EXPLANATION-Matter enclosed in bold-faced brackets [thus] in this bill is not enacted
and is intended to be omitted in the law.
SECOND REGULAR SESSION
SENATE BILL NO. 1279
102ND GENERAL ASSEMBLY
INTRODUCED BY SENATOR MAY.
4814S.01I KRISTINA MARTIN, Secretary
AN ACT
To repeal section 334.104, RSMo, and to enact in lieu thereof one new section relating to
collaborative practice arrangements.
Be it enacted by the General Assembly of the State of Missouri, as follows:
Section A. Section 334.104, RSMo, is repealed and one new 1
section enacted in lieu thereof, to be known as section 334.104, 2
to read as follows:3
334.104. 1. A physician may enter into collaborative 1
practice arrangements with registered professional nurses. 2
Collaborative practice arrangements shall be in the form of 3
written agreements, jointly agreed -upon protocols, or 4
standing orders for the delivery of health care services. 5
Collaborative practice arrangements, which shall be in 6
writing, may delegate to a registered professional nurse the 7
authority to administer or dispense drugs and provide 8
treatment as long as the delivery of such health care 9
services is within the scope of practice of the registered 10
professional nurse and is consistent with that nurse's 11
skill, training and competence. 12
2. (1) Collaborative practice arrangements, which 13
shall be in writing, may delegate to a registered 14
professional nurse the authority to administer, dispense or 15
prescribe drugs and provide treatment if the registered 16
professional nurse is an advanced practice registered nurse 17
as defined in subdivision (2) of section 335.016. 18 SB 1279 2
Collaborative practice arran gements may delegate to an 19
advanced practice registered nurse, as defined in section 20
335.016, the authority to administer, dispense, or prescribe 21
controlled substances listed in Schedules III, IV, and V of 22
section 195.017, and Schedule II - hydrocodone; except that, 23
the collaborative practice arrangement shall not delegate 24
the authority to administer any controlled substances listed 25
in Schedules III, IV, and V of section 195.017, or Schedule 26
II - hydrocodone for the purpose of inducing sedation or 27
general anesthesia for therapeutic, diagnostic, or surgical 28
procedures. Schedule III narcotic controlled substance and 29
Schedule II - hydrocodone prescriptions shall be limited to 30
a one hundred twenty -hour supply without refill. 31
(2) Notwithstanding any other provision of this 32
section to the contrary, a collaborative practice 33
arrangement may delegate to an advanced practice registered 34
nurse the authority to administer, dispense, or prescribe 35
Schedule II controlled substances for hospice patients ; 36
provided, that the advanced practice registered nurse is 37
employed by a hospice provider certified pursuant to chapter 38
197 and the advanced practice registered nurse is providing 39
care to hospice patients pursuant to a collaborative 40
practice arrangement that designates the certified hospice 41
as a location where the advanced practice registered nurse 42
is authorized to practice and prescribe. 43
(3) Such collaborative practice arrangements shall be 44
in the form of written agreements, jointly agreed -upon 45
protocols or standing orders for the delivery of health care 46
services. 47
(4) An advanced practice registered nurse may 48
prescribe buprenorphine for up to a thirty -day supply 49
without refill for patients receiving medication -assisted 50 SB 1279 3
treatment for substance use disorders under the direction of 51
the collaborating physician. 52
3. The written collaborative practice arrangement 53
shall contain at least the following provisions: 54
(1) Complete names, home and business addresses, zip 55
codes, and telephone numbers of the collaborating physician 56
and the advanced practice registered nurse; 57
(2) A list of all other offices or locations besides 58
those listed in subdivision (1) of this subsection where the 59
collaborating physician authorized the ad vanced practice 60
registered nurse to prescribe; 61
(3) A requirement that there shall be posted at every 62
office where the advanced practice registered nurse is 63
authorized to prescribe, in collaboration with a physician, 64
a prominently displayed disclo sure statement informing 65
patients that they may be seen by an advanced practice 66
registered nurse and have the right to see the collaborating 67
physician; 68
(4) All specialty or board certifications of the 69
collaborating physician and all certification s of the 70
advanced practice registered nurse; 71
(5) The manner of collaboration between the 72
collaborating physician and the advanced practice registered 73
nurse, including how the collaborating physician and the 74
advanced practice registered nurse will : 75
(a) Engage in collaborative practice consistent with 76
each professional's skill, training, education, and 77
competence; 78
(b) Maintain geographic proximity, except as specified 79
in this paragraph. The following provisions shall apply 80
with respect to this requirement: 81 SB 1279 4
a. Until August 28, 2025, an advanced practice 82
registered nurse providing services in a correctional 83
center, as defined in section 217.010, and his or her 84
collaborating physician shall satisfy the geographic 85
proximity requirement if they practice within two hundred 86
miles by road of one another. An incarcerated patient who 87
requests or requires a physician consultation shall be 88
treated by a physician as soon as appropriate; 89
b. The collaborative practice arrangement may allow 90
for geographic proximity to be waived for a maximum of 91
twenty-eight days per calendar year for rural health clinics 92
as defined by [Pub.L.] P.L. 95-210 (42 U.S.C. Section 1395x, 93
as amended), as long as the collaborative practice 94
arrangement includes alternative plans as required in 95
paragraph (c) of this subdivision. This exception to 96
geographic proximity shall apply only to independent rural 97
health clinics, provider -based rural health clinics where 98
the provider is a critical access hospi tal as provided in 42 99
U.S.C. Section 1395i -4, and provider-based rural health 100
clinics where the main location of the hospital sponsor is 101
greater than fifty miles from the clinic; 102
c. The collaborative practice arrangement [may allow 103
for] shall be exempt from the geographic proximity [to be 104
waived] requirement when the written collaborative practice 105
arrangement outlines the use of telehealth, as defined in 106
section 191.1145; 107
d. In addition to the waivers and exemptions provided 108
in this subsection, an application for a waiver for any 109
other reason of any applicable geographic proximity shall be 110
available if a physician is collaborating with an advanced 111
practice registered nurse in excess of any geographic 112
proximity limit. The board of nursing and the state board 113 SB 1279 5
of registration for the healing arts shall review each 114
application for a waiver of geographic proximity and approve 115
the application if the boards determine that adequate 116
supervision exists between the collaborating physician an d 117
the advanced practice registered nurse. The boards shall 118
have forty-five calendar days to review the completed 119
application for the waiver of geographic proximity. If no 120
action is taken by the boards within forty -five days after 121
the submission of the application for a waiver, then the 122
application shall be deemed approved. If the application is 123
denied by the boards, the provisions of section 536.063 for 124
contested cases shall apply and govern proceedings for 125
appellate purposes; and 126
e. The collaborating physician is required to maintain 127
documentation related to this requirement and to present it 128
to the state board of registration for the healing arts when 129
requested; and 130
(c) Provide coverage during absence, incapacity, 131
infirmity, or emergency by the collaborating physician; 132
(6) A description of the advanced practice registered 133
nurse's controlled substance prescriptive authority in 134
collaboration with the physician, including a list of the 135
controlled substances the physician au thorizes the nurse to 136
prescribe and documentation that it is consistent with each 137
professional's education, knowledge, skill, and competence; 138
(7) A list of all other written practice agreements of 139
the collaborating physician and the advanced pract ice 140
registered nurse; 141
(8) The duration of the written practice agreement 142
between the collaborating physician and the advanced 143
practice registered nurse; 144 SB 1279 6
(9) A description of the time and manner of the 145
collaborating physician's review of the advanced practice 146
registered nurse's delivery of health care services. The 147
description shall include provisions that the advanced 148
practice registered nurse shall submit a minimum of ten 149
percent of the charts documenting the advanced practice 150
registered nurse's delivery of health care services to the 151
collaborating physician for review by the collaborating 152
physician, or any other physician designated in the 153
collaborative practice arrangement, every [fourteen] thirty 154
days; 155
(10) The collaborating physician, or any other 156
physician designated in the collaborative practice 157
arrangement, shall review every fourteen days a minimum of 158
twenty percent of the charts in which the advanced practice 159
registered nurse prescribes controlled substances. The 160
charts reviewed under this subdivision may be counted in the 161
number of charts required to be reviewed under subdivision 162
(9) of this subsection; and 163
(11) If a collaborative practice arrangement is used 164
in clinical situations where a collaborating advanced 165
practice registered nurse provides health care services that 166
include the diagnosis and initiation of treatment for 167
acutely or chronically ill or injured persons, then the 168
collaborating physician or any other physician designated in 169
the collaborative practice arrangement shall be present for 170
sufficient periods of time, at least once every two weeks, 171
except in extraordinary circumstances that shall be 172
documented, to participate in a chart review and to provide 173
necessary medical direction, m edical services, 174
consultations, and supervision of the health care staff. 175 SB 1279 7
4. The state board of registration for the healing 176
arts pursuant to section 334.125 and the board of nursing 177
pursuant to section 335.036 may jointly promulgate rules 178
regulating the use of collaborative practice arrangements. 179
Such rules shall be limited to the methods of treatment that 180
may be covered by collaborative practice arrangements and 181
the requirements for review of services provided pursuant to 182
collaborative practice arrangements including delegating 183
authority to prescribe controlled substances. Any rules 184
relating to geographic proximity shall allow a collaborating 185
physician and a collaborating advanced practice registered 186
nurse to practice within two hundred miles by road of one 187
another until August 28, 2025, if the nurse is providing 188
services in a correctional center, as defined in section 189
217.010, and any such rules shall be consistent with and not 190
more restrictive than the standards set forth in paragr aph 191
(b) of subdivision (5) of subsection 3 of this section . Any 192
rules relating to dispensing or distribution of medications 193
or devices by prescription or prescription drug orders under 194
this section shall be subject to the approval of the state 195
board of pharmacy. Any rules relating to dispensing or 196
distribution of controlled substances by prescription or 197
prescription drug orders under this section shall be subject 198
to the approval of the department of health and senior 199
services and the state board of pharmacy. In order to take 200
effect, such rules shall be approved by a majority vote of a 201
quorum of each board. Neither the state board of 202
registration for the healing arts nor the board of nursing 203
may separately promulgate rules relating to collabo rative 204
practice arrangements. Such jointly promulgated rules shall 205
be consistent with guidelines for federally funded clinics. 206
The rulemaking authority granted in this subsection shall 207 SB 1279 8
not extend to collaborative practice arrangements of 208
hospital employees providing inpatient care within hospitals 209
as defined pursuant to chapter 197 or population -based 210
public health services as defined by 20 CSR 2150 -5.100 as of 211
April 30, 2008. 212
5. The state board of registration for the healing 213
arts shall not deny, revoke, suspend or otherwise take 214
disciplinary action against a physician for health care 215
services delegated to a registered professional nurse 216
provided the provisions of this section and the rules 217
promulgated thereunder are satisfied. Upon the written 218
request of a physician subject to a disciplinary action 219
imposed as a result of an agreement between a physician and 220
a registered professional nurse or registered physician 221
assistant, whether written or not, prior to August 28, 1993, 222
all records of such disciplinary licensure action and all 223
records pertaining to the filing, investigation or review of 224
an alleged violation of this chapter incurred as a result of 225
such an agreement shall be removed from the records of the 226
state board of regist ration for the healing arts and the 227
division of professional registration and shall not be 228
disclosed to any public or private entity seeking such 229
information from the board or the division. The state board 230
of registration for the healing arts shall ta ke action to 231
correct reports of alleged violations and disciplinary 232
actions as described in this section which have been 233
submitted to the National Practitioner Data Bank. In 234
subsequent applications or representations relating to his 235
or her medical practice, a physician completing forms or 236
documents shall not be required to report any actions of the 237
state board of registration for the healing arts for which 238
the records are subject to removal under this section. 239 SB 1279 9
6. Within thirty days of any cha nge and on each 240
renewal, the state board of registration for the healing 241
arts shall require every physician to identify whether the 242
physician is engaged in any collaborative practice 243
arrangement, including collaborative practice arrangements 244
delegating the authority to prescribe controlled substances, 245
or physician assistant collaborative practice arrangement 246
and also report to the board the name of each licensed 247
professional with whom the physician has entered into such 248
arrangement. The board shall make this information 249
available to the public. The board shall track the reported 250
information and may routinely conduct random reviews of such 251
arrangements to ensure that arrangements are carried out for 252
compliance under this chapter. 253
7. Notwithstanding any law to the contrary, a 254
certified registered nurse anesthetist as defined in 255
subdivision (8) of section 335.016 shall be permitted to 256
provide anesthesia services without a collaborative practice 257
arrangement provided that he or she is unde r the supervision 258
of an anesthesiologist or other physician, dentist, or 259
podiatrist who is immediately available if needed. Nothing 260
in this subsection shall be construed to prohibit or prevent 261
a certified registered nurse anesthetist as defined in 262
subdivision (8) of section 335.016 from entering into a 263
collaborative practice arrangement under this section, 264
except that the collaborative practice arrangement may not 265
delegate the authority to prescribe any controlled 266
substances listed in Schedules II I, IV, and V of section 267
195.017, or Schedule II - hydrocodone. 268
8. A collaborating physician shall not enter into a 269
collaborative practice arrangement with more than six full - 270
time equivalent advanced practice registered nurses, full - 271 SB 1279 10
time equivalent licensed physician assistants, or full -time 272
equivalent assistant physicians, or any combination 273
thereof. This limitation shall not apply to collaborative 274
arrangements of hospital employees providing inpatient care 275
service in hospitals as defined in chapter 197 or population - 276
based public health services as defined by 20 CSR 2150 -5.100 277
as of April 30, 2008, or to a certified registered nurse 278
anesthetist providing anesthesia services under the 279
supervision of an anesthesiologist or other physician, 280
dentist, or podiatrist who is immediately available if 281
needed as set out in subsection 7 of this section. 282
9. It is the responsibility of the collaborating 283
physician to determine and document the completion of at 284
least a one-month period of time du ring which the [advanced 285
practice registered nurse shall practice with the ] 286
collaborating physician [continuously present before 287
practicing in a setting where ] shall review thirty percent 288
of the charts documenting the advanced practice registered 289
nurse's delivery of health care services to the 290
collaborating physician [is not continuously present ] for 291
review by the collaborating physician, or any other 292
physician designated in the collaborative practice 293
arrangement. This limitation shall not apply t o 294
collaborative arrangements of providers of population -based 295
public health services, as defined by 20 CSR 2150 -5.100 as 296
of April 30, 2008, or to collaborative practice arrangements 297
between a primary care physician and a primary care advanced 298
practice registered nurse or a behavioral health physician 299
and a behavioral health advanced practice registered nurse, 300
where the collaborating physician is new to a patient 301
population to which the advanced practice registered nurse 302
is familiar. 303 SB 1279 11
10. No agreement made under this section shall 304
supersede current hospital licensing regulations governing 305
hospital medication orders under protocols or standing 306
orders for the purpose of delivering inpatient or emergency 307
care within a hospital as defined in sec tion 197.020 if such 308
protocols or standing orders have been approved by the 309
hospital's medical staff and pharmaceutical therapeutics 310
committee. 311
11. No contract or other term of employment shall 312
require a physician to act as a collaborating physic ian for 313
an advanced practice registered nurse against the 314
physician's will. A physician shall have the right to 315
refuse to act as a collaborating physician, without penalty, 316
for a particular advanced practice registered nurse. No 317
contract or other ag reement shall limit the collaborating 318
physician's ultimate authority over any protocols or 319
standing orders or in the delegation of the physician's 320
authority to any advanced practice registered nurse, but 321
this requirement shall not authorize a physician in 322
implementing such protocols, standing orders, or delegation 323
to violate applicable standards for safe medical practice 324
established by hospital's medical staff. 325
12. No contract or other term of employment shall 326
require any advanced practice reg istered nurse to serve as a 327
collaborating advanced practice registered nurse for any 328
collaborating physician against the advanced practice 329
registered nurse's will. An advanced practice registered 330
nurse shall have the right to refuse to collaborate, wi thout 331
penalty, with a particular physician. 332