Bill Text: MO HB1371 | 2012 | Regular Session | Introduced
Bill Title: Changes the laws regarding collaborative practice arrangements and advanced practice registered nurses
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2012-04-12 - Public Hearing Completed (H) [HB1371 Detail]
Download: Missouri-2012-HB1371-Introduced.html
SECOND REGULAR SESSION
96TH GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVES WETER (Sponsor), KIRKTON, SATER, SHIVELY, HOUGH, McDONALD, LOEHNER, MEADOWS, REDMON, SHUMAKE, FISHER, SCHIEFFER, WALLINGFORD, FITZWATER, McGHEE, QUINN, McCREERY, WEBB, KELLEY (126), SCHAD, LARGENT, CARTER, HIGDON, BAHR AND CONWAY (14) (Co-sponsors).
4298L.01I D. ADAM CRUMBLISS, Chief Clerk
AN ACT
To repeal sections 195.070, 195.100, 208.152, 334.104, 334.108, 334.810, 335.016, 335.019, 335.046, and 338.198, RSMo, and to enact in lieu thereof ten new sections relating to collaborative practice arrangements.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Sections 195.070, 195.100, 208.152, 334.104, 334.108, 334.810, 335.016, 335.019, 335.046, and 338.198, RSMo, are repealed and ten new sections enacted in lieu thereof, to be known as sections 195.070, 195.100, 208.152, 334.104, 334.108, 334.810, 335.016, 335.019, 335.046, and 338.198, to read as follows:
195.070. 1. A physician, podiatrist, dentist, a registered optometrist certified to administer pharmaceutical agents as provided in section 336.220, an advanced practice registered nurse as defined in section 335.016 or a physician assistant in accordance with section 334.747 in good faith and in the course of his or her professional practice only, may prescribe, administer, and dispense controlled substances or he or she may cause the same to be administered or dispensed by an individual as authorized by statute.
2. [An advanced practice registered nurse, as defined in section 335.016, but not a certified registered nurse anesthetist as defined in subdivision (8) of section 335.016, who holds a certificate of controlled substance prescriptive authority from the board of nursing under section 335.019 and who is delegated the authority to prescribe controlled substances under a collaborative practice arrangement under section 334.104 may prescribe any controlled substances listed in Schedules II, III, IV, and V of section 195.017. However, no such certified advanced practice registered nurse shall prescribe controlled substance for his or her own self or family. Schedule III narcotic controlled substance prescriptions shall be limited to a one hundred twenty-hour supply without refill.
3.] A veterinarian, in good faith and in the course of the veterinarian's professional practice only, and not for use by a human being, may prescribe, administer, and dispense controlled substances and the veterinarian may cause them to be administered by an assistant or orderly under his or her direction and supervision.
[4.] 3. A practitioner shall not accept any portion of a controlled substance unused by a patient, for any reason, if such practitioner did not originally dispense the drug.
[5.] 4. An individual practitioner shall not prescribe or dispense a controlled substance for such practitioner's personal use except in a medical emergency.
195.100. 1. It shall be unlawful to distribute any controlled substance in a commercial container unless such container bears a label containing an identifying symbol for such substance in accordance with federal laws.
2. It shall be unlawful for any manufacturer of any controlled substance to distribute such substance unless the labeling thereof conforms to the requirements of federal law and contains the identifying symbol required in subsection 1 of this section.
3. The label of a controlled substance in Schedule II, III or IV shall, when dispensed to or for a patient, contain a clear, concise warning that it is a criminal offense to transfer such narcotic or dangerous drug to any person other than the patient.
4. Whenever a manufacturer sells or dispenses a controlled substance and whenever a wholesaler sells or dispenses a controlled substance in a package prepared by him or her, the manufacturer or wholesaler shall securely affix to each package in which that drug is contained a label showing in legible English the name and address of the vendor and the quantity, kind, and form of controlled substance contained therein. No person except a pharmacist for the purpose of filling a prescription under sections 195.005 to 195.425, shall alter, deface, or remove any label so affixed.
5. Whenever a pharmacist or practitioner sells or dispenses any controlled substance on a prescription issued by a physician, physician assistant, dentist, podiatrist, veterinarian, or advanced practice registered nurse, the pharmacist or practitioner shall affix to the container in which such drug is sold or dispensed a label showing his or her own name and address of the pharmacy or practitioner for whom he or she is lawfully acting; the name of the patient or, if the patient is an animal, the name of the owner of the animal and the species of the animal; the name of the physician, physician assistant, dentist, podiatrist, advanced practice registered nurse, or veterinarian by whom the prescription was written[; the name of the collaborating physician if the prescription is written by an advanced practice registered nurse] or the supervising physician if the prescription is written by a physician assistant, and such directions as may be stated on the prescription. No person shall alter, deface, or remove any label so affixed.
208.152. 1. MO HealthNet payments shall be made on behalf of those eligible needy persons as defined in section 208.151 who are unable to provide for it in whole or in part, with any payments to be made on the basis of the reasonable cost of the care or reasonable charge for the services as defined and determined by the MO HealthNet division, unless otherwise hereinafter provided, for the following:
(1) Inpatient hospital services, except to persons in an institution for mental diseases who are under the age of sixty-five years and over the age of twenty-one years; provided that the MO HealthNet division shall provide through rule and regulation an exception process for coverage of inpatient costs in those cases requiring treatment beyond the seventy-fifth percentile professional activities study (PAS) or the MO HealthNet children's diagnosis length-of-stay schedule; and provided further that the MO HealthNet division shall take into account through its payment system for hospital services the situation of hospitals which serve a disproportionate number of low-income patients;
(2) All outpatient hospital services, payments therefor to be in amounts which represent no more than eighty percent of the lesser of reasonable costs or customary charges for such services, determined in accordance with the principles set forth in Title XVIII A and B, Public Law 89-97, 1965 amendments to the federal Social Security Act (42 U.S.C. 301, et seq.), but the MO HealthNet division may evaluate outpatient hospital services rendered under this section and deny payment for services which are determined by the MO HealthNet division not to be medically necessary, in accordance with federal law and regulations;
(3) Laboratory and X-ray services;
(4) Nursing home services for participants, except to persons with more than five hundred thousand dollars equity in their home or except for persons in an institution for mental diseases who are under the age of sixty-five years, when residing in a hospital licensed by the department of health and senior services or a nursing home licensed by the department of health and senior services or appropriate licensing authority of other states or government-owned and -operated institutions which are determined to conform to standards equivalent to licensing requirements in Title XIX of the federal Social Security Act (42 U.S.C. 301, et seq.), as amended, for nursing facilities. The MO HealthNet division may recognize through its payment methodology for nursing facilities those nursing facilities which serve a high volume of MO HealthNet patients. The MO HealthNet division when determining the amount of the benefit payments to be made on behalf of persons under the age of twenty-one in a nursing facility may consider nursing facilities furnishing care to persons under the age of twenty-one as a classification separate from other nursing facilities;
(5) Nursing home costs for participants receiving benefit payments under subdivision (4) of this subsection for those days, which shall not exceed twelve per any period of six consecutive months, during which the participant is on a temporary leave of absence from the hospital or nursing home, provided that no such participant shall be allowed a temporary leave of absence unless it is specifically provided for in his plan of care. As used in this subdivision, the term "temporary leave of absence" shall include all periods of time during which a participant is away from the hospital or nursing home overnight because he is visiting a friend or relative;
(6) Physicians' services, whether furnished in the office, home, hospital, nursing home, or elsewhere;
(7) Drugs and medicines when prescribed by a licensed physician, dentist, [or] podiatrist, or an advanced practice registered nurse; except that no payment for drugs and medicines prescribed on and after January 1, 2006, by a licensed physician, dentist, [or] podiatrist, or an advanced practice registered nurse may be made on behalf of any person who qualifies for prescription drug coverage under the provisions of P.L. 108-173;
(8) Emergency ambulance services and, effective January 1, 1990, medically necessary transportation to scheduled, physician-prescribed nonelective treatments;
(9) Early and periodic screening and diagnosis of individuals who are under the age of twenty-one to ascertain their physical or mental defects, and health care, treatment, and other measures to correct or ameliorate defects and chronic conditions discovered thereby. Such services shall be provided in accordance with the provisions of Section 6403 of P.L. 101-239 and federal regulations promulgated thereunder;
(10) Home health care services;
(11) Family planning as defined by federal rules and regulations; provided, however, that such family planning services shall not include abortions unless such abortions are certified in writing by a physician to the MO HealthNet agency that, in his professional judgment, the life of the mother would be endangered if the fetus were carried to term;
(12) Inpatient psychiatric hospital services for individuals under age twenty-one as defined in Title XIX of the federal Social Security Act (42 U.S.C. 1396d, et seq.);
(13) Outpatient surgical procedures, including presurgical diagnostic services performed in ambulatory surgical facilities which are licensed by the department of health and senior services of the state of Missouri; except, that such outpatient surgical services shall not include persons who are eligible for coverage under Part B of Title XVIII, Public Law 89-97, 1965 amendments to the federal Social Security Act, as amended, if exclusion of such persons is permitted under Title XIX, Public Law 89-97, 1965 amendments to the federal Social Security Act, as amended;
(14) Personal care services which are medically oriented tasks having to do with a person's physical requirements, as opposed to housekeeping requirements, which enable a person to be treated by his physician on an outpatient rather than on an inpatient or residential basis in a hospital, intermediate care facility, or skilled nursing facility. Personal care services shall be rendered by an individual not a member of the participant's family who is qualified to provide such services where the services are prescribed by a physician in accordance with a plan of treatment and are supervised by a licensed nurse. Persons eligible to receive personal care services shall be those persons who would otherwise require placement in a hospital, intermediate care facility, or skilled nursing facility. Benefits payable for personal care services shall not exceed for any one participant one hundred percent of the average statewide charge for care and treatment in an intermediate care facility for a comparable period of time. Such services, when delivered in a residential care facility or assisted living facility licensed under chapter 198 shall be authorized on a tier level based on the services the resident requires and the frequency of the services. A resident of such facility who qualifies for assistance under section 208.030 shall, at a minimum, if prescribed by a physician, qualify for the tier level with the fewest services. The rate paid to providers for each tier of service shall be set subject to appropriations. Subject to appropriations, each resident of such facility who qualifies for assistance under section 208.030 and meets the level of care required in this section shall, at a minimum, if prescribed by a physician, be authorized up to one hour of personal care services per day. Authorized units of personal care services shall not be reduced or tier level lowered unless an order approving such reduction or lowering is obtained from the resident's personal physician. Such authorized units of personal care services or tier level shall be transferred with such resident if her or she transfers to another such facility. Such provision shall terminate upon receipt of relevant waivers from the federal Department of Health and Human Services. If the Centers for Medicare and Medicaid Services determines that such provision does not comply with the state plan, this provision shall be null and void. The MO HealthNet division shall notify the revisor of statutes as to whether the relevant waivers are approved or a determination of noncompliance is made;
(15) Mental health services. The state plan for providing medical assistance under Title XIX of the Social Security Act, 42 U.S.C. 301, as amended, shall include the following mental health services when such services are provided by community mental health facilities operated by the department of mental health or designated by the department of mental health as a community mental health facility or as an alcohol and drug abuse facility or as a child-serving agency within the comprehensive children's mental health service system established in section 630.097. The department of mental health shall establish by administrative rule the definition and criteria for designation as a community mental health facility and for designation as an alcohol and drug abuse facility. Such mental health services shall include:
(a) Outpatient mental health services including preventive, diagnostic, therapeutic, rehabilitative, and palliative interventions rendered to individuals in an individual or group setting by a mental health professional in accordance with a plan of treatment appropriately established, implemented, monitored, and revised under the auspices of a therapeutic team as a part of client services management;
(b) Clinic mental health services including preventive, diagnostic, therapeutic, rehabilitative, and palliative interventions rendered to individuals in an individual or group setting by a mental health professional in accordance with a plan of treatment appropriately established, implemented, monitored, and revised under the auspices of a therapeutic team as a part of client services management;
(c) Rehabilitative mental health and alcohol and drug abuse services including home and community-based preventive, diagnostic, therapeutic, rehabilitative, and palliative interventions rendered to individuals in an individual or group setting by a mental health or alcohol and drug abuse professional in accordance with a plan of treatment appropriately established, implemented, monitored, and revised under the auspices of a therapeutic team as a part of client services management. As used in this section, mental health professional and alcohol and drug abuse professional shall be defined by the department of mental health pursuant to duly promulgated rules. With respect to services established by this subdivision, the department of social services, MO HealthNet division, shall enter into an agreement with the department of mental health. Matching funds for outpatient mental health services, clinic mental health services, and rehabilitation services for mental health and alcohol and drug abuse shall be certified by the department of mental health to the MO HealthNet division. The agreement shall establish a mechanism for the joint implementation of the provisions of this subdivision. In addition, the agreement shall establish a mechanism by which rates for services may be jointly developed;
(16) Such additional services as defined by the MO HealthNet division to be furnished under waivers of federal statutory requirements as provided for and authorized by the federal Social Security Act (42 U.S.C. 301, et seq.) subject to appropriation by the general assembly;
(17) [Beginning July 1, 1990,] The services of [a certified pediatric or family nursing practitioner with a collaborative practice agreement] an advanced practice registered nurse to the extent that such services are provided in accordance with [chapters 334 and] chapter 335, and regulations promulgated thereunder;
(18) Nursing home costs for participants receiving benefit payments under subdivision (4) of this subsection to reserve a bed for the participant in the nursing home during the time that the participant is absent due to admission to a hospital for services which cannot be performed on an outpatient basis, subject to the provisions of this subdivision:
(a) The provisions of this subdivision shall apply only if:
a. The occupancy rate of the nursing home is at or above ninety-seven percent of MO HealthNet certified licensed beds, according to the most recent quarterly census provided to the department of health and senior services which was taken prior to when the participant is admitted to the hospital; and
b. The patient is admitted to a hospital for a medical condition with an anticipated stay of three days or less;
(b) The payment to be made under this subdivision shall be provided for a maximum of three days per hospital stay;
(c) For each day that nursing home costs are paid on behalf of a participant under this subdivision during any period of six consecutive months such participant shall, during the same period of six consecutive months, be ineligible for payment of nursing home costs of two otherwise available temporary leave of absence days provided under subdivision (5) of this subsection; and
(d) The provisions of this subdivision shall not apply unless the nursing home receives notice from the participant or the participant's responsible party that the participant intends to return to the nursing home following the hospital stay. If the nursing home receives such notification and all other provisions of this subsection have been satisfied, the nursing home shall provide notice to the participant or the participant's responsible party prior to release of the reserved bed;
(19) Prescribed medically necessary durable medical equipment. An electronic web-based prior authorization system using best medical evidence and care and treatment guidelines consistent with national standards shall be used to verify medical need;
(20) Hospice care. As used in this subdivision, the term "hospice care" means a coordinated program of active professional medical attention within a home, outpatient and inpatient care which treats the terminally ill patient and family as a unit, employing a medically directed interdisciplinary team. The program provides relief of severe pain or other physical symptoms and supportive care to meet the special needs arising out of physical, psychological, spiritual, social, and economic stresses which are experienced during the final stages of illness, and during dying and bereavement and meets the Medicare requirements for participation as a hospice as are provided in 42 CFR Part 418. The rate of reimbursement paid by the MO HealthNet division to the hospice provider for room and board furnished by a nursing home to an eligible hospice patient shall not be less than ninety-five percent of the rate of reimbursement which would have been paid for facility services in that nursing home facility for that patient, in accordance with subsection (c) of Section 6408 of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989);
(21) Prescribed medically necessary dental services. Such services shall be subject to appropriations. An electronic web-based prior authorization system using best medical evidence and care and treatment guidelines consistent with national standards shall be used to verify medical need;
(22) Prescribed medically necessary optometric services. Such services shall be subject to appropriations. An electronic web-based prior authorization system using best medical evidence and care and treatment guidelines consistent with national standards shall be used to verify medical need;
(23) Blood clotting products-related services. For persons diagnosed with a bleeding disorder, as defined in section 338.400, reliant on blood clotting products, as defined in section 338.400, such services include:
(a) Home delivery of blood clotting products and ancillary infusion equipment and supplies, including the emergency deliveries of the product when medically necessary;
(b) Medically necessary ancillary infusion equipment and supplies required to administer the blood clotting products; and
(c) Assessments conducted in the participant's home by a pharmacist, nurse, or local home health care agency trained in bleeding disorders when deemed necessary by the participant's treating physician;
(24) The MO HealthNet division shall, by January 1, 2008, and annually thereafter, report the status of MO HealthNet provider reimbursement rates as compared to one hundred percent of the Medicare reimbursement rates and compared to the average dental reimbursement rates paid by third-party payors licensed by the state. The MO HealthNet division shall, by July 1, 2008, provide to the general assembly a four-year plan to achieve parity with Medicare reimbursement rates and for third-party payor average dental reimbursement rates. Such plan shall be subject to appropriation and the division shall include in its annual budget request to the governor the necessary funding needed to complete the four-year plan developed under this subdivision.
2. Additional benefit payments for medical assistance shall be made on behalf of those eligible needy children, pregnant women and blind persons with any payments to be made on the basis of the reasonable cost of the care or reasonable charge for the services as defined and determined by the division of medical services, unless otherwise hereinafter provided, for the following:
(1) Dental services;
(2) Services of podiatrists as defined in section 330.010;
(3) Optometric services as defined in section 336.010;
(4) Orthopedic devices or other prosthetics, including eye glasses, dentures, hearing aids, and wheelchairs;
(5) Hospice care. As used in this subsection, the term "hospice care" means a coordinated program of active professional medical attention within a home, outpatient and inpatient care which treats the terminally ill patient and family as a unit, employing a medically directed interdisciplinary team. The program provides relief of severe pain or other physical symptoms and supportive care to meet the special needs arising out of physical, psychological, spiritual, social, and economic stresses which are experienced during the final stages of illness, and during dying and bereavement and meets the Medicare requirements for participation as a hospice as are provided in 42 CFR Part 418. The rate of reimbursement paid by the MO HealthNet division to the hospice provider for room and board furnished by a nursing home to an eligible hospice patient shall not be less than ninety-five percent of the rate of reimbursement which would have been paid for facility services in that nursing home facility for that patient, in accordance with subsection (c) of Section 6408 of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989);
(6) Comprehensive day rehabilitation services beginning early posttrauma as part of a coordinated system of care for individuals with disabling impairments. Rehabilitation services must be based on an individualized, goal-oriented, comprehensive and coordinated treatment plan developed, implemented, and monitored through an interdisciplinary assessment designed to restore an individual to optimal level of physical, cognitive, and behavioral function. The MO HealthNet division shall establish by administrative rule the definition and criteria for designation of a comprehensive day rehabilitation service facility, benefit limitations and payment mechanism. Any rule or portion of a rule, as that term is defined in section 536.010, that is created under the authority delegated in this subdivision shall become effective only if it complies with and is subject to all of the provisions of chapter 536 and, if applicable, section 536.028. This section and chapter 536 are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536 to review, to delay the effective date, or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2005, shall be invalid and void.
3. The MO HealthNet division may require any participant receiving MO HealthNet benefits to pay part of the charge or cost until July 1, 2008, and an additional payment after July 1, 2008, as defined by rule duly promulgated by the MO HealthNet division, for all covered services except for those services covered under subdivisions (14) and (15) of subsection 1 of this section and sections 208.631 to 208.657 to the extent and in the manner authorized by Title XIX of the federal Social Security Act (42 U.S.C. 1396, et seq.) and regulations thereunder. When substitution of a generic drug is permitted by the prescriber according to section 338.056, and a generic drug is substituted for a name-brand drug, the MO HealthNet division may not lower or delete the requirement to make a co-payment pursuant to regulations of Title XIX of the federal Social Security Act. A provider of goods or services described under this section must collect from all participants the additional payment that may be required by the MO HealthNet division under authority granted herein, if the division exercises that authority, to remain eligible as a provider. Any payments made by participants under this section shall be in addition to and not in lieu of payments made by the state for goods or services described herein except the participant portion of the pharmacy professional dispensing fee shall be in addition to and not in lieu of payments to pharmacists. A provider may collect the co-payment at the time a service is provided or at a later date. A provider shall not refuse to provide a service if a participant is unable to pay a required payment. If it is the routine business practice of a provider to terminate future services to an individual with an unclaimed debt, the provider may include uncollected co-payments under this practice. Providers who elect not to undertake the provision of services based on a history of bad debt shall give participants advance notice and a reasonable opportunity for payment. A provider, representative, employee, independent contractor, or agent of a pharmaceutical manufacturer shall not make co-payment for a participant. This subsection shall not apply to other qualified children, pregnant women, or blind persons. If the Centers for Medicare and Medicaid Services does not approve the Missouri MO HealthNet state plan amendment submitted by the department of social services that would allow a provider to deny future services to an individual with uncollected co-payments, the denial of services shall not be allowed. The department of social services shall inform providers regarding the acceptability of denying services as the result of unpaid co-payments.
4. The MO HealthNet division shall have the right to collect medication samples from participants in order to maintain program integrity.
5. Reimbursement for obstetrical and pediatric services under subdivision (6) of subsection 1 of this section shall be timely and sufficient to enlist enough health care providers so that care and services are available under the state plan for MO HealthNet benefits at least to the extent that such care and services are available to the general population in the geographic area, as required under subparagraph (a)(30)(A) of 42 U.S.C. 1396a and federal regulations promulgated thereunder.
6. Beginning July 1, 1990, reimbursement for services rendered in federally funded health centers shall be in accordance with the provisions of subsection 6402(c) and Section 6404 of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989) and federal regulations promulgated thereunder.
7. Beginning July 1, 1990, the department of social services shall provide notification and referral of children below age five, and pregnant, breast-feeding, or postpartum women who are determined to be eligible for MO HealthNet benefits under section 208.151 to the special supplemental food programs for women, infants and children administered by the department of health and senior services. Such notification and referral shall conform to the requirements of Section 6406 of P.L. 101-239 and regulations promulgated thereunder.
8. Providers of long-term care services shall be reimbursed for their costs in accordance with the provisions of Section 1902 (a)(13)(A) of the Social Security Act, 42 U.S.C. 1396a, as amended, and regulations promulgated thereunder.
9. Reimbursement rates to long-term care providers with respect to a total change in ownership, at arm's length, for any facility previously licensed and certified for participation in the MO HealthNet program shall not increase payments in excess of the increase that would result from the application of Section 1902 (a)(13)(C) of the Social Security Act, 42 U.S.C. 1396a (a)(13)(C).
10. The MO HealthNet division, may enroll qualified residential care facilities and assisted living facilities, as defined in chapter 198, as MO HealthNet personal care providers.
11. Any income earned by individuals eligible for certified extended employment at a sheltered workshop under chapter 178 shall not be considered as income for purposes of determining eligibility under this section.
334.104. 1. A physician may enter into collaborative practice [arrangements] with registered professional nurses. Collaborative practice [arrangements shall be in the form of written agreements,] shall include jointly agreed-upon written protocols[,] or standing orders for the delivery of health care services. [Collaborative practice arrangements, which shall be in writing,] The written protocols or standing orders may delegate to a registered professional nurse the authority to administer or dispense drugs and provide treatment as long as the delivery of such health care services is within the scope of practice of the registered professional nurse and is consistent with that nurse's skill, training and competence.
2. [Collaborative practice arrangements, which shall be in writing, may delegate to a registered professional nurse the authority to administer, dispense or prescribe drugs and provide treatment if the registered professional nurse is an advanced practice nurse as defined in subdivision (2) of section 335.016. Collaborative practice arrangements may delegate to an advanced practice registered nurse, as defined in section 335.016, the authority to administer, dispense, or prescribe controlled substances listed in Schedules III, IV, and V of section 195.017; except that, the collaborative practice arrangement shall not delegate the authority to administer any controlled substances listed in schedules III, IV, and V of section 195.017 for the purpose of inducing sedation or general anesthesia for therapeutic, diagnostic, or surgical procedures. Schedule III narcotic controlled substance prescriptions shall be limited to a one hundred twenty-hour supply without refill. Such collaborative practice arrangements shall be in the form of written agreements, jointly agreed-upon protocols or standing orders for the delivery of health care services.
3. The written collaborative practice arrangement shall contain at least the following provisions:
(1) Complete names, home and business addresses, zip codes, and telephone numbers of the collaborating physician and the advanced practice registered nurse;
(2) A list of all other offices or locations besides those listed in subdivision (1) of this subsection where the collaborating physician authorized the advanced practice registered nurse to prescribe;
(3) A requirement that there shall be posted at every office where the advanced practice registered nurse is authorized to prescribe, in collaboration with a physician, a prominently displayed disclosure statement informing patients that they may be seen by an advanced practice registered nurse and have the right to see the collaborating physician;
(4) All specialty or board certifications of the collaborating physician and all certifications of the advanced practice registered nurse;
(5) The manner of collaboration between the collaborating physician and the advanced practice registered nurse, including how the collaborating physician and the advanced practice registered nurse will:
(a) Engage in collaborative practice consistent with each professional's skill, training, education, and competence;
(b) Maintain geographic proximity; and
(c) Provide coverage during absence, incapacity, infirmity, or emergency by the collaborating physician;
(6) A description of the advanced practice registered nurse's controlled substance prescriptive authority in collaboration with the physician, including a list of the controlled substances the physician authorizes the nurse to prescribe and documentation that it is consistent with each professional's education, knowledge, skill, and competence;
(7) A list of all other written practice agreements of the collaborating physician and the advanced practice registered nurse;
(8) The duration of the written practice agreement between the collaborating physician and the advanced practice registered nurse;
(9) A description of the time and manner of the collaborating physician's review of the advanced practice registered nurse's delivery of health care services. The description shall include provisions that the advanced practice registered nurse shall submit a minimum of ten percent of the charts documenting the advanced practice registered nurse's delivery of health care services to the collaborating physician for review every fourteen days; and
(10) The collaborating physician shall review every fourteen days a minimum of twenty percent of the charts in which the advanced practice registered nurse prescribes controlled substances. The charts reviewed under this subdivision may be counted in the number of charts required to be reviewed under subdivision (9) of this subsection.
4. The state board of registration for the healing arts pursuant to section 334.125 and the board of nursing pursuant to section 335.036 may jointly promulgate rules regulating the use of collaborative practice arrangements. Such rules shall be limited to specifying geographic areas to be covered, the methods of treatment that may be covered by collaborative practice arrangements and the requirements for review of services provided pursuant to collaborative practice arrangements including delegating authority to prescribe controlled substances. Any rules relating to dispensing or distribution of medications or devices by prescription or prescription drug orders under this section shall be subject to the approval of the state board of pharmacy. Any rules relating to dispensing or distribution of controlled substances by prescription or prescription drug orders under this section shall be subject to the approval of the department of health and senior services and the state board of pharmacy. In order to take effect, such rules shall be approved by a majority vote of a quorum of each board. Neither the state board of registration for the healing arts nor the board of nursing may separately promulgate rules relating to collaborative practice arrangements. Such jointly promulgated rules shall be consistent with guidelines for federally funded clinics. The rulemaking authority granted in this subsection shall not extend to collaborative practice arrangements of hospital employees providing inpatient care within hospitals as defined pursuant to chapter 197 or population-based public health services as defined by 20 CSR 2150-5.100 as of April 30, 2008.
5.] The state board of registration for the healing arts shall not deny, revoke, suspend or otherwise take disciplinary action against a physician for health care services delegated to a registered professional nurse provided the provisions of this section and the rules promulgated thereunder are satisfied. Upon the written request of a physician subject to a disciplinary action imposed as a result of an agreement between a physician and a registered professional nurse or registered physician assistant, whether written or not, prior to August 28, 1993, all records of such disciplinary licensure action and all records pertaining to the filing, investigation or review of an alleged violation of this chapter incurred as a result of such an agreement shall be removed from the records of the state board of registration for the healing arts and the division of professional registration and shall not be disclosed to any public or private entity seeking such information from the board or the division. The state board of registration for the healing arts shall take action to correct reports of alleged violations and disciplinary actions as described in this section which have been submitted to the National Practitioner Data Bank. In subsequent applications or representations relating to his medical practice, a physician completing forms or documents shall not be required to report any actions of the state board of registration for the healing arts for which the records are subject to removal under this section.
[6.] 3. Within thirty days of any change and on each renewal, the state board of registration for the healing arts shall require every physician to identify whether the physician is engaged in [any] collaborative practice [agreement, including collaborative practice agreements delegating the authority to prescribe controlled substances, or] with a registered professional nurse, or in a supervisory arrangement with a physician assistant [agreement] and also report to the board the name of each licensed professional with whom the physician has entered into such [agreement] an arrangement. The board may make this information available to the public. The board shall track the reported information and may routinely conduct random reviews of such [agreements] to ensure [that agreements are carried out for] compliance under this chapter.
[7.] 4. Notwithstanding any law to the contrary, a certified registered nurse anesthetist as defined in subdivision (8) of section 335.016 shall be permitted to provide anesthesia services without a collaborative practice arrangement [provided that he or she is under the supervision of an anesthesiologist or other physician, dentist, or podiatrist who is immediately available if needed. Nothing in this subsection shall be construed to prohibit or prevent a certified registered nurse anesthetist as defined in subdivision (8) of section 335.016 from entering into a collaborative practice arrangement under this section, except that the collaborative practice arrangement may not delegate the authority to prescribe any controlled substances listed in Schedules III, IV, and V of section 195.017.
8. A collaborating physician shall not enter into a collaborative practice arrangement with more than three full-time equivalent advanced practice registered nurses. This limitation shall not apply to collaborative arrangements of hospital employees providing inpatient care service in hospitals as defined in chapter 197 or population-based public health services as defined by 20 CSR 2150-5.100 as of April 30, 2008.
9. It is the responsibility of the collaborating physician to determine and document the completion of at least a one-month period of time during which the advanced practice registered nurse shall practice with the collaborating physician continuously present before practicing in a setting where the collaborating physician is not continuously present. This limitation shall not apply to collaborative arrangements of providers of population-based public health services as defined by 20 CSR 2150-5.100 as of April 30, 2008.
10. No agreement made under this section shall supersede current hospital licensing regulations governing hospital medication orders under protocols or standing orders for the purpose of delivering inpatient or emergency care within a hospital as defined in section 197.020 if such protocols or standing orders have been approved by the hospital's medical staff and pharmaceutical therapeutics committee.
11. No contract or other agreement shall require a physician to act as a collaborating physician for an advanced practice registered nurse against the physician's will. A physician shall have the right to refuse to act as a collaborating physician, without penalty, for a particular advanced practice registered nurse. No contract or other agreement shall limit the collaborating physician's ultimate authority over any protocols or standing orders or in the delegation of the physician's authority to any advanced practice registered nurse, but this requirement shall not authorize a physician in implementing such protocols, standing orders, or delegation to violate applicable standards for safe medical practice established by hospital's medical staff.
12. No contract or other agreement shall require any advanced practice registered nurse to serve as a collaborating advanced practice registered nurse for any collaborating physician against the advanced practice registered nurse's will. An advanced practice registered nurse shall have the right to refuse to collaborate, without penalty, with a particular physician].
334.108. 1. Prior to prescribing any drug, controlled substance, or other treatment through the internet, a physician shall establish a valid physician-patient relationship. This relationship shall include:
(1) Obtaining a reliable medical history and performing a physical examination of the patient, adequate to establish the diagnosis for which the drug is being prescribed and to identify underlying conditions or contraindications to the treatment recommended or provided;
(2) Having sufficient dialogue with the patient regarding treatment options and the risks and benefits of treatment or treatments;
(3) If appropriate, following up with the patient to assess the therapeutic outcome;
(4) Maintaining a contemporaneous medical record that is readily available to the patient and, subject to the patient's consent, to the patient's other health care professionals; and
(5) Including the electronic prescription information as part of the patient's medical record.
2. The requirements of subsection 1 of this section may be satisfied by the prescribing physician's designee when treatment is provided in:
(1) A hospital as defined in section 197.020;
(2) A hospice program as defined in section 197.250;
(3) Home health services provided by a home health agency as defined in section 197.400;
(4) Accordance with a collaborative practice [agreement] arrangement as defined in section 334.104;
(5) Conjunction with a physician assistant licensed pursuant to section 334.738;
(6) Consultation with another physician who has an ongoing physician-patient relationship with the patient, and who has agreed to supervise the patient's treatment, including use of any prescribed medications; or
(7) On-call or cross-coverage situations.
334.810. 1. The "practice of respiratory care" includes, but is not limited to:
(1) The administration of pharmacologic, diagnostic and therapeutic agents related to respiratory care to implement a disease prevention, diagnostic, treatment or pulmonary rehabilitative regimen prescribed by a physician or by clinical protocols pertaining to the practice of respiratory care;
(2) Observing, examining, monitoring, assessment and evaluation of signs, symptoms and general physical response to respiratory care procedures, including whether such are abnormal, and implementation of changes in procedures based on observed abnormalities, appropriate clinical protocols or pursuant to a prescription by a physician licensed under this chapter [334, or a person acting under a collaborative practice agreement as authorized by section 334.104] or an advanced practice registered nurse recognized under chapter 335; or
(3) The initiation of emergency procedures under the regulations of the board or as otherwise permitted in sections 334.800 to 334.930.
2. The practice of respiratory care is not limited to the hospital setting but shall always be performed under the prescription, order or protocol of a licensed physician or an advanced practice registered nurse recognized under chapter 335 and includes the diagnostic and therapeutic use of the following:
(1) Administration of medical gases, except for the purpose of anesthesia;
(2) Administration of pharmacologic agents related to, or in conjunction with, respiratory care procedures;
(3) Aerosolized medications and humidification;
(4) Arterial blood gas puncture or sample collection;
(5) Bronchopulmonary hygiene;
(6) Cardiopulmonary resuscitation;
(7) Environmental control mechanisms and therapy;
(8) Initiation, monitoring, modification of ventilator controls, and discontinuance or withdrawal of continuous mechanical ventilation;
(9) Intubation/extubation of endotracheal tubes, tracheostomy tubes and transtracheal catheters;
(10) Insertion of artificial airways and the maintenance of natural and artificial airways;
(11) Mechanical or physiological ventilatory support;
(12) Point-of-care diagnostic testing;
(13) Specific diagnostic and testing techniques employed in the medical management of patients to assist in diagnosis, monitoring, treatment and research of pulmonary abnormalities, including measurement of ventilatory volumes, pressures, flows, collection of specimens of blood and mucus, measurement and reporting of blood gases, expired and inspired gas samples and pulmonary function testing;
(14) Diagnostic monitoring or therapeutic intervention for oxygen desaturation, aberrant ventilatory patterns and related sleep disorders including obstructive and central apnea; and
(15) Other related physiologic measurements of the cardiopulmonary system.
3. The practice of respiratory care may also include, with special training, the following:
(1) Insertion and maintenance of peripheral arterial or venous lines and hemodynamic monitoring;
(2) Assistance with diagnostic or performing therapeutic bronchoscopy;
(3) Extracorporeal Membrane Oxygenation (ECMO), limited to the intensive care setting, and delivered under the supervision of a Certified Clinical Perfusionist (CCP, as defined by the American Board of Cardiovascular Perfusion, an allied medical professional whose expertise is the science of extracorporeal life support) and a licensed physician;
(4) Air or ground ambulance transport;
(5) Hyperbaric oxygenation therapy;
(6) Electrophysiologic monitoring; or
(7) Other diagnostic testing or special procedures.
4. The state board of registration for the healing arts pursuant to section 334.125, and the board of respiratory care, created pursuant to section 334.830, may jointly promulgate rules defining additional procedures recognized as proper to be performed by respiratory care practitioners. In order to take effect, such rules shall be approved by a majority vote of a quorum of each board. Neither the state board of registration for the healing arts nor the board of respiratory care may separately promulgate rules relating to the practice of respiratory care.
335.016. As used in this chapter, unless the context clearly requires otherwise, the following words and terms mean:
(1) "Accredited", the official authorization or status granted by an agency for a program through a voluntary process;
(2) "Advanced practice registered nurse" or "APRN", a [nurse who has education beyond the basic nursing education and is certified by a nationally recognized professional organization as a certified nurse practitioner, certified nurse midwife, certified registered nurse anesthetist, or a certified clinical nurse specialist. The board shall promulgate rules specifying which nationally recognized professional organization certifications are to be recognized for the purposes of this section. Advanced practice nurses and only such individuals may use the title "Advanced Practice Registered Nurse" and the abbreviation "APRN"] person licensed under this chapter to engage in the practice of advanced practice registered nursing as a certified nurse practitioner, certified clinical nurse specialist, certified nurse midwife, or certified registered nurse anesthetist;
(3) "Advanced practice registered nursing", the performance of an expanded scope of nursing in a role of population focus approved by the board of nursing, with or without compensation or personal profit, and includes the registered professional nurse scope of practice. The scope of practice of an APRN includes, but is not limited to performing acts of advanced assessment, diagnosing, prescribing, ordering, and treatment; serving as primary care providers of record; and practicing as a licensed health care practitioner. Each APRN is accountable to patients, the nursing profession, and the board of nursing for:
(a) Complying with the requirements of the nursing practice act and the quality of advanced nursing care rendered;
(b) Recognizing limits of knowledge and experience;
(c) Planning for the management of situations beyond the APRN's expertise; and
(d) Consulting with or referring patients to other health care providers as appropriate;
(4) "Approval", official recognition of nursing education programs which meet standards established by the board of nursing;
[(4)] (5) "Board" or "state board", the state board of nursing;
[(5)] (6) "Certified clinical nurse specialist", a registered nurse who is currently certified as a clinical nurse specialist by a nationally recognized certifying board approved by the board of nursing;
[(6)] (7) "Certified nurse midwife", a registered nurse who is currently certified as a nurse midwife by the American College of Nurse Midwives, or other nationally recognized certifying body approved by the board of nursing;
[(7)] (8) "Certified nurse practitioner", a registered nurse who is currently certified as a nurse practitioner by a nationally recognized certifying body approved by the board of nursing;
[(8)] (9) "Certified registered nurse anesthetist", a registered nurse who is currently certified as a nurse anesthetist by the [Council on Certification of Nurse Anesthetists] National Board of Certification and Recertification for Nurse Anesthetists, the Council on Recertification of Nurse Anesthetists, or other nationally recognized certifying body approved by the board of nursing;
[(9)] (10) "Executive director", a qualified individual employed by the board as executive secretary or otherwise to administer the provisions of this chapter under the board's direction. Such person employed as executive director shall not be a member of the board;
[(10)] (11) "Inactive nurse", as defined by rule pursuant to section 335.061;
[(11)] (12) "Lapsed license status", as defined by rule under section 335.061;
[(12)] (13) "Licensed practical nurse" or "practical nurse", a person licensed pursuant to the provisions of this chapter to engage in the practice of practical nursing;
[(13)] (14) "Licensure", the issuing of a license to practice advanced practice, professional, or practical nursing to candidates who have met the specified requirements and the recording of the names of those persons as holders of a license to practice advanced practice, professional, or practical nursing;
[(14)] (15) "Practical nursing", the performance for compensation of selected acts for the promotion of health and in the care of persons who are ill, injured, or experiencing alterations in normal health processes. Such performance requires substantial specialized skill, judgment and knowledge. All such nursing care shall be given under the direction of a person licensed by a state regulatory board to prescribe medications and treatments or under the direction of a registered professional nurse. For the purposes of this chapter, the term "direction" shall mean guidance or supervision provided by a person licensed by a state regulatory board to prescribe medications and treatments or a registered professional nurse, including, but not limited to, oral, written, or otherwise communicated orders or directives for patient care. When practical nursing care is delivered pursuant to the direction of a person licensed by a state regulatory board to prescribe medications and treatments or under the direction of a registered professional nurse, such care may be delivered by a licensed practical nurse without direct physical oversight;
[(15)] (16) "Professional nursing", the performance for compensation of any act which requires substantial specialized education, judgment and skill based on knowledge and application of principles derived from the biological, physical, social and nursing sciences, including, but not limited to:
(a) Responsibility for the teaching of health care and the prevention of illness to the patient and his or her family;
(b) Assessment, nursing diagnosis, nursing care, and counsel of persons who are ill, injured or experiencing alterations in normal health processes;
(c) The administration of medications and treatments as prescribed by a person licensed by a state regulatory board to prescribe medications and treatments;
(d) The coordination and assistance in the delivery of a plan of health care with all members of a health team;
(e) The teaching and supervision of other persons in the performance of any of the foregoing;
[(16) A] (17) "Registered professional nurse" or "registered nurse", a person licensed pursuant to the provisions of this chapter to engage in the practice of professional nursing;
[(17)] (18) "Retired license status", any person licensed in this state under this chapter who retires from such practice. Such person shall file with the board an affidavit, on a form to be furnished by the board, which states the date on which the licensee retired from such practice, an intent to retire from the practice for at least two years, and such other facts as tend to verify the retirement as the board may deem necessary; but if the licensee thereafter reengages in the practice, the licensee shall renew his or her license with the board as provided by this chapter and by rule and regulation.
335.019. The board of nursing may grant a certificate of controlled substance prescriptive authority to an advanced practice registered nurse, with the exception of certified registered nurse anesthetist, to administer, dispense, or prescribe controlled substances and provide treatment as long as the delivery of such health care services is within the scope of practice of the advanced practice registered nurse as defined in section 335.016 and is consistent with such nurse's skill, training, and competence who:
(1) Submits proof of successful completion of an advanced pharmacology course that shall include [preceptorial experience in] the prescription of drugs, medicines and therapeutic devices; and
(2) Provides documentation of a minimum of three hundred clock hours preceptorial experience in the prescription of drugs, medicines, and therapeutic devices with a qualified preceptor; and
(3) Provides evidence of a minimum of one thousand hours of practice in an advanced practice nursing category prior to application for a certificate of prescriptive authority for controlled substances. The one thousand hours shall not include clinical hours obtained in the advanced practice nursing education program. The one thousand hours of practice in an advanced practice nursing category may include transmitting a prescription order orally or telephonically or to an inpatient medical record from protocols developed in collaboration with and signed by a licensed physician[; and] or an advanced practice registered nurse, as defined in section 335.016, and has a certificate of controlled substance prescriptive authority.
[(4) Has a controlled substance prescribing authority delegated in the collaborative practice arrangement under section 334.104 with a physician who has an unrestricted federal Drug Enforcement Administration registration number and who is actively engaged in a practice comparable in scope, specialty, or expertise to that of the advanced practice registered nurse.]
335.046. 1. An applicant for a license to practice as a registered professional nurse shall submit to the board a written application on forms furnished to the applicant. The original application shall contain the applicant's statements showing the applicant's education and other such pertinent information as the board may require. The applicant shall be of good moral character and have completed at least the high school course of study, or the equivalent thereof as determined by the state board of education, and have successfully completed the basic professional curriculum in an accredited or approved school of nursing and earned a professional nursing degree or diploma. Each application shall contain a statement that it is made under oath or affirmation and that its representations are true and correct to the best knowledge and belief of the person signing same, subject to the penalties of making a false affidavit or declaration. Applicants from non-English-speaking lands shall be required to submit evidence of proficiency in the English language. The applicant must be approved by the board and shall pass an examination as required by the board. The board may require by rule as a requirement for licensure that each applicant shall pass an oral or practical examination. Upon successfully passing the examination, the board may issue to the applicant a license to practice nursing as a registered professional nurse. The applicant for a license to practice registered professional nursing shall pay a license fee in such amount as set by the board. The fee shall be uniform for all applicants. Applicants from foreign countries shall be licensed as prescribed by rule.
2. An applicant for license to practice as a licensed practical nurse shall submit to the board a written application on forms furnished to the applicant. The original application shall contain the applicant's statements showing the applicant's education and other such pertinent information as the board may require. Such applicant shall be of good moral character, and have completed at least two years of high school, or its equivalent as established by the state board of education, and have successfully completed a basic prescribed curriculum in a state-accredited or approved school of nursing, earned a nursing degree, certificate or diploma and completed a course approved by the board on the role of the practical nurse. Each application shall contain a statement that it is made under oath or affirmation and that its representations are true and correct to the best knowledge and belief of the person signing same, subject to the penalties of making a false affidavit or declaration. Applicants from non-English-speaking countries shall be required to submit evidence of their proficiency in the English language. The applicant must be approved by the board and shall pass an examination as required by the board. The board may require by rule as a requirement for licensure that each applicant shall pass an oral or practical examination. Upon successfully passing the examination, the board may issue to the applicant a license to practice as a licensed practical nurse. The applicant for a license to practice licensed practical nursing shall pay a fee in such amount as may be set by the board. The fee shall be uniform for all applicants. Applicants from foreign countries shall be licensed as prescribed by rule.
3. (1) An applicant for a license to practice as an advanced practice registered nurse shall submit to the board a written application on forms furnished to the applicant. The application shall contain the following:
(a) The applicant's statements showing:
a. The applicant's education;
b. Current licensure as a registered professional nurse;
c. Advanced practice clinical nursing specialty area; and
d. Role in which the applicant is certified by a nationally recognized certifying body approved by the board; and
(b) Any other such pertinent information as the board may require;
(c) A statement that it is made under oath or affirmation and that the representations are true and correct to the best knowledge and belief of the person signing the statement, subject to the penalties of making a false affidavit or declaration; and
(d) For applicants from non-English-speaking lands, submission of evidence of proficiency in the English language.
(2) The board of nursing may promulgate rules specifying the criteria by which nationally recognized certifying bodies are to be recognized, standards for continued licensure of an advanced practice registered nurse, and such other rules as are necessary to enable the board to carry out this provision.
(3) The applicant shall:
(a) Be of good moral character;
(b) Have successfully completed the basic professional curriculum in an accredited or approved school of nursing;
(c) Earned a professional nursing degree or diploma; and
(d) Have successfully completed a graduate or postgraduate advanced practice registered nurse program accredited by the appropriate national accrediting body and earned a graduate degree or postgraduate certificate.
(4) An applicant for licensure to practice advanced practice registered nursing shall pay a license fee in such amount as set by the board. The fee shall be uniform for all applicants.
(5) Applicants from foreign countries shall be licensed as prescribed by rule.
(6) Upon submission of a completed application and required fee, the board may issue to the applicant a license to practice advanced practice registered nursing as an advanced practice registered nurse.
4. Upon refusal of the board to allow any applicant to sit for either the registered professional nurses' examination or the licensed practical nurses' examination, as the case may be, the board shall comply with the provisions of section 621.120 and advise the applicant of his or her right to have a hearing before the administrative hearing commission. The administrative hearing commission shall hear complaints taken pursuant to section 621.120.
[4.] 5. The board shall not deny a license because of sex, religion, race, ethnic origin, age or political affiliation.
338.198. Other provisions of law to the contrary notwithstanding, a pharmacist may fill a physician's prescription or the prescription of an advanced practice nurse working [under a collaborative practice arrangement with a physician,] when it is forwarded to the pharmacist by a registered professional nurse or registered physician's assistant or other authorized agent. [The written collaborative practice arrangement shall specifically state that the registered professional nurse or registered physician assistant is permitted to authorize a pharmacist to fill a prescription on behalf of the physician.]
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