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. 809
102ND GENERAL ASSEMBLY
INTRODUCED BY SENATOR SCHROER.
3517S.01I KRISTINA MARTIN, Secretary
AN ACT
To repeal sections 334.104, 335.016, and 335.019, RSMo, and to enact in lieu thereof three new
sections relating to advanced practice registered nurses.
Be it enacted by the General Assembly of the State of Missouri, as follows:
Section A. Sections 334.104, 335.016, and 335.019, RSMo, 1
are repealed and three new sections enacted in lieu thereof, to 2
be known as sections 334.104, 335.016, and 335.019, to read as 3
follows:4
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 ar rangements, 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 SB 809 2
as defined in subdivision (2) of section 335.016. 18
Collaborative practice arrangements 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 Sc hedules 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, dispe nse, 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 ar rangements 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 SB 809 3
without refill for patients receiving medication -assisted 50
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 advanced 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 disclosure 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 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 speci fied 79
in this paragraph. The following provisions shall apply 80
with respect to this requirement: 81 SB 809 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 physicia n 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. 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 provided 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 geographic 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 an d the state board 112
of registration for the healing arts shall review each 113 SB 809 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 appl ication 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 requirement and to present it 127
to the state board of registration for the healing arts when 128
requested; and 129
(c) Provide coverage during absence, incapacity, 130
infirmity, or emergen cy by the collaborating physician; 131
(6) A description of the advanced 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 authorize s the nurse to 135
prescribe and documentation that it is consistent with 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 agreement 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 advanc ed practice 145 SB 809 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 physician 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 required 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 least 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 c ollaborative practice arrangements. 177 SB 809 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. Any rules relating to dispensing or distribution 188
of medications or devices by prescription or prescription 189
drug orders under this section shall be subject to the 190
approval of the state board of pharmacy. Any rules relating 191
to dispensing or distribution of controlled substances by 192
prescription or prescription drug orders under this section 193
shall be subject to the approval of the department of health 194
and senior services and the state board of pharmacy. In 195
order to take effect, such rules shall be approved by a 196
majority vote of a quorum of each board. Neither the state 197
board of registration for the healing arts nor the board of 198
nursing may separately promulgate rules relating to 199
collaborative practice arrangements. Such jointly 200
promulgated rules shall be consistent with guidelines for 201
federally funded clinics. The rulemaking authority granted 202
in this subsection sh all not extend to collaborative 203
practice arrangements of hospital employees providing 204
inpatient care within hospitals as defined pursuant to 205
chapter 197 or population -based public health services as 206
defined by 20 CSR 2150 - 5.100 as of April 30, 2008. 207
5. The state board of registration for the healing 208
arts shall not deny, revoke, suspend or otherwise take 209 SB 809 8
disciplinary action against a physician for health care 210
services delegated to a registered professional nurse 211
provided the provisions of this section and the rules 212
promulgated thereunder are satisfied. Upon the written 213
request of a physician subject to a disciplinary action 214
imposed as a result of an agreement between a physician and 215
a registered professional nurse or registered physician 216
assistant, whether written or not, prior to August 28, 1993, 217
all records of such disciplinary licensure action and all 218
records pertaining to the filing, investigation or review of 219
an alleged violation of this chapter incurred as a result of 220
such an agreement shall be removed from the records of the 221
state board of registration for the healing arts and the 222
division of professional registration and shall not be 223
disclosed to any public or private entity seeking such 224
information from the board or the div ision. The state board 225
of registration for the healing arts shall take action to 226
correct reports of alleged violations and disciplinary 227
actions as described in this section which have been 228
submitted to the National Practitioner Data Bank. In 229
subsequent applications or representations relating to his 230
or her medical practice, a physician completing forms or 231
documents shall not be required to report any actions of the 232
state board of registration for the healing arts for which 233
the records are subject to removal under this section. 234
6. Within thirty days of any change and on each 235
renewal, the state board of registration for the healing 236
arts shall require every physician to identify whether the 237
physician is engaged in any collaborative practice 238
arrangement, including collaborative practice arrangements 239
delegating the authority to prescribe controlled substances, 240
or physician assistant collaborative practice arrangement 241 SB 809 9
and also report to the board the name of each licensed 242
professional with whom the physician has entered into such 243
arrangement. The board shall make this information 244
available to the public. The board shall track the reported 245
information and may routinely conduct random reviews of such 246
arrangements to ensure that arrangeme nts are carried out for 247
compliance under this chapter. 248
7. Notwithstanding any law to the contrary, a 249
certified registered nurse anesthetist as defined in 250
subdivision (8) of section 335.016 shall be permitted to 251
provide anesthesia services without a collaborative practice 252
arrangement provided that he or she is under the supervision 253
of an anesthesiologist or other physician, dentist, or 254
podiatrist who is immediately available if needed. Nothing 255
in this subsection shall be construed to prohibit or prevent 256
a certified registered nurse anesthetist as defined in 257
subdivision (8) of section 335.016 from entering into a 258
collaborative practice arrangement under this section, 259
except that the collaborative practice arrangement may not 260
delegate the authority to prescribe any controlled 261
substances listed in Schedules III, IV, and V of section 262
195.017, or Schedule II - hydrocodone. 263
8. A collaborating physician shall not enter into a 264
collaborative practice arrangement with more than six full - 265
time equivalent advanced practice registered nurses, full - 266
time equivalent licensed physician assistants, or full -time 267
equivalent assistant physicians, or any combination 268
thereof. This limitation shall not apply to collaborative 269
arrangements of hospital e mployees providing inpatient care 270
service in hospitals as defined in chapter 197 or population - 271
based public health services as defined by 20 CSR 2150 - 272
5.100 as of April 30, 2008, or to a certified registered 273 SB 809 10
nurse anesthetist providing anesthesia servi ces under the 274
supervision of an anesthesiologist or other physician, 275
dentist, or podiatrist who is immediately available if 276
needed as set out in subsection 7 of this section. 277
9. It is the responsibility of the collaborating 278
physician to determine and document the completion of at 279
least a one-month period of time during which the advanced 280
practice registered nurse shall practice with the 281
collaborating physician continuously present before 282
practicing in a setting where the collaborating physicia n is 283
not continuously present. This limitation shall not apply 284
to collaborative arrangements of providers of population - 285
based public health services, as defined by 20 CSR 2150 - 286
5.100 as of April 30, 2008, or to collaborative practice 287
arrangements between a primary care physician and a primary 288
care advanced practice registered nurse or a behavioral 289
health physician and a behavioral health advanced practice 290
registered nurse, where the collaborating physician is new 291
to a patient population to which t he advanced practice 292
registered nurse is familiar. 293
10. No agreement made under this section shall 294
supersede current hospital licensing regulations governing 295
hospital medication orders under protocols or standing 296
orders for the purpose of deliveri ng inpatient or emergency 297
care within a hospital as defined in section 197.020 if such 298
protocols or standing orders have been approved by the 299
hospital's medical staff and pharmaceutical therapeutics 300
committee. 301
11. No contract or other term of emp loyment shall 302
require a physician to act as a collaborating physician for 303
an advanced practice registered nurse against the 304
physician's will. A physician shall have the right to 305 SB 809 11
refuse to act as a collaborating physician, without penalty, 306
for a particular advanced practice registered nurse. No 307
contract or other agreement shall limit the collaborating 308
physician's ultimate authority over any protocols or 309
standing orders or in the delegation of the physician's 310
authority to any advanced practice regi stered nurse, but 311
this requirement shall not authorize a physician in 312
implementing such protocols, standing orders, or delegation 313
to violate applicable standards for safe medical practice 314
established by hospital's medical staff. 315
12. No contract or other term of employment shall 316
require any advanced practice registered nurse to serve as a 317
collaborating advanced practice registered nurse for any 318
collaborating physician against the advanced practice 319
registered nurse's will. An advanced practice registered 320
nurse shall have the right to refuse to collaborate, without 321
penalty, with a particular physician. 322
13. (1) The provisions of this section shall not 323
apply to an advanced practice registered nurse who has been 324
in a collaborative practic e arrangement for a cumulative two 325
thousand documented hours with a collaborating physician and 326
whose license is in good standing. Any such advanced 327
practice registered nurse shall not be required to enter 328
into or remain in an arrangement in order to practice in 329
this state. Any other provisions of law requiring a 330
collaborative practice arrangement or delegation shall not 331
be required for an advanced practice registered nurse 332
described in this subsection. 333
(2) The provisions of this subsection shall not apply 334
to certified registered nurse anesthetists. 335
(3) Notwithstanding any provision of this section to 336
the contrary, an advanced practice registered nurse applying 337 SB 809 12
for licensure by endorsement may demonstrate to the state 338
board of nursing completion of a cumulative two thousand 339
documented hours of practice. Such advanced practice 340
registered nurses shall not be required to enter into a 341
collaborative practice arrangement in order to practice in 342
this state. 343
335.016. As used in this chapter, unless the context 1
clearly requires otherwise, the following words and terms 2
mean: 3
(1) "Accredited", the official authorization or status 4
granted by an agency for a program through a voluntary 5
process; 6
(2) "Advanced practice registered nurse" or "APRN", a 7
person who is licensed under the provisions of this chapter 8
to engage in the practice of advanced practice nursing as a 9
certified clinical nurse specialist, certified nurse 10
midwife, certified nurse practitioner , or certified 11
registered nurse anesthetist; 12
(3) "Approval", official recognition of nursing 13
education programs which meet standards established by the 14
board of nursing; 15
(4) "Board" or "state board", the state board of 16
nursing; 17
(5) "Certified clinical nurse specialist", a 18
registered nurse who is currently certified as a clinical 19
nurse specialist by a nationally recognized certifying board 20
approved by the board of nursing; 21
(6) "Certified nurse midwife", a registered nurse who 22
is currently certified as a nurse midwife by the American 23
Midwifery Certification Board, or other nationally 24
recognized certifying body approved by the board of nursing; 25 SB 809 13
(7) "Certified nurse practitioner", a registered nurse 26
who is currently certi fied as a nurse practitioner by a 27
nationally recognized certifying body approved by the board 28
of nursing; 29
(8) "Certified registered nurse anesthetist", a 30
registered nurse who is currently certified as a nurse 31
anesthetist by the Council on Certifi cation of Nurse 32
Anesthetists, the National Board of Certification and 33
Recertification for Nurse Anesthetists, or other nationally 34
recognized certifying body approved by the board of nursing; 35
(9) "Executive director", a qualified individual 36
employed by the board as executive secretary or otherwise to 37
administer the provisions of this chapter under the board's 38
direction. Such person employed as executive director shall 39
not be a member of the board; 40
(10) "Inactive license status", as define d by rule 41
pursuant to section 335.061; 42
(11) "Lapsed license status", as defined by rule under 43
section 335.061; 44
(12) "Licensed practical nurse" or "practical nurse", 45
a person licensed pursuant to the provisions of this chapter 46
to engage in the practice of practical nursing; 47
(13) "Licensure", the issuing of a license to 48
candidates who have met the requirements specified under 49
this chapter, authorizing the person to engage in the 50
practice of advanced practice, professional, or practi cal 51
nursing, and the recording of the names of those persons as 52
holders of a license to practice advanced practice, 53
professional, or practical nursing; 54
(14) "Practice of advanced practice nursing", the 55
performance for compensation of activities a nd services 56
consistent with the required education, training, 57 SB 809 14
certification, demonstrated competencies, and experiences of 58
an advanced practice registered nurse . In addition to the 59
practice of professional nursing and within the advanced 60
practice registered nurse role and population focus, the 61
term "practice of advanced practice nursing" shall include: 62
(a) Conducting an advanced assessment; 63
(b) Ordering and interpreting diagnostic procedures; 64
(c) Establishing primary and differentia l diagnoses; 65
(d) Prescribing, ordering, administering, dispensing, 66
and furnishing therapeutic measures; 67
(e) Delegating and assigning therapeutic measures to 68
assistive personnel; 69
(f) Consulting with other disciplines and providing 70
referrals to health care agencies, health care providers, 71
and community resources; and 72
(g) Other acts that require education and training 73
consistent with professional standards and commensurate with 74
the advanced practice registered nurse's education, 75
certification, demonstrated competencies, and experience ; 76
(15) "Practice of practical nursing", the performance 77
for compensation of selected acts for the promotion of 78
health and in the care of persons who are ill, injured, or 79
experiencing alterati ons in normal health processes. Such 80
performance requires substantial specialized skill, judgment 81
and knowledge. All such nursing care shall be given under 82
the direction of a person licensed by a state regulatory 83
board to prescribe medications and tr eatments or under the 84
direction of a registered professional nurse. For the 85
purposes of this chapter, the term "direction" shall mean 86
guidance or supervision provided by a person licensed by a 87
state regulatory board to prescribe medications and 88
treatments or a registered professional nurse, including, 89 SB 809 15
but not limited to, oral, written, or otherwise communicated 90
orders or directives for patient care. When practical 91
nursing care is delivered pursuant to the direction of a 92
person licensed by a state regulatory board to prescribe 93
medications and treatments or under the direction of a 94
registered professional nurse, such care may be delivered by 95
a licensed practical nurse without direct physical oversight; 96
(16) "Practice of professional nursing ", the 97
performance for compensation of any act or action which 98
requires substantial specialized education, judgment and 99
skill based on knowledge and application of principles 100
derived from the biological, physical, social, behavioral, 101
and nursing sciences, including, but not limited to: 102
(a) Responsibility for the promotion and teaching of 103
health care and the prevention of illness to the patient and 104
his or her family; 105
(b) Assessment, data collection, nursing diagnosis, 106
nursing care, evalua tion, and counsel of persons who are 107
ill, injured, or experiencing alterations in normal health 108
processes; 109
(c) The administration of medications and treatments 110
as prescribed by a person licensed by a state regulatory 111
board to prescribe medication s and treatments; 112
(d) The coordination and assistance in the 113
determination and delivery of a plan of health care with all 114
members of a health team; 115
(e) The teaching and supervision of other persons in 116
the performance of any of the foregoing; 117
(17) "Registered professional nurse" or "registered 118
nurse", a person licensed pursuant to the provisions of this 119
chapter to engage in the practice of professional nursing; 120 SB 809 16
(18) "Retired license status", any person licensed in 121
this state under this chapter who retires from such 122
practice. Such person shall file with the board an 123
affidavit, on a form to be furnished by the board, which 124
states the date on which the licensee retired from such 125
practice, an intent to retire from the practice f or at least 126
two years, and such other facts as tend to verify the 127
retirement as the board may deem necessary; but if the 128
licensee thereafter reengages in the practice, the licensee 129
shall renew his or her license with the board as provided by 130
this chapter and by rule and regulation. 131
335.019. 1. An advanced practice registered nurse's 1
prescriptive authority shall include authority to: 2
(1) Prescribe, dispense, and administer medications 3
and nonscheduled legend drugs, as define d in section 4
338.330, and controlled substances, as provided in 5
subsection 2 of section 195.070, within such APRN's practice 6
and specialty; and 7
(2) Notwithstanding any other provision of this 8
chapter to the contrary, receive, prescribe, administe r, and 9
provide nonscheduled legend drug samples from pharmaceutical 10
manufacturers to patients at no charge to the patient or any 11
other party. 12
2. In addition to advanced practice registered nurses 13
who have a collaborative practice arrangement, the 14
provisions of subsection 1 of this section shall apply to an 15
advanced practice registered nurse who meets the 16
requirements described in subsection 13 of section 334.104 17
and is no longer required to hold a collaborative practice 18
arrangement. 19 SB 809 17
3. The board of nursing may grant a certificate of 20
controlled substance prescriptive authority to an advanced 21
practice registered nurse who: 22
(1) Submits proof of successful completion of an 23
advanced pharmacology course that shall include preceptorial 24
experience in the prescription of drugs, medicines, and 25
therapeutic devices; and 26
(2) Provides documentation of a minimum of three 27
hundred clock hours preceptorial experience in the 28
prescription of drugs, medicines, and therapeutic devices 29
with a qualified preceptor; and 30
(3) Provides evidence of a minimum of one thousand 31
hours of practice in an advanced practice nursing category 32
prior to application for a certificate of prescriptive 33
authority. The one thousand hours shall not include 34
clinical hours obtained in the advanced practice nursing 35
education program. The one thousand hours of practice in an 36
advanced practice nursing category may include transmitting 37
a prescription order orally or telephonically or to an 38
inpatient medical re cord from protocols developed in 39
collaboration with and signed by a licensed physician; and 40
[(4)] (a) Has a controlled substance prescribing 41
authority delegated in the collaborative practice 42
arrangement under section 334.104 with a physician who h as 43
an unrestricted federal Drug Enforcement Administration 44
registration number and who is actively engaged in a 45
practice comparable in scope, specialty, or expertise to 46
that of the advanced practice registered nurse ; or 47
(b) Provides documentation of a minimum of two 48
thousand hours of practice in advanced practice nursing, as 49
provided in subsection 13 of section 334.104 . 50