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FIRST REGULAR SESSIONSENATE BILL NO. 293101ST GENERAL ASSEMBLYINTRODUCED BY SENATOR HOSKINS.0848S.02IADRIANE D. CROUSE, SecretaryAN ACTTo repeal sections 334.037, 334.104, and 334.735, RSMo, and to enact in lieu thereof three newsections relating to advanced practice registered nurses.Be it enacted by the General Assembly of the State of Missouri, as follows:1Section A.Sections 334.037, 334.104, and 334.735, RSMo,2are repealed and three new sections enacted in lieu thereof, to3be known as sections 334.037, 334.104, and 334.735, to read as4follows:1334.037.1.A physician may enter into collaborative2practice arrangements with assistant physicians.3Collaborative practice arrangements shall be in the form of4written agreements, jointly agreed-upon protocols, or5standing orders for the delivery of health care services.6Collaborative practice arrangements, which shall be in7writing, may delegate to an assistant physician the8authority to administer or dispense drugs and provide9treatment as long as the delivery of such health care10services is within the scope of practice of the assistant11physician and is consistent with that assistant physician's12skill, training, and competence and the skill and training13of the collaborating physician.14152.The written collaborative practice arrangementshall contain at least the following provisions:EXPLANATION-Matter enclosed in bold-faced brackets [thus] in this bill is not enactedand is intended to be omitted in the law.
2SB 29316(1)Complete names, home and business addresses, zip17codes, and telephone numbers of the collaborating physician18and the assistant physician;19(2)A list of all other offices or locations besides20those listed in subdivision (1) of this subsection where the21collaborating physician authorized the assistant physician22to prescribe;23(3)A requirement that there shall be posted at every24office where the assistant physician is authorized to25prescribe, in collaboration with a physician, a prominently26displayed disclosure statement informing patients that they27may be seen by an assistant physician and have the right to28see the collaborating physician;29(4)All specialty or board certifications of the30collaborating physician and all certifications of the31assistant physician;32(5)The manner of collaboration between the33collaborating physician and the assistant physician,34including how the collaborating physician and the assistant35physician shall:36(a)Engage in collaborative practice consistent with37each professional's skill, training, education, and38competence;39(b)Maintain geographic proximity; except, the40collaborative practice arrangement may allow for geographic41proximity to be waived for a maximum of twenty-eight days42per calendar year for rural health clinics as defined by43Pub. L. 95-210 (42 U.S.C. Section 1395x), as amended, as44long as the collaborative practice arrangement includes45alternative plans as required in paragraph (c) of this46subdivision.47apply only to independent rural health clinics, provider-Such exception to geographic proximity shall
3SB 29348based rural health clinics if the provider is a critical49access hospital as provided in 42 U.S.C. Section 1395i-4,50and provider-based rural health clinics if the main location51of the hospital sponsor is greater than fifty miles from the52clinic.53documentation related to such requirement and present it to54the state board of registration for the healing arts when55requested; and565758(c)The collaborating physician shall maintainProvide coverage during absence, incapacity,infirmity, or emergency by the collaborating physician;(6)A description of the assistant physician's59controlled substance prescriptive authority in collaboration60with the physician, including a list of the controlled61substances the physician authorizes the assistant physician62to prescribe and documentation that it is consistent with63each professional's education, knowledge, skill, and64competence;656667(7)A list of all other written practice agreements ofthe collaborating physician and the assistant physician;(8)The duration of the written practice agreement68between the collaborating physician and the assistant69physician;70(9)A description of the time and manner of the71collaborating physician's review of the assistant72physician's delivery of health care services.73description shall include provisions that the assistant74physician shall submit a minimum of ten percent of the75charts documenting the assistant physician's delivery of76health care services to the collaborating physician for77review by the collaborating physician, or any other78physician designated in the collaborative practice79arrangement, every fourteen days; andThe
4SB 29380(10)The collaborating physician, or any other81physician designated in the collaborative practice82arrangement, shall review every fourteen days a minimum of83twenty percent of the charts in which the assistant84physician prescribes controlled substances.85reviewed under this subdivision may be counted in the number86of charts required to be reviewed under subdivision (9) of87this subsection.883.The chartsThe state board of registration for the healing89arts under section 334.125 shall promulgate rules regulating90the use of collaborative practice arrangements for assistant91physicians.Such rules shall specify:92(1)Geographic areas to be covered;93(2)The methods of treatment that may be covered by9495collaborative practice arrangements;(3)In conjunction with deans of medical schools and96primary care residency program directors in the state, the97development and implementation of educational methods and98programs undertaken during the collaborative practice99service which shall facilitate the advancement of the100assistant physician's medical knowledge and capabilities,101and which may lead to credit toward a future residency102program for programs that deem such documented educational103achievements acceptable; and104(4)The requirements for review of services provided105under collaborative practice arrangements, including106delegating authority to prescribe controlled substances.107Any rules relating to dispensing or distribution of108medications or devices by prescription or prescription drug109orders under this section shall be subject to the approval110of the state board of pharmacy.Any rules relating to
5SB 293111dispensing or distribution of controlled substances by112prescription or prescription drug orders under this section113shall be subject to the approval of the department of health114and senior services and the state board of pharmacy.115state board of registration for the healing arts shall116promulgate rules applicable to assistant physicians that117shall be consistent with guidelines for federally funded118clinics.119subsection shall not extend to collaborative practice120arrangements of hospital employees providing inpatient care121within hospitals as defined in chapter 197 or population-122based public health services as defined by 20 CSR 2150-5.100123as of April 30, 2008.1244.TheThe rulemaking authority granted in thisThe state board of registration for the healing125arts shall not deny, revoke, suspend, or otherwise take126disciplinary action against a collaborating physician for127health care services delegated to an assistant physician128provided the provisions of this section and the rules129promulgated thereunder are satisfied.1305.Within thirty days of any change and on each131renewal, the state board of registration for the healing132arts shall require every physician to identify whether the133physician is engaged in any collaborative practice134arrangement, including collaborative practice arrangements135delegating the authority to prescribe controlled substances,136and also report to the board the name of each assistant137physician with whom the physician has entered into such138arrangement.139to the public.140information and may routinely conduct random reviews of such141arrangements to ensure that arrangements are carried out for142compliance under this chapter.The board may make such information availableThe board shall track the reported
6SB 2931436.A collaborating physician shall not enter into a144collaborative practice arrangement with more than six full-145time equivalent assistant physicians[,] or full-time146equivalent physician assistants, [or full-time equivalent147advance practice registered nurses,] or any combination148thereof.149arrangements of hospital employees providing inpatient care150service in hospitals as defined in chapter 197 or population-151based public health services as defined by 20 CSR 2150-5.100152as of April 30, 2008[, or to a certified registered nurse153anesthetist providing anesthesia services under the154supervision of an anesthesiologist or other physician,155dentist, or podiatrist who is immediately available if156needed as set out in subsection 7 of section 334.104].1577.Such limitation shall not apply to collaborativeThe collaborating physician shall determine and158document the completion of at least a one-month period of159time during which the assistant physician shall practice160with the collaborating physician continuously present before161practicing in a setting where the collaborating physician is162not continuously present.163require the collaborating physician to review more than ten164percent of the assistant physician's patient charts or165records during such one-month period.166not apply to collaborative arrangements of providers of167population-based public health services as defined by 20 CSR1682150-5.100 as of April 30, 2008.1698.No rule or regulation shallSuch limitation shallNo agreement made under this section shall170supersede current hospital licensing regulations governing171hospital medication orders under protocols or standing172orders for the purpose of delivering inpatient or emergency173care within a hospital as defined in section 197.020 if such174protocols or standing orders have been approved by the
7SB 293175hospital's medical staff and pharmaceutical therapeutics176committee.1779.No contract or other agreement shall require a178physician to act as a collaborating physician for an179assistant physician against the physician's will.180physician shall have the right to refuse to act as a181collaborating physician, without penalty, for a particular182assistant physician.183limit the collaborating physician's ultimate authority over184any protocols or standing orders or in the delegation of the185physician's authority to any assistant physician, but such186requirement shall not authorize a physician in implementing187such protocols, standing orders, or delegation to violate188applicable standards for safe medical practice established189by a hospital's medical staff.19010.ANo contract or other agreement shallNo contract or other agreement shall require any191assistant physician to serve as a collaborating assistant192physician for any collaborating physician against the193assistant physician's will.194have the right to refuse to collaborate, without penalty,195with a particular physician.19611.An assistant physician shallAll collaborating physicians and assistant197physicians in collaborative practice arrangements shall wear198identification badges while acting within the scope of their199collaborative practice arrangement.200badges shall prominently display the licensure status of201such collaborating physicians and assistant physicians.20212.(1)The identificationAn assistant physician with a certificate of203controlled substance prescriptive authority as provided in204this section may prescribe any controlled substance listed205in Schedule III, IV, or V of section 195.017, and may have206restricted authority in Schedule II, when delegated the
8SB 293207authority to prescribe controlled substances in a208collaborative practice arrangement.209Schedule II medications prescribed by an assistant physician210who has a certificate of controlled substance prescriptive211authority are restricted to only those medications212containing hydrocodone.213the state board of registration for the healing arts.214collaborating physician shall maintain the right to limit a215specific scheduled drug or scheduled drug category that the216assistant physician is permitted to prescribe.217limitations shall be listed in the collaborative practice218arrangement.219controlled substances for themselves or members of their220families.221II - hydrocodone prescriptions shall be limited to a five-222day supply without refill, except that buprenorphine may be223prescribed for up to a thirty-day supply without refill for224patients receiving medication-assisted treatment for225substance use disorders under the direction of the226collaborating physician.227authorized to prescribe controlled substances under this228section shall register with the federal Drug Enforcement229Administration and the state bureau of narcotics and230dangerous drugs, and shall include the Drug Enforcement231Administration registration number on prescriptions for232controlled substances.233(2)Prescriptions forSuch authority shall be filed withTheAnyAssistant physicians shall not prescribeSchedule III controlled substances and ScheduleAssistant physicians who areThe collaborating physician shall be responsible234to determine and document the completion of at least one235hundred twenty hours in a four-month period by the assistant236physician during which the assistant physician shall237practice with the collaborating physician on-site prior to238prescribing controlled substances when the collaborating
SB 2939239physician is not on-site.Such limitation shall not apply240to assistant physicians of population-based public health241services as defined in 20 CSR 2150-5.100 as of April 30,2422009, or assistant physicians providing opioid addiction243treatment.244(3)An assistant physician shall receive a certificate245of controlled substance prescriptive authority from the246state board of registration for the healing arts upon247verification of licensure under section 334.036.24813.Nothing in this section or section 334.036 shall249be construed to limit the authority of hospitals or hospital250medical staff to make employment or medical staff251credentialing or privileging decisions.1334.104.1.A physician may enter into collaborative2practice arrangements with registered professional nurses.3Collaborative practice arrangements shall be in the form of4written agreements, jointly agreed-upon protocols, or5standing orders for the delivery of health care services.6Collaborative practice arrangements, which shall be in7writing, may delegate to a registered professional nurse the8authority to administer or dispense drugs and provide9treatment as long as the delivery of such health care10services is within the scope of practice of the registered11professional nurse and is consistent with that nurse's12skill, training and competence.132.Collaborative practice arrangements, which shall be14in writing, may delegate to a registered professional nurse15the authority to administer, dispense or prescribe drugs and16provide treatment if the registered professional nurse is an17advanced practice registered nurse as defined in subdivision18(2) of section 335.016.19may delegate to an advanced practice registered nurse, asCollaborative practice arrangements
10SB 29320defined in section 335.016, who has been granted a21certificate of controlled substance prescriptive authority,22the authority to administer, dispense, or prescribe23controlled substances listed in Schedules III, IV, and V of24section 195.017, and Schedule II - hydrocodone; except that,25the collaborative practice arrangement shall not delegate26the authority to administer any controlled substances listed27in Schedules III, IV, and V of section 195.017, or Schedule28II - hydrocodone for the purpose of inducing sedation or29general anesthesia for therapeutic, diagnostic, or surgical30procedures.31Schedule II - hydrocodone prescriptions shall be limited to32a one hundred twenty-hour supply without refill.33collaborative practice arrangements shall be in the form of34written agreements, jointly agreed-upon protocols or35standing orders for the delivery of health care services.36An advanced practice registered nurse may prescribe37buprenorphine for up to a thirty-day supply without refill38for patients receiving medication-assisted treatment for39substance use disorders under the direction of the40collaborating physician.4142433.Schedule III narcotic controlled substance andSuchThe written collaborative practice arrangementshall contain at least the [following provisions:(1)]complete names, home and business addresses, zip44codes, [and] telephone numbers, and license numbers of the45collaborating physician and the advanced practice registered46nurse[;47(2)A list of all other offices or locations besides48those listed in subdivision (1) of this subsection where the49collaborating physician authorized the advanced practice50registered nurse to prescribe;
11SB 29351(3)A requirement that there shall be posted at every52office where the advanced practice registered nurse is53authorized to prescribe, in collaboration with a physician,54a prominently displayed disclosure statement informing55patients that they may be seen by an advanced practice56registered nurse and have the right to see the collaborating57physician;58(4)All specialty or board certifications of the59collaborating physician and all certifications of the60advanced practice registered nurse;61(5)The manner of collaboration between the62collaborating physician and the advanced practice registered63nurse, including how the collaborating physician and the64advanced practice registered nurse will:65(a)Engage in collaborative practice consistent with66each professional's skill, training, education, and67competence;68(b)Maintain geographic proximity, except the69collaborative practice arrangement may allow for geographic70proximity to be waived for a maximum of twenty-eight days71per calendar year for rural health clinics as defined by72P.L. 95-210, as long as the collaborative practice73arrangement includes alternative plans as required in74paragraph (c) of this subdivision.75geographic proximity shall apply only to independent rural76health clinics, provider-based rural health clinics where77the provider is a critical access hospital as provided in 4278U.S.C. Section 1395i-4, and provider-based rural health79clinics where the main location of the hospital sponsor is80greater than fifty miles from the clinic.81physician is required to maintain documentation related toThis exception toThe collaborating
12SB 29382this requirement and to present it to the state board of83registration for the healing arts when requested; and848586(c)Provide coverage during absence, incapacity,infirmity, or emergency by the collaborating physician;(6)], and a description of the advanced practice87registered nurse's controlled substance prescriptive88authority in collaboration with the physician, including a89list of the controlled substances the physician authorizes90the nurse to prescribe and documentation that it is91consistent with each professional's education, knowledge,92skill, and competence[;93(7)A list of all other written practice agreements of94the collaborating physician and the advanced practice95registered nurse;96(8)The duration of the written practice agreement97between the collaborating physician and the advanced98practice registered nurse;99(9)A description of the time and manner of the100collaborating physician's review of the advanced practice101registered nurse's delivery of health care services.102description shall include provisions that the advanced103practice registered nurse shall submit a minimum of ten104percent of the charts documenting the advanced practice105registered nurse's delivery of health care services to the106collaborating physician for review by the collaborating107physician, or any other physician designated in the108collaborative practice arrangement, every fourteen days; and109(10)TheThe collaborating physician, or any other110physician designated in the collaborative practice111arrangement, shall review every fourteen days a minimum of112twenty percent of the charts in which the advanced practice113registered nurse prescribes controlled substances.The
13SB 293114charts reviewed under this subdivision may be counted in the115number of charts required to be reviewed under subdivision116(9) of this subsection].1174.(1)The state board of registration for the118healing arts pursuant to section 334.125 and the board of119nursing pursuant to section 335.036 may jointly promulgate120rules regulating the use of collaborative practice121arrangements.122geographic areas to be covered, the methods of treatment123that may be covered by collaborative practice arrangements124and the requirements for review of services provided125pursuant to collaborative practice arrangements including]126delegating authority to prescribe controlled substances.127(2)Such rules shall be limited to [specifyingAny previously adopted rules regulating the use of128collaborative practice arrangements that are not limited to129delegating authority to prescribe controlled substances130shall from the effective date of this act be null and void.131(3)Any rules relating to dispensing or distribution132of medications or devices by prescription or prescription133drug orders under this section shall be subject to the134approval of the state board of pharmacy.135to dispensing or distribution of controlled substances by136prescription or prescription drug orders under this section137shall be subject to the approval of the department of health138and senior services and the state board of pharmacy.139order to take effect, such rules shall be approved by a140majority vote of a quorum of each board.141board of registration for the healing arts nor the board of142nursing may separately promulgate rules relating to143collaborative practice arrangements.144promulgated rules shall be consistent with guidelines for145federally funded clinics.Any rules relatingInNeither the stateSuch jointlyThe rulemaking authority granted
14SB 293146in this subsection shall not extend to collaborative147practice arrangements of hospital employees providing148inpatient care within hospitals as defined pursuant to149chapter 197 or population-based public health services as150defined by 20 CSR 2150-5.100 as of April 30, 2008.1515.The state board of registration for the healing152arts shall not deny, revoke, suspend or otherwise take153disciplinary action against a physician for health care154services delegated to a registered professional nurse155provided the provisions of this section and the rules156promulgated thereunder are satisfied.157request of a physician subject to a disciplinary action158imposed as a result of an agreement between a physician and159a registered professional nurse or registered physician160assistant, whether written or not, prior to August 28, 1993,161all records of such disciplinary licensure action and all162records pertaining to the filing, investigation or review of163an alleged violation of this chapter incurred as a result of164such an agreement shall be removed from the records of the165state board of registration for the healing arts and the166division of professional registration and shall not be167disclosed to any public or private entity seeking such168information from the board or the division.169of registration for the healing arts shall take action to170correct reports of alleged violations and disciplinary171actions as described in this section which have been172submitted to the National Practitioner Data Bank.173subsequent applications or representations relating to his174or her medical practice, a physician completing forms or175documents shall not be required to report any actions of the176state board of registration for the healing arts for which177the records are subject to removal under this section.Upon the writtenThe state boardIn
15SB 2931786.Within thirty days of any change and on each179renewal, the state board of registration for the healing180arts shall require every physician to identify whether the181physician is engaged in any collaborative practice182agreement, including collaborative practice agreements183delegating the authority to prescribe controlled substances,184or physician assistant agreement and also report to the185board the name of each licensed professional with whom the186physician has entered into such agreement.187shall make this information available to the public.188board shall track the reported information and may routinely189conduct random reviews of such agreements to ensure that190agreements are carried out for compliance under this chapter.1917.The board [may]TheNotwithstanding any law to the contrary, a192certified registered nurse anesthetist as defined in193subdivision (8) of section 335.016 shall be permitted to194provide anesthesia services without a collaborative practice195arrangement provided that he or she is under the supervision196of an anesthesiologist or other physician, dentist, or197podiatrist who is immediately available if needed.198in this subsection shall be construed to prohibit or prevent199a certified registered nurse anesthetist as defined in200subdivision (8) of section 335.016 from entering into a201collaborative practice arrangement under this section,202except that the collaborative practice arrangement may not203delegate the authority to prescribe any controlled204substances listed in Schedules III, IV, and V of section205195.017, or Schedule II - hydrocodone.2068.Nothing[A collaborating physician shall not enter into a207collaborative practice arrangement with more than six full-208time equivalent advanced practice registered nurses, full-209time equivalent licensed physician assistants, or full-time
16SB 293210equivalent assistant physicians, or any combination211thereof.212arrangements of hospital employees providing inpatient care213service in hospitals as defined in chapter 197 or population-214based public health services as defined by 20 CSR 2150-5.100215as of April 30, 2008, or to a certified registered nurse216anesthetist providing anesthesia services under the217supervision of an anesthesiologist or other physician,218dentist, or podiatrist who is immediately available if219needed as set out in subsection 7 of this section.2209.This limitation shall not apply to collaborativeIt is the responsibility of the collaborating221physician to determine and document the completion of at222least a one-month period of time during which the advanced223practice registered nurse shall practice with the224collaborating physician continuously present before225practicing in a setting where the collaborating physician is226not continuously present.227to collaborative arrangements of providers of population-228based public health services as defined by 20 CSR 2150-5.100229as of April 30, 2008.23010.This limitation shall not applyNo agreement made under this section shall231supersede current hospital licensing regulations governing232hospital medication orders under protocols or standing233orders for the purpose of delivering inpatient or emergency234care within a hospital as defined in section 197.020 if such235protocols or standing orders have been approved by the236hospital's medical staff and pharmaceutical therapeutics237committee.23811.]No contract or other agreement shall require a239physician to act as a collaborating physician for an240advanced practice registered nurse against the physician's241will.A physician shall have the right to refuse to act as
17SB 293242a collaborating physician, without penalty, for a particular243advanced practice registered nurse.244agreement shall limit the collaborating physician's ultimate245authority over any protocols or standing orders or in the246delegation of the physician's authority to any advanced247practice registered nurse, but this requirement shall not248authorize a physician in implementing such protocols,249standing orders, or delegation to violate applicable250standards for safe medical practice established by251hospital's medical staff.25212.] 9.[No contract or otherNo contract or other agreement shall require253any advanced practice registered nurse to serve as a254collaborating advanced practice registered nurse for any255collaborating physician against the advanced practice256registered nurse's will.257nurse shall have the right to refuse to collaborate, without258penalty, with a particular physician.12345334.735.1.An advanced practice registeredAs used in sections 334.735 to 334.749,the following terms mean:(1)"Applicant", any individual who seeks to becomelicensed as a physician assistant;(2)"Certification" or "registration", a process by a6certifying entity that grants recognition to applicants7meeting predetermined qualifications specified by such8certifying entity;9(3)"Certifying entity", the nongovernmental agency or10association which certifies or registers individuals who11have completed academic and training requirements;12(4)"Collaborative practice arrangement", written13agreements, jointly agreed upon protocols, or standing14orders, all of which shall be in writing, for the delivery15of health care services;
18SB 293161718(5)"Department", the department of commerce andinsurance or a designated agency thereof;(6)"License", a document issued to an applicant by19the board acknowledging that the applicant is entitled to20practice as a physician assistant;21(7)"Physician assistant", a person who has graduated22from a physician assistant program accredited by the23Accreditation Review Commission on Education for the24Physician Assistant or its successor agenc
SB 293 3 48 based rural health clinics if the provider is a critical 49 access hospital as provided in 42 U.S.C. Section 1395i-4, 50 and provider-based rural health clinics if the main location 51 of the hospital sponsor is greater than fifty miles from the clinic.52 The collaborating physician shall maintain 53 documentation related to such requirement and present it to
