By Berlanga, et al. H.B. No. 1520
Substitute the following for H.B. No. 1520:
By Berlanga C.S.H.B. No. 1520
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to health care, including powers and duties of the center
1-3 for rural health initiatives, powers and duties of registered
1-4 nurses and physician assistants, managed health care plans for
1-5 certain inmates, and health facilities and services for the elderly
1-6 or disabled.
1-7 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-8 SECTION 1. Chapter 105, Health and Safety Code, is amended
1-9 by adding Section 105.007 to read as follows:
1-10 Sec. 105.007. CLEARINGHOUSE. (a) As part of the
1-11 comprehensive health professions resource center, the department
1-12 shall develop and establish a clearinghouse for health
1-13 professionals seeking collaborative practice.
1-14 (b) The department may:
1-15 (1) set and collect a reasonable fee to offset the
1-16 cost of complying with this section;
1-17 (2) solicit, receive, and spend grants, gifts, and
1-18 donations from public and private sources to comply with this
1-19 section; and
1-20 (3) contract with public or private entities in the
1-21 performance of its responsibilities under this section.
1-22 SECTION 2. Subsection (a), Section 106.025, Health and
1-23 Safety Code, is amended to read as follows:
2-1 (a) The center shall:
2-2 (1) educate the public and recommend appropriate
2-3 public policies regarding the continued viability of rural health
2-4 care delivery in this state;
2-5 (2) monitor and work with state and federal agencies
2-6 to assess the impact of proposed rules on rural areas;
2-7 (3) provide impact statements of proposed rules as
2-8 considered appropriate by the center;
2-9 (4) streamline regulations to assist in the
2-10 development of service diversification of health care facilities;
2-11 (5) target state and federal programs to rural areas;
2-12 (6) promote and develop community involvement and
2-13 community support in maintaining, rebuilding, or diversifying local
2-14 health services;
2-15 (7) promote and develop diverse and innovative health
2-16 care service models in rural areas;
2-17 (8) encourage the use of advanced communications
2-18 technology to:
2-19 (A) ensure that rural areas receive the maximum
2-20 benefits of telemedicine and distance learning by promoting a
2-21 transmission rate structure that accommodates rural needs and by
2-22 improving the telecommunications infrastructure in rural areas; and
2-23 (B) provide access to specialty expertise,
2-24 clinical consultation, and continuing education;
2-25 (9) assist rural health care providers, communities,
3-1 and individuals in applying for public and private grants and
3-2 programs;
3-3 (10) encourage the development of regional emergency
3-4 transportation networks;
3-5 (11) work with state agencies, universities, and
3-6 private interest groups to conduct and promote research on rural
3-7 health issues, maintain and collect a timely data base, and develop
3-8 and maintain a rural health resource library;
3-9 (12) solicit the assistance of other offices or
3-10 programs of rural health in this state that are university-based to
3-11 carry out the duties of this chapter;
3-12 (13) disseminate information and provide technical
3-13 assistance to communities, health care providers, and individual
3-14 consumers of health care services; <and>
3-15 (14) develop plans to implement a fee-for-service
3-16 health care professional recruitment service and a medical supplies
3-17 group purchasing program within the center;
3-18 (15) develop and initiate a study of rural health
3-19 clinics to:
3-20 (A) determine the efficiency and effectiveness
3-21 of rural health clinics;
3-22 (B) review the health outcomes of rural patients
3-23 treated in rural health clinics and report those outcomes in the
3-24 center's biennial report to the legislature;
3-25 (C) identify and address efficiency barriers for
4-1 the professional clinical relationship of physicians, nurses, and
4-2 physician assistants;
4-3 (D) assess the success of attracting primary
4-4 care physicians and allied health professionals to rural areas; and
4-5 (E) assess the appropriateness of the current
4-6 clinic designation process;
4-7 (16) develop and initiate a quality assessment program
4-8 to evaluate the health outcomes of rural patients treated in rural
4-9 health clinics; and
4-10 (17) encourage the active participation by physicians
4-11 and other health care providers in the early and periodic
4-12 screening, diagnosis, and treatment program.
4-13 SECTION 3. Section 262.034, Health and Safety Code, is
4-14 amended to read as follows:
4-15 Sec. 262.034. FACILITIES AND SERVICES FOR ELDERLY AND
4-16 DISABLED <NURSING HOMES>. (a) <This section applies to an
4-17 authority created by a municipality with a population of more than
4-18 24,000 that is located in a county with a population of 1.5 million
4-19 or more.>
4-20 <(b)> The authority may construct, acquire, own, operate,
4-21 enlarge, improve, furnish, or equip one or more of the following
4-22 types of facilities or services for the care of the elderly or
4-23 disabled:
4-24 (1) a nursing home or similar long-term care facility;
4-25 (2) elderly housing;
5-1 (3) assisted living;
5-2 (4) home health;
5-3 (5) personal care;
5-4 (6) special care;
5-5 (7) continuing care; and
5-6 (8) durable medical equipment <one or more nursing
5-7 homes or similar facilities for the care of the elderly. The
5-8 nursing home or similar facility may be located outside the
5-9 municipal limits>.
5-10 (b) <(c)> The authority may lease or enter into an
5-11 operations or management agreement relating to all or part of a
5-12 <nursing home or similar> facility or service for the care of the
5-13 elderly or disabled that is owned by the authority. The authority
5-14 may sell, transfer, otherwise convey, or close all or part of the
5-15 <nursing home or similar> facility and may discontinue a service.
5-16 (c) <(d)> The authority may issue revenue bonds and other
5-17 notes in accordance with this chapter to acquire, construct, or
5-18 improve a <nursing home or similar> facility for the care of the
5-19 elderly or disabled or to implement the delivery of a service for
5-20 the care of the elderly or disabled.
5-21 (d) <(e)> For the purposes of this section, a <nursing home
5-22 or similar> facility or service described by Subsection (a) <for
5-23 the care of the elderly> is considered to be a hospital project
5-24 under Chapter 223 (Hospital Project Financing Act).
5-25 (e) This section applies only to an authority that owns or
6-1 operates a hospital licensed under Chapter 241 and that is located
6-2 in:
6-3 (1) a county with a population of 35,000 or less;
6-4 (2) those portions of extended municipalities that the
6-5 federal census bureau has determined to be rural; or
6-6 (3) an area that is not delineated as an urbanized
6-7 area by the federal census bureau.
6-8 SECTION 4. Chapter 285, Health and Safety Code, is amended
6-9 by adding Subchapter H to read as follows:
6-10 SUBCHAPTER H. LONG-TERM CARE AND RELATED FACILITIES
6-11 Sec. 285.101. FACILITIES OR SERVICES FOR ELDERLY OR
6-12 DISABLED. (a) This subchapter applies only to a hospital,
6-13 hospital district, or authority created and operated under Article
6-14 IX, Texas Constitution, under a special law, or under this title
6-15 that is located in:
6-16 (1) a county with a population of 35,000 or less;
6-17 (2) those portions of extended municipalities that the
6-18 federal census bureau has determined to be rural; or
6-19 (3) an area that is not delineated as an urbanized
6-20 area by the federal census bureau.
6-21 (b) A hospital, hospital district, or authority covered by
6-22 this subchapter may:
6-23 (1) construct, acquire, own, operate, enlarge,
6-24 improve, furnish, or equip one or more of the following types of
6-25 facilities or services for the care of the elderly or disabled:
7-1 (A) a nursing home or similar long-term care
7-2 facility;
7-3 (B) elderly housing;
7-4 (C) assisted living;
7-5 (D) home health;
7-6 (E) personal care;
7-7 (F) special care;
7-8 (G) continuing care; or
7-9 (H) durable medical equipment;
7-10 (2) lease or enter into an operations or management
7-11 agreement relating to all or part of a facility or service
7-12 described in Subsection (a) that is owned by the hospital district
7-13 or authority;
7-14 (3) close, transfer, sell, or otherwise convey all or
7-15 part of a facility and discontinue services; and
7-16 (4) issue revenue bonds and other notes to acquire,
7-17 construct, or improve a facility for the care of the elderly or
7-18 disabled or to implement the delivery of a service for the care of
7-19 the elderly or disabled.
7-20 (c) For the purpose of this section, a facility or service
7-21 created under Subsection (b) is considered to be a hospital project
7-22 under Chapter 223.
7-23 SECTION 5. Subdivisions (4) and (13), Section 483.001,
7-24 Health and Safety Code, are amended as follows:
7-25 (4) "Designated agent" means:
8-1 (A) a licensed nurse, physician assistant,
8-2 pharmacist, or other individual designated by a practitioner to
8-3 communicate prescription drug orders to a pharmacist;
8-4 (B) a licensed nurse, physician assistant, or
8-5 pharmacist employed in a health care facility to whom the
8-6 practitioner communicates a prescription drug order; or
8-7 (C) a registered nurse or physician assistant
8-8 authorized by a practitioner to carry out a prescription drug order
8-9 for dangerous drugs under Sections 3.06(5) and (6), Medical
8-10 Practice Act (Article 4495b, Vernon's Texas Civil Statutes).
8-11 (13) "Prescription" means an order from a
8-12 practitioner, or an agent of the practitioner designated in writing
8-13 as authorized to communicate prescriptions, or an order made in
8-14 accordance with Sections 3.06(d)(5) and (6), Medical Practice Act
8-15 (Article 4495b, Vernon's Texas Civil Statutes), to a pharmacist for
8-16 a dangerous drug to be dispensed that states:
8-17 (A) the date of the order's issue;
8-18 (B) the name and address of the patient;
8-19 (C) if the drug is prescribed for an animal, the
8-20 species of animal;
8-21 (D) the name and quantity of the drug
8-22 prescribed;
8-23 (E) the directions for the use of the drug;
8-24 <and>
8-25 <(F) the legibly printed or stamped name,
9-1 address, Federal Drug Enforcement Administration registration
9-2 number, and telephone number of the practitioner at the
9-3 practitioner's usual place of business.>
9-4 (F) the intended use of the drug unless the
9-5 practitioner determines the furnishing of this information is not
9-6 in the best interest of the patient; <and>
9-7 (G) the name, address, and telephone number of
9-8 the practitioner at the practitioner's usual place of business,
9-9 legibly printed and stamped; and
9-10 (H) the name, address, and telephone number of
9-11 the registered nurse or physician assistant, legibly printed or
9-12 stamped, if signed by a registered nurse or physician assistant.
9-13 SECTION 6. Subsection (a), Section 483.042, Health and
9-14 Safety Code, is amended as follows:
9-15 (a) A person commits an offense if the person delivers or
9-16 offers to deliver a dangerous drug:
9-17 (1) unless:
9-18 (A) the dangerous drug is delivered or offered
9-19 for delivery by a pharmacist under:
9-20 (i) a prescription issued by a
9-21 practitioner described Section 483.001(12)(A) or (B); <or>
9-22 (ii) a prescription signed by a registered
9-23 nurse or physician assistant in accordance with Sections 3.06(d)(5)
9-24 and (6), Medical Practice Act (Article 4495b, Vernon's Texas Civil
9-25 Statutes); or
10-1 (iii) an original written prescription
10-2 issued by a practitioner described by Section 483.001(12)(C); and
10-3 (B) a label is attached to the immediate
10-4 container in which the drug is delivered or offered to be delivered
10-5 and the label contains the following information:
10-6 (i) the name and address of the pharmacy
10-7 from which the drug is delivered or offered for delivery;
10-8 (ii) the date the prescription for the
10-9 drug is dispensed;
10-10 (iii) the number of the prescription as
10-11 filed in the prescription files of the pharmacy from which the
10-12 prescription is dispensed;
10-13 (iv) the name of the practitioner who
10-14 prescribed the drug and, if applicable, the name of the registered
10-15 nurse or physician assistant who signed the prescription;
10-16 (v) the name of the patient and, if the
10-17 drug is prescribed for an animal, a statement of the species of the
10-18 animal; and
10-19 (vi) directions for the use of the drug as
10-20 contained in the prescription; or
10-21 (2) unless:
10-22 (A) the dangerous drug is delivered or offered
10-23 for delivery by:
10-24 (i) a practitioner in the course of
10-25 practice; or
11-1 (ii) a registered nurse or physician
11-2 assistant in the course of practice in accordance with Sections
11-3 3.06(d)(5) and (6), Medical Practice Act (Article 4495b, Vernon's
11-4 Texas Civil Statutes); and
11-5 (B) a label is attached to the immediate
11-6 container in which the drug is delivered or offered to be delivered
11-7 and the label contains the following information:
11-8 (i) the name and address of the
11-9 practitioner who prescribed the drug, and if applicable, the name
11-10 and address of the registered nurse or physician assistant;
11-11 (ii) the date the drug is delivered;
11-12 (iii) the name of the patient and, if the
11-13 drug is prescribed for an animal, a statement of the species of the
11-14 animal; and
11-15 (iv) the name of the drug, the strength of
11-16 the drug, and directions for the use of the drug.
11-17 SECTION 7. Subsection (d), Section 671.001, Health and
11-18 Safety Code, is amended to read as follows:
11-19 (d) A registered nurse or physician assistant may determine
11-20 and pronounce a person dead in situations other than those
11-21 described by Subsection (b) if permitted by written policies of a
11-22 licensed health care facility, institution, or entity providing
11-23 services to that person. Those policies must include physician
11-24 assistants who are credentialed or otherwise permitted to practice
11-25 at the facility, institution, or entity. If the facility,
12-1 institution, or entity has an organized nursing staff and an
12-2 organized medical staff or medical consultant, the nursing staff
12-3 and medical staff or consultant shall jointly develop and approve
12-4 those policies. The board shall adopt rules to govern policies for
12-5 facilities, institutions, or entities that do not have organized
12-6 nursing staffs and organized medical staffs or medical consultants.
12-7 SECTION 8. Section 671.002, Health and Safety Code, is
12-8 amended to read as follows:
12-9 Sec. 671.002. LIMITATION OF LIABILITY. (a) A physician who
12-10 determines death in accordance with Section 671.001(b) or a
12-11 registered nurse or physician assistant who determines death in
12-12 accordance with Section 671.001(d) is not liable for civil damages
12-13 or subject to criminal prosecution for the physician's, <or>
12-14 registered nurse's, or physician assistant's actions or the actions
12-15 of others based on the determination of death.
12-16 (b) A person who acts in good faith in reliance on a
12-17 physician's, <or> registered nurse's, or physician assistant's
12-18 determination of death is not liable for civil damages or subject
12-19 to criminal prosecution for the person's actions.
12-20 SECTION 9. Subsection (c), Section 51.918, Education Code,
12-21 is amended to read as follows:
12-22 (c) The Center for Rural Health Initiatives shall develop
12-23 relief service programs for rural physicians and allied health
12-24 personnel to facilitate ready access to continuing medical
12-25 education or practice coverage for purposes other than continuing
13-1 medical education.
13-2 SECTION 10. Section 501.059, Government Code, as added by
13-3 Chapter 238, Acts of the 73rd Legislature, 1993, is amended to read
13-4 as follows:
13-5 Sec. 501.059. MANAGED HEALTH CARE ADVISORY COMMITTEE. (a)
13-6 The Managed Health Care Advisory Committee to the Texas Department
13-7 of Criminal Justice is established.
13-8 (b) The committee consists of:
13-9 (1) two members employed full-time by the department,
13-10 at least one of whom is a physician, appointed by the executive
13-11 director;
13-12 (2) two members employed full-time by The University
13-13 of Texas Medical Branch at Galveston, at least one of whom is a
13-14 physician, appointed by the president of the medical branch; and
13-15 (3) two members employed full-time by the Texas Tech
13-16 University Health Sciences Center, at least one of whom is a
13-17 physician, appointed by the president of the university.
13-18 (c) A committee member serves at the pleasure of the
13-19 appointing official or until termination of the member's employment
13-20 with the entity the member represents.
13-21 (d) An appointment to the committee shall be made without
13-22 regard to the race, creed, sex, religion, or national origin of the
13-23 appointee.
13-24 (e) A committee member serves without compensation but is
13-25 entitled to reimbursement for actual and necessary expenses
14-1 incurred in the performance of the duties of the committee.
14-2 (f) The committee may hire a managed health care
14-3 administrator and may employ personnel necessary for the
14-4 administration of the committee's duties.
14-5 (g) The committee shall develop a managed health care plan
14-6 for all inmates at the institutional division that includes:
14-7 (1) the establishment of a managed care network of
14-8 physicians and hospitals that will serve the institutional division
14-9 as the exclusive health care provider for inmates at each facility
14-10 of the institutional division;
14-11 (2) cost containment studies; <and>
14-12 (3) care case management and utilization management
14-13 studies performed exclusively for the institutional division; and
14-14 (4) concerning the establishment of criteria for
14-15 hospitals, home health, or hospice providers, a provision requiring
14-16 the managed health care plan to accept certification by the
14-17 Medicare program under Title XVIII, Social Security Act, as amended
14-18 (42 U.S.C. Section 1395 et seq.), as an alternative to
14-19 accreditation by the Joint Commission on Accreditation of
14-20 Healthcare Organizations.
14-21 (h) To the extent possible the committee shall integrate the
14-22 managed care network with the public medical schools of this state
14-23 and the component and affiliated hospitals of those medical
14-24 schools.
14-25 (i) For those services for which the public medical schools
15-1 and their components and affiliates cannot provide, the committee
15-2 shall initiate a competitive bidding process for contracts with
15-3 other providers for medical care to inmates confined in the
15-4 institutional division.
15-5 (j) The committee may enter into a contract on behalf of the
15-6 department to fully implement the managed health care plan under
15-7 Subsection (g).
15-8 (k) The department shall pay necessary costs for the
15-9 operation of the committee, including costs of personnel, from
15-10 funds appropriated by the legislature to the department.
15-11 (l) The managed health care plan, inclusive of the health
15-12 care administrator and necessary personnel proposed by the
15-13 committee, must cost the state less than what is presently
15-14 provided, otherwise the status quo shall be maintained.
15-15 SECTION 11. Subdivisions (19) and (42), Section 5, Texas
15-16 Pharmacy Act (Article 4542-1, Vernon's Texas Civil Statutes), are
15-17 amended to read as follows:
15-18 (19) "Designated agent" means:
15-19 (A) a licensed nurse, physician assistant,
15-20 pharmacist, or other individual designated by a practitioner, and
15-21 for whom the practitioner assumes legal responsibility, who
15-22 communicates prescription drug orders to a pharmacist;
15-23 (B) a licensed nurse, physician assistant, or
15-24 pharmacist employed in a health care facility to whom the
15-25 practitioner communicates a prescription drug order; or
16-1 (C) a registered nurse or physician assistant
16-2 authorized by a practitioner to carry out a prescription drug order
16-3 for dangerous drugs under Subdivision (5) or (6), Subsection (d),
16-4 Section 3.06, Medical Practice Act (Article 4495b, Vernon's Texas
16-5 Civil Statutes).
16-6 (42) "Prescription drug order" means:
16-7 (A) an order from a practitioner or a
16-8 practitioner's designated agent to a pharmacist for a drug or
16-9 device to be dispensed; or
16-10 (B) an order pursuant to Subdivision (5) or (6),
16-11 Subsection (d), Section 3.06, Medical Practice Act (Article 4495b,
16-12 Vernon's Texas Civil Statutes).
16-13 SECTION 12. Subdivision (5), Subsection (d), Section 3.06,
16-14 Medical Practice Act (Article 4495b, Vernon's Texas Civil
16-15 Statutes), is amended to read as follows:
16-16 (5)(A) At a site serving a medically under served
16-17 population, a physician licensed by the board shall be authorized
16-18 to delegate to a registered nurse or physician assistant acting
16-19 under adequate physician supervision, the act or acts of
16-20 administering, providing, or carrying out or signing a prescription
16-21 drug order as authorized by the physician through physician's
16-22 orders, standing medical orders, standing delegation orders, or
16-23 other orders or protocols as defined by the board.
16-24 (B)(i) The carrying out or signing of
16-25 prescription drug orders under this subsection shall comply with
17-1 other applicable laws.
17-2 (ii) The authority of a physician to
17-3 delegate the carrying out or signing of prescription drug orders is
17-4 limited to dangerous drugs.
17-5 (C) Protocols and other orders shall be defined
17-6 to promote the exercise of professional judgment by the advanced
17-7 nurse practitioner and physician assistant commensurate with their
17-8 education and experience. Under this subdivision, protocols and
17-9 other orders used by a reasonable and prudent physician exercising
17-10 sound medical judgment:
17-11 (i) need not describe the exact steps that
17-12 an advanced nurse practitioner or a physician assistant must take
17-13 with respect to each specific condition, disease or symptom; and
17-14 (ii) may state the types or categories of
17-15 medications that may be prescribed or in terms of categories or
17-16 types of medications that may not be prescribed.
17-17 (D) Physician supervision shall be adequate if a
17-18 delegating physician:
17-19 (i) is responsible for the formulation or
17-20 approval of such physician's orders, standing medical orders,
17-21 standing delegation orders, or other orders or protocols and
17-22 periodically reviews such orders and the services provided patients
17-23 under such orders;
17-24 (ii) is on site at least once a week to
17-25 provide medical direction and consultation;
18-1 (iii) receives a daily status report from
18-2 the registered nurse or physician assistant on any problems or
18-3 complication encountered; and
18-4 (iv) is available through direct
18-5 telecommunication for consultation, assistance with medical
18-6 emergencies, or patient referral.
18-7 <(D)> (E) In this subsection:
18-8 (i) "Registered nurse" means a registered
18-9 nurse recognized by the Board of Nurse Examiners as having the
18-10 specialized education and training required under Section <7> 6,
18-11 Article 4514, Revised Statutes.
18-12 (ii) "Physician assistant" has the meaning
18-13 assigned to that term by Section 2(3), Physician Assistant
18-14 Licensing Act<, and its subsequent amendments> (Article 4495b-1,
18-15 Vernon's Texas Civil Statutes).
18-16 (iii) "Carrying out or signing a
18-17 prescription drug order" means the completion of <to complete> a
18-18 prescription drug order presigned by the delegating physician, or
18-19 the signing of a prescription by a registered nurse or physician
18-20 assistant after the person has been designated with the board by
18-21 the delegating physician as a person delegated to sign a
18-22 prescription. The following information shall be provided on each
18-23 prescription <by providing the following information>: the
18-24 patient's name and address; the drug to be dispensed; directions to
18-25 the patient in regard to the taking and dosage; the intended use of
19-1 the drug, if appropriate; the name, address, and telephone number
19-2 of the physician; the name, address, telephone and identification
19-3 number of the registered nurse or physician assistant completing or
19-4 signing the prescription drug order; the date; and the number of
19-5 refills permitted. The board may adopt additional methods to carry
19-6 into effect or put into force a physician's prescription or
19-7 delegation of the signing of a prescription under physician's
19-8 orders, standing medical orders, standing delegation orders, or
19-9 other orders or protocols.
19-10 (iv) "A site serving a medically
19-11 underserved population" means:
19-12 (a) a site located in a medically
19-13 underserved area;
19-14 (b) a site located in a health
19-15 manpower shortage area;
19-16 (c) a clinic designated as a rural
19-17 health clinic under the Rural Health Clinic Services Act of 1977
19-18 (Pub. L. No. 95-210);
19-19 (d) a public health clinic or a
19-20 family planning clinic under contract with the Texas Department of
19-21 Human Services or the Texas Department of Health;
19-22 (e) a site located in an area in
19-23 which the Texas Department of Health determines there exists an
19-24 insufficient number of physicians providing services to eligible
19-25 clinics of federal, state, or locally funded health care programs;
20-1 or
20-2 (f) a site that the Texas Department
20-3 of Health determines serves a disproportionate number of clients
20-4 eligible to participate in federal, state, or locally funded health
20-5 care programs.
20-6 (v) "Health manpower shortage area" means
20-7 (1) an area in an urban or rural area of Texas (which need not
20-8 conform to the geographic boundaries of a political subdivision and
20-9 which is a rational area for the delivery of health services) which
20-10 the secretary of health and human services determines has a health
20-11 manpower shortage and which is not reasonably accessible to an
20-12 adequately served area; (2) a population group which the secretary
20-13 determines to have such a shortage; or (3) a public or nonprofit
20-14 private medical facility or other facility which the secretary
20-15 determines has such a shortage as delineated in 42 U.S.C. Section
20-16 254(e)(a)(1).
20-17 (vi) "Medically underserved area" means an
20-18 area in Texas with a medically underserved population or an urban
20-19 or rural area designated by the secretary of health and human
20-20 services as an area in Texas with a shortage of personal health
20-21 services or a population group designated by the secretary as
20-22 having a shortage of such services (as defined in 42 U.S.C. Section
20-23 300(e)-1(7)). The term also includes an area defined by rule
20-24 adopted by the Texas Board of Health that is based on demographics
20-25 specific to this state, geographic factors that affect access to
21-1 health care, and environmental health factors.
21-2 <(E)> (F) After making a determination under
21-3 <either> Subdivision (D)(iv)(e), <or> (D)(iv)(f), or (D)(vi) that a
21-4 site serves a medically underserved population, the Texas
21-5 Department of Health shall publish notice of its determination in
21-6 the Texas Register and provide an opportunity for public comment in
21-7 the same manner as for a proposed rule under Chapter 2001,
21-8 Government Code <the Administrative Procedure and Texas Register
21-9 Act (Article 6252-13a, Vernon's Texas Civil Statutes)>.
21-10 <(F)> (G) The authority granted to a physician
21-11 to delegate under this subdivision shall not be construed as
21-12 limiting the authority of a physician to delegate under any other
21-13 subdivision of this subsection.
21-14 <(G)> (H) An advertisement for a site serving a
21-15 medically under served population shall include the name and
21-16 business address of the supervising physician for the site.
21-17 SECTION 13. Subsection (d), Section 3.06, Medical Practice
21-18 Act (Article 4495b, Vernon's Texas Civil Statutes) is amended by
21-19 adding Subdivision (6) to read as follows:
21-20 (6)(A) At a physician's primary practice site or
21-21 a location as defined in Paragraph (H) of this subdivision, a
21-22 physician licensed by the board may delegate to a physician
21-23 assistant or an advanced nurse practitioner acting under adequate
21-24 physician supervision the act or acts of administering, providing,
21-25 carrying out or signing a prescription drug order as authorized
22-1 through physician's orders, standing medical orders, standing
22-2 delegation orders, or other orders or protocols as defined by the
22-3 board. Providing and carrying out or signing a prescription drug
22-4 order under this subdivision is limited to dangerous drugs.
22-5 (B) Protocols and other orders shall be defined
22-6 to promote the exercise of professional judgment by the advanced
22-7 nurse practitioner and physician assistant commensurate with their
22-8 education and experience. Under this subdivision, protocols and
22-9 other orders used by a reasonable and prudent physician exercising
22-10 sound medical judgment:
22-11 (i) need not describe the exact steps that
22-12 an advanced nurse practitioner or a physician assistant must take
22-13 with respect to each specific condition, disease, or symptom; and
22-14 (ii) may state the types or categories of
22-15 medications that may be prescribed or state in terms of categories
22-16 or types of medications that may not be prescribed.
22-17 (C) Physician supervision of the carrying out
22-18 and signing of prescription drug orders shall conform to what a
22-19 reasonable, prudent physician would find consistent with sound
22-20 medical judgment but may vary with the education and experience of
22-21 the advanced nurse practitioner or physician assistant. A
22-22 physician shall provide continuous supervision, but the constant
22-23 physical presence of the physician is not required.
22-24 (D) An alternate physician may provide
22-25 appropriate supervision on a temporary basis as defined and
23-1 established by the board by rule.
23-2 (E) The carrying out or signing of prescription
23-3 drug orders under this subdivision shall comply with other
23-4 applicable laws.
23-5 (F) A physician's authority to delegate the
23-6 carrying out or signing of a prescription drug order at his primary
23-7 practice site under this subdivision is limited to:
23-8 (i) three physician assistants or advanced
23-9 nurse practitioners or their full-time equivalents practicing at
23-10 the physician's primary practice site; and
23-11 (ii) the patients with whom the physician
23-12 has established or will establish a physician-patient relationship,
23-13 but this shall not be construed as requiring the physician to see
23-14 the patient within a specific period of time.
23-15 (G) In this subsection:
23-16 (i) "Advanced nurse practitioner" has the
23-17 meaning assigned to that term by Section 8, Article 4514, Revised
23-18 Statutes.
23-19 (ii) "Physician assistant" has the meaning
23-20 assigned to that term by Section 2(3), Physician Assistant
23-21 Licensing Act, (Article 4495b-1, Vernon's Texas Civil Statutes).
23-22 (iii) "Primary practice site" means:
23-23 (a) the practice location where the
23-24 physician spends the majority of the physician's time;
23-25 (b) a licensed hospital, a licensed
24-1 long term care facility, and a licensed adult care center where
24-2 both the physician and the physician assistant or advanced nurse
24-3 practitioner are authorized to practice, or an established
24-4 patient's residence; or
24-5 (c) where the physician is
24-6 physically present with the physician assistant or advanced nurse
24-7 practitioner.
24-8 (iv) "Carrying out or signing a
24-9 prescription drug order" means the completion of a prescription
24-10 drug order presigned by a delegating physician or the signing of a
24-11 prescription by a physician assistant or advanced nurse
24-12 practitioner after the person has been designated with the board by
24-13 the delegating physician as a person delegated to sign a
24-14 prescription. The following information shall be provided on each
24-15 prescription: the patient's name and address; the drug to be
24-16 dispensed; directions to the patient in regard to the taking and
24-17 dosage; the intended use of the drug, if appropriate; the name,
24-18 address, and telephone number of the physician; the name, address,
24-19 and telephone and identification number of the physician assistant
24-20 or advanced nurse practitioner completing or signing the
24-21 prescription drug order; the date; and the number of refills
24-22 permitted. The board may adopt additional methods to carry into
24-23 effect or put into force a physician's prescription or delegation
24-24 of the signing of a prescription under physician's orders, standing
24-25 medical orders, standing delegation orders, or other orders or
25-1 protocols.
25-2 (H) A physician licensed by the board shall be
25-3 authorized to delegate, to one or more physician assistants or
25-4 advanced nurse practitioners acting under adequate physician
25-5 supervision whose practice is facility based at a licensed hospital
25-6 or licensed long term care facility, the carrying out or signing of
25-7 prescription drug orders if the physician is the medical director
25-8 or chief of medical staff of the facility in which the physician
25-9 assistant or advanced nurse practitioner practices, the chair of
25-10 the facility's credentialing committee, a department chair of a
25-11 facility department in which the physician assistant or advanced
25-12 nurse practitioner practices, or a physician who consents to the
25-13 request of the medical director or chief of medical staff to
25-14 delegate the carrying out or signing of prescription drug orders at
25-15 the facility in which the physician assistant or advanced nurse
25-16 practitioner practices. A physician's authority to delegate under
25-17 this paragraph is limited as follows:
25-18 (i) the delegation is pursuant to a
25-19 physician's order, standing medical order, standing delegation
25-20 order, or other order or protocol developed in accordance with
25-21 policies approved by the facility's medical staff or a committee
25-22 thereof as provided in facility bylaws;
25-23 (ii) the delegation occurs in the facility
25-24 in which the physician is the medical director, the chief of
25-25 medical staff, the chair of the credentialing committee, or a
26-1 departmental chair;
26-2 (iii) the delegation does not permit the
26-3 carrying out or signing of prescription drug orders for the care or
26-4 treatment of the patients of any other physician without the prior
26-5 consent of that physician;
26-6 (iv) delegation in a long term care
26-7 facility must be by the medical director and the medical director
26-8 is limited to delegating the carrying out and signing of
26-9 prescription drug orders to no more than three advanced nurse
26-10 practitioners or physician assistants or their full-time
26-11 equivalents; and
26-12 (v) under this paragraph, a physician may
26-13 not delegate at more than one licensed hospital or more than two
26-14 long term care facilities unless approved by the board.
26-15 (I) In a licensed hospital or ambulatory
26-16 surgical center a physician may delegate to a certified registered
26-17 nurse anesthetist the ordering of drugs and devices necessary for a
26-18 certified registered nurse anesthetist to administer an anesthetic
26-19 or an anesthesia-related service ordered by the physician. The
26-20 physician's order for anesthesia or anesthesia-related services
26-21 does not have to be drug-specific, dose-specific or
26-22 administration-technique specific. Pursuant to the order and in
26-23 accordance with facility policies or medical staff bylaws, the
26-24 nurse anesthetist may select, obtain, and administer those drugs
26-25 and apply the appropriate medical devices necessary to accomplish
27-1 the order and maintain the patient within a sound physiological
27-2 status.
27-3 This subsection shall be liberally construed to permit the
27-4 full use of safe and effective medication orders to utilize the
27-5 skills and services of certified registered nurse anesthetists.
27-6 (J)(i) A physician may delegate to a physician
27-7 assistant offering obstetrical services and certified by the board
27-8 as specializing in obstetrics or an advanced nurse practitioner
27-9 recognized by the Texas State Board of Nurse Examiners as a nurse
27-10 midwife the act or acts of administering or providing controlled
27-11 substances to the nurse midwife's or physician assistant's clients
27-12 during intra-partum and immediate post-partum care. The physician
27-13 shall not delegate the use or issuance of a triplicate prescription
27-14 form under the triplicate prescription program, Section 481.075,
27-15 Health and Safety Code.
27-16 (ii) The delegation of authority to
27-17 administer or provide controlled substances under this paragraph
27-18 must be under a physician's order, medical order, standing
27-19 delegation order, or protocol which shall require adequate and
27-20 documented availability for access to medical care.
27-21 (iii) The physicians' orders, medical
27-22 orders, standing delegation orders, or protocols shall provide for
27-23 reporting or monitoring of clients' progress including
27-24 complications of pregnancy and delivery and the administration and
27-25 provision of controlled substances by the nurse midwife or
28-1 physician assistant to the clients of the nurse midwife or
28-2 physician assistant.
28-3 (iv) The authority of a physician to
28-4 delegate under this paragraph is limited to:
28-5 (a) three nurse midwives or
28-6 physician assistants or their full-time equivalents; and
28-7 (b) the designated facility at which
28-8 the nurse midwife or physician assistant provides care.
28-9 (v) The administering or providing of
28-10 controlled substances under this paragraph shall comply with other
28-11 applicable laws.
28-12 (vi) In this paragraph, "provide" means to
28-13 supply one or more unit doses of a controlled substance for the
28-14 immediate needs of a patient not to exceed 48 hours.
28-15 (vii) The controlled substance shall be
28-16 supplied in a suitable container that has been labeled in
28-17 compliance with the applicable drug laws and shall include the
28-18 patient's name and address; the drug to be provided; the name,
28-19 address and telephone number of the physician; the name, address
28-20 and telephone number of the nurse midwife or physician assistant;
28-21 and the date.
28-22 (viii) This paragraph does not permit the
28-23 physician or nurse midwife or physician assistant to operate a
28-24 retail pharmacy as defined under the Texas Pharmacy Act (Article
28-25 4542a-1, Vernon's Texas Civil Statutes).
29-1 (ix) This paragraph shall be construed to
29-2 provide a physician the authority to delegate the act or acts of
29-3 administering or providing controlled substances to a nurse midwife
29-4 or physician assistant but not as requiring physician delegation of
29-5 further acts to a nurse midwife or as requiring physician
29-6 delegation of the administration of medications to registered
29-7 nurses or physician assistants other than as provided in this
29-8 paragraph.
29-9 (K) A physician shall not be liable for the act
29-10 or acts of a physician assistant or advanced nurse practitioner
29-11 solely on the basis of having signed an order, a standing medical
29-12 order, a standing delegation order, or other order or protocols
29-13 authorizing a physician assistant or advanced nurse practitioner to
29-14 perform the act or acts of administering, providing, carrying out
29-15 or signing a prescription drug order unless the physician has
29-16 reason to believe the physician assistant or advanced nurse
29-17 practitioner lacked the competency to perform the act or acts.
29-18 (L) The authority granted to a physician to
29-19 delegate under this subdivision shall not be construed as limiting
29-20 the authority of a physician to delegate under any other
29-21 subdivision of this subsection.
29-22 SECTION 14. Article 4514, Revised Statutes, is amended by
29-23 adding a Section 8 to read as follows:
29-24 Sec. 8. APPROVAL OF REGISTERED NURSE FOR ADVANCED PRACTICE.
29-25 (a) The Board shall adopt rules for approval of a registered nurse
30-1 as an advanced nurse practitioner or an advanced practice nurse.
30-2 "Advanced nurse practitioner" or "advanced practice nurse" means a
30-3 registered nurse approved by the board to practice as an advanced
30-4 practice nurse on the basis of completion of an advanced
30-5 educational program. The term includes a nurse practitioner, nurse
30-6 midwife, nurse anesthetist and clinical nurse specialist.
30-7 (b) The Board shall adopt rules for the initial approval and
30-8 biennial renewal of an advanced nurse practitioner to carry out or
30-9 sign prescription drug orders under Sections 3.06(d)(5) and (6),
30-10 Medical Practice Act (Article 4495b, Vernon's Texas Civil
30-11 Statutes). The rules at a minimum shall:
30-12 (1) require completion of pharmacology and related
30-13 pathology for initial approval;
30-14 (2) require continuing education in clinical
30-15 pharmacology and related pathology in addition to any continuing
30-16 education otherwise required under Article 4518, Revised Statutes;
30-17 and
30-18 (3) provide for the issuing of a prescription
30-19 authorization number to an advanced nurse practitioner approved
30-20 under this section.
30-21 SECTION 15. Section 5, Article 4518, Revised Statutes, is
30-22 amended to read as follows:
30-23 Sec. 5. Insofar as any of the following acts require
30-24 substantial specialized judgment and skill and insofar as the
30-25 proper performance of any of the following acts is based upon
31-1 knowledge and application of the principles of biological,
31-2 physical, and social science as acquired by a completed course in
31-3 an approved school of professional nursing, "Professional Nursing"
31-4 shall be defined as the performance for compensation of any nursing
31-5 act (a) in the observation, assessment, intervention, evaluation,
31-6 rehabilitation, care and counsel and health teachings of persons
31-7 who are ill, injured or infirm or experiencing changes in normal
31-8 health processes; (b) in the maintenance of health or prevention of
31-9 illness; (c) in the administration of medications or treatments as
31-10 ordered by a licensed physician, including a podiatric physician
31-11 licensed by the Texas State Board of Podiatry Examiners, or
31-12 dentist; (d) in the supervision or teaching of nursing; (e) in the
31-13 administration, supervision, and evaluation of nursing practices,
31-14 policies, and procedures; <or> (f) in the requesting, receiving,
31-15 <and> signing for, <professional samples> and distributing <the> of
31-16 prescription drug samples to patients at <a> sites <serving
31-17 underserved populations, as provided> at which a registered nurse
31-18 is authorized to sign prescription drug orders by Sections
31-19 3.06(d)(5) and (6), Medical Practice Act (Article 4495b, Vernon's
31-20 Texas Civil Statutes) <and rules implementing that section>; or (g)
31-21 in the performing of acts delegated by a physician under Sections
31-22 3.06(d)(5) and (6), Medical Practice Act (Article 4495b, Vernon's
31-23 Texas Civil Statutes). The foregoing shall not be deemed to
31-24 include acts of medical diagnosis or prescription of therapeutic or
31-25 corrective measures. Nothing in this section shall be construed as
32-1 prohibiting a registered nurse recognized by the board as having
32-2 the specialized education and training required under Section <7>
32-3 6, Article 4514, Revised Statutes, and functioning under adequate
32-4 physician supervision from carrying out prescription drug orders or
32-5 treatments under physician's orders, standing medical orders,
32-6 standing delegation orders, or other orders or protocols.
32-7 SECTION 16. The importance of this legislation and the
32-8 crowded condition of the calendars in both houses create an
32-9 emergency and an imperative public necessity that the
32-10 constitutional rule requiring bills to be read on three several
32-11 days in each house be suspended, and this rule is hereby suspended,
32-12 and that this Act take effect and be in force from and after its
32-13 passage, and it is so enacted.