Relating to the licensing and regulation of advanced practice registered nurses and the number of advanced practice registered nurses and physician assistants with whom a physician may enter into a prescriptive authority agreement.

89(R) SB 3055 - Introduced version - Bill Text

89R21662 BEE-D

By: Middleton, Blanco

S.B. No. 3055

A BILL TO BE ENTITLED

AN ACT

relating to the licensing and regulation of advanced practice

registered nurses and the number of advanced practice registered

nurses and physician assistants with whom a physician may enter

into a prescriptive authority agreement.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

ARTICLE 1. SHORT TITLE

SECTION 1.001. This Act may be cited as the Healthcare

Expanded and Accessed Locally for Texans (HEAL Texans) Act.

ARTICLE 2. REGULATION OF ADVANCED PRACTICE REGISTERED NURSES

SECTION 2.001. Section 301.002, Occupations Code, is

amended to read as follows:

Sec. 301.002. DEFINITIONS. In this chapter:

(1)

"Advanced practice registered nurse" means a

registered nurse licensed by the board to practice as an advanced

practice registered nurse on the basis of completion of an advanced

educational program.

(2)
[
(1)
] "Board" means the Texas Board of Nursing.

(3)
[
(1-a)
] "Chief nursing officer" means the

registered nurse who is administratively responsible for the

nursing services at a facility.

(4)

"Controlled substance" has the meaning assigned by

Section 481.002, Health and Safety Code.

(5)

"Dangerous drug" has the meaning assigned by

Section 483.001, Health and Safety Code.

(6)

"Device" has the meaning assigned by Section

551.003, and includes durable medical equipment.

(7)

"Nonprescription drug" has the meaning assigned by

Section 551.003.

(8)

"Nurse" means a person required to be licensed

under this chapter to engage in professional or vocational nursing.

(9)

"Nursing" means professional or vocational

nursing.

(10)
[
(1-b)
] "Patient safety committee" has the

meaning assigned by Section 303.001.

(11)

"Prescribe or order a drug or device" has the

meaning assigned by Section 157.051.

(12)
[
(2)
] "Professional nursing" means the

performance of an act that requires substantial specialized

judgment and skill, the proper performance of which is based on

knowledge and application of the principles of biological,

physical, and social science as acquired by a completed course in an

approved school of professional nursing. The term does not include

acts of medical diagnosis or the prescription of therapeutic or

corrective measures
, except as performed by an advanced practice

registered nurse authorized to practice by the board under Section

301.357
. Professional nursing involves:

(A) the observation, assessment, intervention,

evaluation, rehabilitation, care and counsel, or health teachings

of a person who is ill, injured, infirm, or experiencing a change in

normal health processes;

(B) the maintenance of health or prevention of

illness;

(C) the administration of a medication or

treatment as ordered by a
health care practitioner legally

authorized to prescribe the medication or treatment
[
physician,

podiatrist, or dentist
];

(D) the supervision or teaching of nursing;

(E) the administration, supervision, and

evaluation of nursing practices, policies, and procedures;

(F) the requesting, receiving, signing for, and

distribution of prescription drug samples to patients at practices

at which an advanced practice registered nurse is authorized to

sign prescription drug orders as provided by Subchapter B, Chapter

157;

(G) the performance
by an advanced practice

registered nurse
of an act delegated by a physician under Section

157.0512, 157.054, 157.058, or 157.059; [
and
]

(H) the development of the nursing care plan
; and

(I)

the performance of an act by an advanced

practice registered nurse authorized to practice by the board under

Section 301.357
.

[
(3)

"Nurse" means a person required to be licensed

under this chapter to engage in professional or vocational nursing.

[
(4)

"Nursing" means professional or vocational

nursing.
]

(13)
[
(5)
] "Vocational nursing" means a directed

scope of nursing practice, including the performance of an act that

requires specialized judgment and skill, the proper performance of

which is based on knowledge and application of the principles of

biological, physical, and social science as acquired by a completed

course in an approved school of vocational nursing. The term does

not include acts of medical diagnosis or the prescription of

therapeutic or corrective measures. Vocational nursing involves:

(A) collecting data and performing focused

nursing assessments of the health status of an individual;

(B) participating in the planning of the nursing

care needs of an individual;

(C) participating in the development and

modification of the nursing care plan;

(D) participating in health teaching and

counseling to promote, attain, and maintain the optimum health

level of an individual;

(E) assisting in the evaluation of an

individual's response to a nursing intervention and the

identification of an individual's needs; and

(F) engaging in other acts that require education

and training, as prescribed by board rules and policies,

commensurate with the nurse's experience, continuing education,

and demonstrated competency.

SECTION 2.002. Section 301.005(b), Occupations Code, is

amended to read as follows:

(b) A reference in any other law to an "advanced nurse

practitioner,"
[
practitioner" or
] "advanced practice
nurse," or

"advanced practice registered
nurse" means an advanced practice

registered nurse.

SECTION 2.003. Sections 301.152(a) and (b), Occupations

Code, are amended to read as follows:

(a) [
In this section, "advanced practice registered nurse"

means a registered nurse licensed by the board to practice as an

advanced practice registered nurse on the basis of completion of an

advanced educational program.
] The term
"advanced practice

registered nurse"
includes a nurse practitioner, nurse midwife,

nurse anesthetist, and clinical nurse specialist. [
The term is

synonymous with "advanced nurse practitioner" and "advanced

practice nurse."
]

(b) The board shall adopt rules to:

(1) license a registered nurse as an advanced practice

registered nurse;

(2) establish:

(A) any specialized education or training,

including pharmacology, that an advanced practice registered nurse

must have to prescribe or order a drug or device as delegated by a

physician under Section 157.0512 or 157.054
or authorized by the

board under Section 301.358
;

(B) a system for approving an advanced practice

registered nurse to prescribe or order a drug or device as delegated

by a physician under Section 157.0512 or 157.054
or authorized by

the board under Section 301.358
on the receipt of evidence of

completing the specialized education and training requirement

under Paragraph (A); and

(C) a system for issuing a prescription

authorization number to an advanced practice registered nurse

approved under Paragraph (B); and

(3) concurrently renew any license or approval granted

to an advanced practice registered nurse under this subsection and

a license renewed by the advanced practice registered nurse under

Section 301.301.

SECTION 2.004. Section 301.303(b), Occupations Code, is

amended to read as follows:

(b)
Except as provided by a rule adopted under Section

301.357(h) for an advanced practice registered nurse authorized by

the board to practice under that section, the
[
The
] board may not

require participation in more than a total of 20 hours of continuing

education in a two-year licensing period.

SECTION 2.005. Subchapter H, Chapter 301, Occupations Code,

is amended by adding Sections 301.357, 301.358, and 301.359 to read

as follows:

Sec.

301.357.

INDEPENDENT PRACTICE BY CERTAIN ADVANCED

PRACTICE REGISTERED NURSES. (a) The board shall authorize the

practice under this section of an advanced practice registered

nurse who applies for authorization under this section in the

manner prescribed by the board and who:

(1)

is a nurse practitioner, nurse midwife, or

clinical nurse specialist; and

(2) either:

(A)

has held an active unencumbered license as an

advanced practice registered nurse in any state for at least 10

years or 20,000 hours, as determined by the board; or

(B) has:

(i)

graduated from a program of nursing

education that has a physical presence in this state and has a

requirement of in-person clinical experience; and

(ii)

practiced as an advanced practice

registered nurse under a prescriptive authority agreement with a

physician for at least four years or 8,000 hours, as determined by

the board.

(b)

To be eligible for authorization to practice under this

section, an applicant described by Subsection (a) must:

(1)

hold an active, unencumbered license to practice

as an advanced practice registered nurse in this state;

(2)

hold a current national certification in the role

and population focus of the advanced practice registered nurse;

(3)

have a bachelor's degree in nursing and a master's

or doctoral degree in nursing from a nationally accredited

educational program;

(4)

have completed academic coursework in physical

assessment, advanced pharmacology, and advanced pathophysiology;

and

(5)

not be the subject of any pending disciplinary

action or substantially equivalent action.

(c)

The scope of practice of an advanced practice registered

nurse authorized to practice under this section includes:

(1)

ordering, performing, and interpreting diagnostic

tests;

(2)

formulating primary and differential medical

diagnoses and advanced assessments;

(3) treating actual and potential health problems;

(4)

prescribing therapeutic and corrective measures,

including nutrition and diagnostic support services, home health

care, hospice care, physical therapy, and occupational therapy, and

delegating and assigning the performance of therapeutic and

corrective measures to assistive personnel;

(5)

to the extent authorized by the board under

Section 301.358, prescribing, ordering, procuring, administering,

and dispensing drugs and devices, including blood and blood

products, controlled substances listed in Schedules III, IV, and V,

dangerous drugs, and nonprescription drugs;

(6)

providing referrals to health care agencies,

health care providers, and community resources;

(7) serving as a primary care provider of record; and

(8)

performing other acts that require education and

training consistent with professional standards and that are

commensurate with the advanced practice registered nurse's

education, licensure, and demonstrated competencies and

experience.

(d)

Subject to Subsection (e), an advanced practice

registered nurse authorized to practice under this section shall

practice as a licensed independent practitioner in accordance with

standards established and recognized by the board to protect the

public health and safety.

(e)

An advanced practice registered nurse authorized to

practice under this section may practice as a licensed independent

practitioner only in a county with a population of less than 68,750.

(f)

An advanced practice registered nurse authorized to

practice under this section is accountable to patients, the nursing

profession, and the board for:

(1) complying with the requirements of this chapter;

(2) providing quality advanced nursing care;

(3) recognizing the limits of the nurse's knowledge;

(4)

planning for the management of situations beyond

the nurse's expertise; and

(5)

consulting with or referring patients to other

health care providers as appropriate.

(g)

This section does not limit or modify the scope of

practice of a nurse who is not authorized to practice under this

section.

(h) The board by rule shall establish:

(1)

the application process for authorization to

practice under this section;

(2)

a requirement that an advanced practice registered

nurse authorized to practice under this section complete at least

48 hours of continuing education, including 10 hours of continuing

education in pharmacology, every two years; and

(3) systems to:

(A)

authorize an advanced practice registered

nurse to prescribe or order a drug or device under Section 301.358

when the board receives evidence of the completion of any education

or training required by board rule; and

(B)

concurrently renew for an advanced practice

registered nurse:

(i)

an authorization issued under this

section or Section 301.358; and

(ii)

a license issued under rules adopted

under Section 301.152 or renewed under Section 301.301.

Sec.

301.358.

PRESCRIBING AND ORDERING AUTHORITY OF

ADVANCED PRACTICE REGISTERED NURSE.

The board may authorize an

advanced practice registered nurse authorized to practice by the

board under Section 301.357 to prescribe and order drugs and

devices, including controlled substances listed in Schedules III,

IV, and V, dangerous drugs, and nonprescription drugs.

Sec.

301.359.

REPORT TO BOARD. (a) An advanced practice

registered nurse authorized to practice by the board under Section

301.357 shall, not later than January 15 of each year, submit to the

board a report that includes for the preceding calendar year:

(1)

the location of each setting in which the advanced

practice registered nurse practiced as an independent

practitioner, including the county in which the setting is located;

(2)

the number of patients to whom the advanced

practice registered nurse practiced as an independent

practitioner; and

(3)

the number of instances in which the advanced

practice registered nurse:

(A)

referred the patient to a physician for the

prescription of a controlled substance listed in Schedule II; or

(B)

prescribed a controlled substance listed in

Schedule II to a patient under a prescriptive authority agreement

with a physician.

(b)

An advanced practice registered nurse authorized to

practice by the board under Section 301.357 shall notify the board

if the advanced practice registered nurse practices as an

independent practitioner at a location other than the practice

setting identified in the report submitted to the board under

Subsection (a) for the previous calendar year.

(c)

The board shall annually aggregate, anonymize, and

publish on the board's Internet website the information submitted

by each advanced practice registered nurse under Subsection (a).

ARTICLE 3. DELEGATION AND PRESCRIPTIVE AUTHORITY AGREEMENTS

SECTION 3.001. Section 157.0512(c), Occupations Code, is

amended to read as follows:

(c) Except as provided by Subsection (d), the combined

number of advanced practice registered nurses and physician

assistants with whom a physician may enter into a prescriptive

authority agreement may not exceed
nine
[
seven
] advanced practice

registered nurses and physician assistants or the full-time

equivalent of seven advanced practice registered nurses and

physician assistants.

SECTION 3.002. Chapter 157, Occupations Code, is amended by

adding Subchapter D to read as follows:

SUBCHAPTER D. DELEGATION AGREEMENTS WITH

ADVANCED PRACTICE REGISTERED NURSES

Sec.

157.151.

NONDISCLOSURE AGREEMENTS. A delegation

agreement, including a prescriptive authority agreement, between a

physician and an advanced practice registered nurse may not include

or be the subject of a nondisclosure agreement.

Sec.

157.152.

REPORTING BY PHYSICIAN; REPORT TO BOARD.

(a)

A physician who enters into a delegation agreement with an advanced

practice registered nurse, including a prescriptive authority

agreement under Section 157.0512, shall, not later than January 15

of each year, submit to the board a report that includes for the

preceding calendar year:

(1)

the amount of any fee the physician charges the

advanced practice registered nurse to enter into the agreement;

(2)

any restriction or limitation the physician places

on the advanced practice registered nurse's practice under the

agreement;

(3)

any instance in which the physician changes the

diagnosis or course of treatment of a patient of the advanced

practice registered nurse; and

(4)

the number of case files the physician reviews

each month.

(b)

The board shall annually aggregate, anonymize, and

publish on the board's Internet website the information submitted

by each physician under Subsection (a).

Sec.

157.153.

COMPLAINT REGARDING ADVANCED PRACTICE

REGISTERED NURSE UNDER DELEGATION AGREEMENT. (a)

The board shall

disaggregate from information the board maintains regarding

complaints against a physician any information regarding a

complaint against an advanced practice registered nurse practicing

under a delegation agreement with the physician.

(b)

The board shall separately maintain information

regarding complaints against an advanced practice registered nurse

practicing under a delegation agreement with the physician. The

information maintained under this subsection must include:

(1)

the specialization of the advanced practice

registered nurse who is the subject of the complaint; and

(2)

the disposition of the complaint, including any

disciplinary action taken.

ARTICLE 4. CONFORMING AMENDMENTS

SECTION 4.001. Section 38.151(1), Education Code, is

amended to read as follows:

(1) "Advanced practice nurse" has the meaning assigned

to "advanced practice registered nurse"
by Section
301.002

[
301.152
], Occupations Code.

SECTION 4.002. Section 38.211(a), Education Code, is

amended to read as follows:

(a) A physician
, a
[
or
] person who has been delegated

prescriptive authority under Chapter 157, Occupations Code,
or an

advanced practice registered nurse authorized to prescribe and

order drugs and devices under Section 301.358, Occupations Code,

may prescribe epinephrine auto-injectors or medication for

respiratory distress in the name of a school district,

open-enrollment charter school, or private school.

SECTION 4.003. Section 38.225(a), Education Code, is

amended to read as follows:

(a) A physician
, a
[
or
] person who has been delegated

prescriptive authority under Chapter 157, Occupations Code,
or an

advanced practice registered nurse authorized to prescribe and

order drugs and devices under Section 301.358, Occupations Code,

may prescribe opioid antagonists in the name of a school district,

open-enrollment charter school, or private school.

SECTION 4.004. Section 61.601, Education Code, is amended

to read as follows:

Sec. 61.601. DEFINITION. In this subchapter, "mental

health professional" means:

(1) a licensed physician who is:

(A) a graduate of an accredited psychiatric

residency training program; or

(B) certified in psychiatry by:

(i) the American Board of Psychiatry and

Neurology; or

(ii) the American Osteopathic Board of

Neurology and Psychiatry;

(2) a psychologist, as defined by Section 501.002,

Occupations Code;

(3) a licensed professional counselor, as defined by

Section 503.002, Occupations Code;

(4) an advanced practice registered nurse, as defined

by Section
301.002
[
301.152
], Occupations Code, who holds a

nationally recognized board certification in psychiatric or mental

health nursing;

(5) a licensed clinical social worker, as defined by

Section 505.002, Occupations Code;

(6) a licensed specialist in school psychology, as

defined by Section 501.002, Occupations Code;

(7) a chemical dependency counselor, as defined by

Section 504.001, Occupations Code; and

(8) a licensed marriage and family therapist, as

defined by Section 502.002, Occupations Code.

SECTION 4.005. Section 1101.100(1), Estates Code, is

amended to read as follows:

(1) "Advanced practice registered nurse" has the

meaning assigned by Section
301.002
[
301.152
], Occupations Code.

SECTION 4.006. Section 671.001(b), Government Code, is

amended to read as follows:

(b) The pilot program must provide for the following:

(1)
either:

(A) both:

(i)
a licensed advanced practice registered

nurse as defined by Section
301.002
[
301.152
], Occupations Code, or

a licensed physician assistant as described by Chapter 204,

Occupations Code, who is employed by the state or whose services are

acquired by contract, who will be located at a state office complex;

and

(ii)
[
(2)
] a licensed physician, who is

employed by a state governmental entity for purposes other than the

pilot program or whose services are acquired by contract, who will

delegate to and supervise the advanced practice registered nurse or

physician assistant under a prescriptive authority agreement under

Chapter 157, Occupations Code;
or

(B)

an advanced practice registered nurse

authorized to practice under Section 301.357, Occupations Code;

(2)
[
(3)
] appropriate office space and equipment for

the advanced practice registered nurse or physician assistant to

provide basic medical care to employees at the state office complex

where the nurse or physician assistant is located; and

(3)
[
(4)
] professional liability insurance covering

services provided by the advanced practice registered nurse or the

physician assistant.

SECTION 4.007. Section 47.011(a), Health and Safety Code,

is amended to read as follows:

(a) In this section, "midwife" has the meaning assigned by

Section 203.002, Occupations Code, and includes a nurse midwife

[
described by Section 301.152, Occupations Code
].

SECTION 4.008. Sections 161.0052(b) and (c), Health and

Safety Code, are amended to read as follows:

(b) The executive commissioner by rule shall require a

hospital to inform each elderly person admitted to the hospital for

a period of 24 hours or more that the pneumococcal and influenza

vaccines are available. If the elderly person requests a vaccine,

and if a physician, or an advanced
practice registered
nurse

[
practitioner
] or physician assistant on behalf of a physician,
or

an advanced practice registered nurse authorized to prescribe and

order drugs and devices under Section 301.358, Occupations Code,

determines that the vaccine is in the person's best interest, the

hospital must make the vaccination available to the person before

the person is discharged from the hospital.

(c) The executive commissioner by rule shall require an end

stage renal disease facility to offer, to the extent possible as

determined by the facility, the opportunity to receive the

pneumococcal and influenza vaccines to each elderly person who

receives ongoing care at the facility if a physician, or an advanced

practice registered
nurse [
practitioner
] or physician assistant on

behalf of a physician,
or an advanced practice registered nurse

authorized to prescribe and order drugs and devices under Section

301.358, Occupations Code,
determines that the vaccine is in the

person's best interest. If the facility decides it is not feasible

to offer the vaccine, the facility must provide the person with

information on other options for obtaining the vaccine.

SECTION 4.009. Section 401.504(d), Health and Safety Code,

is amended to read as follows:

(d) This subchapter does not apply to a physician
,
[
or to
] a

physician's employee or delegate acting under Chapter 157,

Occupations Code
, or an advanced practice registered nurse

authorized to prescribe and order drugs and devices under Section

301.358, Occupations Code
.

SECTION 4.010. Section 481.002(39), Health and Safety Code,

is amended to read as follows:

(39) "Practitioner" means:

(A) a physician, dentist, veterinarian,

podiatrist, scientific investigator,
advanced practice registered

nurse authorized to prescribe and order drugs and devices under

Section 301.358, Occupations Code,
or other person licensed,

registered, or otherwise permitted to distribute, dispense,

analyze, conduct research with respect to, or administer a

controlled substance in the course of professional practice or

research in this state;

(B) a pharmacy, hospital, or other institution

licensed, registered, or otherwise permitted to distribute,

dispense, conduct research with respect to, or administer a

controlled substance in the course of professional practice or

research in this state;

(C) a person practicing in and licensed by

another state as a physician, dentist, veterinarian,
advanced

practice registered nurse,
or podiatrist, having a current Federal

Drug Enforcement Administration registration number, who may

legally prescribe Schedule II, III, IV, or V controlled substances

in that state; or

(D) an advanced practice registered nurse or

physician assistant to whom a physician has delegated the authority

to prescribe or order a drug or device under Section 157.0511,

157.0512, or 157.054, Occupations Code.

SECTION 4.011. Section 481.074(d), Health and Safety Code,

is amended to read as follows:

(d) Except as specified in Subsections (e) and (f), the

board, by rule and in consultation with the Texas Medical Board
and

the Texas Board of Nursing
, shall establish the period after the

date on which the prescription is issued that a person may fill a

prescription for a controlled substance listed in Schedule II. A

person may not refill a prescription for a substance listed in

Schedule II.

SECTION 4.012. Section 481.076(c), Health and Safety Code,

is amended to read as follows:

(c) The board by rule shall design and implement a system

for submission of information to the board by electronic or other

means and for retrieval of information submitted to the board under

this section and Sections 481.074 and 481.075. The board shall use

automated information security techniques and devices to preclude

improper access to the information. The board shall submit the

system design to the director
,
[
and
] the Texas Medical Board
, and

the Texas Board of Nursing
for review and comment a reasonable time

before implementation of the system and shall comply with the

comments of those agencies unless it is unreasonable to do so.

SECTION 4.013. Section 481.0767(b), Health and Safety Code,

is amended to read as follows:

(b) The board shall appoint the following members to the

advisory committee:

(1) a physician licensed in this state who practices

in pain management;

(2) a physician licensed in this state who practices

in family medicine;

(3) a physician licensed in this state who performs

surgery;

(4) a physician licensed in this state who practices

in emergency medicine at a hospital;

(5) a physician licensed in this state who practices

in psychiatry;

(6) an oral and maxillofacial surgeon;

(7) a physician assistant or advanced practice

registered nurse to whom a physician has delegated the authority to

prescribe or order a drug
or an advanced practice registered nurse

authorized to prescribe and order drugs and devices under Section

301.358, Occupations Code
;

(8) a pharmacist working at a chain pharmacy;

(9) a pharmacist working at an independent pharmacy;

(10) an academic pharmacist; and

(11) two representatives of the health information

technology industry, at least one of whom is a representative of a

company whose primary line of business is electronic medical

records.

SECTION 4.014. Sections 483.001(4), (12), and (13), Health

and Safety Code, are amended to read as follows:

(4) "Designated agent" means:

(A) a licensed nurse, physician assistant,

pharmacist, or other individual designated by a practitioner to

communicate prescription drug orders to a pharmacist;

(B) a licensed nurse, physician assistant, or

pharmacist employed in a health care facility to whom the

practitioner communicates a prescription drug order; or

(C)
an advanced practice
[
a
] registered nurse or

physician assistant authorized by a practitioner to carry out a

prescription drug order for dangerous drugs under Subchapter B,

Chapter 157, Occupations Code.

(12) "Practitioner" means:

(A) a person licensed by:

(i) the Texas Medical Board, State Board of

Dental Examiners, Texas Optometry Board, or State Board of

Veterinary Medical Examiners to prescribe and administer dangerous

drugs; or

(ii) the Texas Department of Licensing and

Regulation, with respect to podiatry, to prescribe and administer

dangerous drugs;

(B) a person licensed by another state in a

health field in which, under the laws of this state, a licensee may

legally prescribe dangerous drugs;

(C) a person licensed in Canada or Mexico in a

health field in which, under the laws of this state, a licensee may

legally prescribe dangerous drugs; [
or
]

(D) an advanced practice registered nurse or

physician assistant to whom a physician has delegated the authority

to prescribe or order a drug or device under Section 157.0511,

157.0512, or 157.054, Occupations Code
; or

(E)

an advanced practice registered nurse

authorized to prescribe and order drugs and devices under Section

301.358, Occupations Code
.

(13) "Prescription" means an order from a

practitioner, or an agent of the practitioner designated in writing

as authorized to communicate prescriptions, or an order made in

accordance with Subchapter B, Chapter 157, Occupations Code, or

Section 203.353, Occupations Code, to a pharmacist for a dangerous

drug to be dispensed that states:

(A) the date of the order's issue;

(B) the name and address of the patient;

(C) if the drug is prescribed for an animal, the

species of the animal;

(D) the name and quantity of the drug prescribed;

(E) the directions for the use of the drug;

(F) the intended use of the drug unless the

practitioner determines the furnishing of this information is not

in the best interest of the patient;

(G) the name, address, and telephone number of

the practitioner at the practitioner's usual place of business,

legibly printed or stamped; and

(H) the name, address, and telephone number of

the licensed midwife,
advanced practice
registered nurse, or

physician assistant, legibly printed or stamped, if signed by a

licensed midwife,
advanced practice
registered nurse, or physician

assistant.

SECTION 4.015. Section 483.022(f), Health and Safety Code,

is amended to read as follows:

(f) A practitioner may designate a person who is a licensed

vocational nurse or has an education equivalent to or greater than

that required for a licensed vocational nurse to communicate

prescriptions of an advanced practice
registered
nurse or physician

assistant authorized by the practitioner to sign prescription drug

orders under Subchapter B, Chapter 157, Occupations Code
, or of an

advanced practice registered nurse authorized to prescribe and

order drugs and devices under Section 301.358, Occupations Code
.

SECTION 4.016. Section 483.042(a), Health and Safety Code,

is amended to read as follows:

(a) A person commits an offense if the person delivers or

offers to deliver a dangerous drug:

(1) unless:

(A) the dangerous drug is delivered or offered

for delivery by a pharmacist under:

(i) a prescription issued by a practitioner

described by Section 483.001(12)(A)
,
[
or
] (B)
, or (E)
;

(ii) a prescription signed by
an advanced

practice
[
a
] registered nurse or physician assistant in accordance

with Subchapter B, Chapter 157, Occupations Code; or

(iii) an original written prescription

issued by a practitioner described by Section 483.001(12)(C); and

(B) a label is attached to the immediate

container in which the drug is delivered or offered to be delivered

and the label contains the following information:

(i) the name and address of the pharmacy

from which the drug is delivered or offered for delivery;

(ii) the date the prescription for the drug

is dispensed;

(iii) the number of the prescription as

filed in the prescription files of the pharmacy from which the

prescription is dispensed;

(iv) the name of the practitioner who

prescribed the drug and, if applicable, the name of the
advanced

practice
registered nurse or physician assistant who signed the

prescription;

(v) the name of the patient and, if the drug

is prescribed for an animal, a statement of the species of the

animal; and

(vi) directions for the use of the drug as

contained in the prescription; or

(2) unless:

(A) the dangerous drug is delivered or offered

for delivery by:

(i) a practitioner in the course of

practice; or

(ii)
an advanced practice
[
a
] registered

nurse or physician assistant in the course of practice in

accordance with Subchapter B, Chapter 157, Occupations Code; and

(B) a label is attached to the immediate

container in which the drug is delivered or offered to be delivered

and the label contains the following information:

(i) the name and address of the

practitioner who prescribed the drug, and if applicable, the name

and address of the
advanced practice
registered nurse or physician

assistant;

(ii) the date the drug is delivered;

(iii) the name of the patient and, if the

drug is prescribed for an animal, a statement of the species of the

animal; and

(iv) the name of the drug, the strength of

the drug, and directions for the use of the drug.

SECTION 4.017. Section 773.0145(k), Health and Safety Code,

is amended to read as follows:

(k) A physician
, a
[
or
] person who has been delegated

prescriptive authority under Chapter 157, Occupations Code,
or an

advanced practice registered nurse authorized to prescribe and

order drugs and devices under Section 301.358, Occupations Code,

may prescribe epinephrine auto-injectors in the name of an entity.

SECTION 4.018. Section 32.024(gg), Human Resources Code, is

amended to read as follows:

(gg) Notwithstanding any other law, including Sections

843.312 and 1301.052, Insurance Code, the commission shall ensure

that advanced practice registered nurses and physician assistants

may be selected by and assigned to recipients of medical assistance

as the primary care providers of those recipients regardless of

whether
, if applicable,
the physician supervising the advanced

practice registered nurse is included in any directory of providers

of medical assistance maintained by the commission. This

subsection may not be construed as authorizing the commission to

supervise or control the practice of medicine as prohibited by

Subtitle B, Title 3, Occupations Code. The commission must require

that advanced practice registered nurses and physician assistants

be treated in the same manner as primary care physicians with regard

to:

(1) selection and assignment as primary care

providers; and

(2) inclusion as primary care providers in any

directory of providers of medical assistance maintained by the

commission.

SECTION 4.019. Section 32.03141, Human Resources Code, is

amended to read as follows:

Sec. 32.03141. AUTHORITY OF ADVANCED PRACTICE REGISTERED

NURSES AND PHYSICIAN ASSISTANTS REGARDING DURABLE MEDICAL

EQUIPMENT AND SUPPLIES. To the extent allowed by federal law,
in

addition to other health care practitioners authorized by federal

law, the following persons may order and prescribe durable medical

equipment and supplies under the medical assistance program:

(1)

an advanced practice registered nurse authorized

to prescribe and order drugs and devices under Section 301.358,

Occupations Code; and

(2)
an advanced practice registered nurse or physician

assistant acting under adequate physician supervision and to whom a

physician has delegated the authority to prescribe and order drugs

and devices under Chapter 157, Occupations Code[
, may order and

prescribe durable medical equipment and supplies under the medical

assistance program
].

SECTION 4.020. Section 42.067(b), Human Resources Code, is

amended to read as follows:

(b) A physician, [
or
] a person who has been delegated

prescriptive authority under Chapter 157, Occupations Code,
or an

advanced practice registered nurse authorized to prescribe and

order drugs and devices under Section 301.358, Occupations Code,

may prescribe epinephrine auto-injectors in the name of a day-care

center.

SECTION 4.021. Section 843.312, Insurance Code, is amended

to read as follows:

Sec. 843.312. PHYSICIAN ASSISTANTS AND ADVANCED PRACTICE

REGISTERED
NURSES. (a) A health maintenance organization may not

refuse a request by a physician participating in the health

maintenance organization delivery network and a physician

assistant or advanced practice
registered
nurse who is authorized

by the physician to provide care under Subchapter B, Chapter 157,

Occupations Code,
or an advanced practice registered nurse

authorized to prescribe and order drugs and devices under Section

301.358, Occupations Code,
to identify a physician assistant or

advanced practice
registered
nurse as a provider in the network.

(b) A health maintenance organization may refuse a request

under Subsection (a) if the physician assistant or advanced

practice
registered
nurse does not meet the quality of care

standards previously established by the health maintenance

organization for participation in the network by physician

assistants and advanced practice
registered
nurses.

SECTION 4.022. Section 1301.001(1-a), Insurance Code, is

amended to read as follows:

(1-a) "Health care provider" means a practitioner,

institutional provider, or other person or organization that

furnishes health care services and that is licensed or otherwise

authorized to practice in this state. The term includes a

pharmacist
,
[
and
] a pharmacy
, and an advanced practice registered

nurse authorized to practice under Section 301.357, Occupations

Code
. The term does not include a physician.

SECTION 4.023. Section 1452.051(1), Insurance Code, is

amended to read as follows:

(1) "Advanced practice nurse" has the meaning assigned

to "advanced practice registered nurse"
by Section
301.002

[
301.152
], Occupations Code.

SECTION 4.024. Section 408.025, Labor Code, is amended by

amending Subsection (a-1) and adding Subsection (a-2) to read as

follows:

(a-1) A [
treating doctor may delegate to a physician

assistant who is licensed to practice in this state under Chapter

204, Occupations Code, or an advanced practice registered nurse who

is licensed to practice in this state under Chapter 301,

Occupations Code, the authority to complete and sign a
] work status

report regarding an injured employee's ability to return to work

may be completed and signed by:

(1)

a physician assistant licensed to practice in this

state under Chapter 204, Occupations Code, who has been delegated

the authority by a treating doctor;

(2)

an advanced practice registered nurse licensed to

practice in this state under Chapter 301, Occupations Code, who has

been delegated the authority by a treating doctor; or

(3)

an advanced practice registered nurse authorized

to practice under Section 301.357, Occupations Code
.

(a-2)
The delegating treating doctor is responsible for the

acts of
a
[
the
] physician assistant [
or advanced practice

registered nurse
] under
Subsection (a-1)(1) or an advanced practice

registered nurse under Subsection (a-1)(2)
[
this subsection
].

SECTION 4.025. Section 157.051(1), Occupations Code, is

amended to read as follows:

(1) "Advanced practice registered nurse" has the

meaning assigned [
to that term
] by Section
301.002
[
301.152
]. [
The

term includes an advanced nurse practitioner and advanced practice

nurse.
]

SECTION 4.026. Section 203.002(2), Occupations Code, is

amended to read as follows:

(2) "Certified nurse-midwife" means
an advanced

practice
[
a person who is:

[
(A) a
] registered nurse [
under Chapter 301;

[
(B)

recognized as an advanced nurse

practitioner by the Texas Board of Nursing; and

[
(C)
] certified by the American College of

Nurse-Midwives.

SECTION 4.027. Sections 551.003(14) and (34), Occupations

Code, are amended to read as follows:

(14) "Designated agent" means:

(A) an individual, including a licensed nurse,

physician assistant, or pharmacist:

(i) who is designated by a practitioner and

authorized to communicate a prescription drug order to a

pharmacist; and

(ii) for whom the practitioner assumes

legal responsibility;

(B) a licensed nurse, physician assistant, or

pharmacist employed in a health care facility to whom a

practitioner communicates a prescription drug order; or

(C)
an advanced practice
[
a
] registered nurse or

physician assistant authorized by a practitioner to administer a

prescription drug order for a dangerous drug under Subchapter B,

Chapter 157.

(34) "Practitioner" means:

(A) a person licensed or registered to prescribe,

distribute, administer, or dispense a prescription drug or device

in the course of professional practice in this state, including a

physician, dentist, podiatrist,
advanced practice registered nurse

authorized to prescribe and order drugs and devices under Section

301.358,
or veterinarian but excluding a person licensed under this

subtitle;

(B) a person licensed by another state, Canada,

or the United Mexican States in a health field in which, under the

law of this state, a license holder in this state may legally

prescribe a dangerous drug;

(C) a person practicing in another state and

licensed by another state as a physician, dentist, veterinarian,

advanced practice registered nurse,
or podiatrist, who has a

current federal Drug Enforcement Administration registration

number and who may legally prescribe a Schedule II, III, IV, or V

controlled substance, as specified under Chapter 481, Health and

Safety Code, in that other state; or

(D) an advanced practice registered nurse or

physician assistant to whom a physician has delegated the authority

to prescribe or order a drug or device under Section 157.0511,

157.0512, or 157.054.

SECTION 4.028. Section 563.051(e), Occupations Code, is

amended to read as follows:

(e) A practitioner may designate a licensed vocational

nurse or a person having education equivalent to or greater than

that required for a licensed vocational nurse to communicate the

prescriptions of an advanced practice
registered
nurse or physician

assistant authorized by the practitioner to sign prescription drug

orders under Subchapter B, Chapter 157
, or of an advanced practice

registered nurse authorized to prescribe and order drugs and

devices under Section 301.358
.

SECTION 4.029. Section 563.053, Occupations Code, is

amended to read as follows:

Sec. 563.053. DISPENSING OF DANGEROUS DRUGS IN CERTAIN

RURAL AREAS. (a) In this section
:

(1)

"Advanced practice registered nurse" has the

meaning assigned by Section 301.002.

(2) "Reimbursement
[
, "reimbursement
] for cost" means

an additional charge, separate from that imposed for the

physician's
or advanced practice registered nurse's
professional

services, that includes the cost of the drug product and all other

actual costs to the physician
or advanced practice registered nurse

incidental to providing the dispensing service. The term does not

include a separate fee imposed for the act of dispensing the drug

itself.

(a-1)

This section applies to an advanced practice

registered nurse only to the extent that the advanced practice

registered nurse is authorized to prescribe and order drugs and

devices under Section 301.358.

(b) This section applies to an area located in a county with

a population of 5,000 or less, or in a municipality or an

unincorporated town with a population of less than 2,500, that is

within a 15-mile radius of the physician's
or advanced practice

registered nurse's
office and in which a pharmacy is not located.

This section does not apply to a municipality or an unincorporated

town that is adjacent to a municipality with a population of 2,500

or more.

(c) A physician who practices medicine
or advanced practice

registered nurse who practices advanced practice registered

nursing
in an area described by Subsection (b) may:

(1) maintain a supply of dangerous drugs in the

physician's
or advanced practice registered nurse's
office to be

dispensed in the course of treating the physician's
or advanced

practice registered nurse's
patients; and

(2) be reimbursed for the cost of supplying those

drugs without obtaining a license under Chapter 558.

(d) A physician
or advanced practice registered nurse
who

dispenses dangerous drugs under Subsection (c) shall:

(1) comply with each labeling provision under this

subtitle applicable to that class of drugs; and

(2) oversee compliance with packaging and

recordkeeping provisions applicable to that class of drugs.

(e) A physician who desires to dispense dangerous drugs

under this section shall notify both the board and the Texas
Medical

[
State
] Board [
of Medical Examiners
] that the physician practices

in an area described by Subsection (b).
An advanced practice

registered nurse who desires to dispense dangerous drugs under this

section shall notify both the board and the Texas Board of Nursing

that the advanced practice registered nurse practices in an area

described by Subsection (b).
The physician
or advanced practice

registered nurse
may continue to dispense dangerous drugs in the

area until the board determines, after notice and hearing, that the

physician
or advanced practice registered nurse
no longer practices

in an area described by Subsection (b).

SECTION 4.030. Sections 605.002(14) and (18), Occupations

Code, are amended to read as follows:

(14) "Orthotics" means the science and practice of

measuring, designing, fabricating, assembling, fitting, adjusting,

or servicing an orthosis under an order from a licensed physician,

chiropractor, [
or
] podiatrist,
or advanced practice registered

nurse authorized to prescribe and order drugs and devices under

Section 301.358,
or an advanced practice
registered
nurse or

physician assistant acting under the delegation and supervision of

a licensed physician as provided by Subchapter B, Chapter 157, and

rules adopted by the Texas Medical Board, for the correction or

alleviation of a neuromuscular or musculoskeletal dysfunction,

disease, injury, or deformity.

(18) "Prosthetics" means the science and practice of

measuring, designing, fabricating, assembling, fitting, adjusting,

or servicing a prosthesis under an order from a licensed physician,

chiropractor, [
or
] podiatrist,
or advanced practice registered

nurse authorized to prescribe and order drugs and devices under

Section 301.358,
or an advanced practice
registered
nurse or

physician assistant acting under the delegation and supervision of

a licensed physician as provided by Subchapter B, Chapter 157, and

rules adopted by the Texas Medical Board.

SECTION 4.031. Section 605.2515, Occupations Code, is

amended to read as follows:

Sec. 605.2515. ADDITIONAL LICENSE: DEVICE MANUFACTURER. A

person licensed to practice orthotics or prosthetics who measures,

designs, fabricates, fits, assembles, adjusts, or services an

orthosis or a prosthesis under an order from a licensed physician,

chiropractor, [
or
] podiatrist,
or advanced practice registered

nurse authorized to prescribe and order drugs and devices under

Section 301.358,
or an advanced practice
registered
nurse or

physician assistant acting under the delegation and supervision of

a licensed physician as provided by Subchapter B, Chapter 157, and

rules adopted by the Texas Medical Board, for a specific patient is

exempt from licensing as a device manufacturer under Subchapter L,

Chapter 431, Health and Safety Code. A person licensed to practice

orthotics or prosthetics who fabricates or assembles an orthosis or

a prosthesis without an order from a licensed physician,

chiropractor, [
or
] podiatrist,
or advanced practice registered

nurse authorized to prescribe and order drugs and devices under

Section 301.358,
or an advanced practice
registered
nurse or

physician assistant acting under the delegation and supervision of

a licensed physician as provided by Subchapter B, Chapter 157, and

rules adopted by the Texas Medical Board, for a specific patient is

required to be licensed as a device manufacturer under Subchapter

L, Chapter 431, Health and Safety Code.

SECTION 4.032. Section 1701.703(a), Occupations Code, is

amended to read as follows:

(a) A physician, [
or
] a person who has been delegated

prescriptive authority under Chapter 157,
or an advanced practice

registered nurse authorized to prescribe and order drugs and

devices under Section 301.358,
[
Occupations Code,
] may prescribe

epinephrine auto-injectors in the name of a law enforcement agency.

ARTICLE 5. LEGISLATION IMPACT STUDY

SECTION 5.001. (a) The Texas Board of Nursing shall conduct

a study of the effect this Act has had on:

(1) access to primary health care in counties with a

population of less than 68,750 as compared to counties with a

population of 68,750 or greater;

(2) patient outcomes in counties with a population of

less than 68,750;

(3) trends in the practice location of advanced

practice registered nurses; and

(4) costs incurred by rural hospitals.

(b) Not later than September 1, 2028, the Texas Board of

Nursing shall submit to the governor, the lieutenant governor, and

the speaker of the house of representatives:

(1) the study conducted under Subsection (a) of this

section;

(2) the information published by:

(A) the Texas Medical Board under Section

157.152(b), Occupations Code, as added by this Act; and

(B) the Texas Board of Nursing under Section

301.359(c), Occupations Code, as added by this Act; and

(3) recommendations to the legislature to improve

rural access to health care and patient outcomes.

SECTION 5.002. This article expires December 31, 2029.

ARTICLE 6. TRANSITION AND EFFECTIVE DATE

SECTION 6.001. Not later than February 1, 2026, the Texas

Board of Nursing shall adopt the rules necessary to implement the

changes in law made by this Act.

SECTION 6.002. This Act takes effect September 1, 2025.