SECONDREGULARSESSION
HOUSECOMMITTEESUBSTITUTEFOR
HOUSEBILLNO.2434
101STGENERALASSEMBLY
5246H.02C 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
HCSHB2434 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;
HCSHB2434 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.Thedescriptionshall
66includeprovisionsthattheadvancedpracticeregisterednurseshallsubmitaminimumoften
67percentofthechartsdocumentingtheadvancedpracticeregisterednurse'sdeliveryofhealth
68careservicestothecollaboratingphysicianforreviewbythecollaboratingphysician,orany
69otherphysiciandesignatedinthecollaborativepracticearrangement,everyfourteendays;and
HCSHB2434 4 70 (10)Thecollaboratingphysician,oranyotherphysiciandesignatedinthe
71collaborativepracticearrangement,shallrevieweveryfourteendaysaminimumoftwenty
72percentofthechartsinwhichtheadvancedpracticeregisterednurseprescribescontrolled
73substances.Thechartsreviewedunderthissubdivisionmaybecountedinthenumberof
74chartsrequiredtobereviewedundersubdivision(9)ofthissubsection.
75 4.Thestateboardofregistrationforthehealingartspursuanttosection334.125and
76theboardofnursingpursuanttosection335.036mayjointlypromulgaterulesregulatingthe
77useofcollaborativepracticearrangements.Suchrulesshallbelimitedto[specifying
78geographicareastobecovered,] themethodsoftreatmentthatmaybecoveredby
79collaborativepracticearrangementsandtherequirementsforreviewofservicesprovided
80pursuanttocollaborativepracticearrangementsincludingdelegatingauthoritytoprescribe
81controlledsubstances.Anyrulesrelatingtodispensingordistributionofmedicationsor
82devicesbyprescriptionorprescriptiondrugordersunderthissectionshallbesubjecttothe
83approvalofthestateboardofpharmacy.Anyrulesrelatingtodispensingordistributionof
84controlledsubstancesbyprescriptionorprescriptiondrugordersunderthissectionshallbe
85subjecttotheapprovalofthedepartmentofhealthandseniorservicesandthestateboardof
86pharmacy.Inordertotakeeffect,suchrulesshallbeapprovedbyamajorityvoteofa
87quorumofeachboard.Neitherthestateboardofregistrationforthehealingartsnorthe
88boardofnursingmayseparatelypromulgaterulesrelatingtocollaborativepractice
89arrangements.Suchjointlypromulgatedrulesshallbeconsistentwithguidelinesfor
90federallyfundedclinics.Therulemakingauthoritygrantedinthissubsectionshallnotextend
91tocollaborativepracticearrangementsofhospitalemployeesprovidinginpatientcarewithin
92hospitalsasdefinedpursuanttochapter197orpopulation-basedpublichealthservicesas
93definedby20CSR2150-5.100asofApril30,2008.
94 5.Thestateboardofregistrationforthehealingartsshallnotdeny,revoke,suspend
95orotherwisetakedisciplinaryactionagainstaphysicianforhealthcareservicesdelegatedtoa
96registeredprofessionalnurseprovidedtheprovisionsofthissectionandtherules
97promulgatedthereunderaresatisfied.Uponthewrittenrequestofaphysiciansubjecttoa
98disciplinaryactionimposedasaresultofanagreementbetweenaphysicianandaregistered
99professionalnurseorregisteredphysicianassistant,whetherwrittenornot,priortoAugust
10028,1993,allrecordsofsuchdisciplinarylicensureactionandallrecordspertainingtothe
101filing,investigationorreviewofanallegedviolationofthischapterincurredasaresultof
102suchanagreementshallberemovedfromtherecordsofthestateboardofregistrationforthe
103healingartsandthedivisionofprofessionalregistrationandshallnotbedisclosedtoany
104publicorprivateentityseekingsuchinformationfromtheboardorthedivision.Thestate
105boardofregistrationforthehealingartsshalltakeactiontocorrectreportsofalleged
106violationsanddisciplinaryactionsasdescribedinthissectionwhichhavebeensubmittedto
HCSHB2434 5 107theNationalPractitionerDataBank.Insubsequentapplicationsorrepresentationsrelatingto
108hisorhermedicalpractice,aphysiciancompletingformsordocumentsshallnotberequired
109toreportanyactionsofthestateboardofregistrationforthehealingartsforwhichthe
110recordsaresubjecttoremovalunderthissection.
111 6.Withinthirtydaysofanychangeandoneachrenewal,thestateboardof
112registrationforthehealingartsshallrequireeveryphysiciantoidentifywhetherthephysician
113isengagedinanycollaborativepracticeagreement,includingcollaborativepractice
114agreementsdelegatingtheauthoritytoprescribecontrolledsubstances,orphysician
115assistantagreementandalsoreporttotheboardthenameofeachlicensedprofessional
116withwhomthephysicianhasenteredintosuchagreement.Theboardmaymakethis
117informationavailabletothepublic.Theboardshalltrackthereportedinformationandmay
118routinelyconductrandomreviewsofsuchagreementstoensurethatagreementsarecarried
119outforcomplianceunderthischapter.
120 7.Notwithstandinganylawtothecontrary,acertifiedregisterednurseanesthetistas
121definedinsubdivision(8)ofsection335.016shallbepermittedtoprovideanesthesiaservices
122withoutacollaborativepracticearrangementprovidedthatheorsheisunderthesupervision
123ofananesthesiologistorotherphysician,dentist,orpodiatristwhoisimmediatelyavailableif
124needed.Nothinginthissubsectionshallbeconstruedtoprohibitorpreventacertified
125registerednurseanesthetistasdefinedinsubdivision(8)ofsection335.016fromenteringinto
126acollaborativepracticearrangementunderthissection,exceptthatthecollaborativepractice
127arrangementmaynotdelegatetheauthoritytoprescribeanycontrolledsubstanceslistedin
128SchedulesIII,IV,andVofsection195.017,orScheduleII-hydrocodone.
129 8.Acollaboratingphysicianshallnotenterintoacollaborativepracticearrangement
130withmorethansixfull-timeequivalentadvancedpracticeregisterednurses,full-time
131equivalentlicensedphysicianassistants,orfull-timeequivalentassistantphysicians,orany
132combinationthereof.Thislimitationshallnotapplytocollaborativearrangementsofhospital
133employeesprovidinginpatientcareserviceinhospitalsasdefinedinchapter197or
134population-basedpublichealthservicesasdefinedby20CSR2150-5.100asofApril30,
1352008,ortoacertifiedregisterednurseanesthetistprovidinganesthesiaservicesunderthe
136supervisionofananesthesiologistorotherphysician,dentist,orpodiatristwhoisimmediately
137availableifneededassetoutinsubsection7ofthissection.
138 9.Itistheresponsibilityofthecollaboratingphysiciantodetermineanddocument
139thecompletionofatleastaone-monthperiodoftimeduringwhichtheadvancedpractice
140registerednurseshallpracticewiththecollaboratingphysiciancontinuouslypresentbefore
141practicinginasettingwherethecollaboratingphysicianisnotcontinuouslypresent.This
142limitationshallnotapplytocollaborativearrangementsofprovidersofpopulation-based
143publichealthservicesasdefinedby20CSR2150-5.100asofApril30,2008.
HCSHB2434 6 144 10.Noagreementmadeunderthissectionshallsupersedecurrenthospitallicensing
145regulationsgoverninghospitalmedicationordersunderprotocolsorstandingordersforthe
146purposeofdeliveringinpatientoremergencycarewithinahospitalasdefinedinsection
147197.020ifsuchprotocolsorstandingordershavebeenapprovedbythehospital'smedical
148staffandpharmaceuticaltherapeuticscommittee.
149 11.Nocontractorotheragreementshallrequireaphysiciantoactasacollaborating
150physicianforanadvancedpracticeregisterednurseagainstthephysician'swill.Aphysician
151shallhavetherighttorefusetoactasacollaboratingphysician,withoutpenalty,fora
152particularadvancedpracticeregisterednurse.Nocontractorotheragreementshalllimitthe
153collaboratingphysician'sultimateauthorityoveranyprotocolsorstandingordersorinthe
154delegationofthephysician'sauthoritytoanyadvancedpracticeregisterednurse,butthis
155requirementshallnotauthorizeaphysicianinimplementingsuchprotocols,standingorders,
156ordelegationtoviolateapplicablestandardsforsafemedicalpracticeestablishedbyhospital's
157medicalstaff.
158 12.Nocontractorotheragreementshallrequireanyadvancedpracticeregistered
159nursetoserveasacollaboratingadvancedpracticeregisterednurseforanycollaborating
160physicianagainsttheadvancedpracticeregisterednurse'swill.Anadvancedpractice
161registerednurseshallhavetherighttorefusetocollaborate,withoutpenalty,withaparticular
162physician.
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
17withandissubjecttoalloftheprovisionsofchapter536and,ifapplicable,section536.028.
18Thissectionandchapter536arenonseverableandifanyofthepowersvestedwiththe
HCSHB2434 7 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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HCSHB2434 8