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SECOND REGULAR SESSION
HOUSE BILL NO. 2287
103RD GENERAL ASSEMBL Y
INTRODUCED BY REPRESENT A TIVE BROWN.
5967H.01I JOSEPH ENGLER, Chief Clerk
AN ACT
T o repeal sections 195.070, 334.104, 334.735, and 334.747, RSMo, and to enact in lieu
thereof four new sections relating to prescriptive authority for certain health care
professionals.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Sections 195.070, 334.104, 334.735, and 334.747, RSMo, are repealed
2 and four new sections enacted in lieu thereof, to be known as sections 195.070, 334.104,
3 334.735, and 334.747, to read as follows:
195.070. 1. A physician, podiatrist, dentist, a registered optometrist certified to
2 administer pharmaceutical agents as provided in section 336.220, or an assistant physician in
3 accordance with section 334.037 or a physician assistant in accordance with section 334.747
4 in good faith and in the course of his or her professional practice only , may prescribe,
5 administer , and dispense controlled substances or he or she may cause the same to be
6 administered or dispensed by an individual as authorized by statute.
7 2. An advanced practice registered nurse, as defined in section 335.016, but not a
8 certified registered nurse anesthetist as defined in subdivision (8) of section 335.016, who
9 holds a certificate of controlled substance prescriptive authority from the board of nursing
10 under section 335.019 and who is delegated the authority to prescribe controlled substances
11 under a collaborative practice arrangement under section 334.104 may prescribe any
12 controlled substances listed in Schedules III, IV , and V of section 195.017, and may have
13 restricted authority in Schedule II. Prescriptions for Schedule II medications prescribed by an
14 advanced practice registered nurse who has a certificate of controlled substance prescriptive
15 authority are restricted to only those medications containing hydrocodone and Schedule II
EXPLANA TION — Matter enclosed in bold-faced brackets [thus] in the above bill is not enacted and is
intended to be omitted from the law . Matter in bold-face type in the above bill is proposed language.
16 controlled substances for hospice patients and patients of pro viders designated as
17 administrative entities by the department of mental health under section 630.407
18 pursuant to the provisions of section 334.104. However , no such certified advanced practice
19 registered nurse shall prescribe controlled substance for his or her own self or family .
20 Schedule III narcotic controlled substance and Schedule II - hydrocodone prescriptions shall
21 be limited to a one hundred twenty-hour supply without refill.
22 3. A veterinarian, in good faith and in the course of the veterinarian's professional
23 practice only , and not for use by a human being, may prescribe, administer , and dispense
24 controlled substances and the veterinarian may cause them to be administered by an assistant
25 or orderly under his or her direction and supervision.
26 4. A practitioner shall not accept any portion of a controlled substance unused by a
27 patient, for any reason, if such practitioner did not originally dispense the drug, except:
28 (1) When the controlled substance is delivered to the practitioner to administer to the
29 patient for whom the medication is prescribed as authorized by federal law . Practitioners
30 shall maintain records and secure the medication as required by this chapter and regulations
31 promulgated pursuant to this chapter; or
32 (2) As provided in section 195.265.
33 5. An individual practitioner shall not prescribe or dispense a controlled substance for
34 such practitioner's personal use except in a medical emer gency .
334.104. 1. A physician may enter into collaborative practice arrangements with
2 registered professional nurses. Collaborative practice arrangements shall be in the form of
3 written agreements, jointly agreed-upon protocols, or standing orders for the delivery of
4 health care services. Collaborative practice arrangements, which shall be in writing, may
5 delegate to a registered professional nurse the authority to administer or dispense drugs and
6 provide treatment as long as the delivery of such health care services is within the scope of
7 practice of the registered professional nurse and is consistent with that nurse's skill, training
8 and competence.
9 2. (1) Collaborative practice arrangements, which shall be in writing, may delegate to
10 a registered professional nurse the authority to administer , dispense or prescribe drugs and
11 provide treatment if the registered professional nurse is an advanced practice registered nurse
12 as defined in subdivision (2) of section 335.016. Collaborative practice arrangements may
13 delegate to an advanced practice registered nurse, as defined in section 335.016, the authority
14 to administer , dispense, or prescribe controlled substances listed in Schedules III, IV , and V of
15 section 195.017, and Schedule II - hydrocodone; except that, the collaborative practice
16 arrangement shall not delegate the authority to administer any controlled substances listed in
17 Schedules III, IV , and V of section 195.017, or Schedule II - hydrocodone for the purpose of
18 inducing sedation or general anesthesia for therapeutic, diagnostic, or surg ical procedures.
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19 Schedule III narcotic controlled substance and Schedule II - hydrocodone prescriptions shall
20 be limited to a one hundred twenty-hour supply without refill.
21 (2) Notwithstanding any other provision of this section to the contrary , a collaborative
22 practice arrangement may delegate to an advanced practice registered nurse the authority to
23 administer , dispense, or prescribe Schedule II controlled substances for hospice patients or
24 patients of pr oviders designated as administrative entities by the department of mental
25 health under section 630.407 ; provided, that the advanced practice registered nurse is
26 employed by a hospice provider certified pursuant to chapter 197 or by a provi der
27 designated as an administrative entity by the department of mental health under section
28 630.407 and the advanced practice registered nurse is providing care to hospice patients or
29 patients of the pr ovider designated as an administrative entity by the department of
30 mental health under section 630.407 pursuant to a collaborative practice arrangement that
31 designates the certified hospice or the provi der designated as an administrative entity by
32 the department of mental health under section 630.407 as a location where the advanced
33 practice registered nurse is authorized to practice and prescribe.
34 (3) Such collaborative practice arrangements shall be in the form of written
35 agreements, jointly agreed-upon protocols or standing orders for the delivery of health care
36 services.
37 (4) An advanced practice registered nurse may prescribe buprenorphine for up to a
38 thirty-day supply without refill for patients receiving medication-assisted treatment for
39 substance use disorders under the direction of the collaborating physician.
40 3. The written collaborative practice arrangement shall contain at least the following
41 provisions:
42 (1) Complete names, home and business addresses, zip codes, and telephone numbers
43 of the collaborating physician and the advanced practice registered nurse;
44 (2) A list of all other of fices or locations besides those listed in subdivision (1) of this
45 subsection where the collaborating physician authorized the advanced practice registered
46 nurse to prescribe;
47 (3) A requirement that there shall be posted at every of fice where the advanced
48 practice registered nurse is authorized to prescribe, in collaboration with a physician, a
49 prominently displayed disclosure statement informing patients that they may be seen by an
50 advanced practice registered nurse and have the right to see the collaborating physician;
51 (4) All specialty or board certifications of the collaborating physician and all
52 certifications of the advanced practice registered nurse;
53 (5) The manner of collaboration between the collaborating physician and the
54 advanced practice registered nurse, including how the collaborating physician and the
55 advanced practice registered nurse will:
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56 (a) Engage in collaborative practice consistent with each professional's skill, training,
57 education, and competence;
58 (b) Maintain geographic proximity , except as specified in this paragraph. The
59 following provisions shall apply with respect to this requirement:
60 a. Until August 28, 2025, an advanced practice registered nurse providing services in
61 a correctional center , as defined in section 217.010, and his or her collaborating physician
62 shall satisfy the geographic proximity requirement if they practice within two hundred miles
63 by road of one another . An incarcerated patient who requests or requires a physician
64 consultation shall be treated by a physician as soon as appropriate;
65 b. The collaborative practice arrangement may allow for geographic proximity to be
66 waived for a maximum of twenty-eight days per calendar year for rural health clinics as
67 defined by Pub.L. 95-210 (42 U.S.C. Section 1395x, as amended), as long as the collaborative
68 practice arrangement includes alternative plans as required in paragraph (c) of this
69 subdivision. This exception to geographic proximity shall apply only to independent rural
70 health clinics, provider -based rural health clinics where the provider is a critical access
71 hospital as provided in 42 U.S.C. Section 1395i-4, and provider -based rural health clinics
72 where the main location of the hospital sponsor is greater than fifty miles from the clinic;
73 c. The collaborative practice arrangement may allow for geographic proximity to be
74 waived when the arrangement outlines the use of telehealth, as defined in section 191.1 145;
75 d. In addition to the waivers and exemptions provided in this subsection, an
76 application for a waiver for any other reason of any applicable geographic proximity shall be
77 available if a physician is collaborating with an advanced practice registered nurse in excess
78 of any geographic proximity limit. The board of nursing and the state board of registration
79 for the healing arts shall review each application for a waiver of geographic proximity and
80 approve the application if the boards determine that adequate supervision exists between the
81 collaborating physician and the advanced practice registered nurse. The boards shall have
82 forty-five calendar days to review the completed application for the waiver of geographic
83 proximity . If no action is taken by the boards within forty-five days after the submission of
84 the application for a waiver , then the application shall be deemed approved. If the application
85 is denied by the boards, the provisions of section 536.063 for contested cases shall apply and
86 govern proceedings for appellate purposes; and
87 e. The collaborating physician is required to maintain documentation related to this
88 requirement and to present it to the state board of registration for the healing arts when
89 requested; and
90 (c) Provide coverage during absence, incapacity , infirmity , or emer gency by the
91 collaborating physician;
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92 (6) A description of the advanced practice registered nurse's controlled substance
93 prescriptive authority in collaboration with the physician, including a list of the controlled
94 substances the physician authorizes the nurse to prescribe and documentation that it is
95 consistent with each professional's education, knowledge, skill, and competence;
96 (7) A list of all other written practice agreements of the collaborating physician and
97 the advanced practice registered nurse;
98 (8) The duration of the written practice agreement between the collaborating
99 physician and the advanced practice registered nurse;
100 (9) A description of the time and manner of the collaborating physician's review of
101 the advanced practice registered nurse's delivery of health care services. The description shall
102 include provisions that the advanced practice registered nurse shall submit a minimum of ten
103 percent of the charts documenting the advanced practice registered nurse's delivery of health
104 care services to the collaborating physician for review by the collaborating physician, or any
105 other physician designated in the collaborative practice arrangement, every fourteen days;
106 (10) The collaborating physician, or any other physician designated in the
107 collaborative practice arrangement, shall review every fourteen days a minimum of twenty
108 percent of the charts in which the advanced practice registered nurse prescribes controlled
109 substances. The charts reviewed under this subdivision may be counted in the number of
110 charts required to be reviewed under subdivision (9) of this subsection; and
111 (1 1) If a collaborative practice arrangement is used in clinical situations where a
112 collaborating advanced practice registered nurse provides health care services that include the
113 diagnosis and initiation of treatment for acutely or chronically ill or injured persons, then the
114 collaborating physician or any other physician designated in the collaborative practice
115 arrangement shall be present for suf ficient periods of time, at least once every two weeks,
116 except in extraordinary circumstances that shall be documented, to participate in a chart
117 review and to provide necessary medical direction, medical services, consultations, and
118 supervision of the health care staf f.
119 4. The state board of registration for the healing arts pursuant to section 334.125 and
120 the board of nursing pursuant to section 335.036 may jointly promulgate rules regulating the
121 use of collaborative practice arrangements. Such rules shall be limited to the methods of
122 treatment that may be covered by collaborative practice arrangements and the requirements
123 for review of services provided pursuant to collaborative practice arrangements including
124 delegating authority to prescribe controlled substances. Any rules relating to geographic
125 proximity shall allow a collaborating physician and a collaborating advanced practice
126 registered nurse to practice within two hundred miles by road of one another until August 28,
127 2025, if the nurse is providing services in a correctional center , as defined in section 217.010.
128 Any rules relating to dispensing or distribution of medications or devices by prescription or
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129 prescription drug orders under this section shall be subject to the approval of the state board
130 of pharmacy . Any rules relating to dispensing or distribution of controlled substances by
131 prescription or prescription drug orders under this section shall be subject to the approval of
132 the department of health and senior services and the state board of pharmacy . In order to take
133 ef fect, such rules shall be approved by a majority vote of a quorum of each board. Neither the
134 state board of registration for the healing arts nor the board of nursing may separately
135 promulgate rules relating to collaborative practice arrangements. Such jointly promulgated
136 rules shall be consistent with guidelines for federally funded clinics. The rulemaking
137 authority granted in this subsection shall not extend to collaborative practice arrangements of
138 hospital employees providing inpatient care within hospitals as defined pursuant to chapter
139 197 or population-based public health services as defined by 20 CSR 2150-5.100 as of April
140 30, 2008.
141 5. The state board of registration for the healing arts shall not deny , revoke, suspend
142 or otherwise take disciplinary action against a physician for health care services delegated to a
143 registered professional nurse provided the provisions of this section and the rules
14 4 promulgated thereunder are satisfied. Upon the written request of a physician subject to a
145 disciplinary action imposed as a result of an agreement between a physician and a registered
146 professional nurse or registered physician assistant, whether written or not, prior to August
147 28, 1993, all records of such disciplinary licensure action and all records pertaining to the
148 filing, investigation or review of an alleged violation of this chapter incurred as a result of
149 such an agreement shall be removed from the records of the state board of registration for the
150 healing arts and the division of professional registration and shall not be disclosed to any
151 public or private entity seeking such information from the board or the division. The state
152 board of registration for the healing arts shall take action to correct reports of alleged
153 violations and disciplinary actions as described in this section which have been submitted to
154 the National Practitioner Data Bank. In subsequent applications or representations relating to
155 his or her medical practice, a physician completing forms or documents shall not be required
156 to report any actions of the state board of registration for the healing arts for which the
157 records are subject to removal under this section.
158 6. W ithin thirty days of any change and on each renewal, the state board of
159 registration for the healing arts shall require every physician to identify whether the physician
160 is engaged in any collaborative practice arrangement, including collaborative practice
161 arrangements delegating the authority to prescribe controlled substances, or physician
162 assistant collaborative practice arrangement and also report to the board the name of each
163 licensed professional with whom the physician has entered into such arrangement. The board
164 shall make this information available to the public. The board shall track the reported
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165 information and may routinely conduct random reviews of such arrangements to ensure that
166 arrangements are carried out for compliance under this chapter .
167 7. Notwithstanding any law to the contrary , a certified registered nurse anesthetist as
168 defined in subdivision (8) of section 335.016 shall be permitted to provide anesthesia services
169 without a collaborative practice arrangement provided that he or she is under the supervision
170 of an anesthesiologist or other physician, dentist, or podiatrist who is immediately available if
171 needed. Nothing in this subsection shall be construed to prohibit or prevent a certified
172 registered nurse anesthetist as defined in subdivision (8) of section 335.016 from entering into
173 a collaborative practice arrangement under this section, except that the collaborative practice
174 arrangement may not delegate the authority to prescribe any controlled substances listed in
175 Schedules III, IV , and V of section 195.017, or Schedule II - hydrocodone.
176 8. A collaborating physician shall not enter into a collaborative practice arrangement
177 with more than six full-time equivalent advanced practice registered nurses, full-time
178 equivalent licensed physician assistants, or full-time equivalent assistant physicians, or any
179 combination thereof. This limitation shall not apply to collaborative arrangements of hospital
180 employees providing inpatient care service in hospitals as defined in chapter 197 or
181 population-based public health services as defined by 20 CSR 2150-5.100 as of April 30,
182 2008, or to a certified registered nurse anesthetist providing anesthesia services under the
183 supervision of an anesthesiologist or other physician, dentist, or podiatrist who is immediately
184 available if needed as set out in subsection 7 of this section.
185 9. It is the responsibility of the collaborating physician to determine and document
186 the completion of at least a one-month period of time during which the advanced practice
187 registered nurse shall practice with the collaborating physician continuously present before
188 practicing in a setting where the collaborating physician is not continuously present. This
189 limitation shall not apply to collaborative arrangements of providers of population-based
190 public health services, as defined by 20 CSR 2150-5.100 as of April 30, 2008, or to
191 collaborative practice arrangements between a primary care physician and a primary care
192 advanced practice registered nurse or a behavioral health physician and a behavioral health
193 advanced practice registered nurse, where the collaborating physician is new to a patient
194 population to which the advanced practice registered nurse is familiar .
195 10. No agreement made under this section shall supersede current hospital licensing
196 regulations governing hospital medication orders under protocols or standing orders for the
197 purpose of delivering inpatient or emer gency care within a hospital as defined in section
198 197.020 if such protocols or standing orders have been approved by the hospital's medical
199 staf f and pharmaceutical therapeutics committee.
200 1 1. No contract or other term of employment shall require a physician to act as a
201 collaborating physician for an advanced practice registered nurse against the physician's will.
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202 A physician shall have the right to refuse to act as a collaborating physician, without penalty ,
203 for a particular advanced practice registered nurse. No contract or other agreement shall limit
204 the collaborating physician's ultimate authority over any protocols or standing orders or in the
205 delegation of the physician's authority to any advanced practice registered nurse, but this
206 requirement shall not authorize a physician in implementing such protocols, standing orders,
207 or delegation to violate applicable standards for safe medical practice established by hospital's
208 medical staf f.
209 12. No contract or other term of employment shall require any advanced practice
210 registered nurse to serve as a collaborating advanced practice registered nurse for any
211 collaborating physician against the advanced practice registered nurse's will. An advanced
212 practice registered nurse shall have the right to refuse to collaborate, without penalty , with a
213 particular physician.
334.735. 1. As used in sections 334.735 to 334.749, the following terms mean:
2 (1) "Applicant", any individual who seeks to become licensed as a physician
3 assistant;
4 (2) "Certification" or "registration", a process by a certifying entity that grants
5 recognition to applicants meeting predetermined qualifications specified by such certifying
6 entity;
7 (3) "Certifying entity", the nongovernmental agency or association which certifies or
8 registers individuals who have completed academic and training requirements;
9 (4) "Collaborative practice arrangement", written agreements, jointly agreed upon
10 protocols, or standing orders, all of which shall be in writing, for the delivery of health care
11 services;
12 (5) "Department", the department of commerce and insurance or a designated agency
13 thereof;
14 (6) "License", a document issued to an applicant by the board acknowledging that the
15 applicant is entitled to practice as a physician assistant;
16 (7) "Physician assistant", a person who has graduated from a physician assistant
17 program accredited by the Accreditation Review Commission on Education for the Physician
18 Assistant or its successor agency , prior to 2001, or the Committee on Allied Health Education
19 and Accreditation or the Commission on Accreditation of Allied Health Education Programs,
20 who has passed the certifying examination administered by the National Commission on
21 Certification of Physician Assistants and has active certification by the National Commission
22 on Certification of Physician Assistants , and who provides health care services delegated by a
23 licensed physician. A person who has been employed as a physician assistant for three years
24 prior to August 28, 1989, who has passed the National Commission on Certification of
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25 Physician Assistants examination, and has active certification of the National Commission on
26 Certification of Physician Assistants;
27 (8) "Recognition", the formal process of becoming a certifying entity as required by
28 the provisions of sections 334.735 to 334.749.
29 2. The scope of practice of a physician assistant shall consist only of the following
30 services and procedures:
31 (1) T aking patient histories;
32 (2) Performing physical examinations of a patient;
33 (3) Performing or assisting in the performance of routine of fice laboratory and patient
34 screening procedures;
35 (4) Performing routine therapeutic procedures;
36 (5) Recording diagnostic impressions and evaluating situations calling for attention of
37 a physician to institute treatment procedures;
38 (6) Instructing and counseling patients regarding mental and physical health using
39 procedures reviewed and approved by a collaborating physician;
40 (7) Assisting the supervising physician in institutional settings, including reviewing
41 of treatment plans, ordering of tests and diagnostic laboratory and radiological services, and
42 ordering of therapies, using procedures reviewed and approved by a licensed physician;
43 (8) Assisting in surge ry; and
44 (9) Performing such other tasks not prohibited by law under the collaborative practice
45 arrangement with a licensed physician as the physician assistant has been trained and is
46 proficient to perform.
47 3. Physician assistants shall not perform or prescribe abortions.
48 4. Physician assistants shall not prescribe any drug, medicine, device or therapy
49 unless pursuant to a collaborative practice arrangement in accordance with the law , nor
50 prescribe lenses, prisms or contact lenses for the aid, relief or correction of vision or the
51 measurement of visual power or visual ef ficiency of the human eye, nor administer or monitor
52 general or regional block anesthesia during diagnostic tests, sur gery or obstetric procedures.
53 Prescribing of drugs, medications, devices or therapies by a physician assistant shall be
54 pursuant to a collaborative practice arrangement which is specific to the clinical conditions
55 treated by the supervising physician and the physician assistant shall be subject to the
56 following:
57 (1) A physician assistant shall only prescribe controlled substances in accordance
58 with section 334.747;
59 (2) The types of drugs, medications, devices or therapies prescribed by a physician
60 assistant shall be consistent with the scopes of practice of the physician assistant and the
61 collaborating physician;
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62 (3) All prescriptions shall conform with state and federal laws and regulations and
63 shall include the name, address and telephone number of the physician assistant;
64 (4) A physician assistant, or advanced practice registered nurse as defined in section
65 335.016 may request, receive and sign for noncontrolled professional samples and may
66 distribute professional samples to patients; and
67 (5) A physician assistant shall not prescribe any drugs, medicines, devices or
68 therapies the collaborating physician is not qualified or authorized to prescribe.
69 5. A physician assistant shall clearly identify himself or herself as a physician
70 assistant and shall not use or permit to be used in the physician assistant's behalf the terms
71 "doctor", "Dr ." or "doc" nor hold himself or herself out in any way to be a physician or
72 sur geon. No physician assistant shall practice or attempt to practice without physician
73 collaboration or in any location where the collaborating physician is not immediately
74 available for consultation, assistance and intervention, except as otherwise provided in this
75 section, and in an emer gency situation, nor shall any physician assistant bill a patient
76 independently or directly for any services or procedure by the physician assistant; except that,
77 nothing in this subsection shall be construed to prohibit a physician assistant from enrolling
78 with a third-party plan or the department of social services as a MO HealthNet or Medicaid
79 provider while acting under a collaborative practice arrangement between the physician and
80 physician assistant.
81 6. The licensing of physician assistants shall take place within processes established
82 by the state board of registration for the healing arts through rule and regulation. The board
83 of healing arts is authorized to establish rules pursuant to chapter 536 establishing licensing
84 and renewal procedures, collaboration, collaborative practice arrangements, fees, and
85 addressing such other matters as are necessary to protect the public and discipline the
86 profession. An application for licensing may be denied or the license of a physician assistant
87 may be suspended or revoked by the board in the same manner and for violation of the
88 standards as set forth by section 334.100, or such other standards of conduct set by the board
89 by rule or regulation. Persons licensed pursuant to the provisions of chapter 335 shall not be
90 required to be licensed as physician assistants. All applicants for physician assistant licensure
91 who complete a physician assistant training program after January 1, 2008, shall have a
92 master's degree from a physician assistant program.
93 7. At all times the physician is responsible for the oversight of the activities of, and
94 accepts responsibility for , health care services rendered by the physician assistant.
95 8. (1) A physician may enter into collaborative practice arrangements with physician
96 assistants. Collaborative practice arrangements, which shall be in writing, may delegate to a
97 physician assistant the authority to prescribe, administer , or dispense drugs and provide
98 treatment which is within the skill, training, and competence of the physician assistant.
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99 Collaborative practice arrangements may delegate to a physician assistant[ , as defined in
100 section 334.735 , ] the authority to administer , dispense, or prescribe controlled substances
101 listed in Schedules III, IV , and V of section 195.017, and Schedule II - hydrocodone.
102 Schedule III narcotic controlled substances and Schedule II - hydrocodone prescriptions shall
103 be limited to a one hundred twenty-hour supply without refill. Such collaborative practice
104 arrangements shall be in the form of a written arrangement, jointly agreed-upon protocols, or
105 standing orders for the delivery of health care services.
106 (2) Notwithstanding any other provision of this section to the contrary , a collaborative
107 practice arrangement may delegate to a physician assistant the authority to administer ,
108 dispense, or prescribe Schedule II controlled substances for hospice patients or patients of
109 pr oviders designated as administrative entities by the department of mental health
110 under section 630.407 ; provided, that the physician assistant is employed by a hospice
111 provider certified pursuant to chapter 197 or by a pro vider designated as an administrative
112 entity by the department of mental health under section 630.407 and the physician
113 assistant is providing care to hospice patients or patients of the pro vider designated as an
114 administrative entity by the department of mental health under section 630.407 pursuant
115 to a collaborative practice arrangement that designates the certified hospice or the provi der
116 designated as an administrative entity by the department of mental health under section
117 630.407 as a location where the physician assistant is authorized to practice and prescribe.
118 9. The written collaborative practice arrangement shall contain at least the following
119 provisions:
120 (1) Complete names, home and business addresses, zip codes, and telephone numbers
121 of the collaborating physician and the physician assistant;
122 (2) A list of all other of fices or locations, other than those listed in subdivision (1) of
123 this subsection, where the collaborating physician has authorized the physician assistant to
124 prescribe;
125 (3) A requirement that there shall be posted at every of fice where the physician
126 assistant is authorized to prescribe, in collaboration with a physician, a prominently displayed
127 disclosure statement informing patients that they may be seen by a physician assistant and
128 have the right to see the collaborating physician;
129 (4) All specialty or board certifications of the collaborating physician and all
130 certifications of the physician assistant;
131 (5) The manner of collaboration between the collaborating physician and the
132 physician assistant, including how the collaborating physician and the physician assistant
133 will:
134 (a) Engage in collaborative practice consistent with each professional's skill, training,
135 education, and competence;
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136 (b) Maintain geographic proximity , as determined by the board of registration for the
137 healing arts; and
138 (c) Provide coverage during absence, incapacity , infirmity , or emer gency of the
139 collaborating physician;
140 (6) A list of all other written collaborative practice arrangements of the collaborating
141 physician and the physician assistant;
142 (7) The duration of the written practice arrangement between the collaborating
143 physician and the physician assistant;
144 (8) A description of the time and manner of the collaborating physician's review of
145 the physician assistant's delivery of health care services. The description shall include
146 provisions that the physician assistant shall submit a minimum of ten percent of the charts
147 documenting the physician assistant's delivery of health care services to the collaborating
148 physician for review by the collaborating physician, or any other physician designated in the
149 collaborative practice arrangement, every fourteen days. Reviews may be conducted
150 electronically;
151 (9) The collaborating physician, or any other physician designated in the
15 2 collaborative practice arrangement, shall review every fourteen days a minimum of twenty
153 percent of the charts in which the physician assistant prescribes controlled substances. The
154 charts reviewed under this subdivision may be counted in the number of charts required to be
155 reviewed under subdivision (8) of this subsection;
156 (10) A statement that no collaboration requirements in addition to the federal law
157 shall be required for a physician-physician assistant team working in a certified community
158 behavioral health clinic as defined by Pub.L. 1 13-93, or a rural health clinic under the federal
159 Rural Health Services Act, Pub.L. 95-210, as amended, or a federally qualified health center
160 as defined in 42 U.S.C. Section 1395x, as amended; and
161 (1 1) If a collaborative practice arrangement is used in clinical situations where a
162 collaborating physician assistant provides health care services that include the diagnosis and
163 initiation of treatment for acutely or chronically ill or injured persons, then the collaborating
164 physician or any other physician designated in the collaborative practice arrangement shall be
165 present for suff icient periods of time, at least once every two weeks, except in extraordinary
166 circumstances that shall be documented, to participate in a chart review and to provide
167 necessary medical direction, medical services, consultations, and supervision of the health
168 care staff .
169 10. The state board of registration for the healing arts under section 334.125 may
170 promulgate rules regulating the use of collaborative practice arrangements.
171 1 1. The state board of registration for the healing arts shall not deny , revoke, suspend,
172 or otherwise take disciplinary action against a collaborating physician for health care services
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173 delegated to a physician assistant, provided that the provisions of this section and the rules
174 promulgated thereunder are satisfied.
175 12. W ithin thirty days of any change and on each renewal, the state board of
176 registration for the healing arts shall require every physician to identify whether the physician
177 is engaged in any collaborative practice arrangement, including collaborative practice
178 arrangements delegating the authority to prescribe controlled substances, and also report to
179 the board the name of each physician assistant with whom the physician has entered into such
180 arrangement. The board may make such information available to the public. The board shall
181 track the reported information and may routinely conduct random reviews of such
182 arrangements to ensure that the arrangements are carried out in compliance with this chapter .
183 13. The collaborating physician shall determine and document the completion of a
184 period of time during which the physician assistant shall practice with the collaborating
185 physician continuously present before practicing in a setting where the collaborating
186 physician is not continuously present. This limitation shall not apply to collaborative
187 arrangements of providers of population-based public health services as defined by 20 CSR
188 2150-5.100 as of April 30, 2009.
189 14. No contract or other arrangement shall require a physician to act as a
190 collaborating physician for a physician assistant against the physician's will. A physician
191 shall have the right to refuse to act as a supervising physician, without penalty , for a particular
192 physician assistant. No contract or other agreement shall limit the collaborating physician's
193 ultimate authority over any protocols or standing orders or in the delegation of the physician's
194 authority to any physician assistant. No contract or other arrangement shall require any
195 physician assistant to collaborate with any physician against the physician assistant's will. A
196 physician assistant shall have the right to refuse to collaborate, without penalty , with a
197 particular physician.
198 15. Physician assistants shall file with the board a copy of their collaborating
199 physician form.
200 16. No physician shall be designated to serve as a collaborating physician for more
201 than six full-time equivalent licensed physician assistants, full-time equivalent advanced
202 practice registered nurses, or full-time equivalent assistant physicians, or any combination
203 thereof. This limitation shall not apply to physician assistant collaborative practice
204 arrangements of hospital employees providing inpatient care service in hospitals as defined in
205 chapter 197, or to a certified registered nurse anesthetist providing anesthesia services under
206 the supervision of an anesthesiologist or other physician, dentist, or podiatrist who is
207 immediately available if needed as set out in subsection 7 of section 334.104.
208 17. No arrangement made under this section shall supercede current hospital licensing
209 regulations governing hospital medication orders under protocols or standing orders for the
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210 purpose of delivering inpatient or emer gency care within a hospital, as defined in section
211 197.020, if such protocols or standing orders have been approved by the hospital's medical
212 staf f and pharmaceutical therapeutics committee.
334.747. 1. (1) A physician assistant with a certificate of controlled substance
2 prescriptive authority as provided in this section may prescribe any controlled substance
3 listed in Schedule III, IV , or V of section 195.017, and may have restricted authority in
4 Schedule II, when delegated the authority to prescribe controlled substances in a collaborative
5 practice arrangement. Such authority shall be listed on the collaborating physician form on
6 file with the state board of reg istration for the healing arts. The collaborating physician
7 shall maintain the right to limit a specific scheduled drug or scheduled drug category that the
8 physician assistant is permitted to prescribe. Any limitations shall be listed on the
9 collaborating physician form. Prescriptions for Schedule II medications prescribed by a
10 physician assistant with authority to prescribe delegated in a collaborative practice
11 arrangement are restricted to only those medications containing hydrocodone. Physician
12 assistants shall not prescribe controlled substances for themselves or members of their
13 families. Schedule III narcotic controlled substances and Schedule II - hydrocodone
14 prescriptions shall be limited to a five-day supply without refill, except that buprenorphine
15 may be prescribed for up to a thirty-day supply without refill for patients receiving
16 medication-assisted treatment for substance use disorders under the direction of the
17 collaborating physician. Physician assistants who are authorized to prescribe controlled
18 substances under this section shall register with the federal Drug Enforcement Administration
19 and the state bureau of narcotics and dangerous drugs, and shall include the Drug
20 Enforcement Administration registration number on prescriptions for controlled substances.
21 (2) Notwithstanding any other provision of this section to the contrary , a collaborative
22 practice arrangement may delegate to a physician assistant the authority to administer ,
23 dispense, or prescribe Schedule II controlled substances for hospice patients or patients of
24 pr oviders designated as administrative entities by the department of mental health
25 under section 630.407 ; provided, that the physician assistant is employed by a hospice
26 provider certified pursuant to chapter 197 or by a pro vider designated as an administrative
27 entity by the department of mental health under section 630.407 and the physician
28 assistant is providing care to hospice patients or patients of the pro vider designated as an
29 administrative entity by the department of mental health under section 630.407 pursuant
30 to a collaborative practice arrangement that designates the certified hospice or the provi der
31 designated as an administrative entity by the department of mental health under section
32 630.407 as a location where the physician assistant is authorized to practice and prescribe.
33 2. The collaborating physician shall be responsible to determine and document the
34 completion of at least one hundred twenty hours in a four -month period by the physician
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35 assistant during which the physician assistant shall practice with the collaborating physician
36 on-site prior to prescribing controlled substances when the collaborating physician is not on-
37 site. Such limitation shall not apply to physician assistants of population-based public health
38 services as defined in 20 CSR 2150-5.100 as of April 30, 2009.
39 3. A physician assistant shall receive a certificate of controlled substance prescriptive
40 authority from the state board of r egistration for the healing arts upon verification of the
41 completion of the following educational requirements:
42 (1) Successful completion of an advanced pharmacology course that includes clinical
43 training in the prescription of drugs, medicines, and therapeutic devices. A course or courses
44 with advanced pharmacological content in a physician assistant program accredited by the
45 Accreditation Review Commission on Education for the Physician Assistant (ARC-P A) or its
46 predecessor agency shall satisfy such requirement;
47 (2) Completion of a minimum of three hundred clock hours of clinical training by the
48 collaborating physician in the prescription of drugs, medicines, and therapeutic devices;
49 (3) Completion of a minimum of one year of supervised clinical practice or
50 supervised clinical rotations. One year of clinical rotations in a program accredited by the
51 Accreditation Review Commission on Education for the Physician Assistant (ARC-P A) or its
52 predecessor agency , which includes pharmacotherapeutics as a component of its clinical
53 training, shall satisfy such requirement. Proof of such training shall serve to document
54 experience in the prescribing of drugs, medicines, and therapeutic devices;
55 (4) A physician assistant previously licensed in a jurisdiction where physician
56 assistants are authorized to prescribe controlled substances may obtain a state bureau of
57 narcotics and dangerous drugs registration if a collaborating physician can attest that the
58 physician assistant has met the requirements of subdivisions (1) to (3) of this subsection and
59 provides documentation of existing federal Drug Enforcement Agency registration.
✔
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