Bill Text: TX HB2029 | 2021-2022 | 87th Legislature | Introduced

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Bill Title: Relating to the licensing and authority of advanced practice registered nurses.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced - Dead) 2021-03-24 - Left pending in committee [HB2029 Detail]

Download: Texas-2021-HB2029-Introduced.html

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87R3775 BEE-F
By: Klick H.B. No. 2029

A BILL TO BE ENTITLED
AN ACT
relating to the licensing and authority of advanced practice
registered nurses.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
ARTICLE 1. ADVANCED PRACTICE REGISTERED NURSES
SECTION 1.001. Section 301.002, Occupations Code, is
amended to read as follows:
Sec. 301.002. DEFINITIONS. In this chapter:
(1) "Advanced practice registered nurse" means a
registered nurse licensed by the board to practice as an advanced
practice registered nurse on the basis of completion of an advanced
educational program. The term includes a nurse practitioner, nurse
midwife, nurse anesthetist, and clinical nurse specialist.
(2) [(1)] "Board" means the Texas Board of Nursing.
(3) [(1-a)] "Chief nursing officer" means the
registered nurse who is administratively responsible for the
nursing services at a facility.
(4) "Controlled substance" has the meaning assigned by
Section 481.002, Health and Safety Code.
(5) "Dangerous drug" has the meaning assigned by
Section 483.001, Health and Safety Code.
(6) "Device" has the meaning assigned by Section
551.003, and includes durable medical equipment.
(7) "Nonprescription drug" has the meaning assigned by
Section 551.003.
(8) "Nurse" means a person required to be licensed
under this chapter to engage in professional or vocational nursing.
(9) "Nursing" means professional or vocational
nursing.
(10) [(1-b)] "Patient safety committee" has the
meaning assigned by Section 303.001.
(11) "Prescribe or order a drug or device" has the
meaning assigned by Section 157.051.
(12) [(2)] "Professional nursing" means the
performance of an act that requires substantial specialized
judgment and skill, the proper performance of which is based on
knowledge and application of the principles of biological,
physical, and social science as acquired by a completed course in an
approved school of professional nursing. The term does not include
acts of medical diagnosis or the prescription of therapeutic or
corrective measures, except as authorized for an advanced practice
registered nurse. Professional nursing involves:
(A) the observation, assessment, intervention,
evaluation, rehabilitation, care and counsel, or health teachings
of a person who is ill, injured, infirm, or experiencing a change in
normal health processes;
(B) the maintenance of health or prevention of
illness;
(C) the administration of a medication or
treatment as ordered by a health care practitioner legally
authorized to prescribe the medication or treatment [physician,
podiatrist, or dentist];
(D) the supervision or teaching of nursing;
(E) the administration, supervision, and
evaluation of nursing practices, policies, and procedures;
(F) [the requesting, receiving, signing for, and
distribution of prescription drug samples to patients at practices
at which an advanced practice registered nurse is authorized to
sign prescription drug orders as provided by Subchapter B, Chapter
157;
[(G)] the performance of an act by an advanced
practice registered nurse [delegated by a physician under Section
157.0512, 157.054, 157.058, or 157.059]; and
(G) [(H)] the development of the nursing care
plan.
[(3) "Nurse" means a person required to be licensed
under this chapter to engage in professional or vocational nursing.
[(4) "Nursing" means professional or vocational
nursing.]
(13) [(5)] "Vocational nursing" means a directed
scope of nursing practice, including the performance of an act that
requires specialized judgment and skill, the proper performance of
which is based on knowledge and application of the principles of
biological, physical, and social science as acquired by a completed
course in an approved school of vocational nursing. The term does
not include acts of medical diagnosis or the prescription of
therapeutic or corrective measures. Vocational nursing involves:
(A) collecting data and performing focused
nursing assessments of the health status of an individual;
(B) participating in the planning of the nursing
care needs of an individual;
(C) participating in the development and
modification of the nursing care plan;
(D) participating in health teaching and
counseling to promote, attain, and maintain the optimum health
level of an individual;
(E) assisting in the evaluation of an
individual's response to a nursing intervention and the
identification of an individual's needs; and
(F) engaging in other acts that require education
and training, as prescribed by board rules and policies,
commensurate with the nurse's experience, continuing education,
and demonstrated competency.
SECTION 1.002. Section 301.005(b), Occupations Code, is
amended to read as follows:
(b) A reference in any other law to an "advanced nurse
practitioner," [or] "advanced practice nurse," or "advanced
practice registered nurse" means an advanced practice registered
nurse.
SECTION 1.003. Section 301.152, Occupations Code, is
transferred to Subchapter H, Chapter 301, Occupations Code,
redesignated as Section 301.357, Occupations Code, and amended to
read as follows:
Sec. 301.357 [301.152]. ADVANCED PRACTICE REGISTERED NURSES
[RULES REGARDING SPECIALIZED TRAINING]. (a) Advanced practice
registered nursing includes:
(1) ordering, performing, and interpreting diagnostic
tests;
(2) formulating primary and differential medical
diagnoses and advanced assessments;
(3) treating actual and potential health problems;
(4) prescribing therapeutic and corrective measures,
including nutrition and diagnostic support services, home health
care, hospice care, physical therapy, and occupational therapy, and
delegating and assigning the performance of therapeutic and
corrective measures to assistive personnel;
(5) to the extent authorized by the board under
Section 301.358, prescribing, ordering, procuring, administering,
and dispensing drugs and devices, including blood and blood
products, controlled substances listed in Schedules II, III, IV,
and V, dangerous drugs, and nonprescription drugs;
(6) providing referrals to health care agencies,
health care providers, and community resources;
(7) serving as the primary care provider of record;
and
(8) performing other acts that require education and
training consistent with professional standards and that are
commensurate with the advanced practice registered nurse's
education, licensure, and demonstrated competencies and
experience. [In this section, "advanced practice registered nurse"
means a registered nurse licensed by the board to practice as an
advanced practice registered nurse on the basis of completion of an
advanced educational program. The term includes a nurse
practitioner, nurse midwife, nurse anesthetist, and clinical nurse
specialist. The term is synonymous with "advanced nurse
practitioner" and "advanced practice nurse."]
(b) The board shall adopt rules to:
(1) license a registered nurse as an advanced practice
registered nurse;
(2) establish:
(A) any specialized education or training,
including pharmacology, that an advanced practice registered nurse
must have to prescribe or order a drug or device as authorized
[delegated] by the board [a physician] under Section 301.358
[157.0512 or 157.054];
(B) a system for approving an advanced practice
registered nurse to prescribe or order a drug or device as
authorized [delegated] by the board [a physician] under Section
301.358 [157.0512 or 157.054] on the receipt of evidence of
completing the specialized education and training requirement
under Paragraph (A); and
(C) a system for issuing a prescription
authorization number to an advanced practice registered nurse
approved under Paragraph (B); and
(3) concurrently renew any license or approval granted
to an advanced practice registered nurse under this subsection and
a license renewed by the advanced practice registered nurse under
Section 301.301.
(c) At a minimum, the rules adopted under Subsection (b)(2)
must:
(1) require completion of pharmacology and related
pathophysiology education for initial approval; and
(2) require continuing education in clinical
pharmacology and related pathophysiology in addition to any
continuing education otherwise required under Section 301.303.
(d) The signature of an advanced practice registered nurse
attesting to the provision of a legally authorized service by the
advanced practice registered nurse satisfies any documentation
requirement for that service established by a state agency.
(e) An advanced practice registered nurse shall practice as
a licensed independent practitioner in accordance with standards
established and recognized by the board to protect the public
health and safety.
(f) An advanced practice registered nurse is accountable to
patients, the nursing profession, and the board for:
(1) complying with the requirements of this chapter;
(2) providing quality advanced nursing care;
(3) recognizing the nurse's limits of knowledge;
(4) planning for the management of situations beyond
the nurse's expertise; and
(5) consulting with or referring patients to other
health care providers as appropriate.
(g) This section does not limit or modify the scope of
practice of a registered nurse who is not an advanced practice
registered nurse.
(h) Notwithstanding any other law, an advanced practice
registered nurse performing an act described by Subsection (a) is
not considered to be practicing medicine without a license.
SECTION 1.004. Section 301.354(a), Occupations Code, is
amended to read as follows:
(a) In this section, "nurse first assistant" means a
registered nurse who:
(1) has completed a nurse first assistant educational
program approved or recognized by an organization recognized by the
board; and
(2) [is] either:
(A) is certified in perioperative nursing by an
organization recognized by the board; or
(B) is [recognized by the board as] an advanced
practice registered nurse [and] qualified by education, training,
or experience to perform the tasks involved in perioperative
nursing.
SECTION 1.005. Subchapter H, Chapter 301, Occupations Code,
is amended by adding Section 301.358 to read as follows:
Sec. 301.358. PRESCRIBING AND ORDERING AUTHORITY OF
ADVANCED PRACTICE REGISTERED NURSE. (a) The board may authorize an
advanced practice registered nurse to prescribe and order drugs and
devices, including controlled substances listed in Schedules III,
IV, and V, dangerous drugs, and nonprescription drugs.
(b) Except as provided by Subsection (c), the board may
authorize an advanced practice registered nurse to prescribe and
order controlled substances listed in Schedule II only:
(1) in a hospital facility-based practice in
accordance with policies approved by the hospital's medical staff
or a committee of the hospital's medical staff as provided by the
hospital bylaws to ensure patient safety, and as part of the care
provided to a patient who:
(A) has been admitted to the hospital and is
expected to remain in the hospital for a period of 24 hours or more;
or
(B) is receiving services in the emergency
department of the hospital; or
(2) as part of the plan of care for the treatment of a
person who has executed a written certification of a terminal
illness, has elected to receive hospice care, and is receiving
hospice treatment from a qualified hospice provider.
(c) The board may authorize a certified registered nurse
anesthetist practicing in an ambulatory surgical center to order
drugs and devices necessary for the nurse anesthetist to administer
an anesthetic or anesthesia-related service.
ARTICLE 2. CONFORMING AMENDMENTS REGARDING DELEGATION
SECTION 2.001. The heading to Subchapter B, Chapter 157,
Occupations Code, is amended to read as follows:
SUBCHAPTER B. DELEGATION TO [ADVANCED PRACTICE REGISTERED NURSES
AND] PHYSICIAN ASSISTANTS
SECTION 2.002. Sections 157.051(11) and (14), Occupations
Code, are amended to read as follows:
(11) "Practice serving a medically underserved
population" means:
(A) a practice in a health professional shortage
area;
(B) a clinic designated as a rural health clinic
under 42 U.S.C. Section 1395x(aa);
(C) a public health clinic or a family planning
clinic under contract with the Health and Human Services Commission
or the Department of State Health Services;
(D) a clinic designated as a federally qualified
health center under 42 U.S.C. Section 1396d(l)(2)(B);
(E) a county, state, or federal correctional
facility;
(F) a practice:
(i) that either:
(a) is located in an area in which the
Department of State Health Services determines there is an
insufficient number of physicians providing services to eligible
clients of federally, state, or locally funded health care
programs; or
(b) is a practice that the Department
of State Health Services determines serves a disproportionate
number of clients eligible to participate in federally, state, or
locally funded health care programs; and
(ii) for which the Department of State
Health Services publishes notice of the department's determination
in the Texas Register and provides an opportunity for public
comment in the manner provided for a proposed rule under Chapter
2001, Government Code; or
(G) a practice at which a physician was
delegating prescriptive authority to an advanced practice
registered nurse, as defined by Section 301.002, or physician
assistant on or before March 1, 2013, based on the practice
qualifying as a site serving a medically underserved population.
(14) "Prescriptive authority agreement" means an
agreement entered into by a physician and a [an advanced practice
registered nurse or] physician assistant through which the
physician delegates to the [advanced practice registered nurse or]
physician assistant the act of prescribing or ordering a drug or
device.
SECTION 2.003. Section 157.0511(b-2), Occupations Code, is
amended to read as follows:
(b-2) The board shall adopt rules that require a physician
who delegates the prescribing or ordering of a drug or device to
register with the board the name and license number of the physician
assistant [or advanced practice registered nurse] to whom a
delegation is made. The board may develop and use an electronic
online delegation registration process for registration under this
subsection.
SECTION 2.004. Sections 157.0512(a), (b), (c), (e), (f),
(g), (i), (j), (l), (m), (n), and (o), Occupations Code, are amended
to read as follows:
(a) A physician may delegate to a [an advanced practice
registered nurse or] physician assistant, acting under adequate
physician supervision, the act of prescribing or ordering a drug or
device as authorized through a prescriptive authority agreement
between the physician and the [advanced practice registered nurse
or] physician assistant[, as applicable].
(b) A physician and a [an advanced practice registered nurse
or] physician assistant are eligible to enter into or be parties to
a prescriptive authority agreement only if:
(1) [if applicable, the Texas Board of Nursing has
approved the advanced practice registered nurse's authority to
prescribe or order a drug or device as authorized under this
subchapter;
[(2)] the [advanced practice registered nurse or]
physician assistant:
(A) holds an active license to practice in this
state as a [an advanced practice registered nurse or] physician
assistant[, as applicable,] and is in good standing in this state;
and
(B) is not currently prohibited by the [Texas
Board of Nursing or the] Texas Physician Assistant Board[, as
applicable,] from executing a prescriptive authority agreement;
and
(2) [(3)] before executing the prescriptive authority
agreement, the physician and the [advanced practice registered
nurse or] physician assistant disclose to the other prospective
party to the agreement any prior disciplinary action by the board[,
the Texas Board of Nursing,] or the Texas Physician Assistant
Board[, as applicable].
(c) Except as provided by Subsection (d), the [combined]
number of [advanced practice registered nurses and] physician
assistants with whom a physician may enter into a prescriptive
authority agreement may not exceed seven [advanced practice
registered nurses and] physician assistants or the full-time
equivalent of seven [advanced practice registered nurses and]
physician assistants.
(e) A prescriptive authority agreement must, at a minimum:
(1) be in writing and signed and dated by the parties
to the agreement;
(2) state the name, address, and all professional
license numbers of the parties to the agreement;
(3) state the nature of the practice, practice
locations, or practice settings;
(4) identify the types or categories of drugs or
devices that may be prescribed or the types or categories of drugs
or devices that may not be prescribed;
(5) provide a general plan for addressing consultation
and referral;
(6) provide a plan for addressing patient emergencies;
(7) state the general process for communication and
the sharing of information between the physician and the [advanced
practice registered nurse or] physician assistant to whom the
physician has delegated prescriptive authority related to the care
and treatment of patients;
(8) if alternate physician supervision is to be
utilized, designate one or more alternate physicians who may:
(A) provide appropriate supervision on a
temporary basis in accordance with the requirements established by
the prescriptive authority agreement and the requirements of this
subchapter; and
(B) participate in the prescriptive authority
quality assurance and improvement plan meetings required under this
section; and
(9) describe a prescriptive authority quality
assurance and improvement plan and specify methods for documenting
the implementation of the plan that include the following:
(A) chart review, with the number of charts to be
reviewed determined by the physician and [advanced practice
registered nurse or] physician assistant; and
(B) periodic meetings between the [advanced
practice registered nurse or] physician assistant and the
physician.
(f) The periodic meetings described by Subsection (e)(9)(B)
must:
(1) include:
(A) the sharing of information relating to
patient treatment and care, needed changes in patient care plans,
and issues relating to referrals; and
(B) discussion of patient care improvement;
(2) be documented; and
(3) take place at least once a month in a manner
determined by the physician and the [advanced practice registered
nurse or] physician assistant.
(g) The prescriptive authority agreement may include other
provisions agreed to by the physician and [advanced practice
registered nurse or] physician assistant.
(i) The prescriptive authority agreement need not describe
the exact steps that a [an advanced practice registered nurse or]
physician assistant must take with respect to each specific
condition, disease, or symptom.
(j) A physician[, advanced practice registered nurse,] or
physician assistant who is a party to a prescriptive authority
agreement must retain a copy of the agreement until the second
anniversary of the date the agreement is terminated.
(l) In the event that a party to a prescriptive authority
agreement is notified that the individual has become the subject of
an investigation by the board[, the Texas Board of Nursing,] or the
Texas Physician Assistant Board, the individual shall immediately
notify the other party to the prescriptive authority agreement.
(m) The prescriptive authority agreement and any amendments
must be reviewed at least annually, dated, and signed by the parties
to the agreement. The prescriptive authority agreement and any
amendments must be made available to the board[, the Texas Board of
Nursing,] or the Texas Physician Assistant Board not later than the
third business day after the date of receipt of request, if any.
(n) The prescriptive authority agreement should promote the
exercise of professional judgment by the [advanced practice
registered nurse or] physician assistant commensurate with the
[advanced practice registered nurse's or] physician assistant's
education and experience and the relationship between the [advanced
practice registered nurse or] physician assistant and the
physician.
(o) This section shall be liberally construed to allow the
use of prescriptive authority agreements to safely and effectively
utilize the skills and services of [advanced practice registered
nurses and] physician assistants.
SECTION 2.005. Section 157.0513, Occupations Code, is
amended to read as follows:
Sec. 157.0513. PRESCRIPTIVE AUTHORITY AGREEMENT:
INFORMATION. (a) The board[, the Texas Board of Nursing,] and the
Texas Physician Assistant Board shall jointly develop a process:
(1) to exchange information regarding the names,
locations, and license numbers of each physician[, advanced
practice registered nurse,] and physician assistant who has entered
into a prescriptive authority agreement;
(2) by which each board shall immediately notify the
other board [boards] when a license holder of the board becomes the
subject of an investigation involving the delegation and
supervision of prescriptive authority, as well as the final
disposition of any such investigation;
(3) by which each board shall maintain and share a list
of the board's license holders who have been subject to a final
adverse disciplinary action for an act involving the delegation and
supervision of prescriptive authority; and
(4) to ensure that each [advanced practice registered
nurse or] physician assistant who has entered into a prescriptive
authority agreement authorizing the prescribing of opioids is
required to complete not less than two hours of continuing
education annually regarding safe and effective pain management
related to the prescription of opioids and other controlled
substances, including education regarding:
(A) reasonable standards of care;
(B) the identification of drug-seeking behavior
in patients; and
(C) effectively communicating with patients
regarding the prescription of an opioid or other controlled
substance.
(b) If the board[, the Texas Board of Nursing,] or the Texas
Physician Assistant Board receives a notice under Subsection
(a)(2), the board that received notice may open an investigation
against a license holder of the board who is a party to a
prescriptive authority agreement with the license holder who is
under investigation by the board that provided notice under
Subsection (a)(2).
(c) The board shall maintain and make available to the
public a searchable online list of physicians[, advanced practice
registered nurses,] and physician assistants who have entered into
a prescriptive authority agreement authorized under Section
157.0512 and identify the physician[, advanced practice registered
nurse, or physician assistant] with whom each [physician, advanced
practice registered nurse, and] physician assistant has entered
into a prescriptive authority agreement.
(d) The board shall collaborate with the [Texas Board of
Nursing and the] Texas Physician Assistant Board to maintain and
make available to the public a list of physicians[, advanced
practice registered nurses,] and physician assistants who are
prohibited from entering into or practicing under a prescriptive
authority agreement.
SECTION 2.006. Sections 157.054(a), (a-1), (b), and (c),
Occupations Code, are amended to read as follows:
(a) One or more physicians licensed by the board may
delegate, to one or more physician assistants [or advanced practice
registered nurses] acting under adequate physician supervision
whose practice is facility-based at a hospital or licensed
long-term care facility, the administration or provision of a drug
and the prescribing or ordering of a drug or device if each of the
delegating physicians is:
(1) the medical director or chief of medical staff of
the facility in which the physician assistant [or advanced practice
registered nurse] practices;
(2) the chair of the facility's credentialing
committee;
(3) a department chair of a facility department in
which the physician assistant [or advanced practice registered
nurse] practices; or
(4) a physician who consents to the request of the
medical director or chief of medical staff to delegate the
prescribing or ordering of a drug or device at the facility in which
the physician assistant [or advanced practice registered nurse]
practices.
(a-1) The limit [limits] on the number of [advanced practice
registered nurses or] physician assistants to whom a physician may
delegate under Section 157.0512 does [do] not apply to a physician
under Subsection (a) whose practice is facility-based under this
section, provided that the physician is not delegating in a
freestanding clinic, center, or practice of the facility.
(b) A physician's authority to delegate under Subsection
(a) is limited as follows:
(1) the delegation must be made under a physician's
order, standing medical order, standing delegation order, or
another order or protocol developed in accordance with policies
approved by the facility's medical staff or a committee of the
facility's medical staff as provided by the facility bylaws;
(2) the delegation must occur in the facility in which
the physician is the medical director, the chief of medical staff,
the chair of the credentialing committee, a department chair, or a
physician who consents to delegate under Subsection (a)(4);
(3) the delegation may not permit the prescribing or
ordering of a drug or device for the care or treatment of the
patients of any other physician without the prior consent of that
physician; and
(4) delegation in a long-term care facility must be by
the medical director and is limited to the prescribing or ordering
of a drug or device to not more than seven [advanced practice
registered nurses or] physician assistants or their full-time
equivalents.
(c) Physician supervision of the prescribing or ordering of
a drug or device must conform to what a reasonable, prudent
physician would find consistent with sound medical judgment but may
vary with the education and experience of the particular [advanced
practice registered nurse or] physician assistant. A physician
shall provide continuous supervision, but the constant physical
presence of the physician is not required.
SECTION 2.007. Section 157.055, Occupations Code, is
amended to read as follows:
Sec. 157.055. ORDERS AND PROTOCOLS. A protocol or other
order shall be defined in a manner that promotes the exercise of
professional judgment by the [advanced practice registered nurse
and] physician assistant commensurate with the education and
experience of that person. Under this section, an order or
protocol used by a reasonable and prudent physician exercising
sound medical judgment:
(1) is not required to describe the exact steps that
[an advanced practice registered nurse or] a physician assistant
must take with respect to each specific condition, disease, or
symptom; and
(2) may state the types or categories of medications
that may be prescribed or the types or categories of medications
that may not be prescribed.
SECTION 2.008. Section 157.056, Occupations Code, is
amended to read as follows:
Sec. 157.056. PRESCRIPTION INFORMATION. The following
information must be provided on each prescription subject to this
subchapter:
(1) the patient's name and address;
(2) the drug to be dispensed;
(3) directions to the patient regarding the taking of
the drug and the dosage;
(4) the intended use of the drug, if appropriate;
(5) the name, address, and telephone number of the
physician;
(6) the name, address, telephone number, and
identification number of the [registered nurse or] physician
assistant completing or signing the prescription drug order;
(7) the date; and
(8) the number of refills permitted.
SECTION 2.009. Sections 157.059(b), (e), (f), (g), (h), and
(i), Occupations Code, are amended to read as follows:
(b) A physician may delegate to a physician assistant
offering obstetrical services and certified by the board as
specializing in obstetrics [or an advanced practice registered
nurse recognized by the Texas Board of Nursing as a nurse midwife]
the act of administering or providing controlled substances to the
physician assistant's [or nurse midwife's] clients during
intrapartum and immediate postpartum care.
(e) The physician's orders, medical orders, standing
delegation orders, prescriptive authority agreements, or protocols
must require the reporting of or monitoring of each client's
progress, including complications of pregnancy and delivery and the
administration and provision of controlled substances by the [nurse
midwife or] physician assistant to the clients of the [nurse
midwife or] physician assistant.
(f) The authority of a physician to delegate under this
section is limited to:
(1) seven [nurse midwives or] physician assistants or
their full-time equivalents; and
(2) the designated facility at which the [nurse
midwife or] physician assistant provides care.
(g) The controlled substance must be supplied in a suitable
container that is labeled in compliance with the applicable drug
laws and must include:
(1) the patient's name and address;
(2) the drug to be provided;
(3) the name, address, and telephone number of the
physician;
(4) the name, address, and telephone number of the
[nurse midwife or] physician assistant; and
(5) the date.
(h) This section does not authorize a physician or [,]
physician assistant[, or nurse midwife] to operate a retail
pharmacy as defined under Subtitle J.
(i) This section authorizes a physician to delegate the act
of administering or providing a controlled substance to a [nurse
midwife or] physician assistant but does not require physician
delegation of[:
[(1) further acts to a nurse midwife; or
[(2)] the administration of medications by a physician
assistant [or registered nurse] other than as provided by this
section.
SECTION 2.010. Section 157.060, Occupations Code, is
amended to read as follows:
Sec. 157.060. PHYSICIAN LIABILITY FOR DELEGATED
ACT. Unless the physician has reason to believe the physician
assistant [or advanced practice registered nurse] lacked the
competency to perform the act, a physician is not liable for an act
of a physician assistant [or advanced practice registered nurse]
solely because the physician signed a standing medical order, a
standing delegation order, or another order or protocol, or entered
into a prescriptive authority agreement, authorizing the physician
assistant [or advanced practice registered nurse] to administer,
provide, prescribe, or order a drug or device.
ARTICLE 3. GENERAL CONFORMING AMENDMENTS
SECTION 3.001. Section 38.151(1), Education Code, is
amended to read as follows:
(1) "Advanced practice nurse" has the meaning assigned
to "advanced practice registered nurse" by Section 301.002
[301.152], Occupations Code.
SECTION 3.002. Section 61.601, Education Code, as amended
by Chapters 891 (H.B. 3083) and 1101 (H.B. 3808), Acts of the 85th
Legislature, Regular Session, 2017, is reenacted and amended to
read as follows:
Sec. 61.601. DEFINITION. In this subchapter, "mental
health professional" means:
(1) a licensed physician who is:
(A) a graduate of an accredited psychiatric
residency training program; or
(B) certified in psychiatry by:
(i) the American Board of Psychiatry and
Neurology; or
(ii) the American Osteopathic Board of
Neurology and Psychiatry;
(2) a psychologist, as defined by Section 501.002,
Occupations Code;
(3) a licensed professional counselor, as defined by
Section 503.002, Occupations Code;
(4) an advanced practice registered nurse, as defined
by Section 301.002 [301.152], Occupations Code, who holds a
nationally recognized board certification in psychiatric or mental
health nursing;
(5) a licensed clinical social worker, as defined by
Section 505.002, Occupations Code; [and]
(6) a licensed marriage and family therapist, as
defined by Section 502.002, Occupations Code; and
(7) [(6)] a chemical dependency counselor, as defined
by Section 504.001, Occupations Code.
SECTION 3.003. Section 263.001(a)(1), Family Code, is
amended to read as follows:
(1) "Advanced practice nurse" has the meaning assigned
to "advanced practice registered nurse" by Section 301.002
[157.051], Occupations Code.
SECTION 3.004. Section 266.001(1), Family Code, is amended
to read as follows:
(1) "Advanced practice nurse" has the meaning assigned
to "advanced practice registered nurse" by Section 301.002
[157.051], Occupations Code.
SECTION 3.005. Section 531.0217(k), Government Code, is
amended to read as follows:
(k) This section does not affect any requirement relating
to:
(1) a rural health clinic; or
(2) physician delegation of the authority to carry out
or sign prescription drug orders to a [an advanced practice nurse
or] physician assistant.
SECTION 3.006. Section 671.001(b), Government Code, is
amended to read as follows:
(b) The pilot program must provide for the following:
(1) a licensed advanced practice registered nurse as
defined by Section 301.002 [301.152], Occupations Code, or a
licensed physician assistant as described by Chapter 204,
Occupations Code, who is employed by the state or whose services are
acquired by contract, who will be located at a state office complex;
(2) if applicable, a licensed physician, who is
employed by a state governmental entity for purposes other than the
pilot program or whose services are acquired by contract, who will
delegate to and supervise the [advanced practice registered nurse
or] physician assistant under a prescriptive authority agreement
under Chapter 157, Occupations Code;
(3) appropriate office space and equipment for the
advanced practice registered nurse or physician assistant to
provide basic medical care to employees at the state office complex
where the nurse or physician assistant is located; and
(4) professional liability insurance covering
services provided by the advanced practice registered nurse or the
physician assistant.
SECTION 3.007. Section 47.001(3), Health and Safety Code,
is amended to read as follows:
(3) "Health care provider" means:
(A) [a registered nurse recognized as] an
advanced practice registered nurse as defined by Section 301.002,
Occupations Code; [the Texas Board of Nursing] or
(B) a physician assistant licensed by the Texas
Physician Assistant Board.
SECTION 3.008. Section 47.011(a), Health and Safety Code,
is amended to read as follows:
(a) In this section, "midwife" has the meaning assigned by
Section 203.002, Occupations Code, and includes a nurse midwife
[described by Section 301.152, Occupations Code].
SECTION 3.009. Sections 161.0052(b) and (c), Health and
Safety Code, are amended to read as follows:
(b) The executive commissioner by rule shall require a
hospital to inform each elderly person admitted to the hospital for
a period of 24 hours or more that the pneumococcal and influenza
vaccines are available. If the elderly person requests a vaccine,
and if a physician, [or] an advanced nurse practitioner, or a
physician assistant on behalf of a physician, determines that the
vaccine is in the person's best interest, the hospital must make the
vaccination available to the person before the person is discharged
from the hospital.
(c) The executive commissioner by rule shall require an end
stage renal disease facility to offer, to the extent possible as
determined by the facility, the opportunity to receive the
pneumococcal and influenza vaccines to each elderly person who
receives ongoing care at the facility if a physician, [or] an
advanced nurse practitioner, or a physician assistant on behalf of
a physician, determines that the vaccine is in the person's best
interest. If the facility decides it is not feasible to offer the
vaccine, the facility must provide the person with information on
other options for obtaining the vaccine.
SECTION 3.010. Section 241.003(1), Health and Safety Code,
is amended to read as follows:
(1) "Advanced practice nurse" has the meaning assigned
to "advanced practice registered nurse" by Section 301.002,
Occupations Code [means a registered nurse recognized as an
advanced practice nurse by the Texas Board of Nursing].
SECTION 3.011. Section 481.002(39), Health and Safety Code,
is amended to read as follows:
(39) "Practitioner" means:
(A) a physician, dentist, veterinarian,
podiatrist, scientific investigator, advanced practice registered
nurse, or other person licensed, registered, or otherwise permitted
to distribute, dispense, analyze, conduct research with respect to,
or administer a controlled substance in the course of professional
practice or research in this state;
(B) a pharmacy, hospital, or other institution
licensed, registered, or otherwise permitted to distribute,
dispense, conduct research with respect to, or administer a
controlled substance in the course of professional practice or
research in this state;
(C) a person practicing in and licensed by
another state as a physician, dentist, veterinarian, advanced
practice registered nurse, or podiatrist, having a current Federal
Drug Enforcement Administration registration number, who may
legally prescribe Schedule II, III, IV, or V controlled substances
in that state; or
(D) a [an advanced practice registered nurse or]
physician assistant to whom a physician has delegated the authority
to prescribe or order a drug or device under Section 157.0511,
157.0512, or 157.054, Occupations Code.
SECTION 3.012. Section 481.074(d), Health and Safety Code,
is amended to read as follows:
(d) Except as specified in Subsections (e) and (f), the
board, by rule and in consultation with the Texas Medical Board and
the Texas Board of Nursing, shall establish the period after the
date on which the prescription is issued that a person may fill a
prescription for a controlled substance listed in Schedule II. A
person may not refill a prescription for a substance listed in
Schedule II.
SECTION 3.013. Section 481.076(c), Health and Safety Code,
is amended to read as follows:
(c) The board by rule shall design and implement a system
for submission of information to the board by electronic or other
means and for retrieval of information submitted to the board under
this section and Sections 481.074 and 481.075. The board shall use
automated information security techniques and devices to preclude
improper access to the information. The board shall submit the
system design to the director, [and] the Texas Medical Board, and
the Texas Board of Nursing for review and comment a reasonable time
before implementation of the system and shall comply with the
comments of those agencies unless it is unreasonable to do so.
SECTION 3.014. Section 481.0767(b), Health and Safety Code,
is amended to read as follows:
(b) The board shall appoint the following members to the
advisory committee:
(1) a physician licensed in this state who practices
in pain management;
(2) a physician licensed in this state who practices
in family medicine;
(3) a physician licensed in this state who performs
surgery;
(4) a physician licensed in this state who practices
in emergency medicine at a hospital;
(5) a physician licensed in this state who practices
in psychiatry;
(6) an oral and maxillofacial surgeon;
(7) a physician assistant [or advanced practice
registered nurse] to whom a physician has delegated the authority
to prescribe or order a drug or an advanced practice registered
nurse;
(8) a pharmacist working at a chain pharmacy;
(9) a pharmacist working at an independent pharmacy;
(10) an academic pharmacist; and
(11) two representatives of the health information
technology industry, at least one of whom is a representative of a
company whose primary line of business is electronic medical
records.
SECTION 3.015. Sections 483.001(4), (12), and (13), Health
and Safety Code, are amended to read as follows:
(4) "Designated agent" means:
(A) a licensed nurse, physician assistant,
pharmacist, or other individual designated by a practitioner to
communicate prescription drug orders to a pharmacist;
(B) a licensed nurse, physician assistant, or
pharmacist employed in a health care facility to whom the
practitioner communicates a prescription drug order; or
(C) a [registered nurse or] physician assistant
authorized by a practitioner to carry out a prescription drug order
for dangerous drugs under Subchapter B, Chapter 157, Occupations
Code.
(12) "Practitioner" means:
(A) a person licensed by:
(i) the Texas Medical Board, State Board of
Dental Examiners, Texas Optometry Board, or State Board of
Veterinary Medical Examiners to prescribe and administer dangerous
drugs; or
(ii) the Texas Department of Licensing and
Regulation, with respect to podiatry, to prescribe and administer
dangerous drugs;
(B) a person licensed by another state in a
health field in which, under the laws of this state, a licensee may
legally prescribe dangerous drugs;
(C) a person licensed in Canada or Mexico in a
health field in which, under the laws of this state, a licensee may
legally prescribe dangerous drugs; [or]
(D) a [an advanced practice registered nurse or]
physician assistant to whom a physician has delegated the authority
to prescribe or order a drug or device under Section 157.0511,
157.0512, or 157.054, Occupations Code; or
(E) an advanced practice registered nurse
authorized to prescribe and order drugs and devices under Section
301.358, Occupations Code.
(13) "Prescription" means an order from a
practitioner, or an agent of the practitioner designated in writing
as authorized to communicate prescriptions, or an order made in
accordance with Subchapter B, Chapter 157, Occupations Code, or
Section 203.353, Occupations Code, to a pharmacist for a dangerous
drug to be dispensed that states:
(A) the date of the order's issue;
(B) the name and address of the patient;
(C) if the drug is prescribed for an animal, the
species of the animal;
(D) the name and quantity of the drug prescribed;
(E) the directions for the use of the drug;
(F) the intended use of the drug unless the
practitioner determines the furnishing of this information is not
in the best interest of the patient;
(G) the name, address, and telephone number of
the practitioner at the practitioner's usual place of business,
legibly printed or stamped; and
(H) the name, address, and telephone number of
the licensed midwife[, registered nurse,] or physician assistant,
legibly printed or stamped, if signed by a licensed midwife[,
registered nurse,] or physician assistant.
SECTION 3.016. Section 483.022(f), Health and Safety Code,
is amended to read as follows:
(f) A practitioner may designate a person who is a licensed
vocational nurse or has an education equivalent to or greater than
that required for a licensed vocational nurse to communicate
prescriptions of a [an advanced practice nurse or] physician
assistant authorized by the practitioner to sign prescription drug
orders under Subchapter B, Chapter 157, Occupations Code, or of an
advanced practice registered nurse.
SECTION 3.017. Section 483.042(a), Health and Safety Code,
is amended to read as follows:
(a) A person commits an offense if the person delivers or
offers to deliver a dangerous drug:
(1) unless:
(A) the dangerous drug is delivered or offered
for delivery by a pharmacist under:
(i) a prescription issued by a practitioner
described by Section 483.001(12)(A), [or] (B), or (E);
(ii) a prescription signed by a [registered
nurse or] physician assistant in accordance with Subchapter B,
Chapter 157, Occupations Code; or
(iii) an original written prescription
issued by a practitioner described by Section 483.001(12)(C); and
(B) a label is attached to the immediate
container in which the drug is delivered or offered to be delivered
and the label contains the following information:
(i) the name and address of the pharmacy
from which the drug is delivered or offered for delivery;
(ii) the date the prescription for the drug
is dispensed;
(iii) the number of the prescription as
filed in the prescription files of the pharmacy from which the
prescription is dispensed;
(iv) the name of the practitioner who
prescribed the drug and, if applicable, the name of the [registered
nurse or] physician assistant who signed the prescription;
(v) the name of the patient and, if the drug
is prescribed for an animal, a statement of the species of the
animal; and
(vi) directions for the use of the drug as
contained in the prescription; or
(2) unless:
(A) the dangerous drug is delivered or offered
for delivery by:
(i) a practitioner in the course of
practice; or
(ii) a [registered nurse or] physician
assistant in the course of practice in accordance with Subchapter
B, Chapter 157, Occupations Code; and
(B) a label is attached to the immediate
container in which the drug is delivered or offered to be delivered
and the label contains the following information:
(i) the name and address of the
practitioner who prescribed the drug, and if applicable, the name
and address of the [registered nurse or] physician assistant;
(ii) the date the drug is delivered;
(iii) the name of the patient and, if the
drug is prescribed for an animal, a statement of the species of the
animal; and
(iv) the name of the drug, the strength of
the drug, and directions for the use of the drug.
SECTION 3.018. Section 32.024(gg), Human Resources Code, is
amended to read as follows:
(gg) Notwithstanding any other law, including Sections
843.312 and 1301.052, Insurance Code, the commission shall ensure
that advanced practice registered nurses and physician assistants
may be selected by and assigned to recipients of medical assistance
as the primary care providers of those recipients [regardless of
whether the physician supervising the advanced practice registered
nurse is included in any directory of providers of medical
assistance maintained by the commission]. This subsection may not
be construed as authorizing the commission to supervise or control
the practice of medicine as prohibited by Subtitle B, Title 3,
Occupations Code. The commission must require that advanced
practice registered nurses and physician assistants be treated in
the same manner as primary care physicians with regard to:
(1) selection and assignment as primary care
providers; and
(2) inclusion as primary care providers in any
directory of providers of medical assistance maintained by the
commission.
SECTION 3.019. Section 32.03141, Human Resources Code, is
amended to read as follows:
Sec. 32.03141. AUTHORITY OF ADVANCED PRACTICE REGISTERED
NURSES AND PHYSICIAN ASSISTANTS REGARDING DURABLE MEDICAL
EQUIPMENT AND SUPPLIES. To the extent allowed by federal law, in
addition to other health care practitioners authorized by federal
law, the following persons may order and prescribe durable medical
equipment and supplies under the medical assistance program:
(1) an advanced practice registered nurse; and
(2) a [or] physician assistant acting under adequate
physician supervision and to whom a physician has delegated the
authority to prescribe and order drugs and devices under Chapter
157, Occupations Code[, may order and prescribe durable medical
equipment and supplies under the medical assistance program].
SECTION 3.020. Section 843.312, Insurance Code, is amended
to read as follows:
Sec. 843.312. PHYSICIAN ASSISTANTS AND ADVANCED PRACTICE
REGISTERED NURSES. (a) A health maintenance organization may not
refuse a request by a physician participating in the health
maintenance organization delivery network and a physician
assistant [or advanced practice nurse] who is authorized by the
physician to provide care under Subchapter B, Chapter 157,
Occupations Code, or an advanced practice registered nurse, as
defined by Section 301.002, Occupations Code, to identify a
physician assistant or advanced practice registered nurse as a
provider in the network.
(b) A health maintenance organization may refuse a request
under Subsection (a) if the physician assistant or advanced
practice registered nurse does not meet the quality of care
standards previously established by the health maintenance
organization for participation in the network by physician
assistants and advanced practice registered nurses.
SECTION 3.021. Section 1301.001(1-a), Insurance Code, is
amended to read as follows:
(1-a) "Health care provider" means a practitioner,
institutional provider, or other person or organization that
furnishes health care services and that is licensed or otherwise
authorized to practice in this state. The term includes a
pharmacist, [and] a pharmacy, and an advanced practice registered
nurse. The term does not include a physician.
SECTION 3.022. Section 1301.052, Insurance Code, is amended
to read as follows:
Sec. 1301.052. DESIGNATION OF ADVANCED PRACTICE REGISTERED
NURSE OR PHYSICIAN ASSISTANT AS PREFERRED PROVIDER. An insurer
offering a preferred provider benefit plan may not refuse a request
made by a physician participating as a preferred provider under the
plan and an advanced practice registered nurse or physician
assistant to have the advanced practice registered nurse or
physician assistant included as a preferred provider under the plan
if, as applicable:
(1) the [advanced practice nurse or] physician
assistant is authorized by the physician to provide care under
Subchapter B, Chapter 157, Occupations Code; and
(2) the advanced practice registered nurse or
physician assistant meets the quality of care standards previously
established by the insurer for participation in the plan by
advanced practice registered nurses and physician assistants.
SECTION 3.023. Section 1451.001(2), Insurance Code, is
amended to read as follows:
(2) "Advanced practice registered nurse" has the
meaning assigned by Section 301.002, Occupations Code [means an
individual licensed by the Texas Board of Nursing as a registered
nurse and recognized by that board as an advanced practice nurse].
SECTION 3.024. Section 1451.104(c), Insurance Code, is
amended to read as follows:
(c) Notwithstanding Subsection (a), a health insurance
policy may provide for a different amount of payment or
reimbursement for scheduled services or procedures performed by an
advanced practice registered nurse, nurse first assistant,
licensed surgical assistant, or physician assistant if the
methodology used to compute the amount is the same as the
methodology used to compute the amount of payment or reimbursement
when the services or procedures are provided by a physician.
SECTION 3.025. Section 1451.106, Insurance Code, is amended
to read as follows:
Sec. 1451.106. SELECTION OF ADVANCED PRACTICE REGISTERED
NURSE. An insured may select an advanced practice registered nurse
to provide the services scheduled in the health insurance policy
that are within the scope of the nurse's license.
SECTION 3.026. Section 1452.051(1), Insurance Code, is
amended to read as follows:
(1) "Advanced practice nurse" has the meaning assigned
to "advanced practice registered nurse" by Section 301.002
[301.152], Occupations Code.
SECTION 3.027. Section 408.025, Labor Code, is amended by
amending Subsection (a-1) and adding Subsection (a-2) to read as
follows:
(a-1) A [treating doctor may delegate to a physician
assistant who is licensed to practice in this state under Chapter
204, Occupations Code, or an advanced practice registered nurse who
is licensed to practice in this state under Chapter 301,
Occupations Code, the authority to complete and sign a] work status
report regarding an injured employee's ability to return to work
may be completed and signed by:
(1) a physician assistant licensed to practice in this
state under Chapter 204, Occupations Code, who has been delegated
the authority by a treating doctor; or
(2) an advanced practice registered nurse, as defined
by Section 301.002, Occupations Code.
(a-2) The delegating treating doctor is responsible for the
acts of a [the] physician assistant [or advanced practice
registered nurse] under Subsection (a-1) [this subsection].
SECTION 3.028. Section 203.002(2), Occupations Code, is
amended to read as follows:
(2) "Certified nurse-midwife" means an advanced
practice [a person who is:
[(A) a] registered nurse as defined by Section
301.002 who is [under Chapter 301;
[(B) recognized as an advanced nurse
practitioner by the Texas Board of Nursing; and
[(C)] certified by the American College of
Nurse-Midwives.
SECTION 3.029. Section 204.1025, Occupations Code, is
amended to read as follows:
Sec. 204.1025. DUTIES REGARDING PRESCRIPTIVE AUTHORITY
AGREEMENTS. The physician assistant board shall in conjunction
with the Texas Medical Board [and the Texas Board of Nursing]
perform the functions and duties relating to prescriptive authority
agreements assigned to the physician assistant board in Sections
157.0512 and 157.0513.
SECTION 3.030. Sections 551.003(14) and (34), Occupations
Code, are amended to read as follows:
(14) "Designated agent" means:
(A) an individual, including a licensed nurse,
physician assistant, or pharmacist:
(i) who is designated by a practitioner and
authorized to communicate a prescription drug order to a
pharmacist; and
(ii) for whom the practitioner assumes
legal responsibility;
(B) a licensed nurse, physician assistant, or
pharmacist employed in a health care facility to whom a
practitioner communicates a prescription drug order; or
(C) a [registered nurse or] physician assistant
authorized by a practitioner to administer a prescription drug
order for a dangerous drug under Subchapter B, Chapter 157.
(34) "Practitioner" means:
(A) a person licensed or registered to prescribe,
distribute, administer, or dispense a prescription drug or device
in the course of professional practice in this state, including a
physician, dentist, podiatrist, advanced practice registered nurse
authorized to prescribe and order drugs and devices under Section
301.358, or veterinarian but excluding a person licensed under this
subtitle;
(B) a person licensed by another state, Canada,
or the United Mexican States in a health field in which, under the
law of this state, a license holder in this state may legally
prescribe a dangerous drug;
(C) a person practicing in another state and
licensed by another state as a physician, dentist, veterinarian,
advanced practice registered nurse, or podiatrist, who has a
current federal Drug Enforcement Administration registration
number and who may legally prescribe a Schedule II, III, IV, or V
controlled substance, as specified under Chapter 481, Health and
Safety Code, in that other state; or
(D) a [an advanced practice registered nurse or]
physician assistant to whom a physician has delegated the authority
to prescribe or order a drug or device under Section 157.0511,
157.0512, or 157.054.
SECTION 3.031. Section 563.051(e), Occupations Code, is
amended to read as follows:
(e) A practitioner may designate a licensed vocational
nurse or a person having education equivalent to or greater than
that required for a licensed vocational nurse to communicate the
prescriptions of a [an advanced practice nurse or] physician
assistant authorized by the practitioner to sign prescription drug
orders under Subchapter B, Chapter 157, or of an advanced practice
registered nurse.
SECTION 3.032. Sections 605.002(14) and (18), Occupations
Code, are amended to read as follows:
(14) "Orthotics" means the science and practice of
measuring, designing, fabricating, assembling, fitting, adjusting,
or servicing an orthosis under an order from a licensed physician,
chiropractor, [or] podiatrist, or [an] advanced practice
registered nurse, or from a physician assistant acting under the
delegation and supervision of a licensed physician as provided by
Subchapter B, Chapter 157, and rules adopted by the Texas Medical
Board, for the correction or alleviation of a neuromuscular or
musculoskeletal dysfunction, disease, injury, or deformity.
(18) "Prosthetics" means the science and practice of
measuring, designing, fabricating, assembling, fitting, adjusting,
or servicing a prosthesis under an order from a licensed physician,
chiropractor, [or] podiatrist, or [an] advanced practice
registered nurse, or from a physician assistant acting under the
delegation and supervision of a licensed physician as provided by
Subchapter B, Chapter 157, and rules adopted by the Texas Medical
Board.
SECTION 3.033. Section 605.2515, Occupations Code, is
amended to read as follows:
Sec. 605.2515. ADDITIONAL LICENSE: DEVICE MANUFACTURER. A
person licensed to practice orthotics or prosthetics who measures,
designs, fabricates, fits, assembles, adjusts, or services an
orthosis or a prosthesis under an order from a licensed physician,
chiropractor, [or] podiatrist, or [an] advanced practice
registered nurse, or from a physician assistant acting under the
delegation and supervision of a licensed physician as provided by
Subchapter B, Chapter 157, and rules adopted by the Texas Medical
Board, for a specific patient is exempt from licensing as a device
manufacturer under Subchapter L, Chapter 431, Health and Safety
Code. A person licensed to practice orthotics or prosthetics who
fabricates or assembles an orthosis or a prosthesis without an
order from a licensed physician, chiropractor, [or] podiatrist, or
[an] advanced practice registered nurse, or from a physician
assistant acting under the delegation and supervision of a licensed
physician as provided by Subchapter B, Chapter 157, and rules
adopted by the Texas Medical Board, for a specific patient is
required to be licensed as a device manufacturer under Subchapter
L, Chapter 431, Health and Safety Code.
ARTICLE 4. REPEALER
SECTION 4.001. The following provisions are repealed:
(1) Section 533.005(d), Government Code;
(2) Section 62.1551(b), Health and Safety Code; and
(3) Sections 157.051(1), 157.058, and 301.168,
Occupations Code.
ARTICLE 5. TRANSITION AND EFFECTIVE DATE
SECTION 5.001. Not later than February 1, 2022, the Texas
Board of Nursing shall adopt the rules necessary to implement the
changes in law made by this Act.
SECTION 5.002. Notwithstanding any changes in law made by
this Act, an advanced practice registered nurse who has been
delegated the authority to prescribe and order drugs and medical
devices by a physician's protocol or order under Section 157.0511,
157.0512, or 157.054, Occupations Code, may continue to exercise
that authority until February 1, 2022.
SECTION 5.003. This Act takes effect September 1, 2021.