SECOND REGULAR SESSION

HOUSE BILL NO. 1425

92ND GENERAL ASSEMBLY


 

 

INTRODUCED BY REPRESENTATIVE BLACK.

         Read 1st time February 5, 2004, and copies ordered printed.

STEPHEN S. DAVIS, Chief Clerk

4509L.01I


 

AN ACT

To repeal sections 334.104, 335.016, 335.017, 335.056, 335.076, and 335.086, RSMo, and to enact in lieu thereof nine new sections relating to nursing.





Be it enacted by the General Assembly of the state of Missouri, as follows:


            Section A. Sections 334.104, 335.016, 335.017, 335.056, 335.076, and 335.086, RSMo, are repealed and nine new sections enacted in lieu thereof, to be known as sections 334.104, 335.016, 335.017, 335.019, 335.048, 335.049, 335.056, 335.076, and 335.086, to read as follows:

            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, jointly agreed-upon protocols, or standing orders for the delivery of health care services. Collaborative practice arrangements, which shall be in writing, 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, RSMo. 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 state board of registration for the healing arts pursuant to section 334.125 and the board of nursing pursuant to section 335.036, RSMo, 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. 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. 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, RSMo.

            4. 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.

            5. Notwithstanding anything to the contrary in this section, a [registered nurse who has graduated from a school of nurse anesthesia accredited by the Council on Accreditation of Educational Programs of Nurse Anesthesia or its predecessor and has been certified or is eligible for certification as a nurse anesthetist by the Council on Certification of Nurse Anesthetists] registered professional nurse licensed under chapter 335, RSMo, and recognized by the state board of nursing as an advanced practice nurse anesthetist 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.

            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 nurse", a nurse who has had education beyond the basic nursing education and is certified by a nationally recognized professional organization as having a nursing specialty, or who meets criteria for advanced practice nurses established by the board of nursing. The board of nursing may promulgate rules specifying which professional nursing organization certifications are to be recognized as advanced practice nurses, and may set standards for education, training and experience required for those without such specialty certification to become advanced practice nurses;] "Advanced practice nursing", the performance of those acts defined in subdivision (10) of this section and such additional acts as are consistent with the specialized education, training, certification and licensure of the advanced practice registered nurse;

            (3) "Advanced practice registered nurse" or "(APRN)", a registered professional nurse licensed under the provisions of this chapter to engage in the practice of advanced practice nursing within the licensee's advanced practice clinical nursing specialty area as a nurse practitioner, clinical nurse specialist, nurse anesthetist, or nurse midwife and who:

            (a) Has successfully completed a nationally accredited graduate or post-graduate advanced practice registered nurse program and earned a graduate degree or post-graduate certificate as a nurse practitioner, clinical nurse specialist, nurse anesthetist, or nurse midwife;

            (b) Is currently certified by a board-acceptable nationally recognized certifying body as having an advanced practice clinical nursing specialty area as a nurse practitioner, clinical nurse specialist, nurse anesthetist, or nurse midwife;

            (c) Is licensed by the board as an advanced practice registered nurse; or

            (d) Who meets other criteria for advanced practice registered nurse licensure established by the board;

            [(3)] (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) "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;

            [(6)] (7) "Inactive [nurse] license status", as defined by rule pursuant to section 335.061;

            [(7)] (8) "Lapsed license status", as defined by rule under section 335.061;

            (9) A "licensed practical nurse" or "practical nurse", a person licensed pursuant to the provisions of this chapter to engage in the practice of practical nursing;

            [(8)] (10) "Licensure", the issuing of a license to practice advanced practice nursing, professional nursing, 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;

            [(9)] (11) "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 or advanced practice registered 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 or advanced practice registered 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 or advanced practice registered nurse, such care may be delivered by a licensed practical nurse without direct physical oversight;

            [(10)] (12) "Registered 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, delegation, direction, and supervision of other persons in the performance of any of the foregoing;

            (f) The performance of such acts as may be delegated by a collaborating physician;

            [(11)] (13) A "registered professional nurse" or "registered nurse", a person licensed pursuant to the provisions of this chapter to engage in the practice of professional nursing;

            (14) "Retired license status", any person licensed in this state to practice under this chapter who retires from such practice 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.

            335.017. One of the selected acts which may be performed by persons licensed under the provisions of this chapter as licensed practical nurses is the [administration of intravenous fluid treatment. The administration of intravenous fluid treatment] establishment of peripheral vascular access sites for the administration of intravenous infusion treatment modalities. Establishment of peripheral vascular access sites and administration of the intravenous infusion treatment modalities may be performed only by licensed practical nurses who have been instructed and trained in such procedures in a course or program of instruction approved by the board. The board shall have the authority to adopt and revise rules and regulations which limit and define the scope of [intravenous fluid treatment] peripheral vascular access sites and intravenous infusion treatment modalities which may be performed by licensed practical nurses. Nothing herein shall be construed as prohibiting [administration of intravenous fluid treatment by] registered professional nurses from establishing peripheral vascular access and administering intravenous infusion therapy treatment modalities. [The board shall submit emergency rules to the secretary of state to implement the provisions of this section within thirty days of December 15, 1983, and the board shall act promptly on applications of organizations requesting approval of their course of instruction.]

            335.019. 1. The board may certify persons licensed under the provisions of this chapter as having specialized training. The board shall have the authority to adopt and revise rules which specify the specialized knowledge, education, skills, training, judgment, and experience necessary to qualify for initial and continued certification in specialized training.

            2. Training certification specialties shall be those courses endorsed and approved by the department of health and senior services which through formal and ongoing processes of evaluation and verification shall certify that a licensed nurse has met predetermined practice standards in a training specialty area. A list of trained and certified nurses shall be maintained by the board.

            335.048. 1. An applicant for a license to title and practice as an advanced practice registered 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, current licensure as a registered professional nurse, advanced practice clinical nursing specialty area in which the applicant is certified by a nationally recognized certifying body approved by the board, and other such pertinent information as the board may require. An applicant for licensure as an advanced practice registered nurse for whom no appropriate advanced practice clinical nursing specialty certification from a board-approved nationally recognized certifying body exists or is available shall submit evidence of the applicant’s education, training, and experience as set forth by rule. Evidence of an equivalent mechanism to certification examinations as set forth by rule will not be accepted after December 31, 2005, and individuals will no longer be licensed as advanced practice registered nurses without an approved advanced practice registered nurse certification examination.

            2. The applicant shall be of good moral character and have successfully completed the basic professional curriculum in an accredited or approved school of nursing, have earned a professional nursing degree or diploma, have successfully completed a graduate or post-graduate advanced practice registered nurse program accredited by the appropriate national accrediting body, and have earned a graduate degree or post-graduate certificate. 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 the application, subject to the penalties of making a false affidavit or declaration. Applicants from nonEnglish speaking lands shall be required to submit evidence of proficiency in the English language. The applicant for a license to practice advanced practice 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. Upon submission of the completed application and required fee, the board may issue to the applicant a license to practice advanced practice nursing as an advanced practice registered nurse.

            3. An applicant shall be exempt from the academic requirements of subsection 2 of this section if he or she:

            (1) Has successfully completed the basic professional curriculum in an accredited or approved school of nursing and earned a professional nursing degree or diploma; and

            (2) Has enrolled in a formal advanced practice registered nurse program accredited by the appropriate national or regional accreditation body on or before September 1, 2003; and

            (3) Has earned an advanced practice registered nurse certificate on or before December 31, 2005; and

            (4) Has submitted a completed application for licensure as an APRN to the board on or before December 31, 2005; or

            (5) Has duly become licensed, certified, recognized, registered or otherwise authorized to practice as an advanced practice registered nurse pursuant to the laws of another state or territory if the applicant meets the qualifications required of advanced practice registered nurses in this state at the time the applicant was originally licensed, certified, recognized, registered or otherwise authorized to practice in the other state or territory.

            4. Upon refusal of the board to allow any applicant to obtain licensure as an advanced practice registered nurse, the board shall notify the applicant in writing of the reasons for the refusal and shall advise the applicant of his or her right to file a complaint with the administrative hearing commission as provided by chapter 621, RSMo.

            5. The board may promulgate rules specifying the criteria by which nationally recognized certifying bodies and their examinations are to be deemed acceptable to the board, other criteria for initial and continued licensure as an advanced practice registered nurse, and such other rules as are necessary to enable the board to carry out this provision. No rule or portion of a rule promulgated under the authority of this section shall become effective unless it has been promulgated pursuant to chapter 536, RSMo.

            6. Upon application, the board may issue a temporary permit to an advanced practice registered nurse applicant under subsection 1 of this section who has made a prima facie showing that the applicant meets all of the requirements for such a license and submits an application in accord with the rules of the board. The temporary permit shall be effective only until the board has had the opportunity to substantiate the applicant’s qualifications for licensure under subsection 1 of this section and to notify the applicant that his or her application for a license has been either granted or denied/refused. In no event shall such temporary permit be valid for more than twelve months after the date of its issuance nor shall such permit be reissued to the same applicant. No fee shall be charged for such temporary permit. The holder of a temporary permit that has not expired or been suspended or revoked, shall be deemed to be the holder of a license issued under this section until such temporary permit expires, is terminated, suspended, or revoked.

            7. Once an applicant is issued an APRN license, the licensee shall not be required to maintain a separate current RN license.

            335.049. Any registered professional nurse with a current and active registered professional nurse license who was recognized by the board to title and practice as an advanced practice nurse within a particular clinical nursing specialty area as a nurse practitioner, clinical nurse specialist, nurse anesthetist, or nurse midwife on or before December 31, 2003, and whose recognition is current and active shall be issued an advanced practice registered nurse license and shall be exempt from the academic requirements of subsection 2 of section 335.048.

            335.056. The license of every person licensed under the provisions of [sections 335.011 to 335.096] this chapter shall be renewed as provided. An application for renewal of license shall be mailed to every person to whom a license was issued or renewed during the current licensing period. The applicant shall complete the application and return it to the board by the renewal date with a renewal fee in an amount to be set by the board. The fee shall be uniform for all applicants. The certificates of renewal shall render the holder thereof a legal practitioner of nursing for the period stated in the certificate of renewal. Any person who practices nursing as an advanced practice registered nurse, a registered professional nurse, or as a licensed practical nurse during the time his license has lapsed shall be considered an illegal practitioner and shall be subject to the penalties provided for violation of the provisions of [sections 335.011 to 335.096] this chapter.

            335.076. 1. Any person who holds a license to practice professional nursing in this state may use the title "Registered Professional Nurse" and the abbreviation "R.N.". No other person [may] shall use the title "Registered Professional Nurse" or the abbreviation "R.N.". No other person shall assume any title or use any abbreviation or any other words, letters, signs, or devices to indicate that the person using the same is a registered professional nurse.

            2. Any person who holds a license to practice practical nursing in this state may use the title "Licensed Practical Nurse" and the abbreviation "L.P.N.". No other person [may] shall use the title "Licensed Practical Nurse" or the abbreviation "L.P.N.". No other person shall assume any title or use any abbreviation or any other words, letters, signs, or devices to indicate that the person using the same is a licensed practical nurse.

            3. Any person who holds a license to practice advanced practice nursing in this state may use the title "Advanced Practice Registered Nurse", the abbreviation "APRN", and any other title designations appearing on his or her license. No other person shall use the title "Advanced Practice Registered Nurse" or the abbreviation "APRN". No other person shall assume any title or use any abbreviation or any other words, letters, signs, or devices to indicate that the person using the same is an advanced practice registered nurse.

            4. No person shall practice or offer to practice professional nursing [or], practical nursing, or advanced practice nursing in this state [for compensation] or use any title, sign, abbreviation, card, or device to indicate that such person is a practicing professional nurse [or], practical nurse, or advance practice nurse unless he or she has been duly licensed under the provisions of [sections 335.011 to 335.096] this chapter.

            5. In the interest of public safety and consumer awareness, it is unlawful for any person to use the title "Nurse" in reference to himself or herself in any capacity, except individuals who are or have been licensed as a registered nurse, licensed practical nurse or advanced practice registered nurse under this chapter.

335.086. No person, firm, corporation or association shall:

            (1) Sell or attempt to sell or fraudulently obtain or furnish or attempt to furnish any nursing diploma, license, renewal or record or aid or abet therein;

            (2) Practice advanced practice nursing, professional nursing, or practical nursing as defined [by sections 335.011 to 335.096] this chapter under cover of any diploma, license, or record illegally or fraudulently obtained or signed or issued unlawfully or under fraudulent representation;

            (3) Practice advanced practice nursing, professional nursing, or practical nursing as defined by [sections 335.011 to 335.096] this chapter unless duly licensed to do so under the provisions of [sections 335.011 to 335.096] this chapter;

            (4) Use in connection with his name any designation tending to imply that he is a licensed registered professional nurse, advanced practice registered nurse, or a licensed practical nurse unless duly licensed so to practice under the provisions of [sections 335.011 to 335.096] this chapter;

            (5) Practice advanced practice nursing, professional nursing, or practical nursing during the time his license issued under the provisions of [sections 335.011 to 335.096] this chapter shall be suspended or revoked; or

            (6) Conduct a nursing education program for the preparation of professional or practical nurses unless the program has been accredited by the board;

            (7) If the board concludes that a nurse has committed an act or is engaging in a course of conduct which would be grounds for disciplinary action which constitutes a clear and present danger to the public health and safety the board may file a complaint before the administrative hearing commission requesting an expedited hearing and specifying the activities which give rise to the danger and the nature of the proposed restriction or suspension of the nurse's license. Within fifteen days after service of the complaint on the nurse, the administrative hearing commission shall conduct a preliminary hearing to determine whether the alleged activities of the nurse appear to constitute a clear and present danger to the public health and safety which justify that the nurse's license be immediately restricted or suspended. The burden of proving that a nurse is a clear and present danger to the public health and safety shall be upon the state board of nursing. The administrative hearing commission shall issue its decision immediately after the hearing and shall either grant to the board the authority to suspend or restrict the license or dismiss the action;

            (8) If the administrative hearing commission grants temporary authority to the board to restrict or suspend the nurse’s license such temporary authority of the board shall become final authority if there is no request by the nurse for a full hearing within thirty days of the preliminary hearing. The administrative hearing commission shall if requested by the nurse named in the complaint set a date to hold a full hearing under the provisions of chapter 621, RSMo, regarding the activities alleged in the initial complaint filed by the board;

            (9) If the administrative hearing commission dismisses the action filed by the board under subdivision (7) of this section, such dismissal shall not bar the board from initiating a subsequent action on the same grounds.