By Madla, Turner, West, Cain S.B. No. 673
Substitute the following for S.B. No. 673:
By Berlanga C.S.S.B. No. 673
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:
1-24 (a) The center shall:
2-1 (1) educate the public and recommend appropriate
2-2 public policies regarding the continued viability of rural health
2-3 care delivery in this state;
2-4 (2) monitor and work with state and federal agencies
2-5 to assess the impact of proposed rules on rural areas;
2-6 (3) provide impact statements of proposed rules as
2-7 considered appropriate by the center;
2-8 (4) streamline regulations to assist in the
2-9 development of service diversification of health care facilities;
2-10 (5) target state and federal programs to rural areas;
2-11 (6) promote and develop community involvement and
2-12 community support in maintaining, rebuilding, or diversifying local
2-13 health services;
2-14 (7) promote and develop diverse and innovative health
2-15 care service models in rural areas;
2-16 (8) encourage the use of advanced communications
2-17 technology to:
2-18 (A) ensure that rural areas receive the maximum
2-19 benefits of telemedicine and distance learning by promoting a
2-20 transmission rate structure that accommodates rural needs and by
2-21 improving the telecommunications infrastructure in rural areas; and
2-22 (B) provide access to specialty expertise,
2-23 clinical consultation, and continuing education;
2-24 (9) assist rural health care providers, communities,
2-25 and individuals in applying for public and private grants and
2-26 programs;
2-27 (10) encourage the development of regional emergency
3-1 transportation networks;
3-2 (11) work with state agencies, universities, and
3-3 private interest groups to conduct and promote research on rural
3-4 health issues, maintain and collect a timely data base, and develop
3-5 and maintain a rural health resource library;
3-6 (12) solicit the assistance of other offices or
3-7 programs of rural health in this state that are university-based to
3-8 carry out the duties of this chapter;
3-9 (13) disseminate information and provide technical
3-10 assistance to communities, health care providers, and individual
3-11 consumers of health care services; <and>
3-12 (14) develop plans to implement a fee-for-service
3-13 health care professional recruitment service and a medical supplies
3-14 group purchasing program within the center;
3-15 (15) develop and initiate, in conjunction with the
3-16 Texas State Board of Medical Examiners, the Board of Nurse
3-17 Examiners, the Texas Department of Health, the Bureau of State
3-18 Health Data and Policy Analysis, the Texas State Board of Physician
3-19 Assistant Examiners, or other appropriate agencies, a study of
3-20 rural health clinics to:
3-21 (A) determine the efficiency and effectiveness
3-22 of rural health clinics;
3-23 (B) review the health outcomes of rural patients
3-24 treated in rural health clinics and report those outcomes in the
3-25 center's biennial report to the legislature;
3-26 (C) identify and address efficiency barriers for
3-27 the professional clinical relationship of physicians, nurses, and
4-1 physician assistants;
4-2 (D) assess the success of attracting primary
4-3 care physicians and allied health professionals to rural areas; and
4-4 (E) assess the appropriateness of the current
4-5 clinic designation process;
4-6 (16) develop and initiate a quality assessment program
4-7 to evaluate the health outcomes of rural patients treated in rural
4-8 health clinics; and
4-9 (17) encourage the active participation by physicians
4-10 and other health care providers in the early and periodic
4-11 screening, diagnosis, and treatment program.
4-12 SECTION 3. Section 262.034, Health and Safety Code, is
4-13 amended to read as follows:
4-14 Sec. 262.034. FACILITIES AND SERVICES FOR ELDERLY AND
4-15 DISABLED <NURSING HOMES>. (a) <This section applies to an
4-16 authority created by a municipality with a population of more than
4-17 24,000 that is located in a county with a population of 1.5 million
4-18 or more.>
4-19 <(b)> The authority may construct, acquire, own, operate,
4-20 enlarge, improve, furnish, or equip one or more of the following
4-21 types of facilities or services for the care of the elderly or
4-22 disabled:
4-23 (1) a nursing home or similar long-term care facility;
4-24 (2) elderly housing;
4-25 (3) assisted living;
4-26 (4) home health;
4-27 (5) personal care;
5-1 (6) special care;
5-2 (7) continuing care; and
5-3 (8) durable medical equipment <one or more nursing
5-4 homes or similar facilities for the care of the elderly. The
5-5 nursing home or similar facility may be located outside the
5-6 municipal limits>.
5-7 (b) <(c)> The authority may lease or enter into an
5-8 operations or management agreement relating to all or part of a
5-9 <nursing home or similar> facility or service for the care of the
5-10 elderly or disabled that is owned by the authority. The authority
5-11 may sell, transfer, otherwise convey, or close all or part of the
5-12 <nursing home or similar> facility and may discontinue a service.
5-13 (c) <(d)> The authority may issue revenue bonds and other
5-14 notes in accordance with this chapter to acquire, construct, or
5-15 improve a <nursing home or similar> facility for the care of the
5-16 elderly or disabled or to implement the delivery of a service for
5-17 the care of the elderly or disabled.
5-18 (d) <(e)> For the purposes of this section, a <nursing home
5-19 or similar> facility or service described by Subsection (a) <for
5-20 the care of the elderly> is considered to be a hospital project
5-21 under Chapter 223 (Hospital Project Financing Act).
5-22 (e) This section applies only to an authority that owns or
5-23 operates a hospital licensed under Chapter 241 and that is located
5-24 in:
5-25 (1) a county with a population of 35,000 or less;
5-26 (2) those portions of extended municipalities that the
5-27 federal census bureau has determined to be rural; or
6-1 (3) an area that is not delineated as an urbanized
6-2 area by the federal census bureau.
6-3 SECTION 4. Chapter 285, Health and Safety Code, is amended
6-4 by adding Subchapter H to read as follows:
6-5 SUBCHAPTER H. LONG-TERM CARE AND RELATED FACILITIES
6-6 Sec. 285.101. FACILITIES OR SERVICES FOR ELDERLY OR
6-7 DISABLED. (a) This subchapter applies only to a hospital,
6-8 hospital district, or authority created and operated under Article
6-9 IX, Texas Constitution, under a special law, or under this title
6-10 that is located in:
6-11 (1) a county with a population of 35,000 or less;
6-12 (2) those portions of extended municipalities that the
6-13 federal census bureau has determined to be rural; or
6-14 (3) an area that is not delineated as an urbanized
6-15 area by the federal census bureau.
6-16 (b) A hospital, hospital district, or authority covered by
6-17 this subchapter may:
6-18 (1) construct, acquire, own, operate, enlarge,
6-19 improve, furnish, or equip one or more of the following types of
6-20 facilities or services for the care of the elderly or disabled:
6-21 (A) a nursing home or similar long-term care
6-22 facility;
6-23 (B) elderly housing;
6-24 (C) assisted living;
6-25 (D) home health;
6-26 (E) personal care;
6-27 (F) special care;
7-1 (G) continuing care; or
7-2 (H) durable medical equipment;
7-3 (2) lease or enter into an operations or management
7-4 agreement relating to all or part of a facility or service
7-5 described in Subdivision (1) that is owned by the hospital district
7-6 or authority;
7-7 (3) close, transfer, sell, or otherwise convey all or
7-8 part of a facility and discontinue services; and
7-9 (4) issue revenue bonds and other notes to acquire,
7-10 construct, or improve a facility for the care of the elderly or
7-11 disabled or to implement the delivery of a service for the care of
7-12 the elderly or disabled.
7-13 (c) For the purpose of this section, a facility or service
7-14 created under Subsection (b) is considered to be a hospital project
7-15 under Chapter 223.
7-16 SECTION 5. Subdivisions (4) and (13), Section 483.001,
7-17 Health and Safety Code, are amended as follows:
7-18 (4) "Designated agent" means:
7-19 (A) a licensed nurse, physician assistant,
7-20 pharmacist, or other individual designated by a practitioner to
7-21 communicate prescription drug orders to a pharmacist;
7-22 (B) a licensed nurse, physician assistant, or
7-23 pharmacist employed in a health care facility to whom the
7-24 practitioner communicates a prescription drug order; or
7-25 (C) a registered nurse or physician assistant
7-26 authorized by a practitioner to carry out a prescription drug order
7-27 for dangerous drugs under Section 3.06(5) or (6), Medical Practice
8-1 Act (Article 4495b, Vernon's Texas Civil Statutes).
8-2 (13) "Prescription" means an order from a
8-3 practitioner, or an agent of the practitioner designated in writing
8-4 as authorized to communicate prescriptions, or an order made in
8-5 accordance with Section 3.06(d)(5) or (6), Medical Practice Act
8-6 (Article 4495b, Vernon's Texas Civil Statutes), to a pharmacist for
8-7 a dangerous drug to be dispensed that states:
8-8 (A) the date of the order's issue;
8-9 (B) the name and address of the patient;
8-10 (C) if the drug is prescribed for an animal, the
8-11 species of animal;
8-12 (D) the name and quantity of the drug
8-13 prescribed;
8-14 (E) the directions for the use of the drug;
8-15 <and>
8-16 <(F) the legibly printed or stamped name,
8-17 address, Federal Drug Enforcement Administration registration
8-18 number, and telephone number of the practitioner at the
8-19 practitioner's usual place of business.>
8-20 (F) the intended use of the drug unless the
8-21 practitioner determines the furnishing of this information is not
8-22 in the best interest of the patient; <and>
8-23 (G) the name, address, and telephone number of
8-24 the practitioner at the practitioner's usual place of business,
8-25 legibly printed or stamped; and
8-26 (H) the name, address, and telephone number of
8-27 the registered nurse or physician assistant, legibly printed or
9-1 stamped, if signed by a registered nurse or physician assistant.
9-2 SECTION 6. Subsection (a), Section 483.042, Health and
9-3 Safety Code, is amended as follows:
9-4 (a) A person commits an offense if the person delivers or
9-5 offers to deliver a dangerous drug:
9-6 (1) unless:
9-7 (A) the dangerous drug is delivered or offered
9-8 for delivery by a pharmacist under:
9-9 (i) a prescription issued by a
9-10 practitioner described Section 483.001(12)(A) or (B); <or>
9-11 (ii) a prescription signed by a registered
9-12 nurse or physician assistant in accordance with Section 3.06(d)(5)
9-13 or (6), Medical Practice Act (Article 4495b, Vernon's Texas Civil
9-14 Statutes); or
9-15 (iii) an original written prescription
9-16 issued by a practitioner described by Section 483.001(12)(C); and
9-17 (B) a label is attached to the immediate
9-18 container in which the drug is delivered or offered to be delivered
9-19 and the label contains the following information:
9-20 (i) the name and address of the pharmacy
9-21 from which the drug is delivered or offered for delivery;
9-22 (ii) the date the prescription for the
9-23 drug is dispensed;
9-24 (iii) the number of the prescription as
9-25 filed in the prescription files of the pharmacy from which the
9-26 prescription is dispensed;
9-27 (iv) the name of the practitioner who
10-1 prescribed the drug and, if applicable, the name of the registered
10-2 nurse or physician assistant who signed the prescription;
10-3 (v) the name of the patient and, if the
10-4 drug is prescribed for an animal, a statement of the species of the
10-5 animal; and
10-6 (vi) directions for the use of the drug as
10-7 contained in the prescription; or
10-8 (2) unless:
10-9 (A) the dangerous drug is delivered or offered
10-10 for delivery by:
10-11 (i) a practitioner in the course of
10-12 practice; or
10-13 (ii) a registered nurse or physician
10-14 assistant in the course of practice in accordance with Section
10-15 3.06(d)(5) or (6), Medical Practice Act (Article 4495b, Vernon's
10-16 Texas Civil Statutes); and
10-17 (B) a label is attached to the immediate
10-18 container in which the drug is delivered or offered to be delivered
10-19 and the label contains the following information:
10-20 (i) the name and address of the
10-21 practitioner who prescribed the drug, and if applicable, the name
10-22 and address of the registered nurse or physician assistant;
10-23 (ii) the date the drug is delivered;
10-24 (iii) the name of the patient and, if the
10-25 drug is prescribed for an animal, a statement of the species of the
10-26 animal; and
10-27 (iv) the name of the drug, the strength of
11-1 the drug, and directions for the use of the drug.
11-2 SECTION 7. Subsection (d), Section 671.001, Health and
11-3 Safety Code, is amended to read as follows:
11-4 (d) A registered nurse or physician assistant may determine
11-5 and pronounce a person dead in situations other than those
11-6 described by Subsection (b) if permitted by written policies of a
11-7 licensed health care facility, institution, or entity providing
11-8 services to that person. Those policies must include physician
11-9 assistants who are credentialed or otherwise permitted to practice
11-10 at the facility, institution, or entity. If the facility,
11-11 institution, or entity has an organized nursing staff and an
11-12 organized medical staff or medical consultant, the nursing staff
11-13 and medical staff or consultant shall jointly develop and approve
11-14 those policies. The board shall adopt rules to govern policies for
11-15 facilities, institutions, or entities that do not have organized
11-16 nursing staffs and organized medical staffs or medical consultants.
11-17 SECTION 8. Section 671.002, Health and Safety Code, is
11-18 amended to read as follows:
11-19 Sec. 671.002. Limitation of Liability. (a) A physician who
11-20 determines death in accordance with Section 671.001(b) or a
11-21 registered nurse or physician assistant who determines death in
11-22 accordance with Section 671.001(d) is not liable for civil damages
11-23 or subject to criminal prosecution for the physician's, <or>
11-24 registered nurse's, or physician assistant's actions or the actions
11-25 of others based on the determination of death.
11-26 (b) A person who acts in good faith in reliance on a
11-27 physician's, <or> registered nurse's, or physician assistant's
12-1 determination of death is not liable for civil damages or subject
12-2 to criminal prosecution for the person's actions.
12-3 SECTION 9. Subsection (c), Section 51.918, Education Code,
12-4 is amended to read as follows:
12-5 (c) The Center for Rural Health Initiatives shall develop
12-6 relief service programs for rural physicians and allied health
12-7 personnel to facilitate ready access to continuing medical
12-8 education or practice coverage for purposes other than continuing
12-9 medical education.
12-10 SECTION 10. Section 501.059, Government Code, as added by
12-11 Chapter 238, Acts of the 73rd Legislature, 1993, is amended to read
12-12 as follows:
12-13 Sec. 501.059. Managed Health Care Advisory Committee.
12-14 (a) The Managed Health Care Advisory Committee to the Texas
12-15 Department of Criminal Justice is established.
12-16 (b) The committee consists of:
12-17 (1) two members employed full-time by the department,
12-18 at least one of whom is a physician, appointed by the executive
12-19 director;
12-20 (2) two members employed full-time by The University
12-21 of Texas Medical Branch at Galveston, at least one of whom is a
12-22 physician, appointed by the president of the medical branch; and
12-23 (3) two members employed full-time by the Texas Tech
12-24 University Health Sciences Center, at least one of whom is a
12-25 physician, appointed by the president of the university.
12-26 (c) A committee member serves at the pleasure of the
12-27 appointing official or until termination of the member's employment
13-1 with the entity the member represents.
13-2 (d) An appointment to the committee shall be made without
13-3 regard to the race, creed, sex, religion, or national origin of the
13-4 appointee.
13-5 (e) A committee member serves without compensation but is
13-6 entitled to reimbursement for actual and necessary expenses
13-7 incurred in the performance of the duties of the committee.
13-8 (f) The committee may hire a managed health care
13-9 administrator and may employ personnel necessary for the
13-10 administration of the committee's duties.
13-11 (g) The committee shall develop a managed health care plan
13-12 for all inmates at the institutional division that includes:
13-13 (1) the establishment of a managed care network of
13-14 physicians and hospitals that will serve the institutional division
13-15 as the exclusive health care provider for inmates at each facility
13-16 of the institutional division;
13-17 (2) cost containment studies; <and>
13-18 (3) care case management and utilization management
13-19 studies performed exclusively for the institutional division; and
13-20 (4) concerning the establishment of criteria for
13-21 hospitals, home health, or hospice providers, a provision requiring
13-22 the managed health care plan to accept certification by the
13-23 Medicare program under Title XVIII, Social Security Act, as amended
13-24 (42 U.S.C. Section 1395 et seq.), as an alternative to
13-25 accreditation by the Joint Commission on Accreditation of
13-26 Healthcare Organizations.
13-27 (h) To the extent possible the committee shall integrate the
14-1 managed care network with the public medical schools of this state
14-2 and the component and affiliated hospitals of those medical
14-3 schools.
14-4 (i) For those services for which the public medical schools
14-5 and their components and affiliates cannot provide, the committee
14-6 shall initiate a competitive bidding process for contracts with
14-7 other providers for medical care to inmates confined in the
14-8 institutional division.
14-9 (j) The committee may enter into a contract on behalf of the
14-10 department to fully implement the managed health care plan under
14-11 Subsection (g).
14-12 (k) The department shall pay necessary costs for the
14-13 operation of the committee, including costs of personnel, from
14-14 funds appropriated by the legislature to the department.
14-15 (l) The managed health care plan, inclusive of the health
14-16 care administrator and necessary personnel proposed by the
14-17 committee, must cost the state less than what is presently
14-18 provided, otherwise the status quo shall be maintained.
14-19 SECTION 11. Subdivisions (19) and (42), Section 5, Texas
14-20 Pharmacy Act (Article 4542-1, Vernon's Texas Civil Statutes), are
14-21 amended to read as follows:
14-22 (19) "Designated agent" means:
14-23 (A) a licensed nurse, physician assistant,
14-24 pharmacist, or other individual designated by a practitioner, and
14-25 for whom the practitioner assumes legal responsibility, who
14-26 communicates prescription drug orders to a pharmacist;
14-27 (B) a licensed nurse, physician assistant, or
15-1 pharmacist employed in a health care facility to whom the
15-2 practitioner communicates a prescription drug order; or
15-3 (C) a registered nurse or physician assistant
15-4 authorized by a practitioner to carry out a prescription drug order
15-5 for dangerous drugs under Subdivision (5) or (6), Subsection (d),
15-6 Section 3.06, Medical Practice Act (Article 4495b, Vernon's Texas
15-7 Civil Statutes).
15-8 (42) "Prescription drug order" means:
15-9 (A) an order from a practitioner or a
15-10 practitioner's designated agent to a pharmacist for a drug or
15-11 device to be dispensed; or
15-12 (B) an order pursuant to Subdivision (5) or (6),
15-13 Subsection (d), Section 3.06, Medical Practice Act (Article 4495b,
15-14 Vernon's Texas Civil Statutes).
15-15 SECTION 12. Subdivision (5), Subsection (d), Section 3.06,
15-16 Medical Practice Act (Article 4495b, Vernon's Texas Civil
15-17 Statutes), is amended to read as follows:
15-18 (5)(A) At a site serving a medically under served
15-19 population, a physician licensed by the board shall be authorized
15-20 to delegate to a registered nurse or physician assistant acting
15-21 under adequate physician supervision, the act or acts of
15-22 administering, providing, or carrying out or signing a prescription
15-23 drug order as authorized by the physician through physician's
15-24 orders, standing medical orders, standing delegation orders, or
15-25 other orders or protocols as defined by the board.
15-26 (B)(i) The carrying out or signing of
15-27 prescription drug orders under this subsection shall comply with
16-1 other applicable laws.
16-2 (ii) The authority of a physician to
16-3 delegate the carrying out or signing of prescription drug orders is
16-4 limited to dangerous drugs.
16-5 (C) Protocols and other orders shall be defined
16-6 to promote the exercise of professional judgement by the advanced
16-7 nurse practitioner and physician assistant commensurate with their
16-8 education and experience. Under this subdivision, protocols and
16-9 other orders used by a reasonable and prudent physician exercising
16-10 sound medical judgement:
16-11 (i) need not describe the exact steps that
16-12 an advanced nurse practitioner or a physician assistant must take
16-13 with respect to each specific condition, disease or symptom; and
16-14 (ii) may state the types or categories of
16-15 medications that may be prescribed or in terms of categories or
16-16 types of medications that may not be prescribed.
16-17 (D) Physician supervision shall be adequate if a
16-18 delegating physician:
16-19 (i) is responsible for the formulation or
16-20 approval of such physician's orders, standing medical orders,
16-21 standing delegation orders, or other orders or protocols and
16-22 periodically reviews such orders and the services provided patients
16-23 under such orders;
16-24 (ii) is on site at least once a week to
16-25 provide medical direction and consultation;
16-26 (iii) receives a daily status report from
16-27 the registered nurse or physician assistant on any problems or
17-1 complication encountered; and
17-2 (iv) is available through direct
17-3 telecommunication for consultation, assistance with medical
17-4 emergencies, or patient referral.
17-5 (<D> E) In this subsection:
17-6 (i) "Registered nurse" means a registered
17-7 nurse recognized by the Board of Nurse Examiners as having the
17-8 specialized education and training required under Section <7> 6,
17-9 Article 4514, Revised Statutes.
17-10 (ii) "Physician assistant" has the meaning
17-11 assigned to that term by Section 2(3), Physician Assistant
17-12 Licensing Act<, and its subsequent amendments> (Article 4495b-1,
17-13 Vernon's Texas Civil Statutes).
17-14 (iii) "Carrying out or signing a
17-15 prescription drug order" means the completion of <to complete> a
17-16 prescription drug order presigned by the delegating physician, or
17-17 the signing of a prescription by a registered nurse or physician
17-18 assistant after the person has been designated with the board by
17-19 the delegating physician as a person delegated to sign a
17-20 prescription. The following information shall be provided on each
17-21 prescription <by providing the following information>: the
17-22 patient's name and address; the drug to be dispensed; directions to
17-23 the patient in regard to the taking and dosage; the intended use of
17-24 the drug, if appropriate; the name, address, and telephone number
17-25 of the physician; the name, address, telephone and identification
17-26 number of the registered nurse or physician assistant completing or
17-27 signing the prescription drug order; the date; and the number of
18-1 refills permitted. The board may adopt additional methods to carry
18-2 into effect or put into force a physician's prescription or
18-3 delegation of the signing of a prescription under physician's
18-4 orders, standing medical orders, standing delegation orders, or
18-5 other orders or protocols.
18-6 (iv) "A site serving a medically
18-7 underserved population" means:
18-8 (a) a site located in a medically
18-9 underserved area;
18-10 (b) a site located in a health
18-11 manpower shortage area;
18-12 (c) a clinic designated as a rural
18-13 health clinic under the Rural Health Clinic Services Act of 1977
18-14 (Pub. L. No. 95-210);
18-15 (d) a public health clinic or a
18-16 family planning clinic under contract with the Texas Department of
18-17 Human Services or the Texas Department of Health;
18-18 (e) a site located in an area in
18-19 which the Texas Department of Health determines there exists an
18-20 insufficient number of physicians providing services to eligible
18-21 clients of federal, state, or locally funded health care programs;
18-22 or
18-23 (f) a site that the Texas Department
18-24 of Health determines serves a disproportionate number of clients
18-25 eligible to participate in federal, state, or locally funded health
18-26 care programs.
18-27 (v) "Health manpower shortage area" means
19-1 (1) an area in an urban or rural area of Texas (which need not
19-2 conform to the geographic boundaries of a political subdivision and
19-3 which is a rational area for the delivery of health services) which
19-4 the secretary of health and human services determines has a health
19-5 manpower shortage and which is not reasonably accessible to an
19-6 adequately served area; (2) a population group which the secretary
19-7 determines to have such a shortage; or (3) a public or nonprofit
19-8 private medical facility or other facility which the secretary
19-9 determines has such a shortage as delineated in 42 U.S.C. Section
19-10 254(e)(a)(1).
19-11 (vi) "Medically underserved area" means an
19-12 area in Texas with a medically underserved population or an urban
19-13 or rural area designated by the secretary of health and human
19-14 services as an area in Texas with a shortage of personal health
19-15 services or a population group designated by the secretary as
19-16 having a shortage of such services (as defined in 42 U.S.C. Section
19-17 300(e)-1(7)). The term also includes an area defined by rule
19-18 adopted by the Texas Board of Health that is based on demographics
19-19 specific to this state, geographic factors that affect access to
19-20 health care, and environmental health factors.
19-21 (<E> F) After making a determination under
19-22 <either> Subdivision (D)(iv)(e), <or> (D)(iv)(f), or (D)(vi) that a
19-23 site serves a medically underserved population, the Texas
19-24 Department of Health shall publish notice of its determination in
19-25 the Texas Register and provide an opportunity for public comment in
19-26 the same manner as for a proposed rule under Chapter 2001,
19-27 Government Code <the Administrative Procedure and Texas Register
20-1 Act (Article 6252-13a, Vernon's Texas Civil Statutes)>.
20-2 (<F> G) The authority granted to a physician to
20-3 delegate under this subdivision shall not be construed as limiting
20-4 the authority of a physician to delegate under any other
20-5 subdivision of this subsection.
20-6 (<G> H) An advertisement for a site serving a
20-7 medically under served population shall include the name and
20-8 business address of the supervising physician for the site.
20-9 SECTION 13. Subsection (d), Section 3.06, Medical Practice
20-10 Act (Article 4495b, Vernon's Texas Civil Statutes) is amended by
20-11 adding Subdivision (6) to read as follows:
20-12 (6)(A) At a physician's primary practice site or a
20-13 location as described by Paragraph (H) of this subdivision, a
20-14 physician licensed by the board may delegate to a physician
20-15 assistant or an advanced nurse practitioner acting under adequate
20-16 physician supervision the act or acts of administering, providing,
20-17 carrying out or signing a prescription drug order as authorized
20-18 through physician's orders, standing medical orders, standing
20-19 delegation orders, or other orders or protocols as defined by the
20-20 board. Providing and carrying out or signing a prescription drug
20-21 order under this subdivision is limited to dangerous drugs.
20-22 (B) Protocols and other orders shall be defined
20-23 to promote the exercise of professional judgment by the advanced
20-24 nurse practitioner and physician assistant commensurate with their
20-25 education and experience. Under this subdivision, protocols and
20-26 other orders used by a reasonable and prudent physician exercising
20-27 sound medical judgment:
21-1 (i) need not describe the exact steps that
21-2 an advanced nurse practitioner or a physician assistant must take
21-3 with respect to each specific condition, disease, or symptom; and
21-4 (ii) may state the types or categories of
21-5 medications that may be prescribed or state in terms of categories
21-6 or types of medications that may not be prescribed.
21-7 (C) Physician supervision of the carrying out
21-8 and signing of prescription drug orders shall conform to what a
21-9 reasonable, prudent physician would find consistent with sound
21-10 medical judgment but may vary with the education and experience of
21-11 the advanced nurse practitioner or physician assistant. A
21-12 physician shall provide continuous supervision, but the constant
21-13 physical presence of the physician is not required.
21-14 (D) An alternate physician may provide
21-15 appropriate supervision on a temporary basis as defined and
21-16 established by the board by rule.
21-17 (E) The carrying out or signing of prescription
21-18 drug orders under this subdivision shall comply with other
21-19 applicable laws.
21-20 (F) A physician's authority to delegate the
21-21 carrying out or signing of a prescription drug order at his primary
21-22 practice site under this subdivision is limited to:
21-23 (i) three physician assistants or advanced
21-24 nurse practitioners or their full-time equivalents practicing at
21-25 the physician's primary practice site; and
21-26 (ii) the patients with whom the physician
21-27 has established or will establish a physician-patient relationship,
22-1 but this shall not be construed as requiring the physician to see
22-2 the patient within a specific period of time.
22-3 (G) In this subdivision:
22-4 (i) "Advanced nurse practitioner" has the
22-5 meaning assigned to that term by Section 8, Article 4514, Revised
22-6 Statutes.
22-7 (ii) "Physician assistant" has the meaning
22-8 assigned to that term by Section 2(3), Physician Assistant
22-9 Licensing Act, (Article 4495b-1, Vernon's Texas Civil Statutes).
22-10 (iii) "Primary practice site" means:
22-11 (a) the practice location where the
22-12 physician spends the majority of the physician's time;
22-13 (b) a licensed hospital, a licensed
22-14 long term care facility, and a licensed adult care center where
22-15 both the physician and the physician assistant or advanced nurse
22-16 practitioner are authorized to practice, or an established
22-17 patient's residence; or
22-18 (c) where the physician is
22-19 physically present with the physician assistant or advanced nurse
22-20 practitioner.
22-21 (iv) "Carrying out or signing a
22-22 prescription drug order" means the completion of a prescription
22-23 drug order presigned by a delegating physician or the signing of a
22-24 prescription by a physician assistant or advanced nurse
22-25 practitioner after the person has been designated with the board by
22-26 the delegating physician as a person delegated to sign a
22-27 prescription. The following information shall be provided on each
23-1 prescription: the patient's name and address; the drug to be
23-2 dispensed; directions to the patient in regard to the taking and
23-3 dosage; the intended use of the drug, if appropriate; the name,
23-4 address, and telephone number of the physician; the name, address,
23-5 and telephone and identification number of the physician assistant
23-6 or advanced nurse practitioner completing or signing the
23-7 prescription drug order; the date; and the number of refills
23-8 permitted. The board may adopt additional methods to carry into
23-9 effect or put into force a physician's prescription or delegation
23-10 of the signing of a prescription under physician's orders, standing
23-11 medical orders, standing delegation orders, or other orders or
23-12 protocols.
23-13 (H) A physician licensed by the board shall be
23-14 authorized to delegate, to one or more physician assistants or
23-15 advanced nurse practitioners acting under adequate physician
23-16 supervision whose practice is facility based at a licensed hospital
23-17 or licensed long term care facility, the carrying out or signing of
23-18 prescription drug orders if the physician is the medical director
23-19 or chief of medical staff of the facility in which the physician
23-20 assistant or advanced nurse practitioner practices, the chair of
23-21 the facility's credentialing committee, a department chair of a
23-22 facility department in which the physician assistant or advanced
23-23 nurse practitioner practices, or a physician who consents to the
23-24 request of the medical director or chief of medical staff to
23-25 delegate the carrying out or signing of prescription drug orders at
23-26 the facility in which the physician assistant or advanced nurse
23-27 practitioner practices. A physician's authority to delegate under
24-1 this paragraph is limited as follows:
24-2 (i) the delegation is pursuant to a
24-3 physician's order, standing medical order, standing delegation
24-4 order, or other order or protocol developed in accordance with
24-5 policies approved by the facility's medical staff or a committee
24-6 thereof as provided in facility bylaws;
24-7 (ii) the delegation occurs in the facility
24-8 in which the physician is the medical director, the chief of
24-9 medical staff, the chair of the credentialing committee, or a
24-10 department chair;
24-11 (iii) the delegation does not permit the
24-12 carrying out or signing of prescription drug orders for the care or
24-13 treatment of the patients of any other physician without the prior
24-14 consent of that physician;
24-15 (iv) delegation in a long-term care
24-16 facility must be by the medical director and the medical director
24-17 is limited to delegating the carrying out and signing of
24-18 prescription drug orders to no more than three advanced nurse
24-19 practitioners or physician assistants or their full-time
24-20 equivalents; and
24-21 (v) under this paragraph, a physician may
24-22 not delegate at more than one licensed hospital or more than two
24-23 long-term care facilities unless approved by the board.
24-24 (I) In a licensed hospital or ambulatory
24-25 surgical center a physician may delegate to a certified registered
24-26 nurse anesthetist the ordering of drugs and devices necessary for a
24-27 certified registered nurse anesthetist to administer an anesthetic
25-1 or an anesthesia-related service ordered by the physician. The
25-2 physician's order for anesthesia or anesthesia-related services
25-3 does not have to be drug-specific, dose-specific, or
25-4 administration-technique-specific. Pursuant to the order and in
25-5 accordance with facility policies or medical staff bylaws, the
25-6 nurse anesthetist may select, obtain, and administer those drugs
25-7 and apply the appropriate medical devices necessary to accomplish
25-8 the order and maintain the patient within a sound physiological
25-9 status.
25-10 This subsection shall be liberally construed to permit the
25-11 full use of safe and effective medication orders to utilize the
25-12 skills and services of certified registered nurse anesthetists.
25-13 (J)(i) A physician may delegate to a physician
25-14 assistant offering obstetrical services and certified by the board
25-15 as specializing in obstetrics or an advanced nurse practitioner
25-16 recognized by the Texas State Board of Nurse Examiners as a nurse
25-17 midwife the act or acts of administering or providing controlled
25-18 substances to the nurse midwife's or physician assistant's clients
25-19 during intra-partum and immediate post-partum care. The physician
25-20 shall not delegate the use or issuance of a triplicate prescription
25-21 form under the triplicate prescription program, Section 481.075,
25-22 Health and Safety Code.
25-23 (ii) The delegation of authority to
25-24 administer or provide controlled substances under this paragraph
25-25 must be under a physician's order, medical order, standing
25-26 delegation order, or protocol which shall require adequate and
25-27 documented availability for access to medical care.
26-1 (iii) The physicians' orders, medical
26-2 orders, standing delegation orders, or protocols shall provide for
26-3 reporting or monitoring of clients' progress including
26-4 complications of pregnancy and delivery and the administration and
26-5 provision of controlled substances by the nurse midwife or
26-6 physician assistant to the clients of the nurse midwife or
26-7 physician assistant.
26-8 (iv) The authority of a physician to
26-9 delegate under this paragraph is limited to:
26-10 (a) three nurse midwives or
26-11 physician assistants or their full-time equivalents; and
26-12 (b) the designated facility at which
26-13 the nurse midwife or physician assistant provides care.
26-14 (v) The administering or providing of
26-15 controlled substances under this paragraph shall comply with other
26-16 applicable laws.
26-17 (vi) In this paragraph, "provide" means to
26-18 supply one or more unit doses of a controlled substance for the
26-19 immediate needs of a patient not to exceed 48 hours.
26-20 (vii) The controlled substance shall be
26-21 supplied in a suitable container that has been labeled in
26-22 compliance with the applicable drug laws and shall include the
26-23 patient's name and address; the drug to be provided; the name,
26-24 address and telephone number of the physician; the name, address
26-25 and telephone number of the nurse midwife or physician assistant;
26-26 and the date.
26-27 (viii) This paragraph does not permit the
27-1 physician or nurse midwife or physician assistant to operate a
27-2 retail pharmacy as defined under the Texas Pharmacy Act (Article
27-3 4542a-1, Vernon's Texas Civil Statutes).
27-4 (ix) This paragraph shall be construed to
27-5 provide a physician the authority to delegate the act or acts of
27-6 administering or providing controlled substances to a nurse midwife
27-7 or physician assistant but not as requiring physician delegation of
27-8 further acts to a nurse midwife or as requiring physician
27-9 delegation of the administration of medications to registered
27-10 nurses or physician assistants other than as provided in this
27-11 paragraph.
27-12 (K) A physician shall not be liable for the act
27-13 or acts of a physician assistant or advanced nurse practitioner
27-14 solely on the basis of having signed an order, a standing medical
27-15 order, a standing delegation order, or other order or protocols
27-16 authorizing a physician assistant or advanced nurse practitioner to
27-17 perform the act or acts of administering, providing, carrying out
27-18 or signing a prescription drug order unless the physician has
27-19 reason to believe the physician assistant or advanced nurse
27-20 practitioner lacked the competency to perform the act or acts.
27-21 (L) The authority granted to a physician to
27-22 delegate under this subdivision shall not be construed as limiting
27-23 the authority of a physician to delegate under any other
27-24 subdivision of this subsection.
27-25 SECTION 14. Article 4514, Revised Statutes, is amended by
27-26 adding a Section 8 to read as follows:
27-27 Sec. 8. APPROVAL OF REGISTERED NURSE FOR ADVANCED STATUS.
28-1 (a) The board shall adopt rules for approval of a registered nurse
28-2 as an advanced nurse practitioner or an advanced practice nurse.
28-3 "Advanced nurse practitioner" or "advanced practice nurse" means a
28-4 registered nurse approved by the board to practice as an advanced
28-5 practice nurse on the basis of completion of an advanced
28-6 educational program. The term includes a nurse practitioner, nurse
28-7 midwife, nurse anesthetist and clinical nurse specialist.
28-8 (b) The board shall adopt rules for the initial approval and
28-9 biennial renewal of an advanced nurse practitioner to carry out or
28-10 sign prescription drug orders under Section 3.06(d)(5) or (6),
28-11 Medical Practice Act (Article 4495b, Vernon's Texas Civil
28-12 Statutes). The rules at a minimum shall:
28-13 (1) require completion of pharmacology and related
28-14 pathology for initial approval;
28-15 (2) require continuing education in clinical
28-16 pharmacology and related pathology in addition to any continuing
28-17 education otherwise required under Article 4518, Revised Statutes;
28-18 and
28-19 (3) provide for the issuing of a prescription
28-20 authorization number to an advanced nurse practitioner approved
28-21 under this section.
28-22 SECTION 15. Section 5, Article 4518, Revised Statutes, is
28-23 amended to read as follows:
28-24 Sec. 5. Insofar as any of the following acts require
28-25 substantial specialized judgment and skill and insofar as the
28-26 proper performance of any of the following acts is based upon
28-27 knowledge and application of the principles of biological,
29-1 physical, and social science as acquired by a completed course in
29-2 an approved school of professional nursing, "Professional Nursing"
29-3 shall be defined as the performance for compensation of any nursing
29-4 act (a) in the observation, assessment, intervention, evaluation,
29-5 rehabilitation, care and counsel and health teachings of persons
29-6 who are ill, injured or infirm or experiencing changes in normal
29-7 health processes; (b) in the maintenance of health or prevention of
29-8 illness; (c) in the administration of medications or treatments as
29-9 ordered by a licensed physician, including a podiatric physician
29-10 licensed by the Texas State Board of Podiatry Examiners, or
29-11 dentist; (d) in the supervision or teaching of nursing; (e) in the
29-12 administration, supervision, and evaluation of nursing practices,
29-13 policies, and procedures; <or> (f) in the requesting, receiving,
29-14 <and> signing for, <professional samples> and distributing <the> of
29-15 prescription drug samples to patients at <a> sites <serving
29-16 underserved populations, as provided> at which a registered nurse
29-17 is authorized to sign prescription drug orders by Section
29-18 3.06(d)(5) or (6), Medical Practice Act (Article 4495b, Vernon's
29-19 Texas Civil Statutes)<, and rules implementing that section>; or
29-20 (g) in the performing of acts delegated by a physician under
29-21 Section 3.06(d)(5) or (6), Medical Practice Act (Article 4495b,
29-22 Vernon's Texas Civil Statutes). The foregoing shall not be deemed
29-23 to include acts of medical diagnosis or prescription of therapeutic
29-24 or corrective measures. Nothing in this section shall be construed
29-25 as prohibiting a registered nurse recognized by the board as having
29-26 the specialized education and training required under Section <7>
29-27 6, Article 4514, Revised Statutes, and functioning under adequate
30-1 physician supervision from carrying out prescription drug orders or
30-2 treatments under physician's orders, standing medical orders,
30-3 standing delegation orders, or other orders or protocols.
30-4 SECTION 16. The importance of this legislation and the
30-5 crowded condition of the calendars in both houses create an
30-6 emergency and an imperative public necessity that the
30-7 constitutional rule requiring bills to be read on three several
30-8 days in each house be suspended, and this rule is hereby suspended,
30-9 and that this Act take effect and be in force from and after its
30-10 passage, and it is so enacted.