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. 807
102ND GENERAL ASSEMBLY
INTRODUCED BY SENATOR BLACK.
3665S.02I 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Section A. Section 334.104, RSMo, is repealed and one new 1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 hea lth 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 807 2
Collaborative practice arrangem ents 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 807 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 advan ced 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 disclosur e 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 certifications o f 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 79
specified in this paragraph. The following provisions shall 80
apply with respect to this requirement: 81 SB 807 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 m ay 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. 95 -210 (42 U.S.C. Section 1395x, as 93
amended), as long as the collaborative practice arrangement 94
includes alternative plans as required in paragraph (c) of 95
this subdivision. This exception to geographic proximity 96
shall apply only to independent rural health clinics, 97
provider-based rural health clinics where the provider is a 98
critical access hospital as pr ovided in 42 U.S.C. Section 99
1395i-4, and provider-based rural health clinics where the 100
main location of the hospital sponsor is greater than fifty 101
miles from the clinic; 102
c. The collaborative practice arrangement may allow 103
for geographic proximity to be waived when the arrangement 104
outlines the use of telehealth, as defined in section 105
191.1145; 106
d. In addition to the waivers and exemptions provided 107
in this subsection, an application for a waiver for any 108
other reason of any applicable geogra phic proximity shall be 109
available if a physician is collaborating with an advanced 110
practice registered nurse in excess of any geographic 111
proximity limit. The board of nursing and the state board 112
of registration for the healing arts shall review each 113 SB 807 5
application for a waiver of geographic proximity and approve 114
the application if the boards determine that adequate 115
supervision exists between the collaborating physician and 116
the advanced practice registered nurse. The boards shall 117
have forty-five calendar days to review the completed 118
application for the waiver of geographic proximity. If no 119
action is taken by the boards within forty -five days after 120
the submission of the application for a waiver, then the 121
application shall be deemed approved. If the application is 122
denied by the boards, the provisions of section 536.063 for 123
contested cases shall apply and govern proceedings for 124
appellate purposes; and 125
e. The collaborating physician is required to maintain 126
documentation related to this requ irement and to present it 127
to the state board of registration for the healing arts when 128
requested;] and 129
[(c)] (b) Provide coverage during absence, incapacity, 130
infirmity, or emergency by the collaborating physician; 131
(6) A description of the ad vanced practice registered 132
nurse's controlled substance prescriptive authority in 133
collaboration with the physician, including a list of the 134
controlled substances the physician authorizes the nurse to 135
prescribe and documentation that it is consistent wi th each 136
professional's education, knowledge, skill, and competence; 137
(7) A list of all other written practice agreements of 138
the collaborating physician and the advanced practice 139
registered nurse; 140
(8) The duration of the written practice agree ment 141
between the collaborating physician and the advanced 142
practice registered nurse; 143
(9) A description of the time and manner of the 144
collaborating physician's review of the advanced practice 145 SB 807 6
registered nurse's delivery of health care services. The 146
description shall include provisions that the advanced 147
practice registered nurse shall submit a minimum of ten 148
percent of the charts documenting the advanced practice 149
registered nurse's delivery of health care services to the 150
collaborating physicia n for review by the collaborating 151
physician, or any other physician designated in the 152
collaborative practice arrangement, every fourteen days; 153
(10) The collaborating physician, or any other 154
physician designated in the collaborative practice 155
arrangement, shall review every fourteen days a minimum of 156
twenty percent of the charts in which the advanced practice 157
registered nurse prescribes controlled substances. The 158
charts reviewed under this subdivision may be counted in the 159
number of charts requ ired to be reviewed under subdivision 160
(9) of this subsection; and 161
(11) If a collaborative practice arrangement is used 162
in clinical situations where a collaborating advanced 163
practice registered nurse provides health care services that 164
include the diagnosis and initiation of treatment for 165
acutely or chronically ill or injured persons, then the 166
collaborating physician or any other physician designated in 167
the collaborative practice arrangement shall be present for 168
sufficient periods of time, at le ast once every two weeks, 169
except in extraordinary circumstances that shall be 170
documented, to participate in a chart review and to provide 171
necessary medical direction, medical services, 172
consultations, and supervision of the health care staff. 173
4. The state board of registration for the healing 174
arts pursuant to section 334.125 and the board of nursing 175
pursuant to section 335.036 may jointly promulgate rules 176
regulating the use of collaborative practice arrangements. 177 SB 807 7
Such rules shall be limited to the methods of treatment that 178
may be covered by collaborative practice arrangements and 179
the requirements for review of services provided pursuant to 180
collaborative practice arrangements including delegating 181
authority to prescribe controlled substances. [Any rules 182
relating to geographic proximity shall allow a collaborating 183
physician and a collaborating advanced practice registered 184
nurse to practice within two hundred miles by road of one 185
another until August 28, 2025, if the nurse is providing 186
services in a correctional center, as defined in section 187
217.010.] The state board of registration for the healing 188
arts and the board of nursing shall not promulgate rules to 189
enforce any geographic proximity requirements, including any 190
mileage or distance restrictions for a physician or advanced 191
practice registered nurse, on collaborative practice 192
arrangements between physicians and registered professional 193
nurses located in this state. Any regulations governing 194
proximity that are in effect on August 2 8, 2024, shall no 195
longer be effective. Any provision of a collaborative 196
practice arrangement that requires geographic proximity 197
between a physician and a registered professional nurse 198
shall be unenforceable. Any rules relating to dispensing or 199
distribution of medications or devices by prescription or 200
prescription drug orders under this section shall be subject 201
to the approval of the state board of pharmacy. Any rules 202
relating to dispensing or distribution of controlled 203
substances by prescription or prescription drug orders under 204
this section shall be subject to the approval of the 205
department of health and senior services and the state board 206
of pharmacy. In order to take effect, such rules shall be 207
approved by a majority vote of a quorum of e ach board. 208
Neither the state board of registration for the healing arts 209 SB 807 8
nor the board of nursing may separately promulgate rules 210
relating to collaborative practice arrangements. Such 211
jointly promulgated rules shall be consistent with 212
guidelines for federally funded clinics. The rulemaking 213
authority granted in this subsection shall not extend to 214
collaborative practice arrangements of hospital employees 215
providing inpatient care within hospitals as defined 216
pursuant to chapter 197 or population -based public health 217
services as defined by 20 CSR 2150 -5.100 as of April 30, 218
2008. 219
5. The state board of registration for the healing 220
arts shall not deny, revoke, suspend or otherwise take 221
disciplinary action against a physician for health care 222
services delegated to a registered professional nurse 223
provided the provisions of this section and the rules 224
promulgated thereunder are satisfied. Upon the written 225
request of a physician subject to a disciplinary action 226
imposed as a result of an agreement between a physician and 227
a registered professional nurse or registered physician 228
assistant, whether written or not, prior to August 28, 1993, 229
all records of such disciplinary licensure action and all 230
records pertaining to the filing, investigation or re view of 231
an alleged violation of this chapter incurred as a result of 232
such an agreement shall be removed from the records of the 233
state board of registration for the healing arts and the 234
division of professional registration and shall not be 235
disclosed to any public or private entity seeking such 236
information from the board or the division. The state board 237
of registration for the healing arts shall take action to 238
correct reports of alleged violations and disciplinary 239
actions as described in this secti on which have been 240
submitted to the National Practitioner Data Bank. In 241 SB 807 9
subsequent applications or representations relating to his 242
or her medical practice, a physician completing forms or 243
documents shall not be required to report any actions of the 244
state board of registration for the healing arts for which 245
the records are subject to removal under this section. 246
6. Within thirty days of any change and on each 247
renewal, the state board of registration for the healing 248
arts shall require every phys ician to identify whether the 249
physician is engaged in any collaborative practice 250
arrangement, including collaborative practice arrangements 251
delegating the authority to prescribe controlled substances, 252
or physician assistant collaborative practice arran gement 253
and also report to the board the name of each licensed 254
professional with whom the physician has entered into such 255
arrangement. The board shall make this information 256
available to the public. The board shall track the reported 257
information and may routinely conduct random reviews of such 258
arrangements to ensure that arrangements are carried out for 259
compliance under this chapter. 260
7. Notwithstanding any law to the contrary, a 261
certified registered nurse anesthetist as defined in 262
subdivision (8) of section 335.016 shall be permitted to 263
provide anesthesia services without a collaborative practice 264
arrangement provided that he or she is under the supervision 265
of an anesthesiologist or other physician, dentist, or 266
podiatrist who is immediately available if needed. Nothing 267
in this subsection shall be construed to prohibit or prevent 268
a certified registered nurse anesthetist as defined in 269
subdivision (8) of section 335.016 from entering into a 270
collaborative practice arrangement under this sec tion, 271
except that the collaborative practice arrangement may not 272
delegate the authority to prescribe any controlled 273 SB 807 10
substances listed in Schedules III, IV, and V of section 274
195.017, or Schedule II - hydrocodone. 275
8. A collaborating physician shall not enter into a 276
collaborative practice arrangement with more than six full - 277
time equivalent advanced practice registered nurses, full - 278
time equivalent licensed physician assistants, or full -time 279
equivalent assistant physicians, or any combination 280
thereof. This limitation shall not apply to collaborative 281
arrangements of hospital employees providing inpatient care 282
service in hospitals as defined in chapter 197 or population - 283
based public health services as defined by 20 CSR 2150 -5.100 284
as of April 30, 2008, or to a certified registered nurse 285
anesthetist providing anesthesia services under the 286
supervision of an anesthesiologist or other physician, 287
dentist, or podiatrist who is immediately available if 288
needed as set out in subsection 7 of this sectio n. 289
9. It is the responsibility of the collaborating 290
physician to determine and document the completion of at 291
least a one-month period of time during which the advanced 292
practice registered nurse shall practice with the 293
collaborating physician cont inuously present before 294
practicing in a setting where the collaborating physician is 295
not continuously present. This limitation shall not apply 296
to collaborative arrangements of providers of population - 297
based public health services, as defined by 20 CSR 2150- 298
5.100 as of April 30, 2008, or to collaborative practice 299
arrangements between a primary care physician and a primary 300
care advanced practice registered nurse or a behavioral 301
health physician and a behavioral health advanced practice 302
registered nurse, where the collaborating physician is new 303
to a patient population to which the advanced practice 304
registered nurse is familiar. 305 SB 807 11
10. No agreement made under this section shall 306
supersede current hospital licensing regulations governing 307
hospital medication orders under protocols or standing 308
orders for the purpose of delivering inpatient or emergency 309
care within a hospital as defined in section 197.020 if such 310
protocols or standing orders have been approved by the 311
hospital's medical staff and ph armaceutical therapeutics 312
committee. 313
11. No contract or other term of employment shall 314
require a physician to act as a collaborating physician for 315
an advanced practice registered nurse against the 316
physician's will. A physician shall have the rig ht to 317
refuse to act as a collaborating physician, without penalty, 318
for a particular advanced practice registered nurse. No 319
contract or other agreement shall limit the collaborating 320
physician's ultimate authority over any protocols or 321
standing orders or in the delegation of the physician's 322
authority to any advanced practice registered nurse, but 323
this requirement shall not authorize a physician in 324
implementing such protocols, standing orders, or delegation 325
to violate applicable standards for safe me dical practice 326
established by hospital's medical staff. 327
12. No contract or other term of employment shall 328
require any advanced practice registered nurse to serve as a 329
collaborating advanced practice registered nurse for any 330
collaborating physicia n against the advanced practice 331
registered nurse's will. An advanced practice registered 332
nurse shall have the right to refuse to collaborate, without 333
penalty, with a particular physician. 334