FIRSTREGULARSESSION
HOUSEBILLNO.327
103RDGENERALASSEMBLY
INTRODUCEDBYREPRESENTATIVECASTEEL.
0987H.01I DANARADEMANMILLER,ChiefClerk
ANACT
Torepealsections195.070and334.104,RSMo,andtoenactinlieuthereoftwonewsections
relatingtotheprescriptiveauthorityofadvancedpracticeregisterednurses.
BeitenactedbytheGeneralAssemblyofthestateofMissouri,asfollows:
SectionA.Sections195.070and334.104,RSMo,arerepealedandtwonewsections
2enactedinlieuthereof,tobeknownassections195.070and334.104,toreadasfollows:
195.070.1.Aphysician,podiatrist,dentist,aregisteredoptometristcertifiedto
2administerpharmaceuticalagentsasprovidedinsection336.220,oranassistantphysicianin
3accordancewithsection334.037oraphysicianassistantinaccordancewithsection334.747
4ingoodfaithandinthecourseofhisorherprofessionalpracticeonly,mayprescribe,
5administer,anddispensecontrolledsubstancesorheorshemaycausethesametobe
6administeredordispensedbyanindividualasauthorizedbystatute.
7 2.Anadvancedpracticeregisterednurse,asdefinedinsection335.016,butnota
8certifiedregisterednurseanesthetistasdefinedinsubdivision(8)ofsection335.016,who
9holdsacertificateofcontrolledsubstanceprescriptiveauthorityfromtheboardofnursing
10undersection335.019andwhoisdelegatedtheauthoritytoprescribecontrolledsubstances
11underacollaborativepracticearrangementundersection334.104mayprescribeany
12controlledsubstanceslistedinSchedulesIII,IV,andVofsection195.017,andmayhave
13restrictedauthorityinScheduleII.PrescriptionsforScheduleIImedicationsprescribedbyan
14advancedpracticeregisterednursewhohasacertificateofcontrolledsubstanceprescriptive
15authorityarerestrictedtoonlythosemedicationscontaininghydrocodone[and],ScheduleII
16controlledsubstancesforhospicepatients, andScheduleIIbenzodiazepinesandstimulants
17pursuanttotheprovisionsofsection334.104.However,nosuchcertifiedadvancedpractice
EXPLANATION—Matterenclosedinbold-facedbrackets[thus] intheabovebillisnotenactedandis
intendedtobeomittedfromthelaw.Matterinbold-facetypeintheabovebillisproposedlanguage. 18registerednurseshallprescribecontrolledsubstanceforhisorherownselforfamily.
19ScheduleIIInarcoticcontrolledsubstanceandScheduleII-hydrocodoneprescriptionsshall
20belimitedtoaonehundredtwenty-hoursupplywithoutrefill.
21 3.Aveterinarian,ingoodfaithandinthecourseoftheveterinarian'sprofessional
22practiceonly,andnotforusebyahumanbeing,mayprescribe,administer,anddispense
23controlledsubstancesandtheveterinarianmaycausethemtobeadministeredbyanassistant
24ororderlyunderhisorherdirectionandsupervision.
25 4.Apractitionershallnotacceptanyportionofacontrolledsubstanceunusedbya
26patient,foranyreason,ifsuchpractitionerdidnotoriginallydispensethedrug,except:
27 (1)Whenthecontrolledsubstanceisdeliveredtothepractitionertoadministertothe
28patientforwhomthemedicationisprescribedasauthorizedbyfederallaw.Practitioners
29shallmaintainrecordsandsecurethemedicationasrequiredbythischapterandregulations
30promulgatedpursuanttothischapter;or
31 (2)Asprovidedinsection195.265.
32 5.Anindividualpractitionershallnotprescribeordispenseacontrolledsubstancefor
33suchpractitioner'spersonaluseexceptinamedicalemergency.
334.104.1.Aphysicianmayenterintocollaborativepracticearrangementswith
2registeredprofessionalnurses.Collaborativepracticearrangementsshallbeintheformof
3writtenagreements,jointlyagreed-uponprotocols,orstandingordersforthedeliveryof
4healthcareservices.Collaborativepracticearrangements,whichshallbeinwriting,may
5delegatetoaregisteredprofessionalnursetheauthoritytoadministerordispensedrugsand
6providetreatmentaslongasthedeliveryofsuchhealthcareservicesiswithinthescopeof
7practiceoftheregisteredprofessionalnurseandisconsistentwiththatnurse'sskill,training
8andcompetence.
9 2.(1)Collaborativepracticearrangements,whichshallbeinwriting,maydelegateto
10aregisteredprofessionalnursetheauthoritytoadminister,dispenseorprescribedrugsand
11providetreatmentiftheregisteredprofessionalnurseisanadvancedpracticeregisterednurse
12asdefinedinsubdivision(2)ofsection335.016.Collaborativepracticearrangementsmay
13delegatetoanadvancedpracticeregisterednurse,asdefinedinsection335.016,theauthority
14toadminister,dispense,orprescribecontrolledsubstanceslistedinSchedulesIII,IV,andVof
15section195.017[, and];ScheduleII-hydrocodone; andScheduleIIbenzodiazepinesand
16stimulants; exceptthat,thecollaborativepracticearrangementshallnotdelegatethe
17authoritytoadministeranycontrolledsubstanceslistedinSchedulesIII,IV,andVofsection
18195.017[, or];ScheduleII-hydrocodone; orScheduleIIbenzodiazepinesorstimulantsfor
19thepurposeofinducingsedationorgeneralanesthesiafortherapeutic,diagnostic,orsurgical
20procedures.ScheduleIIInarcoticcontrolledsubstanceandScheduleII-hydrocodone
21prescriptionsshallbelimitedtoaonehundredtwenty-hoursupplywithoutrefill.
HB327 2 22 (2)Notwithstandinganyotherprovisionofthissectiontothecontrary,acollaborative
23practicearrangementmaydelegatetoanadvancedpracticeregisterednursetheauthorityto
24administer,dispense,orprescribeScheduleIIcontrolledsubstancesforhospicepatients;
25provided,thattheadvancedpracticeregisterednurseisemployedbyahospiceprovider
26certifiedpursuanttochapter197andtheadvancedpracticeregisterednurseisprovidingcare
27tohospicepatientspursuanttoacollaborativepracticearrangementthatdesignatesthe
28certifiedhospiceasalocationwheretheadvancedpracticeregisterednurseisauthorizedto
29practiceandprescribe.
30 (3)Suchcollaborativepracticearrangementsshallbeintheformofwritten
31agreements,jointlyagreed-uponprotocolsorstandingordersforthedeliveryofhealthcare
32services.
33 (4)Anadvancedpracticeregisterednursemayprescribebuprenorphineforuptoa
34thirty-daysupplywithoutrefillforpatientsreceivingmedication-assistedtreatmentfor
35substanceusedisordersunderthedirectionofthecollaboratingphysician.
36 3.Thewrittencollaborativepracticearrangementshallcontainatleastthefollowing
37provisions:
38 (1)Completenames,homeandbusinessaddresses,zipcodes,andtelephonenumbers
39ofthecollaboratingphysicianandtheadvancedpracticeregisterednurse;
40 (2)Alistofallotherofficesorlocationsbesidesthoselistedinsubdivision(1)ofthis
41subsectionwherethecollaboratingphysicianauthorizedtheadvancedpracticeregistered
42nursetoprescribe;
43 (3)Arequirementthatthereshallbepostedateveryofficewheretheadvanced
44practiceregisterednurseisauthorizedtoprescribe,incollaborationwithaphysician,a
45prominentlydisplayeddisclosurestatementinformingpatientsthattheymaybeseenbyan
46advancedpracticeregisterednurseandhavetherighttoseethecollaboratingphysician;
47 (4)Allspecialtyorboardcertificationsofthecollaboratingphysicianandall
48certificationsoftheadvancedpracticeregisterednurse;
49 (5)Themannerofcollaborationbetweenthecollaboratingphysicianandthe
50advancedpracticeregisterednurse,includinghowthecollaboratingphysicianandthe
51advancedpracticeregisterednursewill:
52 (a)Engageincollaborativepracticeconsistentwitheachprofessional'sskill,training,
53education,andcompetence;
54 (b)Maintaingeographicproximity,exceptasspecifiedinthisparagraph.The
55followingprovisionsshallapplywithrespecttothisrequirement:
56 a.UntilAugust28,2025,anadvancedpracticeregisterednurseprovidingservicesin
57acorrectionalcenter,asdefinedinsection217.010,andhisorhercollaboratingphysician
58shallsatisfythegeographicproximityrequirementiftheypracticewithintwohundredmiles
HB327 3 59byroadofoneanother.Anincarceratedpatientwhorequestsorrequiresaphysician
60consultationshallbetreatedbyaphysicianassoonasappropriate;
61 b.Thecollaborativepracticearrangementmayallowforgeographicproximitytobe
62waivedforamaximumoftwenty-eightdayspercalendaryearforruralhealthclinicsas
63definedbyPub.L.95-210(42U.S.C.Section1395x,asamended),aslongasthecollaborative
64practicearrangementincludesalternativeplansasrequiredinparagraph(c)ofthis
65subdivision.Thisexceptiontogeographicproximityshallapplyonlytoindependentrural
66healthclinics,provider-basedruralhealthclinicswheretheproviderisacriticalaccess
67hospitalasprovidedin42U.S.C.Section1395i-4,andprovider-basedruralhealthclinics
68wherethemainlocationofthehospitalsponsorisgreaterthanfiftymilesfromtheclinic;
69 c.Thecollaborativepracticearrangementmayallowforgeographicproximitytobe
70waivedwhenthearrangementoutlinestheuseoftelehealth,asdefinedinsection191.1145;
71 d.Inadditiontothewaiversandexemptionsprovidedinthissubsection,an
72applicationforawaiverforanyotherreasonofanyapplicablegeographicproximityshallbe
73availableifaphysicianiscollaboratingwithanadvancedpracticeregisterednurseinexcess
74ofanygeographicproximitylimit.Theboardofnursingandthestateboardofregistration
75forthehealingartsshallrevieweachapplicationforawaiverofgeographicproximityand
76approvetheapplicationiftheboardsdeterminethatadequatesupervisionexistsbetweenthe
77collaboratingphysicianandtheadvancedpracticeregisterednurse.Theboardsshallhave
78forty-fivecalendardaystoreviewthecompletedapplicationforthewaiverofgeographic
79proximity.Ifnoactionistakenbytheboardswithinforty-fivedaysafterthesubmissionof
80theapplicationforawaiver,thentheapplicationshallbedeemedapproved.Iftheapplication
81isdeniedbytheboards,theprovisionsofsection536.063forcontestedcasesshallapplyand
82governproceedingsforappellatepurposes;and
83 e.Thecollaboratingphysicianisrequiredtomaintaindocumentationrelatedtothis
84requirementandtopresentittothestateboardofregistrationforthehealingartswhen
85requested;and
86 (c)Providecoverageduringabsence,incapacity,infirmity,oremergencybythe
87collaboratingphysician;
88 (6)Adescriptionoftheadvancedpracticeregisterednurse'scontrolledsubstance
89prescriptiveauthorityincollaborationwiththephysician,includingalistofthecontrolled
90substancesthephysicianauthorizesthenursetoprescribeanddocumentationthatitis
91consistentwitheachprofessional'seducation,knowledge,skill,andcompetence;
92 (7)Alistofallotherwrittenpracticeagreementsofthecollaboratingphysicianand
93theadvancedpracticeregisterednurse;
94 (8)Thedurationofthewrittenpracticeagreementbetweenthecollaborating
95physicianandtheadvancedpracticeregisterednurse;
HB327 4 96 (9)Adescriptionofthetimeandmannerofthecollaboratingphysician'sreviewof
97theadvancedpracticeregisterednurse'sdeliveryofhealthcareservices.Thedescriptionshall
98includeprovisionsthattheadvancedpracticeregisterednurseshallsubmitaminimumoften
99percentofthechartsdocumentingtheadvancedpracticeregisterednurse'sdeliveryofhealth
100careservicestothecollaboratingphysicianforreviewbythecollaboratingphysician,orany
101otherphysiciandesignatedinthecollaborativepracticearrangement,everyfourteendays;
102 (10)Thecollaboratingphysician,oranyotherphysiciandesignatedinthe
103collaborativepracticearrangement,shallrevieweveryfourteendaysaminimumoftwenty
104percentofthechartsinwhichtheadvancedpracticeregisterednurseprescribescontrolled
105substances.Thechartsreviewedunderthissubdivisionmaybecountedinthenumberof
106chartsrequiredtobereviewedundersubdivision(9)ofthissubsection;and
107 (11)Ifacollaborativepracticearrangementisusedinclinicalsituationswherea
108collaboratingadvancedpracticeregisterednurseprovideshealthcareservicesthatincludethe
109diagnosisandinitiationoftreatmentforacutelyorchronicallyillorinjuredpersons,thenthe
110collaboratingphysicianoranyotherphysiciandesignatedinthecollaborativepractice
111arrangementshallbepresentforsufficientperiodsoftime,atleastonceeverytwoweeks,
112exceptinextraordinarycircumstancesthatshallbedocumented,toparticipateinachart
113reviewandtoprovidenecessarymedicaldirection,medicalservices,consultations,and
114supervisionofthehealthcarestaff.
115 4.Thestateboardofregistrationforthehealingartspursuanttosection334.125and
116theboardofnursingpursuanttosection335.036mayjointlypromulgaterulesregulatingthe
117useofcollaborativepracticearrangements.Suchrulesshallbelimitedtothemethodsof
118treatmentthatmaybecoveredbycollaborativepracticearrangementsandtherequirements
119forreviewofservicesprovidedpursuanttocollaborativepracticearrangementsincluding
120delegatingauthoritytoprescribecontrolledsubstances.Anyrulesrelatingtogeographic
121proximityshallallowacollaboratingphysicianandacollaboratingadvancedpractice
122registerednursetopracticewithintwohundredmilesbyroadofoneanotheruntilAugust28,
1232025,ifthenurseisprovidingservicesinacorrectionalcenter,asdefinedinsection217.010.
124Anyrulesrelatingtodispensingordistributionofmedicationsordevicesbyprescriptionor
125prescriptiondrugordersunderthissectionshallbesubjecttotheapprovalofthestateboard
126ofpharmacy.Anyrulesrelatingtodispensingordistributionofcontrolledsubstancesby
127prescriptionorprescriptiondrugordersunderthissectionshallbesubjecttotheapprovalof
128thedepartmentofhealthandseniorservicesandthestateboardofpharmacy.Inordertotake
129effect,suchrulesshallbeapprovedbyamajorityvoteofaquorumofeachboard.Neitherthe
130stateboardofregistrationforthehealingartsnortheboardofnursingmayseparately
131promulgaterulesrelatingtocollaborativepracticearrangements.Suchjointlypromulgated
132rulesshallbeconsistentwithguidelinesforfederallyfundedclinics.Therulemaking
HB327 5 133authoritygrantedinthissubsectionshallnotextendtocollaborativepracticearrangementsof
134hospitalemployeesprovidinginpatientcarewithinhospitalsasdefinedpursuanttochapter
135197orpopulation-basedpublichealthservicesasdefinedby20CSR2150-5.100asofApril
13630,2008.
137 5.Thestateboardofregistrationforthehealingartsshallnotdeny,revoke,suspend
138orotherwisetakedisciplinaryactionagainstaphysicianforhealthcareservicesdelegatedtoa
139registeredprofessionalnurseprovidedtheprovisionsofthissectionandtherules
140promulgatedthereunderaresatisfied.Uponthewrittenrequestofaphysiciansubjecttoa
141disciplinaryactionimposedasaresultofanagreementbetweenaphysicianandaregistered
142professionalnurseorregisteredphysicianassistant,whetherwrittenornot,priortoAugust
14328,1993,allrecordsofsuchdisciplinarylicensureactionandallrecordspertainingtothe
144filing,investigationorreviewofanallegedviolationofthischapterincurredasaresultof
145suchanagreementshallberemovedfromtherecordsofthestateboardofregistrationforthe
146healingartsandthedivisionofprofessionalregistrationandshallnotbedisclosedtoany
147publicorprivateentityseekingsuchinformationfromtheboardorthedivision.Thestate
148boardofregistrationforthehealingartsshalltakeactiontocorrectreportsofalleged
149violationsanddisciplinaryactionsasdescribedinthissectionwhichhavebeensubmittedto
150theNationalPractitionerDataBank.Insubsequentapplicationsorrepresentationsrelatingto
151hisorhermedicalpractice,aphysiciancompletingformsordocumentsshallnotberequired
152toreportanyactionsofthestateboardofregistrationforthehealingartsforwhichthe
153recordsaresubjecttoremovalunderthissection.
154 6.Withinthirtydaysofanychangeandoneachrenewal,thestateboardof
155registrationforthehealingartsshallrequireeveryphysiciantoidentifywhetherthephysician
156isengagedinanycollaborativepracticearrangement,includingcollaborativepractice
157arrangementsdelegatingtheauthoritytoprescribecontrolledsubstances,orphysician
158assistantcollaborativepracticearrangementandalsoreporttotheboardthenameofeach
159licensedprofessionalwithwhomthephysicianhasenteredintosucharrangement.Theboard
160shallmakethisinformationavailabletothepublic.Theboardshalltrackthereported
161informationandmayroutinelyconductrandomreviewsofsucharrangementstoensurethat
162arrangementsarecarriedoutforcomplianceunderthischapter.
163 7.Notwithstandinganylawtothecontrary,acertifiedregisterednurseanesthetistas
164definedinsubdivision(8)ofsection335.016shallbepermittedtoprovideanesthesiaservices
165withoutacollaborativepracticearrangementprovidedthatheorsheisunderthesupervision
166ofananesthesiologistorotherphysician,dentist,orpodiatristwhoisimmediatelyavailableif
167needed.Nothinginthissubsectionshallbeconstruedtoprohibitorpreventacertified
168registerednurseanesthetistasdefinedinsubdivision(8)ofsection335.016fromenteringinto
169acollaborativepracticearrangementunderthissection,exceptthatthecollaborativepractice
HB327 6 170arrangementmaynotdelegatetheauthoritytoprescribeanycontrolledsubstanceslistedin
171SchedulesIII,IV,andVofsection195.017[, or];ScheduleII-hydrocodone; orScheduleII
172benzodiazepinesorstimulants.
173 8.Acollaboratingphysicianshallnotenterintoacollaborativepracticearrangement
174withmorethansixfull-timeequivalentadvancedpracticeregisterednurses,full-time
175equivalentlicensedphysicianassistants,orfull-timeequivalentassistantphysicians,orany
176combinationthereof.Thislimitationshallnotapplytocollaborativearrangementsofhospital
177employeesprovidinginpatientcareserviceinhospitalsasdefinedinchapter197or
178population-basedpublichealthservicesasdefinedby20CSR2150-5.100asofApril30,
1792008,ortoacertifiedregisterednurseanesthetistprovidinganesthesiaservicesunderthe
180supervisionofananesthesiologistorotherphysician,dentist,orpodiatristwhoisimmediately
181availableifneededassetoutinsubsection7ofthissection.
182 9.Itistheresponsibilityofthecollaboratingphysiciantodetermineanddocument
183thecompletionofatleastaone-monthperiodoftimeduringwhichtheadvancedpractice
184registerednurseshallpracticewiththecollaboratingphysiciancontinuouslypresentbefore
185practicinginasettingwherethecollaboratingphysicianisnotcontinuouslypresent.This
186limitationshallnotapplytocollaborativearrangementsofprovidersofpopulation-based
187publichealthservices,asdefinedby20CSR2150-5.100asofApril30,2008,orto
188collaborativepracticearrangementsbetweenaprimarycarephysicianandaprimarycare
189advancedpracticeregisterednurseorabehavioralhealthphysicianandabehavioralhealth
190advancedpracticeregisterednurse,wherethecollaboratingphysicianisnewtoapatient
191populationtowhichtheadvancedpracticeregisterednurseisfamiliar.
192 10.Noagreementmadeunderthissectionshallsupersedecurrenthospitallicensing
193regulationsgoverninghospitalmedicationordersunderprotocolsorstandingordersforthe
194purposeofdeliveringinpatientoremergencycarewithinahospitalasdefinedinsection
195197.020ifsuchprotocolsorstandingordershavebeenapprovedbythehospital'smedical
196staffandpharmaceuticaltherapeuticscommittee.
197 11.Nocontractorothertermofemploymentshallrequireaphysiciantoactasa
198collaboratingphysicianforanadvancedpracticeregisterednurseagainstthephysician'swill.
199Aphysicianshallhavetherighttorefusetoactasacollaboratingphysician,withoutpenalty,
200foraparticularadvancedpracticeregisterednurse.Nocontractorotheragreementshalllimit
201thecollaboratingphysician'sultimateauthorityoveranyprotocolsorstandingordersorinthe
202delegationofthephysician'sauthoritytoanyadvancedpracticeregisterednurse,butthis
203requirementshallnotauthorizeaphysicianinimplementingsuchprotocols,standingorders,
204ordelegationtoviolateapplicablestandardsforsafemedicalpracticeestablishedbyhospital's
205medicalstaff.
HB327 7 206 12.Nocontractorothertermofemploymentshallrequireanyadvancedpractice
207registerednursetoserveasacollaboratingadvancedpracticeregisterednurseforany
208collaboratingphysicianagainsttheadvancedpracticeregisterednurse'swill.Anadvanced
209practiceregisterednurseshallhavetherighttorefusetocollaborate,withoutpenalty,witha
210particularphysician.
âś”
HB327 8