Amended in Senate April 1, 2013

Senate Bill No. 491

Introduced by Senator Hernandez

February 21, 2013

An act to amend begin delete Section 2834 end delete begin insert Sections 2835.5, 2835.7, 2836.1, 2836.2, and 2836.3 end insert of the Business and Professions Code, relating to healing arts.

LEGISLATIVE COUNSEL’S DIGEST

SB 491, as amended, Hernandez. Nurse practitioners.

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Existing law, the Nursing Practice Act, provides for the licensure and regulation of nurse practitioners by the Board of Registered Nursing. Existing law requires an applicant for initial qualification or certification as a nurse practitioner who has never been qualified or certified as a nurse practitioner in California or in any other state to meet specified requirements, including possessing a master’s degree in nursing, a master’s degree in a clinical field related to nursing, or a graduate degree in nursing, and to have satisfactorily completed a nurse practitioner program approved by the board. Existing law authorizes the implementation of standardized procedures that authorize a nurse practitioner to perform certain acts, including, among others, ordering durable medical equipment, and, in consultation with a physician and surgeon, approve, sign, modify, or add to a plan of treatment or plan for an individual receiving home health services or personal care services.

end insert begin insert

This bill would revise these provisions by deleting the requirement that those acts be performed pursuant to a standardized procedure or in consultation with a physician and surgeon. The bill would also authorize a nurse practitioner to perform specified additional acts, including, among others, diagnosing patients, performing therapeutic procedures, and prescribing drugs and devices. The bill would require that, on and after July 1, 2016, an applicant for initial qualification or certification as a nurse practitioner hold a national certification as a nurse practitioner from a national certifying body recognized by the board.

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Existing law declares the findings of the Legislature that the public is harmed by conflicting usage of the title of nurse practitioner and lack of correspondence between use of the title and qualifications of the registered nurse using the title.

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This bill would make a nonsubstantive change to this declaration.

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Vote: majority. Appropriation: no. Fiscal committee:  begin delete no end delete begin insert yes end insert . State-mandated local program: no.

The people of the State of California do enact as follows:

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begin insert SECTION 1. end insert   

end insert

begin insert The Legislature finds and declares all of the
following: end insert

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(a) Nurse practitioners are a longstanding, vital, safe, effective,
and important part of the state’s health care delivery system. They
are especially important given California’s shortage of physicians,
with just 16 of 58 counties having the federally recommended ratio
of physicians to residents.

end insert begin insert

(b) Nurse practitioners will play an especially important part
in the implementation of the federal Patient Protection and
Affordable Care Act, which will bring an estimated five million
more Californians into the health care delivery system, because
they will provide for greater access to primary care services in all
areas of the state. This is particularly true for patients in medically
underserved urban and rural communities.

end insert begin insert

(c) Due to the excellent safety and efficacy record that nurse
practitioners have earned, the Institute of Medicine of the National
Academy of Sciences has recommended full independent practice
for nurse practitioners. Currently, 17 states allow nurse
practitioners to practice to the full extent of their training and
education with independent practice.

end insert begin insert

(d) Furthermore, nurse practitioners will assist in addressing
the primary care provider shortage by removing delays in the
provision of care that are created when dated regulations require
a physician’s signature or protocol before a patient can initiate
treatment or obtain diagnostic tests that are ordered by a nurse
practitioner.

end insert

begin insert

begin insert SEC. 2. end insert   

end insert

begin insert Section 2835.5 of the end insert begin insert Business and Professions Code end insert
begin insert is amended to read: end insert

2835.5.  

(a) A registered nurse who is holding himself or herself
out as a nurse practitioner or who desires to hold himself or herself
out as a nurse practitioner shall, within the time prescribed by the
board and prior to his or her next license renewal or the issuance
of an initial license, submit educational, experience, and other
credentials and information as the board may require for it to
determine that the person qualifies to use the title “nurse
practitioner,” pursuant to the standards and qualifications
established by the board.

(b) Upon finding that a person is qualified to hold himself or
herself out as a nurse practitioner, the board shall appropriately
indicate on the license issued or renewed, that the person is
qualified to use the title “nurse practitioner.” The board shall also
issue to each qualified person a certificate evidencing that the
person is qualified to use the title “nurse practitioner.”

(c) A person who has been found to be qualified by the board
to use the title “nurse practitioner” prior to begin delete the effective date of
this section end delete begin insert January 1, 2005 end insert , shall not be required to submit any
further qualifications or information to the board and shall be
deemed to have met the requirements of this section.

(d) On and after January 1, 2008, an applicant for initial
qualification or certification as a nurse practitioner under this article
who has not been qualified or certified as a nurse practitioner in
California or any other state shall meet the following requirements:

(1) Hold a valid and active registered nursing license issued
under this chapter.

(2) Possess a master’s degree in nursing, a master’s degree in
a clinical field related to nursing, or a graduate degree in nursing.

(3) Satisfactorily complete a nurse practitioner program
approved by the board.

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(e) On and after July 1, 2016, an applicant for initial
qualification or certification as a nurse practitioner shall, in
addition, hold a national certification as a nurse practitioner from
a national certifying body recognized by the board.

end insert

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begin insert SEC. 3. end insert   

end insert

begin insert Section 2835.7 of the end insert begin insert Business and Professions Code end insert
begin insert is amended to read: end insert

2835.7.  

(a) Notwithstanding any other begin delete provision of end delete law, in
addition to any other practices begin delete that meet the general criteria set
forth end delete begin insert authorized end insert in statute or regulation begin delete for inclusion in
standardized procedures developed through collaboration among
administrators and health professionals, including physicians and
surgeons and nurses, pursuant to Section 2725, standardized
procedures may be implemented that authorize end delete begin insert , end insert a nurse practitioner
begin delete to end delete begin insert may end insert do any of the following:

(1) Order durable medical equipment begin delete , subject to any limitations
set forth in the standardized procedures end delete . Notwithstanding that
authority, nothing in this paragraph shall operate to limit the ability
of a third-party payer to require prior approval.

(2) After performance of a physical examination by the nurse
practitioner begin delete and collaboration with a physician and surgeon end delete , certify
disability pursuant to Section 2708 of the Unemployment Insurance
Code.

(3) For individuals receiving home health services or personal
care services, begin delete after consultation with the treating physician and
surgeon, end delete approve, sign, modify, or add to a plan of treatment or
plan of care.

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(b) Nothing in this section shall be construed to affect the
validity of any standardized procedures in effect prior to the
enactment of this section or those adopted subsequent to enactment.

end delete begin insert

(4) Assess patients, synthesize and analyze data, and apply
principles of health care at an advanced level.

end insert begin insert

(5) Manage the physical and psychosocial health status of
patients.

end insert begin insert

(6) Analyze multiple sources of data, identify alternative
possibilities as to the nature of a health care problem, and select,
implement, and evaluate appropriate treatment.

end insert begin insert

(7) Make independent decisions in treating health conditions.

end insert begin insert

(8) Diagnose patients and perform diagnostic and therapeutic
procedures.

end insert begin insert

(9) Order, furnish, or prescribe drugs or devices pursuant to
Section 2836.1.

end insert begin insert

(10) Refer patients to other health care providers when
appropriate due to the limits of the nurse practitioner’s knowledge,
experience, or educational preparation.

end insert begin insert

(11) Delegate to a medical assistant.

end insert begin insert

(12) Perform additional acts that require education and training
and that are recognized by the nursing profession as proper to be
performed by a nurse practitioner.

end insert begin insert

(13) Order hospice care as appropriate.

end insert begin insert

(14) Perform procedures that are necessary and consistent with
the nurse practitioner’s training and education.

end insert begin insert

(b) A nurse practitioner shall maintain medical malpractice
insurance.

end insert

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begin insert SEC. 4. end insert   

end insert

begin insert Section 2836.1 of the end insert begin insert Business and Professions Code end insert
begin insert is amended to read: end insert

2836.1.  

Neither this chapter nor any other provision of law
shall be construed to prohibit a nurse practitioner from furnishing
begin delete or end delete begin insert , end insert ordering begin insert , or prescribing end insert drugs or devices when all of the
following apply:

(a) The drugs or devices begin insert that end insert are begin delete furnished or ordered by a nurse
practitioner in accordance with standardized procedures or
protocols developed by the nurse practitioner and the supervising
physician and surgeon when the drugs or devices furnished or
ordered end delete begin insert furnished, ordered, or prescribed end insert are consistent with the
practitioner’s educational preparation or for which clinical
competency has been established and maintained.

begin delete

(b) The nurse practitioner is functioning pursuant to standardized
procedure, as defined by Section 2725, or protocol. The
standardized procedure or protocol shall be developed and
approved by the supervising physician and surgeon, the nurse
practitioner, and the facility administrator or the designee.

(c) (1) The standardized procedure or protocol covering the
furnishing of drugs or devices shall specify which nurse
practitioners may furnish or order drugs or devices, which drugs
or devices may be furnished or ordered, under what circumstances,
the extent of physician and surgeon supervision, the method of
periodic review of the nurse practitioner’s competence, including
peer review, and review of the provisions of the standardized
procedure.

(2) In addition to the requirements in paragraph (1), for Schedule
II controlled substance protocols, the provision for furnishing
Schedule II controlled substances shall address the diagnosis of
the illness, injury, or condition for which the Schedule II controlled
substance is to be furnished.

(d) The furnishing or ordering of drugs or devices by a nurse
practitioner occurs under physician and surgeon supervision.
Physician and surgeon supervision shall not be construed to require
the physical presence of the physician, but does include (1)
collaboration on the development of the standardized procedure,
(2) approval of the standardized procedure, and (3) availability by
telephonic contact at the time of patient examination by the nurse
practitioner.

(e) For purposes of this section, no physician and surgeon shall
supervise more than four nurse practitioners at one time.

(f) (1) Drugs or devices furnished or ordered by a nurse
practitioner may include Schedule II through Schedule V controlled
substances under the California Uniform Controlled Substances
Act (Division 10 (commencing with Section 11000) of the Health
and Safety Code) and shall be further limited to those drugs agreed
upon by the nurse practitioner and physician and surgeon and
specified in the standardized procedure.

(2) When Schedule II or III controlled substances, as defined
in Sections 11055 and 11056, respectively, of the Health and Safety
Code, are furnished or ordered by a nurse practitioner, the
controlled substances shall be furnished or ordered in accordance
with a patient-specific protocol approved by the treating or
supervising physician. A copy of the section of the nurse
practitioner’s standardized procedure relating to controlled
substances shall be provided, upon request, to any licensed
pharmacist who dispenses drugs or devices, when there is
uncertainty about the nurse practitioner furnishing the order.

(g)

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begin insert (b) end insert  (1) The board has certified in accordance with Section
2836.3 that the nurse practitioner has satisfactorily completed a
course in pharmacology covering the drugs or devices to be
begin delete furnished or end delete begin insert furnished, end insert ordered begin insert , or prescribed end insert under this section.

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(2) A physician and surgeon may determine the extent of
supervision necessary pursuant to this section in the furnishing or
ordering of drugs and devices.

end delete begin delete

(3)

end delete

begin insert (2) end insert  Nurse practitioners who are certified by the board and hold
an active furnishing number begin delete , who are authorized through
standardized procedures or protocols to furnish Schedule II
controlled substances, end delete and who are registered with the United
States Drug Enforcement Administration, shall complete, as part
of their continuing education requirements, a course including
Schedule II controlled substances based on the standards developed
by the board. The board shall establish the requirements for
satisfactory completion of this subdivision.

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(c) A nurse practitioner shall not furnish, order, or prescribe a
dangerous drug, as defined in Section 4022, without an appropriate
prior examination and a medical indication, unless one of the
following applies:

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(1) The nurse practitioner was a designated practitioner serving
in the absence of the patient’s physician and surgeon, podiatrist,
or nurse practitioner, as the case may be, and if the drugs were
prescribed, dispensed, or furnished only as necessary to maintain
the patient until the return of his or her practitioner, but in any
case no longer than 72 hours.

end insert begin insert

(2) The nurse practitioner transmitted the order for the drugs
to a registered nurse or to a licensed vocational nurse in an
inpatient facility, and if both of the following conditions exist:

end insert begin insert

(A) The nurse practitioner had consulted with the registered
nurse or licensed vocational nurse who had reviewed the patient’s
records.

end insert begin insert

(B) The nurse practitioner was designated as the practitioner
to serve in the absence of the patient’s physician and surgeon,
podiatrist, or nurse practitioner, as the case may be.

end insert begin insert

(3) The nurse practitioner was a designated practitioner serving
in the absence of the patient’s physician and surgeon, podiatrist,
or nurse practitioner, as the case may be, and was in possession
of or had utilized the patient’s records and ordered the renewal
of a medically indicated prescription for an amount not exceeding
the original prescription in strength or amount or for more than
one refill.

end insert begin insert

(4) The licensee was acting in accordance with subdivision (b)
of Section 120582 of the Health and Safety Code.

end insert begin delete

(h)

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begin insert (d) end insert  Use of the term “furnishing” in this section, in health
facilities defined in Section 1250 of the Health and Safety Code,
shall include begin delete (1) end delete the ordering of a drug or device begin delete in accordance
with the standardized procedure and (2) transmitting an order of
a supervising physician and surgeon end delete .

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(i)

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begin insert (e) end insert  “Drug order” or “order” for purposes of this section means
an order for medication which is dispensed to or for an ultimate
user, issued by a nurse practitioner as an individual practitioner,
within the meaning of Section 1306.02 of Title 21 of the Code of
Federal Regulations. Notwithstanding any other provision of law,
begin delete (1) a drug order issued pursuant to this section shall be treated in
the same manner as a prescription of the supervising physician;
(2) end delete begin insert (1) end insert all references to “prescription” in this code and the Health
and Safety Code shall include drug orders issued by nurse
practitioners; and begin delete (3) end delete begin insert (2) end insert the signature of a nurse practitioner on a
drug order issued in accordance with this section shall be deemed
to be the signature of a prescriber for purposes of this code and
the Health and Safety Code.

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begin insert SEC. 5. end insert   

end insert

begin insert Section 2836.2 of the end insert begin insert Business and Professions Code end insert
begin insert is amended to read: end insert

2836.2.  

begin delete Furnishing or ordering of drugs or devices by nurse
practitioners is defined to mean the act of making a pharmaceutical
agent or agents available to the patient in strict accordance with a
standardized procedure. end delete All nurse practitioners who are authorized
pursuant to Section 2836.1 to begin insert prescribe, end insert furnish begin insert , end insert or issue drug
orders for controlled substances shall register with the United
States Drug Enforcement Administration.

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begin insert SEC. 6. end insert   

end insert

begin insert Section 2836.3 of the end insert begin insert Business and Professions Code end insert
begin insert is amended to read: end insert

2836.3.  

(a) The furnishing of drugs or devices by nurse
practitioners is conditional on issuance by the board of a number
to the nurse applicant who has successfully completed the
requirements of subdivision begin delete (g) end delete begin insert (b) end insert of Section 2836.1. The number
shall be included on all transmittals of orders for drugs or devices
by the nurse practitioner. The board shall make the list of numbers
issued available to the Board of Pharmacy. The board may charge
the applicant a fee to cover all necessary costs to implement this
section.

(b) The number shall be renewable at the time of the applicant’s
registered nurse license renewal.

(c) The board may revoke, suspend, or deny issuance of the
numbers for incompetence or gross negligence in the performance
of functions specified in Sections 2836.1 and 2836.2.

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SECTION 1.  

Section 2834 of the Business and Professions
Code is amended to read:

2834.  

The Legislature finds that various and conflicting
definitions of the nurse practitioner are being created by state
agencies and private organizations within California. The
Legislature also finds that the public is harmed by conflicting usage
of the title of nurse practitioner and by lack of correspondence
between use of the title and qualifications of the registered nurse
using the title. Therefore, the Legislature finds the public interest
served by determination of the legitimate use of the title “nurse
practitioner” by registered nurses.

end delete