BILL NUMBER: SB 491 AMENDED BILL TEXT AMENDED IN SENATE MAY 1, 2013 AMENDED IN SENATE APRIL 16, 2013 AMENDED IN SENATE APRIL 1, 2013 INTRODUCED BY Senator Hernandez FEBRUARY 21, 2013 An act to amend 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, approving, signing, modifying, or adding 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, examining patients and establishing a medical diagnosis 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. Vote: majority. Appropriation: no. Fiscal committee: 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 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 law, in addition to any other practices authorized in statute or regulation, a nurse practitioner may do any of the following: (1) Order durable medical equipment. 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, certify disability pursuant to Section 2708 of the Unemployment Insurance Code. (3) For individuals receiving home health services or personal care services, approve, sign, modify, or add to a plan of treatment or plan of care. (4) Assess patients, synthesize and analyze data, and apply principles of health care. (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) Examine patients and establish a medical diagnosis by client history, physical examination, and other criteria. (8) Order, furnish, or prescribe drugs or devices pursuant to Section 2836.1. (9) Refer patients to other health care providers as provided in subdivision (b). (10) Delegate tasks to a medical assistant pursuant to standardized procedures and protocols developed by the nurse practitioner and medical assistant, that are within the medical assistant's scope of practice . (11) 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. (12) Order hospice care as appropriate. (13) Perform procedures that are necessary and consistent with the nurse practitioner's
training and educationscope of practice . (b) A nurse practitioner shall refer a patient to a physician or another licensed health care provider if the referral will protect the health and welfare of the patient, and shall consult with a physician or other licensed health care provider if a situation or condition occurs in a patient that is beyond the nurse practitioner's knowledge and experience. (c) 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. (a) Neither this chapter nor any other provision of law shall be construed to prohibit a nurse practitioner from furnishing, ordering, or prescribing drugs or devices when both of the following apply: (1) The drugs or devices that are furnished, ordered, or prescribed are consistent with the practitioner's educational preparation or for which clinical competency has been established and maintained. (2) (A) 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, ordered, or prescribed under this section. (B) Nurse practitioners who are certified by the board and hold an active furnishing number 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. (b) 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. (c) Use of the term "furnishing" in this section, in health facilities defined in Section 1250 of the Health and Safety Code, shall include the ordering of a drug or device. (d) "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) all references to "prescription" in this code and the Health and Safety Code shall include drug orders issued by nurse practitioners; and (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. 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 read: 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 paragraph (2) of subdivision (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.