BILL NUMBER: SB 491 AMENDED
BILL TEXT
AMENDED IN SENATE APRIL 1, 2013
INTRODUCED BY Senator Hernandez
FEBRUARY 21, 2013
An act to amend Section 2834 Sections
2835.5, 2835.7, 2836.1, 2836.2, and 2836.3 of the Business and
Professions Code, relating to healing arts.
LEGISLATIVE COUNSEL'S DIGEST
SB 491, as amended, Hernandez. Nurse practitioners.
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.
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.
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.
This bill would make a nonsubstantive change to this declaration.
Vote: majority. Appropriation: no. Fiscal committee: no
yes . State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. The Legislature finds and declares all
of the following:
(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.
(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.
(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.
(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.
SEC. 2. Section 2835.5 of the Business
and Professions Code is amended to read:
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 the effective
date of this section January 1, 2005 , 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.
(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.
SEC. 3. Section 2835.7 of the Business
and Professions Code is amended to read:
2835.7. (a) Notwithstanding any other provision of
law, in addition to any other practices that meet
the general criteria set forth authorized in
statute or regulation 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 , a nurse practitioner to
may do any of the following:
(1) Order durable medical equipment , subject to any
limitations set forth in the standardized procedures .
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 and collaboration with a physician and surgeon
, certify disability pursuant to Section 2708 of the
Unemployment Insurance Code.
(3) For individuals receiving home health services or personal
care services, after consultation with the treating
physician and surgeon, approve, sign, modify, or add to a
plan of treatment or plan of care.
(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.
(4) Assess patients, synthesize and analyze data, and apply
principles of health care at an advanced level.
(5) Manage the physical and psychosocial health status of
patients.
(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.
(7) Make independent decisions in treating health conditions.
(8) Diagnose patients and perform diagnostic and therapeutic
procedures.
(9) Order, furnish, or prescribe drugs or devices pursuant to
Section 2836.1.
(10) Refer patients to other health care providers when
appropriate due to the limits of the nurse practitioner's knowledge,
experience, or educational preparation.
(11) Delegate to a medical assistant.
(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.
(13) Order hospice care as appropriate.
(14) Perform procedures that are necessary and consistent with the
nurse practitioner's training and education.
(b) A nurse practitioner shall maintain medical malpractice
insurance.
SEC. 4. Section 2836.1 of the Business
and Professions Code is amended to read:
2836.1. Neither this chapter nor any other provision of law shall
be construed to prohibit a nurse practitioner from furnishing
or , ordering , or prescribing
drugs or devices when all of the following apply:
(a) The drugs or devices that are 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 furnished, ordered, or prescribed
are consistent with the practitioner's educational preparation or for
which clinical competency has been established and maintained.
(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)
(b) (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 furnished or furnished, ordered
, or prescribed under this section.
(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.
(3)
(2) Nurse practitioners who are certified by the board
and hold an active furnishing number , who are authorized
through standardized procedures or protocols to furnish Schedule II
controlled substances, 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.
(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:
(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.
(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:
(A) The nurse practitioner had consulted with the registered nurse
or licensed vocational nurse who had reviewed the patient's records.
(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.
(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.
(4) The licensee was acting in accordance with subdivision (b) of
Section 120582 of the Health and Safety Code.
(h)
(d) Use of the term "furnishing" in this section, in
health facilities defined in Section 1250 of the Health and Safety
Code, shall include (1) the ordering of a drug or
device in accordance with the standardized procedure and (2)
transmitting an order of a supervising physician and surgeon
.
(i)
(e) "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, (1) a drug order issued pursuant to this section
shall be treated in the same manner as a prescription of the
supervising physician; (2) (1) all references to
"prescription" in this code and the Health and Safety Code shall
include drug orders issued by nurse practitioners; and (3)
(2) 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.
SEC. 5. Section 2836.2 of the Business
and Professions Code is amended to read:
2836.2. 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. All nurse
practitioners who are authorized pursuant to Section 2836.1 to
prescribe, furnish , or issue drug orders for
controlled substances shall register with the United States Drug
Enforcement Administration.
SEC. 6. Section 2836.3 of the Business
and Professions Code is amended to re ad:
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 (g) (b) 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.
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.