1     
Senator Curtis S. Bramble proposes the following substitute bill:


2     
NURSE PRACTITIONER AMENDMENTS

3     
2016 GENERAL SESSION

4     
STATE OF UTAH

5     
Chief Sponsor: David P. Hinkins

6     
House Sponsor: Justin L. Fawson

7     

8     LONG TITLE
9     General Description:
10          This bill allows an advanced practice registered nurse to prescribe a Schedule II
11     controlled substance without a consultation and referral plan under certain
12     circumstances.
13     Highlighted Provisions:
14          This bill:
15          ▸     defines pain clinic for Title 58, Division of Occupational and Professional
16     Licensing Act;
17          ▸     allows an advanced practice registered nurse to prescribe a Schedule II controlled
18     substance without a consultation and referral plan if the advanced practice
19     registered nurse:
20               •      meets certain experience requirements;
21               •     consults the Controlled Substance Database; and
22               •     when treating an injured worker, follows prescribing for chronic pain guidelines
23     developed by the Workers' Compensation System;
24          ▸     prohibits an advanced practice registered nurse from establishing an independent
25     pain clinic without a consultation and referral plan; and
26          ▸     makes technical and conforming amendments.

27     Money Appropriated in this Bill:
28          None
29     Other Special Clauses:
30          None
31     Utah Code Sections Affected:
32     AMENDS:
33          26-55-102, as enacted by Laws of Utah 2014, Chapter 130
34          58-1-102, as last amended by Laws of Utah 2012, Chapter 362
35          58-31b-102, as last amended by Laws of Utah 2011, Chapter 366
36          58-31b-502, as last amended by Laws of Utah 2014, Chapter 72
37          58-31d-103, as last amended by Laws of Utah 2015, Chapter 258
38     ENACTS:
39          58-31b-803, Utah Code Annotated 1953
40     

41     Be it enacted by the Legislature of the state of Utah:
42          Section 1. Section 26-55-102 is amended to read:
43          26-55-102. Definitions.
44          As used in this chapter:
45          (1) "Health care facility" means a hospital, a hospice inpatient residence, a nursing
46     facility, a dialysis treatment facility, an assisted living residence, an entity that provides home-
47     and community-based services, a hospice or home health care agency, or another facility that
48     provides or contracts to provide health care services, which facility is licensed under Chapter
49     21, Health Care Facility Licensing and Inspection Act.
50          (2) "Health care provider" means:
51          (a) a physician as defined in Section 58-67-102;
52          (b) an advanced practice registered nurse as defined in [Subsection] Section
53     58-31b-102[(13)]; or
54          (c) a physician assistant as defined in Section 58-70a-102.
55          (3) "Opiate" is as defined in Section 58-37-2.
56          (4) "Opiate antagonist" means naloxone hydrochloride or any similarly acting drug that
57     is not a controlled substance and that is approved by the federal Food and Drug Administration

58     for the treatment of a drug overdose.
59          (5) "Opiate-related drug overdose event" means an acute condition, including a
60     decreased level of consciousness or respiratory depression resulting from the consumption or
61     use of a controlled substance, or another substance with which a controlled substance was
62     combined, and that a person would reasonably believe to require medical assistance.
63          Section 2. Section 58-1-102 is amended to read:
64          58-1-102. Definitions.
65          For purposes of this title:
66          (1) "Ablative procedure" is as defined in Section 58-67-102.
67          (2) "Cosmetic medical procedure":
68          (a) is as defined in Section 58-67-102; and
69          (b) except for Chapter 67, Utah Medical Practice Act, and Chapter 68, Utah
70     Osteopathic Medical Practice Act, does not apply to the scope of practice of an individual
71     licensed under this title if the individual's scope of practice includes the authority to operate or
72     perform surgical procedures.
73          (3) "Department" means the Department of Commerce.
74          (4) "Director" means the director of the Division of Occupational and Professional
75     Licensing.
76          (5) "Division" means the Division of Occupational and Professional Licensing created
77     in Section 58-1-103.
78          (6) "Executive director" means the executive director of the Department of Commerce.
79          (7) "Licensee" includes any holder of a license, certificate, registration, permit, student
80     card, or apprentice card authorized under this title.
81          (8) (a) (i) "Nonablative procedure" means a procedure that is expected or intended to
82     alter living tissue, but not intended or expected to excise, vaporize, disintegrate, or remove
83     living tissue.
84          (ii) Notwithstanding Subsection (8)(a)(i), nonablative procedure includes hair removal.
85          (b) "Nonablative procedure" does not include:
86          (i) a superficial procedure;
87          (ii) the application of permanent make-up; or
88          (iii) the use of photo therapy and lasers for neuromusculoskeletal treatments that are

89     performed by an individual licensed under this title who is acting within their scope of practice.
90          (9) "Pain clinic" means:
91          (a) a clinic that advertises its primary purpose is the treatment of chronic pain; or
92          (b) a clinic in which greater than 50% of the clinic's annual patient population receive
93     treatment primarily for non-terminal chronic pain using Schedule II-III controlled substances.
94          (10) "Superficial procedure" means a procedure that is expected or intended to
95     temporarily alter living skin tissue and may excise or remove stratum corneum but have no
96     appreciable risk of damage to any tissue below the stratum corneum.
97          [(10)] (11) "Unlawful conduct" has the meaning given in Subsection 58-1-501(1).
98          [(11)] (12) "Unprofessional conduct" has the meaning given in Subsection
99     58-1-501(2).
100          Section 3. Section 58-31b-102 is amended to read:
101          58-31b-102. Definitions.
102          In addition to the definitions in Section 58-1-102, as used in this chapter:
103          (1) "Administrative penalty" means a monetary fine or citation imposed by the division
104     for acts or omissions determined to constitute unprofessional or unlawful conduct in
105     accordance with a fine schedule established by rule and as a result of an adjudicative
106     proceeding conducted in accordance with Title 63G, Chapter 4, Administrative Procedures Act.
107          (2) "Applicant" means a person who applies for licensure or certification under this
108     chapter by submitting a completed application for licensure or certification and the required
109     fees to the department.
110          (3) "Approved education program" means a nursing education program that meets the
111     minimum standards for educational programs established under this chapter and by division
112     rule in collaboration with the board.
113          (4) "Board" means the Board of Nursing created in Section 58-31b-201.
114          (5) "Consultation and referral plan" means a written plan jointly developed by an
115     advanced practice registered nurse and a consulting physician that permits the advanced
116     practice registered nurse to prescribe Schedule II[-III] controlled substances in consultation
117     with the consulting physician.
118          (6) "Consulting physician" means a physician and surgeon or osteopathic physician and
119     surgeon licensed in accordance with this title who has agreed to consult with an advanced

120     practice registered nurse with a controlled substance license, a DEA registration number, and
121     who will be prescribing Schedule II[-III] controlled substances.
122          (7) "Diagnosis" means the identification of and discrimination between physical and
123     psychosocial signs and symptoms essential to the effective execution and management of
124     health care.
125          (8) "Examinee" means a person who applies to take or does take any examination
126     required under this chapter for licensure.
127          (9) "Licensee" means a person who is licensed or certified under this chapter.
128          (10) "Long-term care facility" means any of the following facilities licensed by the
129     Department of Health pursuant to Title 26, Chapter 21, Health Care Facility Licensing and
130     Inspection Act:
131          (a) a nursing care facility;
132          (b) a small health care facility;
133          (c) an intermediate care facility for people with an intellectual disability;
134          (d) an assisted living facility Type I or II; or
135          (e) a designated swing bed unit in a general hospital.
136          (11) "Medication aide certified" means a certified nurse aide who:
137          (a) has a minimum of 2,000 hours experience working as a certified nurse aide;
138          (b) has received a minimum of 60 hours of classroom and 40 hours of practical training
139     that is approved by the division in collaboration with the board, in administering routine
140     medications to patients or residents of long-term care facilities; and
141          (c) is certified by the division as a medication aide certified.
142          (12) "Pain clinic" means the same as that term is defined in Section 58-1-102.
143          [(12)] (13) (a) "Practice as a medication aide certified" means the limited practice of
144     nursing under the supervision, as defined by the division by administrative rule, of a licensed
145     nurse, involving routine patient care that requires minimal or limited specialized or general
146     knowledge, judgment, and skill, to an individual who:
147          (i) is ill, injured, infirm, has a physical, mental, developmental, or intellectual
148     disability; and
149          (ii) is in a regulated long-term care facility.
150          (b) "Practice as a medication aide certified":

151          (i) includes:
152          (A) providing direct personal assistance or care; and
153          (B) administering routine medications to patients in accordance with a formulary and
154     protocols to be defined by the division by rule; and
155          (ii) does not include assisting a resident of an assisted living facility, a long term care
156     facility, or an intermediate care facility for people with an intellectual disability to self
157     administer a medication, as regulated by the Department of Health by administrative rule.
158          [(13)] (14) "Practice of advanced practice registered nursing" means the practice of
159     nursing within the generally recognized scope and standards of advanced practice registered
160     nursing as defined by rule and consistent with professionally recognized preparation and
161     education standards of an advanced practice registered nurse by a person licensed under this
162     chapter as an advanced practice registered nurse. Advanced practice registered nursing
163     includes:
164          (a) maintenance and promotion of health and prevention of disease;
165          (b) diagnosis, treatment, correction, consultation, and referral for common health
166     problems;
167          (c) prescription or administration of prescription drugs or devices including:
168          (i) local anesthesia;
169          (ii) Schedule [IV] III-V controlled substances; and
170          (iii) Schedule II[-III] controlled substances in accordance with [a consultation and
171     referral plan] Section 58-31b-803; or
172          (d) the provision of preoperative, intraoperative, and postoperative anesthesia care and
173     related services upon the request of a licensed health care professional by an advanced practice
174     registered nurse specializing as a certified registered nurse anesthetist, including:
175          (i) preanesthesia preparation and evaluation including:
176          (A) performing a preanesthetic assessment of the patient;
177          (B) ordering and evaluating appropriate lab and other studies to determine the health of
178     the patient; and
179          (C) selecting, ordering, or administering appropriate medications;
180          (ii) anesthesia induction, maintenance, and emergence, including:
181          (A) selecting and initiating the planned anesthetic technique;

182          (B) selecting and administering anesthetics and adjunct drugs and fluids; and
183          (C) administering general, regional, and local anesthesia;
184          (iii) postanesthesia follow-up care, including:
185          (A) evaluating the patient's response to anesthesia and implementing corrective
186     actions; and
187          (B) selecting, ordering, or administering the medications and studies listed in
188     Subsection [(13)] (14)(d); and
189          (iv) other related services within the scope of practice of a certified registered nurse
190     anesthetist, including:
191          (A) emergency airway management;
192          (B) advanced cardiac life support; and
193          (C) the establishment of peripheral, central, and arterial invasive lines; and
194          (v) for purposes of Subsection [(13)] (14)(d), "upon the request of a licensed health
195     care professional":
196          (A) means a health care professional practicing within the scope of the health care
197     professional's license, requests anesthesia services for a specific patient; and
198          (B) does not require an advanced practice registered nurse specializing as a certified
199     registered nurse anesthetist to enter into a consultation and referral plan or obtain additional
200     authority to select, administer, or provide preoperative, intraoperative, or postoperative
201     anesthesia care and services.
202          [(14)] (15) "Practice of nursing" means assisting individuals or groups to maintain or
203     attain optimal health, implementing a strategy of care to accomplish defined goals and
204     evaluating responses to care and treatment. The practice of nursing requires substantial
205     specialized or general knowledge, judgment, and skill based upon principles of the biological,
206     physical, behavioral, and social sciences, and includes:
207          (a) initiating and maintaining comfort measures;
208          (b) promoting and supporting human functions and responses;
209          (c) establishing an environment conducive to well-being;
210          (d) providing health counseling and teaching;
211          (e) collaborating with health care professionals on aspects of the health care regimen;
212          (f) performing delegated procedures only within the education, knowledge, judgment,

213     and skill of the licensee; and
214          (g) delegating nurse interventions that may be performed by others and are not in
215     conflict with this chapter.
216          [(15)] (16) "Practice of practical nursing" means the performance of nursing acts in the
217     generally recognized scope of practice of licensed practical nurses as defined by rule and as
218     provided in this Subsection [(15)] (16) by a person licensed under this chapter as a licensed
219     practical nurse and under the direction of a registered nurse, licensed physician, or other
220     specified health care professional as defined by rule. Practical nursing acts include:
221          (a) contributing to the assessment of the health status of individuals and groups;
222          (b) participating in the development and modification of the strategy of care;
223          (c) implementing appropriate aspects of the strategy of care;
224          (d) maintaining safe and effective nursing care rendered to a patient directly or
225     indirectly; and
226          (e) participating in the evaluation of responses to interventions.
227          [(16)] (17) "Practice of registered nursing" means performing acts of nursing as
228     provided in this Subsection [(16)] (17) by a person licensed under this chapter as a registered
229     nurse within the generally recognized scope of practice of registered nurses as defined by rule.
230     Registered nursing acts include:
231          (a) assessing the health status of individuals and groups;
232          (b) identifying health care needs;
233          (c) establishing goals to meet identified health care needs;
234          (d) planning a strategy of care;
235          (e) prescribing nursing interventions to implement the strategy of care;
236          (f) implementing the strategy of care;
237          (g) maintaining safe and effective nursing care that is rendered to a patient directly or
238     indirectly;
239          (h) evaluating responses to interventions;
240          (i) teaching the theory and practice of nursing; and
241          (j) managing and supervising the practice of nursing.
242          [(17)] (18) "Routine medications":
243          (a) means established medications administered to a medically stable individual as

244     determined by a licensed health care practitioner or in consultation with a licensed medical
245     practitioner; and
246          (b) is limited to medications that are administered by the following routes:
247          (i) oral;
248          (ii) sublingual;
249          (iii) buccal;
250          (iv) eye;
251          (v) ear;
252          (vi) nasal;
253          (vii) rectal;
254          (viii) vaginal;
255          (ix) skin ointments, topical including patches and transdermal;
256          (x) premeasured medication delivered by aerosol/nebulizer; and
257          (xi) medications delivered by metered hand-held inhalers.
258          [(18)] (19) "Unlawful conduct" [is as] means the same as that term is defined in
259     Sections 58-1-501 and 58-31b-501.
260          [(19)] (20) "Unlicensed assistive personnel" means any unlicensed person, regardless
261     of title, to whom tasks are delegated by a licensed nurse as permitted by rule and in accordance
262     with the standards of the profession.
263          [(20)] (21) "Unprofessional conduct" [is as] means the same as that term is defined in
264     Sections 58-1-501 and 58-31b-502 and as may be further defined by rule.
265          Section 4. Section 58-31b-502 is amended to read:
266          58-31b-502. Unprofessional conduct.
267          "Unprofessional conduct" includes:
268          (1) failure to safeguard a patient's right to privacy as to the patient's person, condition,
269     diagnosis, personal effects, or any other matter about which the licensee is privileged to know
270     because of the licensee's or person with a certification's position or practice as a nurse or
271     practice as a medication aide certified;
272          (2) failure to provide nursing service or service as a medication aide certified in a
273     manner that demonstrates respect for the patient's human dignity and unique personal character
274     and needs without regard to the patient's race, religion, ethnic background, socioeconomic

275     status, age, sex, or the nature of the patient's health problem;
276          (3) engaging in sexual relations with a patient during any:
277          (a) period when a generally recognized professional relationship exists between the
278     person licensed or certified under this chapter and patient; or
279          (b) extended period when a patient has reasonable cause to believe a professional
280     relationship exists between the person licensed or certified under the provisions of this chapter
281     and the patient;
282          (4) (a) as a result of any circumstance under Subsection (3), exploiting or using
283     information about a patient or exploiting the licensee's or the person with a certification's
284     professional relationship between the licensee or holder of a certification under this chapter and
285     the patient; or
286          (b) exploiting the patient by use of the licensee's or person with a certification's
287     knowledge of the patient obtained while acting as a nurse or a medication aide certified;
288          (5) unlawfully obtaining, possessing, or using any prescription drug or illicit drug;
289          (6) unauthorized taking or personal use of nursing supplies from an employer;
290          (7) unauthorized taking or personal use of a patient's personal property;
291          (8) knowingly entering into any medical record any false or misleading information or
292     altering a medical record in any way for the purpose of concealing an act, omission, or record
293     of events, medical condition, or any other circumstance related to the patient and the medical or
294     nursing care provided;
295          (9) unlawful or inappropriate delegation of nursing care;
296          (10) failure to exercise appropriate supervision of persons providing patient care
297     services under supervision of the licensed nurse;
298          (11) employing or aiding and abetting the employment of an unqualified or unlicensed
299     person to practice as a nurse;
300          (12) failure to file or record any medical report as required by law, impeding or
301     obstructing the filing or recording of such a report, or inducing another to fail to file or record
302     such a report;
303          (13) breach of a statutory, common law, regulatory, or ethical requirement of
304     confidentiality with respect to a person who is a patient, unless ordered by a court;
305          (14) failure to pay a penalty imposed by the division;

306          (15) prescribing a Schedule II-III controlled substance without [a consulting physician
307     or outside of a consultation and referral plan;] complying with the requirements in Section
308     58-31b-803;
309          (16) violating Section 58-31b-801; [and]
310          (17) violating the dispensing requirements of Section 58-17b-309 or Chapter 17b, Part
311     8, Dispensing Medical Practitioner and Dispensing Medical Practitioner Clinic Pharmacy, if
312     applicable[.]; and
313          (18) establishing or operating a pain clinic without a consultation and referral plan for
314     Schedule II-III controlled substances.
315          Section 5. Section 58-31b-803 is enacted to read:
316          58-31b-803. Prescriptive authority for advanced practice registered nurses --
317     Schedule II controlled substance or device -- Workers' compensation -- Pain clinics.
318          (1) This section does not apply to an advanced practice registered nurse specializing as
319     a certified registered nurse anesthetist under Subsection 58-31b-102(14)(d).
320          (2) Except as provided in Subsection (3), an advanced practice registered nurse shall
321     prescribe or administer a Schedule II controlled substance in accordance with a consultation
322     and referral plan.
323          (3) Except as provided by Subsection 58-31b-502(18), an advanced practice registered
324     nurse may prescribe or administer a Schedule II controlled substance without a consultation
325     and referral plan if the advanced practice registered nurse:
326          (a) has the lesser of:
327          (i) two years of licensure as a nurse practicing advanced practice registered nursing; or
328          (ii) 2,000 hours of experience practicing advanced practice registered nursing;
329          (b) (i) prior to the first time prescribing or administering a Schedule II or III controlled
330     substance to a particular patient, checks information about the patient in the Controlled
331     Substance Database created in Section 58-37f-201; and
332          (ii) periodically, thereafter, checks information about the patient in the Controlled
333     Substance Database created in Section 58-37f-201; and
334          (c) follows the health care provider prescribing guidelines for the treatment of an
335     injured worker, developed by the Labor Commission under Title 34A, Chapter 2, Workers'
336     Compensation Act, or Title 34A, Chapter 3, Utah Occupational Disease Act, if:

337          (i) the patient is an injured worker; and
338          (ii) the Schedule II or III controlled substance is prescribed for chronic pain.
339          Section 6. Section 58-31d-103 is amended to read:
340          58-31d-103. Rulemaking authority -- Enabling provisions.
341          (1) The division may adopt rules necessary to implement Section 58-31d-102.
342          (2) As used in Article VIII (1) of the Advanced Practice Registered Nurse Compact,
343     "head of the licensing board" means the executive administrator of the Utah Board of Nursing.
344          (3) For purposes of the Advanced Practice Registered Nurse Compact, "APRN" as
345     defined in Article II (1) of the compact includes an individual who is:
346          (a) licensed to practice under Subsection 58-31b-301(2) as an advanced practice
347     registered nurse; or
348          (b) licensed to practice under Section 58-44a-301 as a certified nurse midwife.
349          (4) An APRN practicing in this state under a multistate licensure privilege may only be
350     granted prescriptive authority if that individual can document completion of graduate level
351     course work in the following areas:
352          (a) advanced health assessment;
353          (b) pharmacotherapeutics; and
354          (c) diagnosis and treatment.
355          (5) (a) An APRN practicing in this state under a multistate privilege who seeks to
356     obtain prescriptive authority must:
357          (i) meet all the requirements of Subsection (4) and this Subsection (5); and
358          (ii) be placed on a registry with the division.
359          (b) To be placed on a registry under Subsection (5)(a)(ii), an APRN must:
360          (i) submit a form prescribed by the division;
361          (ii) pay a fee; and
362          (iii) if prescribing a controlled substance:
363          (A) obtain a controlled substance license as required under Section 58-37-6; and
364          (B) [if prescribing] that is a Schedule II [or III] controlled substance, [have a
365     consultation and referral plan with a physician licensed in Utah as required under Subsection
366     58-31b-102(13)(c)(iii) or 58-44a-102(9)(c)(iii)(C)] comply with the requirements of Section
367     58-31b-803.

368