Amended in Assembly April 23, 2014

California Legislature—2013–14 Regular Session

Assembly Bill No. 2346

Introduced by Assembly Member Gonzalez

February 21, 2014

An act to begin delete amend Sections 2746.51, 2836.1, and 3516 of end delete begin insert add Article 15.1 (commencing with Section 2372 end insert begin insert ) to Chapter 5 of Division 2 of end insert the Business and Professions Code, relating to healing arts.

LEGISLATIVE COUNSEL’S DIGEST

AB 2346, as amended, Gonzalez. begin delete Nurse practitioners, certified nurse-midwives, and physician assistants: supervision. end delete begin insert Physician and surgeon assistance program. end insert

begin insert

Existing law, the Attorney Diversion and Assistance Act requires the establishment and administration of an Attorney Diversion and Assistance Program to provide services for the treatment and recovery of attorneys for the abuse of drugs or alcohol or mental illness, and who may be enrolled as inactive members of the State Bar.

end insert begin insert

This bill would authorize establishment of a similar assistance program for physicians and surgeons. The bill would authorize the Medical Board of California to make available the means to rehabilitate a physician and surgeon with impairment due to abuse of dangerous drugs or alcohol, or mental or physical illness, that affects his or her competency so that a physician and surgeon may be treated in a manner that will not endanger the public health and safety. The bill would make participants in the program responsible for all expenses relating to treatment and recovery, and would authorize the board to charge a reasonable administrative fee to participants for the purpose of offsetting the costs of maintaining the program. The bill would require the board, if the program is established, to engage in outreach to make physicians and surgeons and others aware of the existence and availability of the program.

end insert begin delete

Existing law, the Nursing Practice Act, provides for the licensure and regulation of the practice of nursing by the Board of Registered Nursing. Existing law authorizes a nurse practitioner and a certified nurse-midwife to furnish or order drugs or devices under specified circumstances subject to physician and surgeon supervision. Existing law prohibits a physician and surgeon from supervising more than 4 nurse practitioners and certified nurse-midwives at one time for purposes of furnishing drugs or devices. A violation of the Nursing Practice Act is a crime.

end delete begin delete

This bill would prohibit a physician and surgeon from supervising more than 6 nurse practitioners and certified nurse-midwives at one time for purposes of furnishing drugs or devices.

end delete begin delete

The Physician Assistant Practice Act provides for the licensure and regulation of physician assistants by the Physician Assistant Board within the jurisdiction of the Medical Board of California. Existing law authorizes a physician assistant to perform certain health care activities subject to physician and surgeon supervision. Existing law prohibits a physician and surgeon from supervising more than 4 physician assistants at one time, except as specified.

end delete begin delete

This bill would prohibit a physician and surgeon from supervising more than 6 physician assistants at one time, except as specified.

end delete

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:

begin insert

begin insert SECTION 1. end insert   

end insert

begin insert Article 15.1 (commencing with Section 2372) is
added to Chapter 5 of Division 2 of the end insert begin insert Business and Professions
Code end insert begin insert , to read: end insert

begin insert

 

Article begin insert 15.1. end insert   Physician and Surgeon Assistance Program

 

begin insert 2372. end insert   

The board is authorized to establish a program as a
voluntary and confidential program to support a physician and
surgeon in his or her rehabilitation and competent practice of
medicine, enhance public protection, and maintain the integrity
of the medical profession. Confidentiality pursuant to this article
shall be absolute unless waived by a physician and surgeon, except
as specified in Section 2373. The program shall, if established,
aid a physician and surgeon struggling with substance abuse,
mental health concerns, stress, burnout, and other issues impacting
his or her productivity. This program shall be modeled after the
State Bar’s Lawyer Assistance Program.

begin insert 2373. end insert   

The board may refer a physician and surgeon to the
program, but neither acceptance into or participation in the
program shall relieve the physician or surgeon of any lawful duties
and obligations under this chapter or otherwise under any
disciplinary action. Participation in the program shall be disclosed
if required as a condition of probation, pursuant to Section 2228.

begin insert 2374. end insert   

Participants in the program shall be responsible for all
expenses relating to treatment and recovery. In addition, the board
may charge a reasonable administrative fee to participants for the
purpose of offsetting the costs of maintaining the program.

begin insert 2375. end insert   

If a program is established, the board shall actively
engage in outreach activities to make physicians and surgeons,
the medical community, and the general public aware of the
existence and availability of the program. Outreach may include,
but not be limited to, the development and certification of minimum
continuing education courses relating to the prevention, detection,
and treatment of substance abuse, including no-cost and low-cost
programs and materials.

end insert

begin delete

SECTION 1.  

Section 2746.51 of the Business and Professions
Code is amended to read:

2746.51.  

(a) Neither this chapter nor any other provision of
law shall be construed to prohibit a certified nurse-midwife from
furnishing or ordering drugs or devices, including controlled
substances classified in Schedule II, III, IV, or V under the
California Uniform Controlled Substances Act (Division 10
(commencing with Section 11000) of the Health and Safety Code),
when all of the following apply:

(1) The drugs or devices are furnished or ordered incidentally
to the provision of any of the following:

(A) Family planning services, as defined in Section 14503 of
the Welfare and Institutions Code.

(B) Routine health care or perinatal care, as defined in
subdivision (d) of Section 123485 of the Health and Safety Code.

(C) Care rendered, consistent with the certified nurse-midwife’s
educational preparation or for which clinical competency has been
established and maintained, to persons within a facility specified
in subdivision (a), (b), (c), (d), (i), or (j) of Section 1206 of the
Health and Safety Code, a clinic as specified in Section 1204 of
the Health and Safety Code, a general acute care hospital as defined
in subdivision (a) of Section 1250 of the Health and Safety Code,
a licensed alternative birth center as defined in Section 1204.3 of
the Health and Safety Code, or a special hospital specified as a
maternity hospital in subdivision (f) of Section 1250 of the Health
and Safety Code.

(2) The drugs or devices are furnished or ordered by a certified
nurse-midwife in accordance with standardized procedures or
protocols. For purposes of this section, standardized procedure
means a document, including protocols, developed and approved
by the supervising physician and surgeon, the certified
nurse-midwife, and the facility administrator or his or her designee.
The standardized procedure covering the furnishing or ordering
of drugs or devices shall specify all of the following:

(A) Which certified nurse-midwife may furnish or order drugs
or devices.

(B) Which drugs or devices may be furnished or ordered and
under what circumstances.

(C) The extent of physician and surgeon supervision.

(D) The method of periodic review of the certified
nurse-midwife’s competence, including peer review, and review
of the provisions of the standardized procedure.

(3) If Schedule II or III controlled substances, as defined in
Sections 11055 and 11056 of the Health and Safety Code, are
furnished or ordered by a certified nurse-midwife, the controlled
substances shall be furnished or ordered in accordance with a
patient-specific protocol approved by the treating or supervising
physician and surgeon. For Schedule II controlled substance
protocols, the provision for furnishing the Schedule II controlled
substance shall address the diagnosis of the illness, injury, or
condition for which the Schedule II controlled substance is to be
furnished.

(4) The furnishing or ordering of drugs or devices by a certified
nurse-midwife occurs under physician and surgeon supervision.
For purposes of this section, a physician and surgeon shall not
supervise more than six certified nurse-midwives at one time.
Physician and surgeon supervision shall not be construed to require
the physical presence of the physician, but does include all of the
following:

(A) Collaboration on the development of the standardized
procedure or protocol.

(B) Approval of the standardized procedure or protocol.

(C) Availability by telephonic contact at the time of patient
examination by the certified nurse-midwife.

(b) (1) The furnishing or ordering of drugs or devices by a
certified nurse-midwife is conditional on the issuance by the board
of a number to the applicant who has successfully completed the
requirements of paragraph (2). The number shall be included on
all transmittals of orders for drugs or devices by the certified
nurse-midwife. The board shall maintain a list of the certified
nurse-midwives that it has certified pursuant to this paragraph and
the number it has issued to each one. The board shall make the list
available to the California State Board of Pharmacy upon its
request. Every certified nurse-midwife who is authorized pursuant
to this section to furnish or issue a drug order for a controlled
substance shall register with the United States Drug Enforcement
Administration.

(2) The board has certified in accordance with paragraph (1)
that the certified nurse-midwife has satisfactorily completed a
course in pharmacology covering the drugs or devices to be
furnished or ordered under this section. The board shall establish
the requirements for satisfactory completion of this paragraph.

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

(4) A copy of the standardized procedure or protocol relating
to the furnishing or ordering of controlled substances by a certified
nurse-midwife shall be provided upon request to any licensed
pharmacist who is uncertain of the authority of the certified
nurse-midwife to perform these functions.

(5) Certified nurse-midwives who are certified by the board and
hold an active furnishing number, who are currently authorized
through standardized procedures or protocols to furnish Schedule
II controlled substances, and who are registered with the United
States Drug Enforcement Administration shall provide
documentation of continuing education specific to the use of
Schedule II controlled substances in settings other than a hospital
based on standards developed by the board.

(c) Drugs or devices furnished or ordered by a certified
nurse-midwife may include Schedule II controlled substances
under the California Uniform Controlled Substances Act (Division
10 (commencing with Section 11000) of the Health and Safety
Code) under the following conditions:

(1) The drugs and devices are furnished or ordered in accordance
with requirements referenced in paragraphs (2) to (4), inclusive,
of subdivision (a) and in paragraphs (1) to (3), inclusive, of
subdivision (b).

(2) When Schedule II controlled substances, as defined in
Section 11055 of the Health and Safety Code, are furnished or
ordered by a certified nurse-midwife, the controlled substances
shall be furnished or ordered in accordance with a patient-specific
protocol approved by the treating or supervising physician and
surgeon.

(d) Furnishing of drugs or devices by a certified nurse-midwife
means the act of making a pharmaceutical agent or agents available
to the patient in strict accordance with a standardized procedure
or protocol. Use of the term “furnishing” in this section shall
include the following:

(1) The ordering of a drug or device in accordance with the
standardized procedure or protocol.

(2) Transmitting an order of a supervising physician and
surgeon.

(e) “Drug order” or “order” for purposes of this section means
an order for medication or for a drug or device that is dispensed
to or for an ultimate user, issued by a certified nurse-midwife as
an individual practitioner, within the meaning of Section 1306.03
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) all references to “prescription” in this
code and the Health and Safety Code shall include drug orders
issued by certified nurse-midwives; and (3) the signature of a
certified nurse-midwife 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. 2.  

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 drugs or devices when all of the following apply:

(a) The drugs or devices 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 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, a physician and surgeon shall
not supervise more than six 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) (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 ordered 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) 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.

(h) 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) “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 1306.03 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) all references to “prescription” in this code and the Health and
Safety Code shall include drug orders issued by nurse practitioners;
and (3) 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. 3.  

Section 3516 of the Business and Professions Code is
amended to read:

3516.  

(a) Notwithstanding any other provision of law, a
physician assistant licensed by the board shall be eligible for
employment or supervision by any physician and surgeon who is
not subject to a disciplinary condition imposed by the Medical
Board of California prohibiting that employment or supervision.

(b) A physician and surgeon shall not supervise more than six
physician assistants at one time, except as provided in Section
3502.5.

(c) The Medical Board of California may restrict a physician
and surgeon to supervising specific types of physician assistants
including, but not limited to, restricting a physician and surgeon
from supervising physician assistants outside of the field of
specialty of the physician and surgeon.

end delete