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.