Mo. Rev. Stat. § 334.104 — MO Code / Chapter 334 / Section 334.104
334.104 Collaborative practice arrangements, form, contents, delegation of ...
Status: in_force

334.104. Collaborative practice arrangements, form, contents, delegation of authority — rules, approval, restrictions — disciplinary actions — notice of collaborative practice or physician assistant agreements to board, when — certain nurses may provide anesthesia services, when — contract limitations. — 1. A physician may enter into collaborative practice arrangements with registered professional nurses. Collaborative practice arrangements shall be in the form of written agreements, jointly agreed-upon protocols, or standing orders for the delivery of health care services. Collaborative practice arrangements, which shall be in writing, may delegate to a registered professional nurse the authority to administer or dispense drugs and provide treatment as long as the delivery of such health care services is within the scope of practice of the registered professional nurse and is consistent with that nurse's skill, training and competence.

2. (1) Collaborative practice arrangements, which shall be in writing, may delegate to a registered professional nurse the authority to administer, dispense or prescribe drugs and provide treatment if the registered professional nurse is an advanced practice registered nurse as defined in subdivision (2) of section 335.016 . Collaborative practice arrangements may delegate to an advanced practice registered nurse, as defined in section 335.016 , the authority to administer, dispense, or prescribe controlled substances listed in Schedules III, IV, and V of section 195.017 , and Schedule II - hydrocodone; except that, the collaborative practice arrangement shall not delegate the authority to administer any controlled substances listed in Schedules III, IV, and V of section 195.017 , or Schedule II - hydrocodone for the purpose of inducing sedation or general anesthesia for therapeutic, diagnostic, or surgical procedures. Schedule III narcotic controlled substance and Schedule II - hydrocodone prescriptions shall be limited to a one hundred twenty-hour supply without refill.

(2) Notwithstanding any other provision of this section to the contrary, a collaborative practice arrangement may delegate to an advanced practice registered nurse the authority to administer, dispense, or prescribe Schedule II controlled substances for hospice patients; provided, that the advanced practice registered nurse is employed by a hospice provider certified pursuant to chapter 197 and the advanced practice registered nurse is providing care to hospice patients pursuant to a collaborative practice arrangement that designates the certified hospice as a location where the advanced practice registered nurse is authorized to practice and prescribe.

(3) Such collaborative practice arrangements shall be in the form of written agreements, jointly agreed-upon protocols or standing orders for the delivery of health care services.

(4) An advanced practice registered nurse may prescribe buprenorphine for up to a thirty-day supply without refill for patients receiving medication-assisted treatment for substance use disorders under the direction of the collaborating physician.

3. The written collaborative practice arrangement shall contain at least the following provisions:

(1) Complete names, home and business addresses, zip codes, and telephone numbers of the collaborating physician and the advanced practice registered nurse;

(2) A list of all other offices or locations besides those listed in subdivision (1) of this subsection where the collaborating physician authorized the advanced practice registered nurse to prescribe;

(3) A requirement that there shall be posted at every office where the advanced practice registered nurse is authorized to prescribe, in collaboration with a physician, a prominently displayed disclosure statement informing patients that they may be seen by an advanced practice registered nurse and have the right to see the collaborating physician;

(4) All specialty or board certifications of the collaborating physician and all certifications of the advanced practice registered nurse;

(5) The manner of collaboration between the collaborating physician and the advanced practice registered nurse, including how the collaborating physician and the advanced practice registered nurse will:

(a) Engage in collaborative practice consistent with each professional's skill, training, education, and competence;

(b) Maintain geographic proximity, except as specified in this paragraph. The following provisions shall apply with respect to this requirement:

a. Until August 28, 2025, an advanced practice registered nurse providing services in a correctional center, as defined in section 217.010 , and his or her collaborating physician shall satisfy the geographic proximity requirement if they practice within two hundred miles by road of one another. An incarcerated patient who requests or requires a physician consultation shall be treated by a physician as soon as appropriate;

b. The collaborative practice arrangement may allow for geographic proximity to be waived for a maximum of twenty-eight days per calendar year for rural health clinics as defined by Pub.L. 95-210 (42 U.S.C. Section 1395x, as amended), as long as the collaborative practice arrangement includes alternative plans as required in paragraph (c) of this subdivision. This exception to geographic proximity shall apply only to independent rural health clinics, provider-based rural health clinics where the provider is a critical access hospital as provided in 42 U.S.C. Section 1395i-4, and provider-based rural health clinics where the main location of the hospital sponsor is greater than fifty miles from the clinic;

c. The collaborative practice arrangement may allow for geographic proximity to be waived when the arrangement outlines the use of telehealth, as defined in section 191.1145 ;

d. In addition to the waivers and exemptions provided in this subsection, an application for a waiver for any other reason of any applicable geographic proximity shall be available if a physician is collaborating with an advanced practice registered nurse in excess of any geographic proximity limit. The board of nursing and the state board of registration for the healing arts shall review each application for a waiver of geographic proximity and approve the application if the boards determine that adequate supervision exists between the collaborating physician and the advanced practice registered nurse. The boards shall have forty-five calendar days to review the completed application for the waiver of geographic proximity. If no action is taken by the boards within forty-five days after the submission of the application for a waiver, then the application shall be deemed approved. If the application is denied by the boards, the provisions of section 536.063 for contested cases shall apply and govern proceedings for appellate purposes; and

e. The collaborating physician is required to maintain documentation related to this requirement and to present it to the state board of registration for the healing arts when requested; and

(c) Provide coverage during absence, incapacity, infirmity, or emergency by the collaborating physician;

(6) A description of the advanced practice registered nurse's controlled substance prescriptive authority in collaboration with the physician, including a list of the controlled substances the physician authorizes the nurse to prescribe and documentation that it is consistent with each professional's education, knowledge, skill, and competence;

(7) A list of all other written practice agreements of the collaborating physician and the advanced practice registered nurse;

(8) The duration of the written practice agreement between the collaborating physician and the advanced practice registered nurse;

(9) A description of the time and manner of the collaborating physician's review of the advanced practice registered nurse's delivery of health care services. The description shall include provisions that the advanced practice registered nurse shall submit a minimum of ten percent of the charts documenting the advanced practice registered nurse's delivery of health care services to the collaborating physician for review by the collaborating physician, or any other physician designated in the collaborative practice arrangement, every fourteen days;

(10) The collaborating physician, or any other physician designated in the collaborative practice arrangement, shall review every fourteen days a minimum of twenty percent of the charts in which the advanced practice registered nurse prescribes controlled substances. The charts reviewed under this subdivision may be counted in the number of charts required to be reviewed under subdivision (9) of this subsection; and

(11) If a collaborative practice arrangement is used in clinical situations where a collaborating advanced practice registered nurse provides health care services that include the diagnosis and initiation of treatment for acutely or chronically ill or injured persons, then the collaborating physician or any other physician designated in the collaborative practice arrangement shall be present for sufficient periods of time, at least once every two weeks, except in extraordinary circumstances that shall be documented, to participate in a chart review and to provide necessary medical direction, medical services, consultations, and supervision of the health care staff.

4. The state board of registration for the healing arts pursuant to section 334.125 and the board of nursing pursuant to section 335.036 may jointly promulgate rules regulating the use of collaborative practice arrangements. Such rules shall be limited to the methods of treatment that may be covered by collaborative practice arrangements and the requirements for review of services provided pursuant to collaborative practice arrangements including delegating authority to prescribe controlled substances. Any rules relating to geographic proximity shall allow a collaborating physician and a collaborating advanced practice registered nurse to practice within two hundred miles by road of one another until August 28, 2025, if the nurse is providing services in a correctional center, as defined in section 217.010 . Any rules relating to dispensing or distribution of medications or devices by prescription or prescription drug orders under this section shall be subject to the approval of the state board of pharmacy. Any rules relating to dispensing or distribution of controlled substances by prescription or prescription drug orders under this section shall be subject to the approval of the department of health and senior services and the state board of pharmacy. In order to take effect, such rules shall be approved by a majority vote of a quorum of each board. Neither the state board of registration for the healing arts nor the board of nursing may separately promulgate rules relating to collaborative practice arrangements. Such jointly promulgated rules shall be consistent with guidelines for federally funded clinics. The rulemaking authority granted in this subsection shall not extend to collaborative practice arrangements of hospital employees providing inpatient care within hospitals as defined pursuant to chapter 197 or population-based public health services as defined by 20 CSR 2150-5.100 as of April 30, 2008.

5. The state board of registration for the healing arts shall not deny, revoke, suspend or otherwise take disciplinary action against a physician for health care services delegated to a registered professional nurse provided the provisions of this section and the rules promulgated thereunder are satisfied. Upon the written request of a physician subject to a disciplinary action imposed as a result of an agreement between a physician and a registered professional nurse or registered physician assistant, whether written or not, prior to August 28, 1993, all records of such disciplinary licensure action and all records pertaining to the filing, investigation or review of an alleged violation of this chapter incurred as a result of such an agreement shall be removed from the records of the state board of registration for the healing arts and the division of professional registration and shall not be disclosed to any public or private entity seeking such information from the board or the division. The state board of registration for the healing arts shall take action to correct reports of alleged violations and disciplinary actions as described in this section which have been submitted to the National Practitioner Data Bank. In subsequent applications or representations relating to his or her medical practice, a physician completing forms or documents shall not be required to report any actions of the state board of registration for the healing arts for which the records are subject to removal under this section.

6. Within thirty days of any change and on each renewal, the state board of registration for the healing arts shall require every physician to identify whether the physician is engaged in any collaborative practice arrangement, including collaborative practice arrangements delegating the authority to prescribe controlled substances, or physician assistant collaborative practice arrangement and also report to the board the name of each licensed professional with whom the physician has entered into such arrangement. The board shall make this information available to the public. The board shall track the reported information and may routinely conduct random reviews of such arrangements to ensure that arrangements are carried out for compliance under this chapter.

7. Notwithstanding any law to the contrary, a certified registered nurse anesthetist as defined in subdivision (8) of section 335.016 shall be permitted to provide anesthesia services without a collaborative practice arrangement provided that he or she is under the supervision of an anesthesiologist or other physician, dentist, or podiatrist who is immediately available if needed. Nothing in this subsection shall be construed to prohibit or prevent a certified registered nurse anesthetist as defined in subdivision (8) of section 335.016 from entering into a collaborative practice arrangement under this section, except that the collaborative practice arrangement may not delegate the authority to prescribe any controlled substances listed in Schedules III, IV, and V of section 195.017 , or Schedule II - hydrocodone.

8. A collaborating physician shall not enter into a collaborative practice arrangement with more than six full-time equivalent advanced practice registered nurses, full-time equivalent licensed physician assistants, or full-time equivalent assistant physicians, or any combination thereof. This limitation shall not apply to collaborative arrangements of hospital employees providing inpatient care service in hospitals as defined in chapter 197 or population-based public health services as defined by 20 CSR 2150-5.100 as of April 30, 2008, or to a certified registered nurse anesthetist providing anesthesia services under the supervision of an anesthesiologist or other physician, dentist, or podiatrist who is immediately available if needed as set out in subsection 7 of this section.

9. It is the responsibility of the collaborating physician to determine and document the completion of at least a one-month period of time during which the advanced practice registered nurse shall practice with the collaborating physician continuously present before practicing in a setting where the collaborating physician is not continuously present. This limitation shall not apply to collaborative arrangements of providers of population-based public health services, as defined by 20 CSR 2150-5.100 as of April 30, 2008, or to collaborative practice arrangements between a primary care physician and a primary care advanced practice registered nurse or a behavioral health physician and a behavioral health advanced practice registered nurse, where the collaborating physician is new to a patient population to which the advanced practice registered nurse is familiar.

10. No agreement made under this section shall supersede current hospital licensing regulations governing hospital medication orders under protocols or standing orders for the purpose of delivering inpatient or emergency care within a hospital as defined in section 197.020 if such protocols or standing orders have been approved by the hospital's medical staff and pharmaceutical therapeutics committee.

11. No contract or other term of employment shall require a physician to act as a collaborating physician for an advanced practice registered nurse against the physician's will. A physician shall have the right to refuse to act as a collaborating physician, without penalty, for a particular advanced practice registered nurse. No contract or other agreement shall limit the collaborating physician's ultimate authority over any protocols or standing orders or in the delegation of the physician's authority to any advanced practice registered nurse, but this requirement shall not authorize a physician in implementing such protocols, standing orders, or delegation to violate applicable standards for safe medical practice established by hospital's medical staff.

12. No contract or other term of employment shall require any advanced practice registered nurse to serve as a collaborating advanced practice registered nurse for any collaborating physician against the advanced practice registered nurse's will. An advanced practice registered nurse shall have the right to refuse to collaborate, without penalty, with a particular physician.

(L. 1993 H.B. 564, A.L. 2002 S.B. 1182, A.L. 2003 H.B. 390, A.L. 2006 H.B. 1515 merged with S.B. 756, A.L. 2008 S.B. 724, A.L. 2009 H.B. 247, A.L. 2012 H.B. 1563, A.L. 2013 S.B. 330, A.L. 2015 H.B. 709, A.L. 2018 S.B. 718 merged with S.B. 951, A.L. 2019 S.B. 514, A.L. 2023 H.B. 115 & 99 merged with H.B. 402 merged with S.B. 45 & 90 merged with S.B. 70 merged with S.B. 157)