87R3775 BEE-F

By: Klick H.B. No. 2029

A BILL TO BE ENTITLED

AN ACT

relating to the licensing and authority of advanced practice registered nurses.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

ARTICLE 1. ADVANCED PRACTICE REGISTERED NURSES

SECTION 1.001. Section 301.002, Occupations Code, is amended to read as follows:

Sec. 301.002. DEFINITIONS. In this chapter:

(1) "Advanced practice registered nurse" means a registered nurse licensed by the board to practice as an advanced practice registered nurse on the basis of completion of an advanced educational program. The term includes a nurse practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialist.

(2) [(1)] "Board" means the Texas Board of Nursing.

(3) [(1-a)] "Chief nursing officer" means the registered nurse who is administratively responsible for the nursing services at a facility.

(4) "Controlled substance" has the meaning assigned by Section 481.002, Health and Safety Code.

(5) "Dangerous drug" has the meaning assigned by Section 483.001, Health and Safety Code.

(6) "Device" has the meaning assigned by Section 551.003, and includes durable medical equipment.

(7) "Nonprescription drug" has the meaning assigned by Section 551.003.

(8) "Nurse" means a person required to be licensed under this chapter to engage in professional or vocational nursing.

(9) "Nursing" means professional or vocational nursing.

(10) [(1-b)] "Patient safety committee" has the meaning assigned by Section 303.001.

(11) "Prescribe or order a drug or device" has the meaning assigned by Section 157.051.

(12) [(2)] "Professional nursing" means the performance of an act that requires substantial specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of professional nursing. The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures, except as authorized for an advanced practice registered nurse. Professional nursing involves:

(A) the observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings of a person who is ill, injured, infirm, or experiencing a change in normal health processes;

(B) the maintenance of health or prevention of illness;

(C) the administration of a medication or treatment as ordered by a health care practitioner legally authorized to prescribe the medication or treatment [physician, podiatrist, or dentist];

(D) the supervision or teaching of nursing;

(E) the administration, supervision, and evaluation of nursing practices, policies, and procedures;

(F) [the requesting, receiving, signing for, and distribution of prescription drug samples to patients at practices at which an advanced practice registered nurse is authorized to sign prescription drug orders as provided by Subchapter B, Chapter 157;

[(G)] the performance of an act by an advanced practice registered nurse [delegated by a physician under Section 157.0512, 157.054, 157.058, or 157.059]; and

(G) [(H)] the development of the nursing care plan.

[(3) "Nurse" means a person required to be licensed under this chapter to engage in professional or vocational nursing.

[(4) "Nursing" means professional or vocational nursing.]

(13) [(5)] "Vocational nursing" means a directed scope of nursing practice, including the performance of an act that requires specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of vocational nursing. The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. Vocational nursing involves:

(A) collecting data and performing focused nursing assessments of the health status of an individual;

(B) participating in the planning of the nursing care needs of an individual;

(C) participating in the development and modification of the nursing care plan;

(D) participating in health teaching and counseling to promote, attain, and maintain the optimum health level of an individual;

(E) assisting in the evaluation of an individual's response to a nursing intervention and the identification of an individual's needs; and

(F) engaging in other acts that require education and training, as prescribed by board rules and policies, commensurate with the nurse's experience, continuing education, and demonstrated competency.

SECTION 1.002. Section 301.005(b), Occupations Code, is amended to read as follows:

(b) A reference in any other law to an "advanced nurse practitioner," [or] "advanced practice nurse," or "advanced practice registered nurse" means an advanced practice registered nurse.

SECTION 1.003. Section 301.152, Occupations Code, is transferred to Subchapter H, Chapter 301, Occupations Code, redesignated as Section 301.357, Occupations Code, and amended to read as follows:

Sec. 301.357 [301.152]. ADVANCED PRACTICE REGISTERED NURSES [RULES REGARDING SPECIALIZED TRAINING]. (a) Advanced practice registered nursing includes:

(1) ordering, performing, and interpreting diagnostic tests;

(2) formulating primary and differential medical diagnoses and advanced assessments;

(3) treating actual and potential health problems;

(4) prescribing therapeutic and corrective measures, including nutrition and diagnostic support services, home health care, hospice care, physical therapy, and occupational therapy, and delegating and assigning the performance of therapeutic and corrective measures to assistive personnel;

(5) to the extent authorized by the board under Section 301.358, prescribing, ordering, procuring, administering, and dispensing drugs and devices, including blood and blood products, controlled substances listed in Schedules II, III, IV, and V, dangerous drugs, and nonprescription drugs;

(6) providing referrals to health care agencies, health care providers, and community resources;

(7) serving as the primary care provider of record; and

(8) performing other acts that require education and training consistent with professional standards and that are commensurate with the advanced practice registered nurse's education, licensure, and demonstrated competencies and experience. [In this section, "advanced practice registered nurse" means a registered nurse licensed by the board to practice as an advanced practice registered nurse on the basis of completion of an advanced educational program. The term includes a nurse practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialist. The term is synonymous with "advanced nurse practitioner" and "advanced practice nurse."]

(b) The board shall adopt rules to:

(1) license a registered nurse as an advanced practice registered nurse;

(2) establish:

(A) any specialized education or training, including pharmacology, that an advanced practice registered nurse must have to prescribe or order a drug or device as authorized [delegated] by the board [a physician] under Section 301.358 [157.0512 or 157.054];

(B) a system for approving an advanced practice registered nurse to prescribe or order a drug or device as authorized [delegated] by the board [a physician] under Section 301.358 [157.0512 or 157.054] on the receipt of evidence of completing the specialized education and training requirement under Paragraph (A); and

(C) a system for issuing a prescription authorization number to an advanced practice registered nurse approved under Paragraph (B); and

(3) concurrently renew any license or approval granted to an advanced practice registered nurse under this subsection and a license renewed by the advanced practice registered nurse under Section 301.301.

(c) At a minimum, the rules adopted under Subsection (b)(2) must:

(1) require completion of pharmacology and related pathophysiology education for initial approval; and

(2) require continuing education in clinical pharmacology and related pathophysiology in addition to any continuing education otherwise required under Section 301.303.

(d) The signature of an advanced practice registered nurse attesting to the provision of a legally authorized service by the advanced practice registered nurse satisfies any documentation requirement for that service established by a state agency.

(e) An advanced practice registered nurse shall practice as a licensed independent practitioner in accordance with standards established and recognized by the board to protect the public health and safety.

(f) An advanced practice registered nurse is accountable to patients, the nursing profession, and the board for:

(1) complying with the requirements of this chapter;

(2) providing quality advanced nursing care;

(3) recognizing the nurse's limits of knowledge;

(4) planning for the management of situations beyond the nurse's expertise; and

(5) consulting with or referring patients to other health care providers as appropriate.

(g) This section does not limit or modify the scope of practice of a registered nurse who is not an advanced practice registered nurse.

(h) Notwithstanding any other law, an advanced practice registered nurse performing an act described by Subsection (a) is not considered to be practicing medicine without a license.

SECTION 1.004. Section 301.354(a), Occupations Code, is amended to read as follows:

(a) In this section, "nurse first assistant" means a registered nurse who:

(1) has completed a nurse first assistant educational program approved or recognized by an organization recognized by the board; and

(2) [is] either:

(A) is certified in perioperative nursing by an organization recognized by the board; or

(B) is [recognized by the board as] an advanced practice registered nurse [and] qualified by education, training, or experience to perform the tasks involved in perioperative nursing.

SECTION 1.005. Subchapter H, Chapter 301, Occupations Code, is amended by adding Section 301.358 to read as follows:

Sec. 301.358. PRESCRIBING AND ORDERING AUTHORITY OF ADVANCED PRACTICE REGISTERED NURSE. (a) The board may authorize an advanced practice registered nurse to prescribe and order drugs and devices, including controlled substances listed in Schedules III, IV, and V, dangerous drugs, and nonprescription drugs.

(b) Except as provided by Subsection (c), the board may authorize an advanced practice registered nurse to prescribe and order controlled substances listed in Schedule II only:

(1) in a hospital facility-based practice in accordance with policies approved by the hospital's medical staff or a committee of the hospital's medical staff as provided by the hospital bylaws to ensure patient safety, and as part of the care provided to a patient who:

(A) has been admitted to the hospital and is expected to remain in the hospital for a period of 24 hours or more; or

(B) is receiving services in the emergency department of the hospital; or

(2) as part of the plan of care for the treatment of a person who has executed a written certification of a terminal illness, has elected to receive hospice care, and is receiving hospice treatment from a qualified hospice provider.

(c) The board may authorize a certified registered nurse anesthetist practicing in an ambulatory surgical center to order drugs and devices necessary for the nurse anesthetist to administer an anesthetic or anesthesia-related service.

ARTICLE 2. CONFORMING AMENDMENTS REGARDING DELEGATION

SECTION 2.001. The heading to Subchapter B, Chapter 157, Occupations Code, is amended to read as follows:

SUBCHAPTER B. DELEGATION TO [ADVANCED PRACTICE REGISTERED NURSES

AND] PHYSICIAN ASSISTANTS

SECTION 2.002. Sections 157.051(11) and (14), Occupations Code, are amended to read as follows:

(11) "Practice serving a medically underserved population" means:

(A) a practice in a health professional shortage area;

(B) a clinic designated as a rural health clinic under 42 U.S.C. Section 1395x(aa);

(C) a public health clinic or a family planning clinic under contract with the Health and Human Services Commission or the Department of State Health Services;

(D) a clinic designated as a federally qualified health center under 42 U.S.C. Section 1396d(l)(2)(B);

(E) a county, state, or federal correctional facility;

(F) a practice:

(i) that either:

(a) is located in an area in which the Department of State Health Services determines there is an insufficient number of physicians providing services to eligible clients of federally, state, or locally funded health care programs; or

(b) is a practice that the Department of State Health Services determines serves a disproportionate number of clients eligible to participate in federally, state, or locally funded health care programs; and

(ii) for which the Department of State Health Services publishes notice of the department's determination in the Texas Register and provides an opportunity for public comment in the manner provided for a proposed rule under Chapter 2001, Government Code; or

(G) a practice at which a physician was delegating prescriptive authority to an advanced practice registered nurse, as defined by Section 301.002, or physician assistant on or before March 1, 2013, based on the practice qualifying as a site serving a medically underserved population.

(14) "Prescriptive authority agreement" means an agreement entered into by a physician and a [an advanced practice registered nurse or] physician assistant through which the physician delegates to the [advanced practice registered nurse or] physician assistant the act of prescribing or ordering a drug or device.

SECTION 2.003. Section 157.0511(b-2), Occupations Code, is amended to read as follows:

(b-2) The board shall adopt rules that require a physician who delegates the prescribing or ordering of a drug or device to register with the board the name and license number of the physician assistant [or advanced practice registered nurse] to whom a delegation is made. The board may develop and use an electronic online delegation registration process for registration under this subsection.

SECTION 2.004. Sections 157.0512(a), (b), (c), (e), (f), (g), (i), (j), (l), (m), (n), and (o), Occupations Code, are amended to read as follows:

(a) A physician may delegate to a [an advanced practice registered nurse or] physician assistant, acting under adequate physician supervision, the act of prescribing or ordering a drug or device as authorized through a prescriptive authority agreement between the physician and the [advanced practice registered nurse or] physician assistant[, as applicable].

(b) A physician and a [an advanced practice registered nurse or] physician assistant are eligible to enter into or be parties to a prescriptive authority agreement only if:

(1) [if applicable, the Texas Board of Nursing has approved the advanced practice registered nurse's authority to prescribe or order a drug or device as authorized under this subchapter;

[(2)] the [advanced practice registered nurse or] physician assistant:

(A) holds an active license to practice in this state as a [an advanced practice registered nurse or] physician assistant[, as applicable,] and is in good standing in this state; and

(B) is not currently prohibited by the [Texas Board of Nursing or the] Texas Physician Assistant Board[, as applicable,] from executing a prescriptive authority agreement; and

(2) [(3)] before executing the prescriptive authority agreement, the physician and the [advanced practice registered nurse or] physician assistant disclose to the other prospective party to the agreement any prior disciplinary action by the board[, the Texas Board of Nursing,] or the Texas Physician Assistant Board[, as applicable].

(c) Except as provided by Subsection (d), the [combined] number of [advanced practice registered nurses and] physician assistants with whom a physician may enter into a prescriptive authority agreement may not exceed seven [advanced practice registered nurses and] physician assistants or the full-time equivalent of seven [advanced practice registered nurses and] physician assistants.

(e) A prescriptive authority agreement must, at a minimum:

(1) be in writing and signed and dated by the parties to the agreement;

(2) state the name, address, and all professional license numbers of the parties to the agreement;

(3) state the nature of the practice, practice locations, or practice settings;

(4) identify the types or categories of drugs or devices that may be prescribed or the types or categories of drugs or devices that may not be prescribed;

(5) provide a general plan for addressing consultation and referral;

(6) provide a plan for addressing patient emergencies;

(7) state the general process for communication and the sharing of information between the physician and the [advanced practice registered nurse or] physician assistant to whom the physician has delegated prescriptive authority related to the care and treatment of patients;

(8) if alternate physician supervision is to be utilized, designate one or more alternate physicians who may:

(A) provide appropriate supervision on a temporary basis in accordance with the requirements established by the prescriptive authority agreement and the requirements of this subchapter; and

(B) participate in the prescriptive authority quality assurance and improvement plan meetings required under this section; and

(9) describe a prescriptive authority quality assurance and improvement plan and specify methods for documenting the implementation of the plan that include the following:

(A) chart review, with the number of charts to be reviewed determined by the physician and [advanced practice registered nurse or] physician assistant; and

(B) periodic meetings between the [advanced practice registered nurse or] physician assistant and the physician.

(f) The periodic meetings described by Subsection (e)(9)(B) must:

(1) include:

(A) the sharing of information relating to patient treatment and care, needed changes in patient care plans, and issues relating to referrals; and

(B) discussion of patient care improvement;

(2) be documented; and

(3) take place at least once a month in a manner determined by the physician and the [advanced practice registered nurse or] physician assistant.

(g) The prescriptive authority agreement may include other provisions agreed to by the physician and [advanced practice registered nurse or] physician assistant.

(i) The prescriptive authority agreement need not describe the exact steps that a [an advanced practice registered nurse or] physician assistant must take with respect to each specific condition, disease, or symptom.

(j) A physician[, advanced practice registered nurse,] or physician assistant who is a party to a prescriptive authority agreement must retain a copy of the agreement until the second anniversary of the date the agreement is terminated.

(l) In the event that a party to a prescriptive authority agreement is notified that the individual has become the subject of an investigation by the board[, the Texas Board of Nursing,] or the Texas Physician Assistant Board, the individual shall immediately notify the other party to the prescriptive authority agreement.

(m) The prescriptive authority agreement and any amendments must be reviewed at least annually, dated, and signed by the parties to the agreement. The prescriptive authority agreement and any amendments must be made available to the board[, the Texas Board of Nursing,] or the Texas Physician Assistant Board not later than the third business day after the date of receipt of request, if any.

(n) The prescriptive authority agreement should promote the exercise of professional judgment by the [advanced practice registered nurse or] physician assistant commensurate with the [advanced practice registered nurse's or] physician assistant's education and experience and the relationship between the [advanced practice registered nurse or] physician assistant and the physician.

(o) This section shall be liberally construed to allow the use of prescriptive authority agreements to safely and effectively utilize the skills and services of [advanced practice registered nurses and] physician assistants.

SECTION 2.005. Section 157.0513, Occupations Code, is amended to read as follows:

Sec. 157.0513. PRESCRIPTIVE AUTHORITY AGREEMENT: INFORMATION. (a) The board[, the Texas Board of Nursing,] and the Texas Physician Assistant Board shall jointly develop a process:

(1) to exchange information regarding the names, locations, and license numbers of each physician[, advanced practice registered nurse,] and physician assistant who has entered into a prescriptive authority agreement;

(2) by which each board shall immediately notify the other board [boards] when a license holder of the board becomes the subject of an investigation involving the delegation and supervision of prescriptive authority, as well as the final disposition of any such investigation;

(3) by which each board shall maintain and share a list of the board's license holders who have been subject to a final adverse disciplinary action for an act involving the delegation and supervision of prescriptive authority; and

(4) to ensure that each [advanced practice registered nurse or] physician assistant who has entered into a prescriptive authority agreement authorizing the prescribing of opioids is required to complete not less than two hours of continuing education annually regarding safe and effective pain management related to the prescription of opioids and other controlled substances, including education regarding:

(A) reasonable standards of care;

(B) the identification of drug-seeking behavior in patients; and

(C) effectively communicating with patients regarding the prescription of an opioid or other controlled substance.

(b) If the board[, the Texas Board of Nursing,] or the Texas Physician Assistant Board receives a notice under Subsection (a)(2), the board that received notice may open an investigation against a license holder of the board who is a party to a prescriptive authority agreement with the license holder who is under investigation by the board that provided notice under Subsection (a)(2).

(c) The board shall maintain and make available to the public a searchable online list of physicians[, advanced practice registered nurses,] and physician assistants who have entered into a prescriptive authority agreement authorized under Section 157.0512 and identify the physician[, advanced practice registered nurse, or physician assistant] with whom each [physician, advanced practice registered nurse, and] physician assistant has entered into a prescriptive authority agreement.

(d) The board shall collaborate with the [Texas Board of Nursing and the] Texas Physician Assistant Board to maintain and make available to the public a list of physicians[, advanced practice registered nurses,] and physician assistants who are prohibited from entering into or practicing under a prescriptive authority agreement.

SECTION 2.006. Sections 157.054(a), (a-1), (b), and (c), Occupations Code, are amended to read as follows:

(a) One or more physicians licensed by the board may delegate, to one or more physician assistants [or advanced practice registered nurses] acting under adequate physician supervision whose practice is facility-based at a hospital or licensed long-term care facility, the administration or provision of a drug and the prescribing or ordering of a drug or device if each of the delegating physicians is:

(1) the medical director or chief of medical staff of the facility in which the physician assistant [or advanced practice registered nurse] practices;

(2) the chair of the facility's credentialing committee;

(3) a department chair of a facility department in which the physician assistant [or advanced practice registered nurse] practices; or

(4) a physician who consents to the request of the medical director or chief of medical staff to delegate the prescribing or ordering of a drug or device at the facility in which the physician assistant [or advanced practice registered nurse] practices.

(a-1) The limit [limits] on the number of [advanced practice registered nurses or] physician assistants to whom a physician may delegate under Section 157.0512 does [do] not apply to a physician under Subsection (a) whose practice is facility-based under this section, provided that the physician is not delegating in a freestanding clinic, center, or practice of the facility.

(b) A physician's authority to delegate under Subsection (a) is limited as follows:

(1) the delegation must be made under a physician's order, standing medical order, standing delegation order, or another order or protocol developed in accordance with policies approved by the facility's medical staff or a committee of the facility's medical staff as provided by the facility bylaws;

(2) the delegation must occur in the facility in which the physician is the medical director, the chief of medical staff, the chair of the credentialing committee, a department chair, or a physician who consents to delegate under Subsection (a)(4);

(3) the delegation may not permit the prescribing or ordering of a drug or device for the care or treatment of the patients of any other physician without the prior consent of that physician; and

(4) delegation in a long-term care facility must be by the medical director and is limited to the prescribing or ordering of a drug or device to not more than seven [advanced practice registered nurses or] physician assistants or their full-time equivalents.

(c) Physician supervision of the prescribing or ordering of a drug or device must conform to what a reasonable, prudent physician would find consistent with sound medical judgment but may vary with the education and experience of the particular [advanced practice registered nurse or] physician assistant. A physician shall provide continuous supervision, but the constant physical presence of the physician is not required.

SECTION 2.007. Section 157.055, Occupations Code, is amended to read as follows:

Sec. 157.055. ORDERS AND PROTOCOLS. A protocol or other order shall be defined in a manner that promotes the exercise of professional judgment by the [advanced practice registered nurse and] physician assistant commensurate with the education and experience of that person. Under this section, an order or protocol used by a reasonable and prudent physician exercising sound medical judgment:

(1) is not required to describe the exact steps that [an advanced practice registered nurse or] a physician assistant must take with respect to each specific condition, disease, or symptom; and

(2) may state the types or categories of medications that may be prescribed or the types or categories of medications that may not be prescribed.

SECTION 2.008. Section 157.056, Occupations Code, is amended to read as follows:

Sec. 157.056. PRESCRIPTION INFORMATION. The following information must be provided on each prescription subject to this subchapter:

(1) the patient's name and address;

(2) the drug to be dispensed;

(3) directions to the patient regarding the taking of the drug and the dosage;

(4) the intended use of the drug, if appropriate;

(5) the name, address, and telephone number of the physician;

(6) the name, address, telephone number, and identification number of the [registered nurse or] physician assistant completing or signing the prescription drug order;

(7) the date; and

(8) the number of refills permitted.

SECTION 2.009. Sections 157.059(b), (e), (f), (g), (h), and (i), Occupations Code, are amended to read as follows:

(b) A physician may delegate to a physician assistant offering obstetrical services and certified by the board as specializing in obstetrics [or an advanced practice registered nurse recognized by the Texas Board of Nursing as a nurse midwife] the act of administering or providing controlled substances to the physician assistant's [or nurse midwife's] clients during intrapartum and immediate postpartum care.

(e) The physician's orders, medical orders, standing delegation orders, prescriptive authority agreements, or protocols must require the reporting of or monitoring of each client's progress, including complications of pregnancy and delivery and the administration and provision of controlled substances by the [nurse midwife or] physician assistant to the clients of the [nurse midwife or] physician assistant.

(f) The authority of a physician to delegate under this section is limited to:

(1) seven [nurse midwives or] physician assistants or their full-time equivalents; and

(2) the designated facility at which the [nurse midwife or] physician assistant provides care.

(g) The controlled substance must be supplied in a suitable container that is labeled in compliance with the applicable drug laws and must include:

(1) the patient's name and address;

(2) the drug to be provided;

(3) the name, address, and telephone number of the physician;

(4) the name, address, and telephone number of the [nurse midwife or] physician assistant; and

(5) the date.

(h) This section does not authorize a physician or [,] physician assistant[, or nurse midwife] to operate a retail pharmacy as defined under Subtitle J.

(i) This section authorizes a physician to delegate the act of administering or providing a controlled substance to a [nurse midwife or] physician assistant but does not require physician delegation of[:

[(1) further acts to a nurse midwife; or

[(2)] the administration of medications by a physician assistant [or registered nurse] other than as provided by this section.

SECTION 2.010. Section 157.060, Occupations Code, is amended to read as follows:

Sec. 157.060. PHYSICIAN LIABILITY FOR DELEGATED ACT. Unless the physician has reason to believe the physician assistant [or advanced practice registered nurse] lacked the competency to perform the act, a physician is not liable for an act of a physician assistant [or advanced practice registered nurse] solely because the physician signed a standing medical order, a standing delegation order, or another order or protocol, or entered into a prescriptive authority agreement, authorizing the physician assistant [or advanced practice registered nurse] to administer, provide, prescribe, or order a drug or device.

ARTICLE 3. GENERAL CONFORMING AMENDMENTS

SECTION 3.001. Section 38.151(1), Education Code, is amended to read as follows:

(1) "Advanced practice nurse" has the meaning assigned to "advanced practice registered nurse" by Section 301.002 [301.152], Occupations Code.

SECTION 3.002. Section 61.601, Education Code, as amended by Chapters 891 (H.B. 3083) and 1101 (H.B. 3808), Acts of the 85th Legislature, Regular Session, 2017, is reenacted and amended to read as follows:

Sec. 61.601. DEFINITION. In this subchapter, "mental health professional" means:

(1) a licensed physician who is:

(A) a graduate of an accredited psychiatric residency training program; or

(B) certified in psychiatry by:

(i) the American Board of Psychiatry and Neurology; or

(ii) the American Osteopathic Board of Neurology and Psychiatry;

(2) a psychologist, as defined by Section 501.002, Occupations Code;

(3) a licensed professional counselor, as defined by Section 503.002, Occupations Code;

(4) an advanced practice registered nurse, as defined by Section 301.002 [301.152], Occupations Code, who holds a nationally recognized board certification in psychiatric or mental health nursing;

(5) a licensed clinical social worker, as defined by Section 505.002, Occupations Code; [and]

(6) a licensed marriage and family therapist, as defined by Section 502.002, Occupations Code; and

(7) [(6)] a chemical dependency counselor, as defined by Section 504.001, Occupations Code.

SECTION 3.003. Section 263.001(a)(1), Family Code, is amended to read as follows:

(1) "Advanced practice nurse" has the meaning assigned to "advanced practice registered nurse" by Section 301.002 [157.051], Occupations Code.

SECTION 3.004. Section 266.001(1), Family Code, is amended to read as follows:

(1) "Advanced practice nurse" has the meaning assigned to "advanced practice registered nurse" by Section 301.002 [157.051], Occupations Code.

SECTION 3.005. Section 531.0217(k), Government Code, is amended to read as follows:

(k) This section does not affect any requirement relating to:

(1) a rural health clinic; or

(2) physician delegation of the authority to carry out or sign prescription drug orders to a [an advanced practice nurse or] physician assistant.

SECTION 3.006. Section 671.001(b), Government Code, is amended to read as follows:

(b) The pilot program must provide for the following:

(1) a licensed advanced practice registered nurse as defined by Section 301.002 [301.152], Occupations Code, or a licensed physician assistant as described by Chapter 204, Occupations Code, who is employed by the state or whose services are acquired by contract, who will be located at a state office complex;

(2) if applicable, a licensed physician, who is employed by a state governmental entity for purposes other than the pilot program or whose services are acquired by contract, who will delegate to and supervise the [advanced practice registered nurse or] physician assistant under a prescriptive authority agreement under Chapter 157, Occupations Code;

(3) appropriate office space and equipment for the advanced practice registered nurse or physician assistant to provide basic medical care to employees at the state office complex where the nurse or physician assistant is located; and

(4) professional liability insurance covering services provided by the advanced practice registered nurse or the physician assistant.

SECTION 3.007. Section 47.001(3), Health and Safety Code, is amended to read as follows:

(3) "Health care provider" means:

(A) [a registered nurse recognized as] an advanced practice registered nurse as defined by Section 301.002, Occupations Code; [the Texas Board of Nursing] or

(B) a physician assistant licensed by the Texas Physician Assistant Board.

SECTION 3.008. Section 47.011(a), Health and Safety Code, is amended to read as follows:

(a) In this section, "midwife" has the meaning assigned by Section 203.002, Occupations Code, and includes a nurse midwife [described by Section 301.152, Occupations Code].

SECTION 3.009. Sections 161.0052(b) and (c), Health and Safety Code, are amended to read as follows:

(b) The executive commissioner by rule shall require a hospital to inform each elderly person admitted to the hospital for a period of 24 hours or more that the pneumococcal and influenza vaccines are available. If the elderly person requests a vaccine, and if a physician, [or] an advanced nurse practitioner, or a physician assistant on behalf of a physician, determines that the vaccine is in the person's best interest, the hospital must make the vaccination available to the person before the person is discharged from the hospital.

(c) The executive commissioner by rule shall require an end stage renal disease facility to offer, to the extent possible as determined by the facility, the opportunity to receive the pneumococcal and influenza vaccines to each elderly person who receives ongoing care at the facility if a physician, [or] an advanced nurse practitioner, or a physician assistant on behalf of a physician, determines that the vaccine is in the person's best interest. If the facility decides it is not feasible to offer the vaccine, the facility must provide the person with information on other options for obtaining the vaccine.

SECTION 3.010. Section 241.003(1), Health and Safety Code, is amended to read as follows:

(1) "Advanced practice nurse" has the meaning assigned to "advanced practice registered nurse" by Section 301.002, Occupations Code [means a registered nurse recognized as an advanced practice nurse by the Texas Board of Nursing].

SECTION 3.011. Section 481.002(39), Health and Safety Code, is amended to read as follows:

(39) "Practitioner" means:

(A) a physician, dentist, veterinarian, podiatrist, scientific investigator, advanced practice registered nurse, or other person licensed, registered, or otherwise permitted to distribute, dispense, analyze, conduct research with respect to, or administer a controlled substance in the course of professional practice or research in this state;

(B) a pharmacy, hospital, or other institution licensed, registered, or otherwise permitted to distribute, dispense, conduct research with respect to, or administer a controlled substance in the course of professional practice or research in this state;

(C) a person practicing in and licensed by another state as a physician, dentist, veterinarian, advanced practice registered nurse, or podiatrist, having a current Federal Drug Enforcement Administration registration number, who may legally prescribe Schedule II, III, IV, or V controlled substances in that state; or

(D) a [an advanced practice registered nurse or] physician assistant to whom a physician has delegated the authority to prescribe or order a drug or device under Section 157.0511, 157.0512, or 157.054, Occupations Code.

SECTION 3.012. Section 481.074(d), Health and Safety Code, is amended to read as follows:

(d) Except as specified in Subsections (e) and (f), the board, by rule and in consultation with the Texas Medical Board and the Texas Board of Nursing, shall establish the period after the date on which the prescription is issued that a person may fill a prescription for a controlled substance listed in Schedule II. A person may not refill a prescription for a substance listed in Schedule II.

SECTION 3.013. Section 481.076(c), Health and Safety Code, is amended to read as follows:

(c) The board by rule shall design and implement a system for submission of information to the board by electronic or other means and for retrieval of information submitted to the board under this section and Sections 481.074 and 481.075. The board shall use automated information security techniques and devices to preclude improper access to the information. The board shall submit the system design to the director, [and] the Texas Medical Board, and the Texas Board of Nursing for review and comment a reasonable time before implementation of the system and shall comply with the comments of those agencies unless it is unreasonable to do so.

SECTION 3.014. Section 481.0767(b), Health and Safety Code, is amended to read as follows:

(b) The board shall appoint the following members to the advisory committee:

(1) a physician licensed in this state who practices in pain management;

(2) a physician licensed in this state who practices in family medicine;

(3) a physician licensed in this state who performs surgery;

(4) a physician licensed in this state who practices in emergency medicine at a hospital;

(5) a physician licensed in this state who practices in psychiatry;

(6) an oral and maxillofacial surgeon;

(7) a physician assistant [or advanced practice registered nurse] to whom a physician has delegated the authority to prescribe or order a drug or an advanced practice registered nurse;

(8) a pharmacist working at a chain pharmacy;

(9) a pharmacist working at an independent pharmacy;

(10) an academic pharmacist; and

(11) two representatives of the health information technology industry, at least one of whom is a representative of a company whose primary line of business is electronic medical records.

SECTION 3.015. Sections 483.001(4), (12), and (13), Health and Safety Code, are amended to read as follows:

(4) "Designated agent" means:

(A) a licensed nurse, physician assistant, pharmacist, or other individual designated by a practitioner to communicate prescription drug orders to a pharmacist;

(B) a licensed nurse, physician assistant, or pharmacist employed in a health care facility to whom the practitioner communicates a prescription drug order; or

(C) a [registered nurse or] physician assistant authorized by a practitioner to carry out a prescription drug order for dangerous drugs under Subchapter B, Chapter 157, Occupations Code.

(12) "Practitioner" means:

(A) a person licensed by:

(i) the Texas Medical Board, State Board of Dental Examiners, Texas Optometry Board, or State Board of Veterinary Medical Examiners to prescribe and administer dangerous drugs; or

(ii) the Texas Department of Licensing and Regulation, with respect to podiatry, to prescribe and administer dangerous drugs;

(B) a person licensed by another state in a health field in which, under the laws of this state, a licensee may legally prescribe dangerous drugs;

(C) a person licensed in Canada or Mexico in a health field in which, under the laws of this state, a licensee may legally prescribe dangerous drugs; [or]

(D) a [an advanced practice registered nurse or] physician assistant to whom a physician has delegated the authority to prescribe or order a drug or device under Section 157.0511, 157.0512, or 157.054, Occupations Code; or

(E) an advanced practice registered nurse authorized to prescribe and order drugs and devices under Section 301.358, Occupations Code.

(13) "Prescription" means an order from a practitioner, or an agent of the practitioner designated in writing as authorized to communicate prescriptions, or an order made in accordance with Subchapter B, Chapter 157, Occupations Code, or Section 203.353, Occupations Code, to a pharmacist for a dangerous drug to be dispensed that states:

(A) the date of the order's issue;

(B) the name and address of the patient;

(C) if the drug is prescribed for an animal, the species of the animal;

(D) the name and quantity of the drug prescribed;

(E) the directions for the use of the drug;

(F) the intended use of the drug unless the practitioner determines the furnishing of this information is not in the best interest of the patient;

(G) the name, address, and telephone number of the practitioner at the practitioner's usual place of business, legibly printed or stamped; and

(H) the name, address, and telephone number of the licensed midwife[, registered nurse,] or physician assistant, legibly printed or stamped, if signed by a licensed midwife[, registered nurse,] or physician assistant.

SECTION 3.016. Section 483.022(f), Health and Safety Code, is amended to read as follows:

(f) A practitioner may designate a person who is a licensed vocational nurse or has an education equivalent to or greater than that required for a licensed vocational nurse to communicate prescriptions of a [an advanced practice nurse or] physician assistant authorized by the practitioner to sign prescription drug orders under Subchapter B, Chapter 157, Occupations Code, or of an advanced practice registered nurse.

SECTION 3.017. Section 483.042(a), Health and Safety Code, is amended to read as follows:

(a) A person commits an offense if the person delivers or offers to deliver a dangerous drug:

(1) unless:

(A) the dangerous drug is delivered or offered for delivery by a pharmacist under:

(i) a prescription issued by a practitioner described by Section 483.001(12)(A), [or] (B), or (E);

(ii) a prescription signed by a [registered nurse or] physician assistant in accordance with Subchapter B, Chapter 157, Occupations Code; or

(iii) an original written prescription issued by a practitioner described by Section 483.001(12)(C); and

(B) a label is attached to the immediate container in which the drug is delivered or offered to be delivered and the label contains the following information:

(i) the name and address of the pharmacy from which the drug is delivered or offered for delivery;

(ii) the date the prescription for the drug is dispensed;

(iii) the number of the prescription as filed in the prescription files of the pharmacy from which the prescription is dispensed;

(iv) the name of the practitioner who prescribed the drug and, if applicable, the name of the [registered nurse or] physician assistant who signed the prescription;

(v) the name of the patient and, if the drug is prescribed for an animal, a statement of the species of the animal; and

(vi) directions for the use of the drug as contained in the prescription; or

(2) unless:

(A) the dangerous drug is delivered or offered for delivery by:

(i) a practitioner in the course of practice; or

(ii) a [registered nurse or] physician assistant in the course of practice in accordance with Subchapter B, Chapter 157, Occupations Code; and

(B) a label is attached to the immediate container in which the drug is delivered or offered to be delivered and the label contains the following information:

(i) the name and address of the practitioner who prescribed the drug, and if applicable, the name and address of the [registered nurse or] physician assistant;

(ii) the date the drug is delivered;

(iii) the name of the patient and, if the drug is prescribed for an animal, a statement of the species of the animal; and

(iv) the name of the drug, the strength of the drug, and directions for the use of the drug.

SECTION 3.018. Section 32.024(gg), Human Resources Code, is amended to read as follows:

(gg) Notwithstanding any other law, including Sections 843.312 and 1301.052, Insurance Code, the commission shall ensure that advanced practice registered nurses and physician assistants may be selected by and assigned to recipients of medical assistance as the primary care providers of those recipients [regardless of whether the physician supervising the advanced practice registered nurse is included in any directory of providers of medical assistance maintained by the commission]. This subsection may not be construed as authorizing the commission to supervise or control the practice of medicine as prohibited by Subtitle B, Title 3, Occupations Code. The commission must require that advanced practice registered nurses and physician assistants be treated in the same manner as primary care physicians with regard to:

(1) selection and assignment as primary care providers; and

(2) inclusion as primary care providers in any directory of providers of medical assistance maintained by the commission.

SECTION 3.019. Section 32.03141, Human Resources Code, is amended to read as follows:

Sec. 32.03141. AUTHORITY OF ADVANCED PRACTICE REGISTERED NURSES AND PHYSICIAN ASSISTANTS REGARDING DURABLE MEDICAL EQUIPMENT AND SUPPLIES. To the extent allowed by federal law, in addition to other health care practitioners authorized by federal law, the following persons may order and prescribe durable medical equipment and supplies under the medical assistance program:

(1) an advanced practice registered nurse; and

(2) a [or] physician assistant acting under adequate physician supervision and to whom a physician has delegated the authority to prescribe and order drugs and devices under Chapter 157, Occupations Code[, may order and prescribe durable medical equipment and supplies under the medical assistance program].

SECTION 3.020. Section 843.312, Insurance Code, is amended to read as follows:

Sec. 843.312. PHYSICIAN ASSISTANTS AND ADVANCED PRACTICE REGISTERED NURSES. (a) A health maintenance organization may not refuse a request by a physician participating in the health maintenance organization delivery network and a physician assistant [or advanced practice nurse] who is authorized by the physician to provide care under Subchapter B, Chapter 157, Occupations Code, or an advanced practice registered nurse, as defined by Section 301.002, Occupations Code, to identify a physician assistant or advanced practice registered nurse as a provider in the network.

(b) A health maintenance organization may refuse a request under Subsection (a) if the physician assistant or advanced practice registered nurse does not meet the quality of care standards previously established by the health maintenance organization for participation in the network by physician assistants and advanced practice registered nurses.

SECTION 3.021. Section 1301.001(1-a), Insurance Code, is amended to read as follows:

(1-a) "Health care provider" means a practitioner, institutional provider, or other person or organization that furnishes health care services and that is licensed or otherwise authorized to practice in this state. The term includes a pharmacist, [and] a pharmacy, and an advanced practice registered nurse. The term does not include a physician.

SECTION 3.022. Section 1301.052, Insurance Code, is amended to read as follows:

Sec. 1301.052. DESIGNATION OF ADVANCED PRACTICE REGISTERED NURSE OR PHYSICIAN ASSISTANT AS PREFERRED PROVIDER. An insurer offering a preferred provider benefit plan may not refuse a request made by a physician participating as a preferred provider under the plan and an advanced practice registered nurse or physician assistant to have the advanced practice registered nurse or physician assistant included as a preferred provider under the plan if, as applicable:

(1) the [advanced practice nurse or] physician assistant is authorized by the physician to provide care under Subchapter B, Chapter 157, Occupations Code; and

(2) the advanced practice registered nurse or physician assistant meets the quality of care standards previously established by the insurer for participation in the plan by advanced practice registered nurses and physician assistants.

SECTION 3.023. Section 1451.001(2), Insurance Code, is amended to read as follows:

(2) "Advanced practice registered nurse" has the meaning assigned by Section 301.002, Occupations Code [means an individual licensed by the Texas Board of Nursing as a registered nurse and recognized by that board as an advanced practice nurse].

SECTION 3.024. Section 1451.104(c), Insurance Code, is amended to read as follows:

(c) Notwithstanding Subsection (a), a health insurance policy may provide for a different amount of payment or reimbursement for scheduled services or procedures performed by an advanced practice registered nurse, nurse first assistant, licensed surgical assistant, or physician assistant if the methodology used to compute the amount is the same as the methodology used to compute the amount of payment or reimbursement when the services or procedures are provided by a physician.

SECTION 3.025. Section 1451.106, Insurance Code, is amended to read as follows:

Sec. 1451.106. SELECTION OF ADVANCED PRACTICE REGISTERED NURSE. An insured may select an advanced practice registered nurse to provide the services scheduled in the health insurance policy that are within the scope of the nurse's license.

SECTION 3.026. Section 1452.051(1), Insurance Code, is amended to read as follows:

(1) "Advanced practice nurse" has the meaning assigned to "advanced practice registered nurse" by Section 301.002 [301.152], Occupations Code.

SECTION 3.027. Section 408.025, Labor Code, is amended by amending Subsection (a-1) and adding Subsection (a-2) to read as follows:

(a-1) A [treating doctor may delegate to a physician assistant who is licensed to practice in this state under Chapter 204, Occupations Code, or an advanced practice registered nurse who is licensed to practice in this state under Chapter 301, Occupations Code, the authority to complete and sign a] work status report regarding an injured employee's ability to return to work may be completed and signed by:

(1) a physician assistant licensed to practice in this state under Chapter 204, Occupations Code, who has been delegated the authority by a treating doctor; or

(2) an advanced practice registered nurse, as defined by Section 301.002, Occupations Code.

(a-2) The delegating treating doctor is responsible for the acts of a [the] physician assistant [or advanced practice registered nurse] under Subsection (a-1) [this subsection].

SECTION 3.028. Section 203.002(2), Occupations Code, is amended to read as follows:

(2) "Certified nurse-midwife" means an advanced practice [a person who is:

[(A) a] registered nurse as defined by Section 301.002 who is [under Chapter 301;

[(B) recognized as an advanced nurse practitioner by the Texas Board of Nursing; and

[(C)] certified by the American College of Nurse-Midwives.

SECTION 3.029. Section 204.1025, Occupations Code, is amended to read as follows:

Sec. 204.1025. DUTIES REGARDING PRESCRIPTIVE AUTHORITY AGREEMENTS. The physician assistant board shall in conjunction with the Texas Medical Board [and the Texas Board of Nursing] perform the functions and duties relating to prescriptive authority agreements assigned to the physician assistant board in Sections 157.0512 and 157.0513.

SECTION 3.030. Sections 551.003(14) and (34), Occupations Code, are amended to read as follows:

(14) "Designated agent" means:

(A) an individual, including a licensed nurse, physician assistant, or pharmacist:

(i) who is designated by a practitioner and authorized to communicate a prescription drug order to a pharmacist; and

(ii) for whom the practitioner assumes legal responsibility;

(B) a licensed nurse, physician assistant, or pharmacist employed in a health care facility to whom a practitioner communicates a prescription drug order; or

(C) a [registered nurse or] physician assistant authorized by a practitioner to administer a prescription drug order for a dangerous drug under Subchapter B, Chapter 157.

(34) "Practitioner" means:

(A) a person licensed or registered to prescribe, distribute, administer, or dispense a prescription drug or device in the course of professional practice in this state, including a physician, dentist, podiatrist, advanced practice registered nurse authorized to prescribe and order drugs and devices under Section 301.358, or veterinarian but excluding a person licensed under this subtitle;

(B) a person licensed by another state, Canada, or the United Mexican States in a health field in which, under the law of this state, a license holder in this state may legally prescribe a dangerous drug;

(C) a person practicing in another state and licensed by another state as a physician, dentist, veterinarian, advanced practice registered nurse, or podiatrist, who has a current federal Drug Enforcement Administration registration number and who may legally prescribe a Schedule II, III, IV, or V controlled substance, as specified under Chapter 481, Health and Safety Code, in that other state; or

(D) a [an advanced practice registered nurse or] physician assistant to whom a physician has delegated the authority to prescribe or order a drug or device under Section 157.0511, 157.0512, or 157.054.

SECTION 3.031. Section 563.051(e), Occupations Code, is amended to read as follows:

(e) A practitioner may designate a licensed vocational nurse or a person having education equivalent to or greater than that required for a licensed vocational nurse to communicate the prescriptions of a [an advanced practice nurse or] physician assistant authorized by the practitioner to sign prescription drug orders under Subchapter B, Chapter 157, or of an advanced practice registered nurse.

SECTION 3.032. Sections 605.002(14) and (18), Occupations Code, are amended to read as follows:

(14) "Orthotics" means the science and practice of measuring, designing, fabricating, assembling, fitting, adjusting, or servicing an orthosis under an order from a licensed physician, chiropractor, [or] podiatrist, or [an] advanced practice registered nurse, or from a physician assistant acting under the delegation and supervision of a licensed physician as provided by Subchapter B, Chapter 157, and rules adopted by the Texas Medical Board, for the correction or alleviation of a neuromuscular or musculoskeletal dysfunction, disease, injury, or deformity.

(18) "Prosthetics" means the science and practice of measuring, designing, fabricating, assembling, fitting, adjusting, or servicing a prosthesis under an order from a licensed physician, chiropractor, [or] podiatrist, or [an] advanced practice registered nurse, or from a physician assistant acting under the delegation and supervision of a licensed physician as provided by Subchapter B, Chapter 157, and rules adopted by the Texas Medical Board.

SECTION 3.033. Section 605.2515, Occupations Code, is amended to read as follows:

Sec. 605.2515. ADDITIONAL LICENSE: DEVICE MANUFACTURER. A person licensed to practice orthotics or prosthetics who measures, designs, fabricates, fits, assembles, adjusts, or services an orthosis or a prosthesis under an order from a licensed physician, chiropractor, [or] podiatrist, or [an] advanced practice registered nurse, or from a physician assistant acting under the delegation and supervision of a licensed physician as provided by Subchapter B, Chapter 157, and rules adopted by the Texas Medical Board, for a specific patient is exempt from licensing as a device manufacturer under Subchapter L, Chapter 431, Health and Safety Code. A person licensed to practice orthotics or prosthetics who fabricates or assembles an orthosis or a prosthesis without an order from a licensed physician, chiropractor, [or] podiatrist, or [an] advanced practice registered nurse, or from a physician assistant acting under the delegation and supervision of a licensed physician as provided by Subchapter B, Chapter 157, and rules adopted by the Texas Medical Board, for a specific patient is required to be licensed as a device manufacturer under Subchapter L, Chapter 431, Health and Safety Code.

ARTICLE 4. REPEALER

SECTION 4.001. The following provisions are repealed:

(1) Section 533.005(d), Government Code;

(2) Section 62.1551(b), Health and Safety Code; and

(3) Sections 157.051(1), 157.058, and 301.168, Occupations Code.

ARTICLE 5. TRANSITION AND EFFECTIVE DATE

SECTION 5.001. Not later than February 1, 2022, the Texas Board of Nursing shall adopt the rules necessary to implement the changes in law made by this Act.

SECTION 5.002. Notwithstanding any changes in law made by this Act, an advanced practice registered nurse who has been delegated the authority to prescribe and order drugs and medical devices by a physician's protocol or order under Section 157.0511, 157.0512, or 157.054, Occupations Code, may continue to exercise that authority until February 1, 2022.

SECTION 5.003. This Act takes effect September 1, 2021.