1-1 By: Madla, Turner, Cain, West S.B. No. 673
1-2 (In the Senate - Filed February 21, 1995; February 21, 1995,
1-3 read first time and referred to Committee on Health and Human
1-4 Services; May 1, 1995, reported adversely, with favorable Committee
1-5 Substitute by the following vote: Yeas 9, Nays 0; May 1, 1995,
1-6 sent to printer.)
1-7 COMMITTEE SUBSTITUTE FOR S.B. No. 673 By: Madla
1-8 A BILL TO BE ENTITLED
1-9 AN ACT
1-10 relating to health care, including powers and duties of the center
1-11 for rural health initiatives, powers and duties of registered
1-12 nurses and physician assistants, managed health care plans for
1-13 certain inmates, and health facilities and services for the elderly
1-14 or disabled.
1-15 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-16 SECTION 1. Chapter 105, Health and Safety Code, is amended
1-17 by adding Section 105.007 to read as follows:
1-18 Sec. 105.007. CLEARINGHOUSE. (a) As part of the
1-19 comprehensive health professions resource center, the department
1-20 shall develop and establish a clearinghouse for health
1-21 professionals seeking collaborative practice.
1-22 (b) The department may:
1-23 (1) set and collect a reasonable fee to offset the
1-24 cost of complying with this section;
1-25 (2) solicit, receive, and spend grants, gifts, and
1-26 donations from public and private sources to comply with this
1-27 section; and
1-28 (3) contract with public or private entities in the
1-29 performance of its responsibilities under this section.
1-30 SECTION 2. Subsection (a), Section 106.025, Health and
1-31 Safety Code, is amended to read as follows:
1-32 (a) The center shall:
1-33 (1) educate the public and recommend appropriate
1-34 public policies regarding the continued viability of rural health
1-35 care delivery in this state;
1-36 (2) monitor and work with state and federal agencies
1-37 to assess the impact of proposed rules on rural areas;
1-38 (3) provide impact statements of proposed rules as
1-39 considered appropriate by the center;
1-40 (4) streamline regulations to assist in the
1-41 development of service diversification of health care facilities;
1-42 (5) target state and federal programs to rural areas;
1-43 (6) promote and develop community involvement and
1-44 community support in maintaining, rebuilding, or diversifying local
1-45 health services;
1-46 (7) promote and develop diverse and innovative health
1-47 care service models in rural areas;
1-48 (8) encourage the use of advanced communications
1-49 technology to:
1-50 (A) ensure that rural areas receive the maximum
1-51 benefits of telemedicine and distance learning by promoting a
1-52 transmission rate structure that accommodates rural needs and by
1-53 improving the telecommunications infrastructure in rural areas; and
1-54 (B) provide access to specialty expertise,
1-55 clinical consultation, and continuing education;
1-56 (9) assist rural health care providers, communities,
1-57 and individuals in applying for public and private grants and
1-58 programs;
1-59 (10) encourage the development of regional emergency
1-60 transportation networks;
1-61 (11) work with state agencies, universities, and
1-62 private interest groups to conduct and promote research on rural
1-63 health issues, maintain and collect a timely data base, and develop
1-64 and maintain a rural health resource library;
1-65 (12) solicit the assistance of other offices or
1-66 programs of rural health in this state that are university-based to
1-67 carry out the duties of this chapter;
1-68 (13) disseminate information and provide technical
2-1 assistance to communities, health care providers, and individual
2-2 consumers of health care services; <and>
2-3 (14) develop plans to implement a fee-for-service
2-4 health care professional recruitment service and a medical supplies
2-5 group purchasing program within the center;
2-6 (15) develop and initiate a study of rural health
2-7 clinics to:
2-8 (A) determine the efficiency and effectiveness
2-9 of rural health clinics;
2-10 (B) review the health outcomes of rural patients
2-11 treated in rural health clinics and report those outcomes in the
2-12 center's biennial report to the legislature;
2-13 (C) identify and address efficiency barriers for
2-14 the professional clinical relationship of physicians, nurses, and
2-15 physician assistants;
2-16 (D) assess the success of attracting primary
2-17 care physicians and allied health professionals to rural areas; and
2-18 (E) assess the appropriateness of the current
2-19 clinic designation process;
2-20 (16) develop and initiate a quality assessment program
2-21 to evaluate the health outcomes of rural patients treated in rural
2-22 health clinics; and
2-23 (17) encourage the active participation by physicians
2-24 and other health care providers in the early periodic diagnosis and
2-25 treatment program.
2-26 SECTION 3. Section 262.034, Health and Safety Code, is
2-27 amended to read as follows:
2-28 Sec. 262.034. FACILITIES AND SERVICES FOR ELDERLY AND
2-29 DISABLED <NURSING HOMES>. (a) <This section applies to an
2-30 authority created by a municipality with a population of more than
2-31 24,000 that is located in a county with a population of 1.5 million
2-32 or more.>
2-33 <(b)> The authority may construct, acquire, own, operate,
2-34 enlarge, improve, furnish, or equip one or more of the following
2-35 types of facilities or services for the care of the elderly or
2-36 disabled:
2-37 (1) a nursing home or similar long-term care facility;
2-38 (2) elderly housing;
2-39 (3) assisted living;
2-40 (4) home health;
2-41 (5) personal care;
2-42 (6) special care;
2-43 (7) continuing care; and
2-44 (8) durable medical equipment <one or more nursing
2-45 homes or similar facilities for the care of the elderly. The
2-46 nursing home or similar facility may be located outside the
2-47 municipal limits>.
2-48 (b) <(c)> The authority may lease or enter into an
2-49 operations or management agreement relating to all or part of a
2-50 <nursing home or similar> facility or service for the care of the
2-51 elderly or disabled that is owned by the authority. The authority
2-52 may sell, transfer, otherwise convey, or close all or part of the
2-53 <nursing home or similar> facility and may discontinue a service.
2-54 (c) <(d)> The authority may issue revenue bonds and other
2-55 notes in accordance with this chapter to acquire, construct, or
2-56 improve a <nursing home or similar> facility for the care of the
2-57 elderly or disabled or to implement the delivery of a service for
2-58 the care of the elderly or disabled.
2-59 (d) <(e)> For the purposes of this section, a <nursing home
2-60 or similar> facility or service described by Subsection (a) <for
2-61 the care of the elderly> is considered to be a hospital project
2-62 under Chapter 223 (Hospital Project Financing Act).
2-63 (e) This section applies only to an authority that owns or
2-64 operates a hospital licensed under Chapter 241 and that is located
2-65 in:
2-66 (1) a county with a population of 35,000 or less;
2-67 (2) those portions of extended municipalities that the
2-68 federal census bureau has determined to be rural; or
2-69 (3) an area that is not delineated as an urbanized
2-70 area by the federal census bureau.
3-1 SECTION 4. Chapter 285, Health and Safety Code, is amended
3-2 by adding Subchapter H to read as follows:
3-3 SUBCHAPTER H. LONG-TERM CARE AND RELATED FACILITIES
3-4 Sec. 285.101. FACILITIES OR SERVICES FOR ELDERLY OR
3-5 DISABLED. (a) This subchapter applies only to a hospital,
3-6 hospital district, or authority created and operated under Article
3-7 IX, Texas Constitution, under a special law, or under this title
3-8 that is located in:
3-9 (1) a county with a population of 35,000 or less;
3-10 (2) those portions of extended municipalities that the
3-11 federal census bureau has determined to be rural; or
3-12 (3) an area that is not delineated as an urbanized
3-13 area by the federal census bureau.
3-14 (b) A hospital, hospital district, or authority covered by
3-15 this subchapter may:
3-16 (1) construct, acquire, own, operate, enlarge,
3-17 improve, furnish, or equip one or more of the following types of
3-18 facilities or services for the care of the elderly or disabled:
3-19 (A) a nursing home or similar long-term care
3-20 facility;
3-21 (B) elderly housing;
3-22 (C) assisted living;
3-23 (D) home health;
3-24 (E) personal care;
3-25 (F) special care;
3-26 (G) continuing care; or
3-27 (H) durable medical equipment;
3-28 (2) lease or enter into an operations or management
3-29 agreement relating to all or part of a facility or service
3-30 described in Subdivision (1) that is owned by the hospital district
3-31 or authority;
3-32 (3) close, transfer, sell, or otherwise convey all or
3-33 part of a facility and discontinue services; and
3-34 (4) issue revenue bonds and other notes to acquire,
3-35 construct, or improve a facility for the care of the elderly or
3-36 disabled or to implement the delivery of a service for the care of
3-37 the elderly or disabled.
3-38 (c) For the purpose of this section, a facility or service
3-39 created under Subsection (b) is considered to be a hospital project
3-40 under Chapter 223.
3-41 SECTION 5. Subdivision (13), Section 483.001, Health and
3-42 Safety Code, is amended to read as follows:
3-43 (13) "Prescription" means an order from a
3-44 practitioner, or an agent of the practitioner designated in writing
3-45 as authorized to communicate prescriptions, or an order made in
3-46 accordance with Section 3.06(d)(5) or (6), Medical Practice Act
3-47 (Article 4495b, Vernon's Texas Civil Statutes), to a pharmacist for
3-48 a dangerous drug to be dispensed that states:
3-49 (A) the date of the order's issue;
3-50 (B) the name and address of the patient;
3-51 (C) if the drug is prescribed for an animal, the
3-52 species of the animal;
3-53 (D) the name and quantity of the drug
3-54 prescribed;
3-55 (E) the directions for the use of the drug; <and>
3-56 <(F) the legibly printed or stamped name,
3-57 address, Federal Drug Enforcement Administration registration
3-58 number, and telephone number of the practitioner at the
3-59 practitioner's usual place of business.>
3-60 (F) the intended use of the drug unless the
3-61 practitioner determines the furnishing of this information is not
3-62 in the best interest of the patient; and
3-63 (G) the name, address, and telephone number of
3-64 the practitioner at the practitioner's usual place of business,
3-65 legibly printed or stamped.
3-66 SECTION 6. Subsection (d), Section 671.001, Health and
3-67 Safety Code, is amended to read as follows:
3-68 (d) A registered nurse or physician assistant may determine
3-69 and pronounce a person dead in situations other than those
3-70 described by Subsection (b) if permitted by written policies of a
4-1 licensed health care facility, institution, or entity providing
4-2 services to that person. Those policies must consider physician
4-3 assistants who are credentialed or otherwise permitted to practice
4-4 at the facility, institution, or entity. If the facility,
4-5 institution, or entity has an organized nursing staff and an
4-6 organized medical staff or medical consultant, the nursing staff
4-7 and medical staff or consultant shall jointly develop and approve
4-8 those policies. The board shall adopt rules to govern policies for
4-9 facilities, institutions, or entities that do not have organized
4-10 nursing staffs and organized medical staffs or medical consultants.
4-11 SECTION 7. Section 671.002, Health and Safety Code, is
4-12 amended to read as follows:
4-13 Sec. 671.002. Limitation of Liability. (a) A physician who
4-14 determines death in accordance with Section 671.001(b) or a
4-15 registered nurse or physician assistant who determines death in
4-16 accordance with Section 671.001(d) is not liable for civil damages
4-17 or subject to criminal prosecution for the physician's, <or>
4-18 registered nurse's, or physician assistant's actions or the actions
4-19 of others based on the determination of death.
4-20 (b) A person who acts in good faith in reliance on a
4-21 physician's, <or> registered nurse's, or physician assistant's
4-22 determination of death is not liable for civil damages or subject
4-23 to criminal prosecution for the person's actions.
4-24 SECTION 8. Subsection (c), Section 51.918, Education Code,
4-25 is amended to read as follows:
4-26 (c) The Center for Rural Health Initiatives shall develop
4-27 relief service programs for rural physicians and allied health
4-28 personnel to facilitate ready access to continuing medical
4-29 education or practice coverage for purposes other than continuing
4-30 medical education.
4-31 SECTION 9. Section 501.059, Government Code, as added by
4-32 Chapter 238, Acts of the 73rd Legislature, 1993, is amended to read
4-33 as follows:
4-34 Sec. 501.059. MANAGED HEALTH CARE ADVISORY COMMITTEE.
4-35 (a) The Managed Health Care Advisory Committee to the Texas
4-36 Department of Criminal Justice is established.
4-37 (b) The committee consists of:
4-38 (1) two members employed full-time by the department,
4-39 at least one of whom is a physician, appointed by the executive
4-40 director;
4-41 (2) two members employed full-time by The University
4-42 of Texas Medical Branch at Galveston, at least one of whom is a
4-43 physician, appointed by the president of the medical branch; and
4-44 (3) two members employed full-time by the Texas Tech
4-45 University Health Sciences Center, at least one of whom is a
4-46 physician, appointed by the president of the university.
4-47 (c) A committee member serves at the pleasure of the
4-48 appointing official or until termination of the member's employment
4-49 with the entity the member represents.
4-50 (d) An appointment to the committee shall be made without
4-51 regard to the race, creed, sex, religion, or national origin of the
4-52 appointee.
4-53 (e) A committee member serves without compensation but is
4-54 entitled to reimbursement for actual and necessary expenses
4-55 incurred in the performance of the duties of the committee.
4-56 (f) The committee may hire a managed health care
4-57 administrator and may employ personnel necessary for the
4-58 administration of the committee's duties.
4-59 (g) The committee shall develop a managed health care plan
4-60 for all inmates at the institutional division that includes:
4-61 (1) the establishment of a managed care network of
4-62 physicians and hospitals that will serve the institutional division
4-63 as the exclusive health care provider for inmates at each facility
4-64 of the institutional division;
4-65 (2) cost containment studies; <and>
4-66 (3) care case management and utilization management
4-67 studies performed exclusively for the institutional division; and
4-68 (4) concerning the establishment of criteria for
4-69 hospitals, home health, or hospice providers, a provision requiring
4-70 the managed health care plan to accept certification by the
5-1 Medicare program under Title XVIII, Social Security Act, as amended
5-2 (42 U.S.C. Section 1395 et seq.), as an alternative to
5-3 accreditation by the Joint Commission on Accreditation of
5-4 Healthcare Organizations.
5-5 (h) To the extent possible the committee shall integrate the
5-6 managed care network with the public medical schools of this state
5-7 and the component and affiliated hospitals of those medical
5-8 schools.
5-9 (i) For those services for which the public medical schools
5-10 and their components and affiliates cannot provide, the committee
5-11 shall initiate a competitive bidding process for contracts with
5-12 other providers for medical care to inmates confined in the
5-13 institutional division.
5-14 (j) The committee may enter into a contract on behalf of the
5-15 department to fully implement the managed health care plan under
5-16 Subsection (g).
5-17 (k) The department shall pay necessary costs for the
5-18 operation of the committee, including costs of personnel, from
5-19 funds appropriated by the legislature to the department.
5-20 (l) The managed health care plan, inclusive of the health
5-21 care administrator and necessary personnel proposed by the
5-22 committee, must cost the state less than what is presently
5-23 provided, otherwise the status quo shall be maintained.
5-24 SECTION 10. Subdivision (42), Section 5, Texas Pharmacy Act
5-25 (Article 4542a-1, Vernon's Texas Civil Statutes), is amended to
5-26 read as follows:
5-27 (42) "Prescription drug order" means:
5-28 (A) an order from a practitioner or a
5-29 practitioner's designated agent to a pharmacist for a drug or
5-30 device to be dispensed; or
5-31 (B) an order pursuant to Subdivision (5) or (6),
5-32 Subsection (d), Section 3.06, Medical Practice Act (Article 4495b,
5-33 Vernon's Texas Civil Statutes).
5-34 SECTION 11. Subdivision (5), Subsection (d), Section 3.06,
5-35 Medical Practice Act (Article 4495b, Vernon's Texas Civil
5-36 Statutes), is amended to read as follows:
5-37 (5)(A) At a site serving a medically underserved
5-38 population, a physician licensed by the board shall be authorized
5-39 to delegate to a registered nurse or physician assistant acting
5-40 under adequate physician supervision, the act or acts of
5-41 administering, providing, or carrying out or signing a prescription
5-42 drug order as authorized by the physician through physician's
5-43 orders, standing medical orders, standing delegation orders, or
5-44 other orders or protocols as defined by the board.
5-45 (B)(i) The carrying out or signing of
5-46 prescription drug orders under this subsection shall comply with
5-47 other applicable laws.
5-48 (ii) The authority of a physician to
5-49 delegate the carrying out or signing of prescription drug orders is
5-50 limited to dangerous drugs.
5-51 (C) Physician supervision shall be adequate if a
5-52 delegating physician:
5-53 (i) is responsible for the formulation or
5-54 approval of such physician's orders, standing medical orders,
5-55 standing delegation orders, or other orders or protocols and
5-56 periodically reviews such orders and the services provided patients
5-57 under such orders;
5-58 (ii) is on site at least once a week to
5-59 provide medical direction and consultation;
5-60 (iii) receives a daily status report from
5-61 the registered nurse or physician assistant on any problems or
5-62 complications encountered; and
5-63 (iv) is available through direct
5-64 telecommunication for consultation, assistance with medical
5-65 emergencies, or patient referral.
5-66 (D) In this subsection:
5-67 (i) "Registered nurse" means a registered
5-68 nurse recognized by the Board of Nurse Examiners as having the
5-69 specialized education and training required under Section 7,
5-70 Article 4514, Revised Statutes.
6-1 (ii) "Physician assistant" has the meaning
6-2 assigned to that term by Section 2(3), Physician Assistant
6-3 Licensing Act, and its subsequent amendments.
6-4 (iii) "Carrying out or signing a
6-5 prescription drug order" means the completion of <to complete> a
6-6 prescription drug order presigned by the delegating physician or
6-7 the signing of a prescription by a registered nurse or physician
6-8 assistant after the delegating physician notifies the board that
6-9 the person is a person to whom the physician has delegated the
6-10 authority to sign the prescription. The following information
6-11 shall be provided on each prescription <by providing the following
6-12 information>: the patient's name and address; the drug to be
6-13 dispensed; directions to the patient in regard to the taking and
6-14 dosage; the name, address, and telephone number of the physician;
6-15 the name, address, telephone and identification number of the
6-16 registered nurse or physician assistant completing or signing the
6-17 prescription drug order; the date; and the number of refills
6-18 permitted. The board may adopt additional methods to carry into
6-19 effect or put into force a physician's prescription or delegation
6-20 of a prescription under physician's orders, standing medical
6-21 orders, standing delegation orders, or other orders or protocols.
6-22 (iv) "A site serving a medically
6-23 underserved population" means:
6-24 (a) a site located in a medically
6-25 underserved area;
6-26 (b) a site located in a health
6-27 manpower shortage area;
6-28 (c) a clinic designated as a rural
6-29 health clinic under the Rural Health Clinic Services Act of 1977
6-30 (Pub. L. No. 95-210);
6-31 (d) a public health clinic or a
6-32 family planning clinic under contract with the Texas Department of
6-33 Human Services or the Texas Department of Health;
6-34 (e) a site located in an area in
6-35 which the Texas Department of Health determines there exists an
6-36 insufficient number of physicians providing services to eligible
6-37 clients of federal, state, or locally funded health care programs;
6-38 or
6-39 (f) a site that the Texas Department
6-40 of Health determines serves a disproportionate number of clients
6-41 eligible to participate in federal, state, or locally funded health
6-42 care programs.
6-43 (v) "Health manpower shortage area" means
6-44 (1) an area in an urban or rural area of Texas (which need not
6-45 conform to the geographic boundaries of a political subdivision and
6-46 which is a rational area for the delivery of health services) which
6-47 the secretary of health and human services determines has a health
6-48 manpower shortage and which is not reasonably accessible to an
6-49 adequately served area; (2) a population group which the secretary
6-50 determines to have such a shortage; or (3) a public or nonprofit
6-51 private medical facility or other facility which the secretary
6-52 determines has such a shortage as delineated in 42 U.S.C. Section
6-53 254(e)(a)(1).
6-54 (vi) "Medically underserved area" means an
6-55 area in Texas with a medically underserved population or an urban
6-56 or rural area designated by the secretary of health and human
6-57 services as an area in Texas with a shortage of personal health
6-58 services or a population group designated by the secretary as
6-59 having a shortage of such services (as defined in 42 U.S.C. Section
6-60 300(e)-1(7)). The term also includes an area defined by rule
6-61 adopted by the Texas Board of Health that is based on demographics
6-62 specific to this state, geographic factors that affect access to
6-63 health care, and environmental health factors.
6-64 (E) After making a determination under <either>
6-65 Subdivision (D)(iv)(e), <or> (D)(iv)(f), or (D)(vi) that a site
6-66 serves a medically underserved population, the Texas Department of
6-67 Health shall publish notice of its determination in the Texas
6-68 Register and provide an opportunity for public comment in the same
6-69 manner as for a proposed rule under Chapter 2001, Government Code
6-70 <the Administrative Procedure and Texas Register Act (Article
7-1 6252-13a, Vernon's Texas Civil Statutes)>.
7-2 (F) The authority granted to a physician to
7-3 delegate under this subdivision shall not be construed as limiting
7-4 the authority of a physician to delegate under any other
7-5 subdivision of this subsection.
7-6 (G) An advertisement for a site serving a
7-7 medically underserved population shall include the name and
7-8 business address of the supervising physician for the site.
7-9 SECTION 12. Subsection (d), Section 3.06, Medical Practice
7-10 Act (Article 4495b, Vernon's Texas Civil Statutes), is amended by
7-11 adding Subdivision (6) to read as follows:
7-12 (6)(A) At a physician's primary practice site or a
7-13 location as described by Paragraph (H) of this subdivision, a
7-14 physician licensed by the board may delegate to a physician
7-15 assistant or an advanced nurse practitioner acting under adequate
7-16 physician supervision the act or acts of administering, providing,
7-17 carrying out, or signing a prescription drug order as authorized
7-18 through physician's orders, standing medical orders, standing
7-19 delegation orders, or protocols as defined by the board. Providing
7-20 and carrying out or signing a prescription drug order under this
7-21 subdivision is limited to dangerous drugs.
7-22 (B) Protocols and other orders shall be defined
7-23 to promote the exercise of professional judgment by the advanced
7-24 nurse practitioner and physician assistant commensurate with their
7-25 education and experience. Under this subdivision, protocols and
7-26 other orders used by a reasonable and prudent physician exercising
7-27 sound medical judgment:
7-28 (i) need not describe the exact steps that
7-29 an advanced nurse practitioner or a physician assistant must take
7-30 with respect to each specific condition, disease, or symptom; and
7-31 (ii) may state the types or categories of
7-32 medications that may be prescribed or state in terms of categories
7-33 or types the medications that may not be prescribed.
7-34 (C) Physician supervision of the carrying out
7-35 and signing of prescription drug orders shall conform to what a
7-36 reasonable, prudent physician would find consistent with sound
7-37 medical judgment but may vary with the education and experience of
7-38 the advanced nurse practitioner or physician assistant. A
7-39 physician shall provide continuous supervision, but the constant
7-40 physical presence of the physician is not required.
7-41 (D) An alternate physician may provide
7-42 appropriate supervision on a temporary basis as defined and
7-43 established by the board by rule.
7-44 (E) The carrying out or signing of prescription
7-45 drug orders under this subdivision shall comply with other
7-46 applicable laws.
7-47 (F) A physician's authority to delegate the
7-48 carrying out or signing of a prescription drug order at his primary
7-49 practice site under this subdivision is limited to:
7-50 (i) three physician assistants or advanced
7-51 nurse practitioners or their full-time equivalents practicing at
7-52 the physician's primary practice site; and
7-53 (ii) the patients with whom the physician
7-54 has established or will establish a physician-patient relationship,
7-55 but this shall not be construed as requiring the physician to see
7-56 the patient within a specific period of time.
7-57 (G) In this subdivision:
7-58 (i) "Advanced nurse practitioner" has the
7-59 meaning assigned to that term by Section 8, Article 4514, Revised
7-60 Statutes.
7-61 (ii) "Physician assistant" has the meaning
7-62 assigned to that term by Section 2(3), Physician Assistant
7-63 Licensing Act (Article 4495b-1, Vernon's Texas Civil Statutes).
7-64 (iii) "Primary practice site" means:
7-65 (a) the practice location
7-66 where the physician spends the majority of the physician's time;
7-67 (b) a licensed hospital,
7-68 licensed long-term care facility, licensed adult care center where
7-69 both the physician and the physician assistant or advanced nurse
7-70 practitioner are authorized to practice, or an established
8-1 patient's residence; or
8-2 (c) where the physician is
8-3 physically present with the physician assistant or advanced nurse
8-4 practitioner.
8-5 (iv) "Carrying out or signing a
8-6 prescription drug order" means either the completion of a
8-7 prescription drug order presigned by a delegating physician or the
8-8 signing of a prescription by a physician assistant or advanced
8-9 nurse practitioner after the person has been designated with the
8-10 board by the delegating physician as a person delegated to sign a
8-11 prescription. The following information shall be provided on each
8-12 prescription: the patient's name and address; the drug to be
8-13 dispensed; directions to the patient in regard to the taking and
8-14 dosage; the intended use of the drug, if appropriate; the name,
8-15 address, and telephone number of the physician; the name, address,
8-16 and telephone and identification number of the physician assistant
8-17 or advanced nurse practitioner completing or signing the
8-18 prescription drug order; the date; and the number of refills
8-19 permitted. The board may adopt additional methods to carry into
8-20 effect or put into force a physician's prescription under
8-21 physician's orders, standing medical orders, standing delegation
8-22 orders, protocols, or other orders.
8-23 (H) A physician licensed by the board shall be
8-24 authorized to delegate, to one or more physician assistants or
8-25 advanced nurse practitioners acting under adequate supervision by a
8-26 physician whose practice is facility-based at a licensed hospital
8-27 or licensed long-term care facility, the carrying out or signing of
8-28 prescription drug orders if the physician is the medical director
8-29 or chief of medical staff of the facility in which the physician
8-30 assistant or advanced nurse practitioner practices, the chair of
8-31 the facility's credentialing committee, a department chair of a
8-32 facility department in which the physician assistant or advanced
8-33 nurse practitioner practices, or a physician who consents to the
8-34 request of the medical director or chief of medical staff to
8-35 delegate the carrying out or signing of prescription drug orders at
8-36 the facility in which the physician assistant or advanced nurse
8-37 practitioner practices. A physician's authority to delegate under
8-38 this subdivision is limited as follows:
8-39 (i) the delegation is pursuant to a
8-40 physician's order, standing medical order, standing delegation
8-41 order, or protocol developed in accordance with policies approved
8-42 by the facility's medical staff or a committee thereof as provided
8-43 in facility bylaws;
8-44 (ii) the delegation occurs in the facility
8-45 in which the physician is the medical director, the chief of
8-46 medical staff, the chair of the credentialing committee, or a
8-47 department chair;
8-48 (iii) the delegation does not permit the
8-49 carrying out or signing of prescription drug orders for the care or
8-50 treatment of the patients of any other physician without the prior
8-51 consent of that physician;
8-52 (iv) delegation in a long-term care
8-53 facility must be by the medical director, and the medical director
8-54 is limited to delegating the carrying out and signing of
8-55 prescription drug orders to no more than three advanced nurse
8-56 practitioners or physician assistants or their full-time
8-57 equivalents; and
8-58 (v) under this paragraph, a physician may
8-59 not delegate at more than one licensed hospital or more than one
8-60 long-term care facility unless approved by the board.
8-61 (I) In a licensed hospital or ambulatory
8-62 surgical center, a physician may delegate to a certified registered
8-63 nurse anesthetist the ordering of drugs and devices necessary to
8-64 enable the certified registered nurse anesthetist to administer an
8-65 anesthetic or an anesthesia-related service ordered by the
8-66 physician. The physician's order for anesthesia or
8-67 anesthesia-related services need not be drug-specific,
8-68 dose-specific, or administration-technique-specific. Pursuant to
8-69 the order and in accordance with facility policies or medical staff
8-70 bylaws, the nurse anesthetist may select, obtain, and administer
9-1 those drugs and apply the appropriate medical devices necessary to
9-2 accomplish the order and maintain the patient within a sound
9-3 physiological status.
9-4 (J) A physician shall not be liable for the act
9-5 or acts of a physician assistant or advanced nurse practitioner
9-6 solely on the basis of having signed an order, a standing medical
9-7 order, a standing delegation order, or protocols authorizing a
9-8 physician assistant or advanced nurse practitioner to perform the
9-9 act or acts of administering, providing, carrying out, or signing a
9-10 prescription drug order unless the physician has reason to believe
9-11 the physician assistant or advanced nurse practitioner lacked the
9-12 competency to perform the act or acts.
9-13 (K) The authority granted to a physician to
9-14 delegate under this subdivision shall not be construed as limiting
9-15 the authority of a physician to delegate under any other
9-16 subdivision of this subsection.
9-17 SECTION 13. Article 4514, Revised Statutes, is amended by
9-18 adding Section 8 to read as follows:
9-19 Sec. 8. APPROVAL OF REGISTERED NURSE FOR ADVANCED STATUS.
9-20 (a) The board shall adopt rules for approval of a registered nurse
9-21 as an advanced nurse practitioner or an advanced practice nurse.
9-22 "Advanced nurse practitioner" or "advanced practice nurse" means a
9-23 registered nurse approved by the board to practice as an advanced
9-24 practice nurse on the basis of completion of an advanced
9-25 educational program. The term includes a nurse practitioner, nurse
9-26 midwife, nurse anesthetist, and clinical nurse specialist.
9-27 (b) The board shall adopt rules for the initial approval and
9-28 biennial renewal of an advanced nurse practitioner to carry out or
9-29 sign prescription drug orders under Section 3.06(d)(5) and (6),
9-30 Medical Practice Act (Article 4495b, Vernon's Texas Civil
9-31 Statutes). The rules at a minimum shall:
9-32 (1) require completion of pharmacology and related
9-33 pathology for initial approval;
9-34 (2) require continuing education in clinical
9-35 pharmacology and related pathology in addition to any continuing
9-36 education otherwise required under Article 4518, Revised Statutes;
9-37 and
9-38 (3) provide for the issuing of a prescription
9-39 authorization number to an advanced nurse practitioner approved
9-40 under this section.
9-41 SECTION 14. Section 5, Article 4518, Revised Statutes, is
9-42 amended to read as follows:
9-43 Sec. 5. Insofar as any of the following acts require
9-44 substantial specialized judgment and skill and insofar as the
9-45 proper performance of any of the following acts is based upon
9-46 knowledge and application of the principles of biological,
9-47 physical, and social science as acquired by a completed course in
9-48 an approved school of professional nursing, "Professional Nursing"
9-49 shall be defined as the performance for compensation of any nursing
9-50 act (a) in the observation, assessment, intervention, evaluation,
9-51 rehabilitation, care and counsel and health teachings of persons
9-52 who are ill, injured or infirm or experiencing changes in normal
9-53 health processes; (b) in the maintenance of health or prevention of
9-54 illness; (c) in the administration of medications or treatments as
9-55 ordered by a licensed physician, including a podiatric physician
9-56 licensed by the Texas State Board of Podiatry Examiners, or
9-57 dentists; (d) in the supervision or teaching of nursing; (e) in the
9-58 administration, supervision, and evaluation of nursing practices,
9-59 policies, and procedures; <or> (f) in <the requesting,> receiving
9-60 <, and signing for> professional samples which have been requested
9-61 and presigned for by the supervising physician and distributing the
9-62 samples to patients at sites to which Sections <a site serving
9-63 underserved populations, as provided by Section> 3.06(d)(5) and
9-64 (6), Medical Practice Act (Article 4495b, Vernon's Texas Civil
9-65 Statutes), apply; or (g) in the performing of acts delegated by a
9-66 physician under Sections 3.06(d)(5) and (6), Medical Practice Act
9-67 (Article 4495b, Vernon's Texas Civil Statutes) <and rules
9-68 implementing that section>. The foregoing shall not be deemed to
9-69 include acts of medical diagnosis or prescription of therapeutic or
9-70 corrective measures. Nothing in this section shall be construed as
10-1 prohibiting a registered nurse recognized by the board as having
10-2 the specialized education and training required under Section 7,
10-3 Article 4514, Revised Statutes, and functioning under adequate
10-4 physician supervision from carrying out prescription drug orders or
10-5 treatments under physician's orders, standing medical orders,
10-6 standing delegation orders, or other orders or protocols.
10-7 SECTION 15. The importance of this legislation and the
10-8 crowded condition of the calendars in both houses create an
10-9 emergency and an imperative public necessity that the
10-10 constitutional rule requiring bills to be read on three several
10-11 days in each house be suspended, and this rule is hereby suspended,
10-12 and that this Act take effect and be in force from and after its
10-13 passage, and it is so enacted.
10-14 * * * * *