforceandeffectuponitspassageandapproval.
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HB2434 8