Amended in Assembly August 5, 2013

Amended in Senate May 21, 2013

Amended in Senate May 1, 2013

Amended in Senate April 16, 2013

Amended in Senate April 1, 2013

Senate Bill No. 491

Introduced by Senator Hernandez

February 21, 2013

An act to begin delete amend Sections 2835.5, 2835.7, 2836.1, 2836.2, and 2836.3 of end delete begin insert add Section 2835.3 to end insert 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. begin delete 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. end delete 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. begin insert A violation of those provisions is a crime. end insert

begin delete

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, establishing physical diagnoses 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.

end delete begin insert

This bill would authorize a nurse practitioner to perform those acts and certain additional acts without physician supervision if the nurse practitioner meets specified experience and certification requirements. The bill would require a nurse practitioner to refer a patient to a physician and surgeon or other licensed health care provider under certain circumstances, and would require specified nurse practitioners to maintain a current list of licensed health care providers most often used for the purposes of obtaining information or advice. The bill would also require a nurse practitioner practicing under these provisions to maintain professional liability insurance, as specified. Because a violation of those provisions would be a crime, this bill would impose a state-mandated local program.

end insert begin insert

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

end insert begin insert

This bill would provide that no reimbursement is required by this act for a specified reason.

end insert

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

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

begin insert

begin insert SECTION 1. end insert   

end insert

begin insert Section 2835.3 is added to the end insert begin insert Business and
Professions Code end insert begin insert , to read: end insert

begin insert

begin insert 2835.3. end insert   

(a) Notwithstanding any other provision of this
chapter, a nurse practitioner who holds a certification as a nurse
practitioner from a national certifying body may practice under
this section without physician supervision if the nurse practitioner
meets the requirements of this article and one of the following is
met:

(1) He or she has practiced under the supervision of a physician
for two years or 4160 hours and is practicing in one of the
following:

(A) A clinic, health facility, or county medical facility.

(B) An accountable care organization, as defined in Section
3022 of the federal Patient Protection and Affordable Care Act
(Public Law 111-148).

(C) A group practice, including a professional medical
corporation, another form of corporation controlled by physicians
and surgeons, a medical partnership, a medical foundation exempt
from licensure, or another lawfully organized group of physicians
that delivers, furnishes, or otherwise arranges for or provides
health care services.

(2) He or she has practiced under the supervision of a physician
for at least three years or 6240 hours.

(b) Notwithstanding any other law, in addition to any other
practices authorized in statute or regulation, a nurse practitioner
practicing under this section 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, including patient history,
general behavior, and signs and symptoms of illness, identify
alternative possibilities as to the nature of a health care problem,
and select, implement, and evaluate appropriate treatment.

(7) Establish a diagnosis by client history, physical examination,
and other criteria, consistent with this section.

(8) Order, furnish, or prescribe drugs or devices.

(9) Refer patients to physicians or other licensed health care
providers as provided in subdivision (c).

(10) Delegate tasks to a 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 education and training.

(c) A nurse practitioner shall refer a patient to a physician and
surgeon or another licensed health care provider if a situation or
condition of the patient is beyond the nurse practitioner’s education
or training.

(d) A nurse practitioner described in paragraph (2) of
subdivision (a) shall maintain a current list of licensed health care
providers most often used for the purposes of obtaining information
or advice.

(e) A nurse practitioner practicing under this section shall
maintain professional liability insurance that is appropriate for
his or her practice setting.

(f) Nothing in this section shall do either of the following:

(1) Limit a nurse practitioner’s authority to practice nursing.

(2) Limit the scope of practice of a registered nurse authorized
pursuant to this chapter.

(g) The board shall adopt regulations by September 1, 2014,
establishing the means of documenting completion of the
requirements of this section.

end insert

begin insert

begin insert SEC. 2. end insert   

end insert begin insert

No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of
the Government Code, or changes the definition of a crime within
the meaning of Section 6 of Article XIII B of the California
Constitution.

end insert

begin delete

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) Establish a physical diagnosis by client history, physical
examination, and other criteria, consistent with this section.

(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 scope 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 of
a patient is beyond the nurse practitioner’s education, training, or
certification.

(c) A nurse practitioner shall maintain professional liability
insurance that is appropriate for his or her practice setting.

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 (a) 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 California State 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.

end delete