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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. 1016
103RD GENERAL ASSEMBLY
INTRODUCED BY SENATOR LEWIS.
4987S.01I KRISTINA MARTIN, Secretary
AN ACT
To repeal sections 195.070, 334.104, 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 195.070, 334.104, and 335.019, RSMo, 1
are repealed and three new sections enacted in lieu thereof, to 2
be known as sections 195.070, 334.104, and 335.019, to read as 3
follows:4
195.070. 1. A physician, podiatrist, dentist, a 1
registered optometrist certified to administer 2
pharmaceutical agents as provided in section 336.220, or an 3
assistant physician in accordance with section 334.037 or a 4
physician assistant in accordance with section 334.747 in 5
good faith and in the course of his or her professional 6
practice only, may prescribe, administer, and dispense 7
controlled substances or he or she may cause the same to be 8
administered or dispensed by an individual as authorized by 9
statute. 10
2. An advanced practice registered nurse, as defined 11
in section 335.016, but not a certified registered nurse 12
anesthetist as defined in subdivision (8) of section 13
335.016, who holds a certificate of controlled substance 14
prescriptive authority from the board of nursing under 15
section 335.019 and who is delegated the authority to 16
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prescribe controlled substances under a collaborative 17
practice arrangement under section 334.104 may prescribe any 18
controlled substances listed in Schedules III, IV, and V of 19
section 195.017, and may have restricted authority in 20
Schedule II. Prescriptions for Schedule II medications 21
prescribed by an advanced practice registered nurse who has 22
a certificate of controlled substance prescriptive authority 23
are restricted to only those medications containing 24
hydrocodone [and], Schedule II controlled substances for 25
hospice patients, and Schedule II stimulants for behavioral 26
health patients pursuant to the provisions of section 27
334.104. However, no such certified advanced practice 28
registered nurse shall prescribe controlled substance for 29
his or her own self or family. Schedule III narcotic 30
controlled substance and Schedule II - hydrocodone 31
prescriptions shall be limited to a one hundred twenty-hour 32
supply without refill. 33
3. A veterinarian, in good faith and in the course of 34
the veterinarian's professional practice only, and not for 35
use by a human being, may prescribe, administer, and 36
dispense controlled substances and the veterinarian may 37
cause them to be administered by an assistant or orderly 38
under his or her direction and supervision. 39
4. A practitioner shall not accept any portion of a 40
controlled substance unused by a patient, for any reason, if 41
such practitioner did not originally dispense the drug, 42
except: 43
(1) When the controlled substance is delivered to the 44
practitioner to administer to the patient for whom the 45
medication is prescribed as authorized by federal law. 46
Practitioners shall maintain records and secure the 47
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medication as required by this chapter and regulations 48
promulgated pursuant to this chapter; or 49
(2) As provided in section 195.265. 50
5. An individual practitioner shall not prescribe or 51
dispense a controlled substance for such practitioner's 52
personal use except in a medical emergency. 53
334.104. 1. A physician may enter into collaborative 1
practice arrangements with registered professional nurses. 2
Collaborative practice arrangements shall be in the form of 3
written agreements, jointly agreed-upon protocols, or 4
standing orders for the delivery of health care services. 5
Collaborative practice arrangements, which shall be in 6
writing, may delegate to a registered professional nurse the 7
authority to administer or dispense drugs and provide 8
treatment as long as the delivery of such health care 9
services is within the scope of practice of the registered 10
professional nurse and is consistent with that nurse's 11
skill, training and competence. 12
2. (1) Collaborative practice arrangements, which 13
shall be in writing, may delegate to a registered 14
professional nurse the authority to administer, dispense or 15
prescribe drugs and provide treatment if the registered 16
professional nurse is an advanced practice registered nurse 17
as defined in subdivision (2) of section 335.016. 18
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 Schedules III, IV, and V of 22
section 195.017, [and] Schedule II - hydrocodone, and for 23
behavioral health patients, Schedule II stimulants; except 24
that, the collaborative practice arrangement shall not 25
delegate the authority to administer any controlled 26
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substances listed in Schedules III, IV, and V of section 27
195.017, or Schedule II - hydrocodone for the purpose of 28
inducing sedation or general anesthesia for therapeutic, 29
diagnostic, or surgical procedures. Schedule III narcotic 30
controlled substance and Schedule II - hydrocodone 31
prescriptions shall be limited to a one hundred twenty-hour 32
supply without refill. 33
(2) Notwithstanding any other provision of this 34
section to the contrary, a collaborative practice 35
arrangement may delegate to an advanced practice registered 36
nurse the authority to administer, dispense, or prescribe 37
Schedule II controlled substances for hospice patients; 38
provided, that the advanced practice registered nurse is 39
employed by a hospice provider certified pursuant to chapter 40
197 and the advanced practice registered nurse is providing 41
care to hospice patients pursuant to a collaborative 42
practice arrangement that designates the certified hospice 43
as a location where the advanced practice registered nurse 44
is authorized to practice and prescribe. 45
(3) Such collaborative practice arrangements shall be 46
in the form of written agreements, jointly agreed-upon 47
protocols or standing orders for the delivery of health care 48
services. 49
(4) An advanced practice registered nurse may 50
prescribe buprenorphine for up to a thirty-day supply 51
without refill for patients receiving medication-assisted 52
treatment for substance use disorders under the direction of 53
the collaborating physician. 54
3. The written collaborative practice arrangement 55
shall contain at least the following provisions: 56
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(1) Complete names, home and business addresses, zip 57
codes, and telephone numbers of the collaborating physician 58
and the advanced practice registered nurse; 59
(2) A list of all other offices or locations besides 60
those listed in subdivision (1) of this subsection where the 61
collaborating physician authorized the advanced practice 62
registered nurse to prescribe; 63
(3) A requirement that there shall be posted at every 64
office where the advanced practice registered nurse is 65
authorized to prescribe, in collaboration with a physician, 66
a prominently displayed disclosure statement informing 67
patients that they may be seen by an advanced practice 68
registered nurse and have the right to see the collaborating 69
physician; 70
(4) All specialty or board certifications of the 71
collaborating physician and all certifications of the 72
advanced practice registered nurse; 73
(5) The manner of collaboration between the 74
collaborating physician and the advanced practice registered 75
nurse, including how the collaborating physician and the 76
advanced practice registered nurse will: 77
(a) Engage in collaborative practice consistent with 78
each professional's skill, training, education, and 79
competence; 80
(b) Maintain geographic proximity, except as specified 81
in this paragraph. The following provisions shall apply 82
with respect to this requirement: 83
a. Until August 28, 2025, an advanced practice 84
registered nurse providing services in a correctional 85
center, as defined in section 217.010, and his or her 86
collaborating physician shall satisfy the geographic 87
proximity requirement if they practice within two hundred 88
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miles by road of one another. An incarcerated patient who 89
requests or requires a physician consultation shall be 90
treated by a physician as soon as appropriate; 91
b. The collaborative practice arrangement may allow 92
for geographic proximity to be waived for a maximum of 93
twenty-eight days per calendar year for rural health clinics 94
as defined by Pub.L. 95-210 (42 U.S.C. Section 1395x, as 95
amended), as long as the collaborative practice arrangement 96
includes alternative plans as required in paragraph (c) of 97
this subdivision. This exception to geographic proximity 98
shall apply only to independent rural health clinics, 99
provider-based rural health clinics where the provider is a 100
critical access hospital as provided in 42 U.S.C. Section 101
1395i-4, and provider-based rural health clinics where the 102
main location of the hospital sponsor is greater than fifty 103
miles from the clinic; 104
c. The collaborative practice arrangement may allow 105
for geographic proximity to be waived when the arrangement 106
outlines the use of telehealth, as defined in section 107
191.1145; 108
d. In addition to the waivers and exemptions provided 109
in this subsection, an application for a waiver for any 110
other reason of any applicable geographic proximity shall be 111
available if a physician is collaborating with an advanced 112
practice registered nurse in excess of any geographic 113
proximity limit. The board of nursing and the state board 114
of registration for the healing arts shall review each 115
application for a waiver of geographic proximity and approve 116
the application if the boards determine that adequate 117
supervision exists between the collaborating physician and 118
the advanced practice registered nurse. The boards shall 119
have forty-five calendar days to review the completed 120
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application for the waiver of geographic proximity. If no 121
action is taken by the boards within forty-five days after 122
the submission of the application for a waiver, then the 123
application shall be deemed approved. If the application is 124
denied by the boards, the provisions of section 536.063 for 125
contested cases shall apply and govern proceedings for 126
appellate purposes; and 127
e. The collaborating physician is required to maintain 128
documentation related to this requirement and to present it 129
to the state board of registration for the healing arts when 130
requested; and 131
(c) Provide coverage during absence, incapacity, 132
infirmity, or emergency by the collaborating physician; 133
(6) A description of the advanced practice registered 134
nurse's controlled substance prescriptive authority in 135
collaboration with the physician, including a list of the 136
controlled substances the physician authorizes the nurse to 137
prescribe and documentation that it is consistent with each 138
professional's education, knowledge, skill, and competence; 139
(7) A list of all other written practice agreements of 140
the collaborating physician and the advanced practice 141
registered nurse; 142
(8) The duration of the written practice agreement 143
between the collaborating physician and the advanced 144
practice registered nurse; 145
(9) A description of the time and manner of the 146
collaborating physician's review of the advanced practice 147
registered nurse's delivery of health care services. The 148
description shall include provisions that the advanced 149
practice registered nurse shall submit a minimum of ten 150
percent of the charts documenting the advanced practice 151
registered nurse's delivery of health care services to the 152
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collaborating physician for review by the collaborating 153
physician, or any other physician designated in the 154
collaborative practice arrangement, every fourteen days; 155
(10) The collaborating physician, or any other 156
physician designated in the collaborative practice 157
arrangement, shall review every fourteen days a minimum of 158
twenty percent of the charts in which the advanced practice 159
registered nurse prescribes controlled substances. The 160
charts reviewed under this subdivision may be counted in the 161
number of charts required to be reviewed under subdivision 162
(9) of this subsection; and 163
(11) If a collaborative practice arrangement is used 164
in clinical situations where a collaborating advanced 165
practice registered nurse provides health care services that 166
include the diagnosis and initiation of treatment for 167
acutely or chronically ill or injured persons, then the 168
collaborating physician or any other physician designated in 169
the collaborative practice arrangement shall be present for 170
sufficient periods of time, at least once every two weeks, 171
except in extraordinary circumstances that shall be 172
documented, to participate in a chart review and to provide 173
necessary medical direction, medical services, 174
consultations, and supervision of the health care staff. 175
4. The state board of registration for the healing 176
arts pursuant to section 334.125 and the board of nursing 177
pursuant to section 335.036 may jointly promulgate rules 178
regulating the use of collaborative practice arrangements. 179
Such rules shall be limited to the methods of treatment that 180
may be covered by collaborative practice arrangements and 181
the requirements for review of services provided pursuant to 182
collaborative practice arrangements including delegating 183
authority to prescribe controlled substances. Any rules 184
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relating to geographic proximity shall allow a collaborating 185
physician and a collaborating advanced practice registered 186
nurse to practice within two hundred miles by road of one 187
another until August 28, 2025, if the nurse is providing 188
services in a correctional center, as defined in section 189
217.010. Any rules relating to dispensing or distribution 190
of medications or devices by prescription or prescription 191
drug orders under this section shall be subject to the 192
approval of the state board of pharmacy. Any rules relating 193
to dispensing or distribution of controlled substances by 194
prescription or prescription drug orders under this section 195
shall be subject to the approval of the department of health 196
and senior services and the state board of pharmacy. In 197
order to take effect, such rules shall be approved by a 198
majority vote of a quorum of each board. Neither the state 199
board of registration for the healing arts nor the board of 200
nursing may separately promulgate rules relating to 201
collaborative practice arrangements. Such jointly 202
promulgated rules shall be consistent with guidelines for 203
federally funded clinics. The rulemaking authority granted 204
in this subsection shall not extend to collaborative 205
practice arrangements of hospital employees providing 206
inpatient care within hospitals as defined pursuant to 207
chapter 197 or population-based public health services as 208
defined by 20 CSR 2150-5.100 as of April 30, 2008. 209
5. The state board of registration for the healing 210
arts shall not deny, revoke, suspend or otherwise take 211
disciplinary action against a physician for health care 212
services delegated to a registered professional nurse 213
provided the provisions of this section and the rules 214
promulgated thereunder are satisfied. Upon the written 215
request of a physician subject to a disciplinary action 216
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imposed as a result of an agreement between a physician and 217
a registered professional nurse or registered physician 218
assistant, whether written or not, prior to August 28, 1993, 219
all records of such disciplinary licensure action and all 220
records pertaining to the filing, investigation or review of 221
an alleged violation of this chapter incurred as a result of 222
such an agreement shall be removed from the records of the 223
state board of registration for the healing arts and the 224
division of professional registration and shall not be 225
disclosed to any public or private entity seeking such 226
information from the board or the division. The state board 227
of registration for the healing arts shall take action to 228
correct reports of alleged violations and disciplinary 229
actions as described in this section which have been 230
submitted to the National Practitioner Data Bank. In 231
subsequent applications or representations relating to his 232
or her medical practice, a physician completing forms or 233
documents shall not be required to report any actions of the 234
state board of registration for the healing arts for which 235
the records are subject to removal under this section. 236
6. Within thirty days of any change and on each 237
renewal, the state board of registration for the healing 238
arts shall require every physician to identify whether the 239
physician is engaged in any collaborative practice 240
arrangement, including collaborative practice arrangements 241
delegating the authority to prescribe controlled substances, 242
or physician assistant collaborative practice arrangement 243
and also report to the board the name of each licensed 244
professional with whom the physician has entered into such 245
arrangement. The board shall make this information 246
available to the public. The board shall track the reported 247
information and may routinely conduct random reviews of such 248
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arrangements to ensure that arrangements are carried out for 249
compliance under this chapter. 250
7. Notwithstanding any law to the contrary, a 251
certified registered nurse anesthetist as defined in 252
subdivision (8) of section 335.016 shall be permitted to 253
provide anesthesia services without a collaborative practice 254
arrangement provided that he or she is under the supervision 255
of an anesthesiologist or other physician, dentist, or 256
podiatrist who is immediately available if needed. Nothing 257
in this subsection shall be construed to prohibit or prevent 258
a certified registered nurse anesthetist as defined in 259
subdivision (8) of section 335.016 from entering into a 260
collaborative practice arrangement under this section, 261
except that the collaborative practice arrangement may not 262
delegate the authority to prescribe any controlled 263
substances listed in Schedules III, IV, and V of section 264
195.017, or Schedule II - hydrocodone. 265
8. A collaborating physician shall not enter into a 266
collaborative practice arrangement with more than six full- 267
time equivalent advanced practice registered nurses, full- 268
time equivalent licensed physician assistants, or full-time 269
equivalent assistant physicians, or any combination 270
thereof. This limitation shall not apply to collaborative 271
arrangements of hospital employees providing inpatient care 272
service in hospitals as defined in chapter 197 or population- 273
based public health services as defined by 20 CSR 2150-5.100 274
as of April 30, 2008, or to a certified registered nurse 275
anesthetist providing anesthesia services under the 276
supervision of an anesthesiologist or other physician, 277
dentist, or podiatrist who is immediately available if 278
needed as set out in subsection 7 of this section. 279
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9. It is the responsibility of the collaborating 280
physician to determine and document the completion of at 281
least a one-month period of time during which the advanced 282
practice registered nurse shall practice with the 283
collaborating physician continuously present before 284
practicing in a setting where the collaborating physician is 285
not continuously present. This limitation shall not apply 286
to collaborative arrangements of providers of population- 287
based public health services, as defined by 20 CSR 2150- 288
5.100 as of April 30, 2008, or to collaborative practice 289
arrangements between a primary care physician and a primary 290
care advanced practice registered nurse or a behavioral 291
health physician and a behavioral health advanced practice 292
registered nurse, where the collaborating physician is new 293
to a patient population to which the advanced practice 294
registered nurse is familiar. 295
10. No agreement made under this section shall 296
supersede current hospital licensing regulations governing 297
hospital medication orders under protocols or standing 298
orders for the purpose of delivering inpatient or emergency 299
care within a hospital as defined in section 197.020 if such 300
protocols or standing orders have been approved by the 301
hospital's medical staff and pharmaceutical therapeutics 302
committee. 303
11. No contract or other term of employment shall 304
require a physician to act as a collaborating physician for 305
an advanced practice registered nurse against the 306
physician's will. A physician shall have the right to 307
refuse to act as a collaborating physician, without penalty, 308
for a particular advanced practice registered nurse. No 309
contract or other agreement shall limit the collaborating 310
physician's ultimate authority over any protocols or 311
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standing orders or in the delegation of the physician's 312
authority to any advanced practice registered nurse, but 313
this requirement shall not authorize a physician in 314
implementing such protocols, standing orders, or delegation 315
to violate applicable standards for safe medical practice 316
established by hospital's medical staff. 317
12. No contract or other term of employment shall 318
require any advanced practice registered nurse to serve as a 319
collaborating advanced practice registered nurse for any 320
collaborating physician against the advanced practice 321
registered nurse's will. An advanced practice registered 322
nurse shall have the right to refuse to collaborate, without 323
penalty, with a particular physician. 324
13. (1) The provisions of this section shall not 325
apply to an advanced practice registered nurse who has been 326
in a collaborative practice arrangement for a cumulative two 327
thousand documented hours with a collaborating physician and 328
whose license is in good standing. Any such advanced 329
practice registered nurse shall not be required to enter 330
into or remain in an arrangement in order to practice in 331
this state. Any other provisions of law requiring a 332
collaborative practice arrangement or delegation shall not 333
be required for an advanced practice registered nurse 334
described in this subsection. 335
(2) The provisions of this subsection shall not apply 336
to certified registered nurse anesthetists. 337
(3) Notwithstanding any provision of this section to 338
the contrary, an advanced practice registered nurse applying 339
for licensure by endorsement may demonstrate to the state 340
board of nursing completion of a cumulative two thousand 341
documented hours of practice. Such advanced practice 342
registered nurses shall not be required to enter into a 343
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collaborative practice arrangement in order to practice in 344
this state. 345
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 defined 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, administer, 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
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
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(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 record 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 has 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
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