APRN Public Act 99-168 Attorney General Ruling

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Substitute Senate Bill No. 333

Public Act No. 99-168
An Act Concerning Advanced Practice Nursing.

Be it enacted by the Senate and House of Representatives in General Assembly convened:

Section 1. Section 20-87a of the general statutes is repealed and the following is substituted in lieu thereof:

(a) The practice of nursing by a registered nurse is defined as the process of diagnosing human responses to actual or potential health problems, providing supportive and restorative care, health counseling and teaching, case finding and referral, collaborating in the implementation of the total health care regimen, and executing the medical regimen under the direction of a licensed physician or dentist.

(b) Advanced nursing practice is defined as the performance of advanced level nursing practice activities[which] that, by virtue of postbasic specialized education and experience, are appropriate to and may be performed by an advanced practice registered nurse. The advanced practice registered nurse performs acts of diagnosis and treatment of alterations in health status, as described in subsection (a) of this section, [. The advanced practice registered nurse may, under the direction of] and shall collaborate with a physician licensed to practice medicine in this state. [and in accordance with written protocols, and if] If practicing in (1) an institution licensed pursuant to subsection (a) of section 19a-491 as a hospital, residential care home, health care facility for the handicapped, nursing home, rest home, mental health facility, substance abuse treatment facility, infirmary operated by an educational institution for the care of students enrolled in, and faculty and staff of, such institution, or facility operated and maintained by any state agency and providing services for the prevention, diagnosis and treatment or care of human health conditions, or (2) an industrial health facility licensed pursuant to subsection (h) of section 31-374 which serves at least two thousand employees, or (3) a clinic operated by a state agency, municipality, or private nonprofit corporation, or (4) a clinic operated by any educational institution prescribed by regulations adopted pursuant to section 20-99a,the advanced practice registered nurse may, in collaboration with a physician licensed to practice medicine in this state, prescribe, dispense, and administer medical therapeutics and corrective measures. [, except that an advanced practice registered nurse licensed pursuant to section 20-94a and maintaining current certification from the American Association of Nurse Anesthetists who is prescribing and administering medical therapeutics during surgery may only do so if the physician who is medically directing the prescriptive activity is physically present in the institution, clinic, or other setting where such surgery is being performed.] In all other settings, the advanced practice registered nurse may, [under the direction of] in collaboration with a physician licensed to practice medicine in the state, [and in accordance with written protocol,] prescribe and administer medical therapeutics and corrective measures and may dispense drugs in the form of professional samples in accordance with sections 20-14c to 20-14e, inclusive, except that an advanced practice registered nurse licensed pursuant to section 20-94a, as amended by this act, and maintaining current certification from the American Association of Nurse Anesthetists who is prescribing and administrating medical therapeutics during surgery may only do so if the physician who is medically directing the prescriptive activity is physically present in the institution, clinic or other setting where the surgery is being performed. For purposes of this subsection, "collaboration" means a mutually agreed upon relationship between an advanced practice registered nurse and a physician who is educated, trained or has relevant experience that is related to the work of such advanced practice registered nurse. The collaboration shall address a reasonable and appropriate level of consultation and referral, coverage for the patient in the absence of the advanced practice registered nurse, a method to review patient outcomes and a method of disclosure of the relationship to the patient. Relative to the exercise of prescriptive authority, the collaboration between an advanced practice registered nurse and a physician shall be in writing and shall address the level of schedule II and III controlled substances that the advanced practice registered nurse may prescribe and provide a method to review patient outcomes, including, but not limited to, the review of medical therapeutics, corrective measures, laboratory tests and other diagnostic procedures that the advanced practice registered nurse may prescribe, dispense and administer.

(c) The practice of nursing by a licensed practical nurse is defined as the performing of selected tasks and sharing of responsibility under the direction of a registered nurse or an advanced practice registered nurse and within the framework of supportive and restorative care, health counseling and teaching, case finding and referral, collaborating in the implementation of the total health care regimen and executing the medical regimen under the direction of a licensed physician or dentist.

(d) In the case of a registered or licensed practical nurse employed by a home health care agency, the practice of nursing includes, but is not limited to, executing the medical regimen under the direction of a physician licensed in a state [which] that borders Connecticut.

Sec. 2. Subsection (a) of section 20-94a of the general statutes is repealed and the following is substituted in lieu thereof:

(a) The Department of Public Health may issue an advanced practice registered nurse license to a person seeking to perform the activities described in subsection (b) of section 20-87a, as amended by this act, upon receipt of a fee of one hundred dollars, to an applicant who satisfies the following requirements: (1) [Is eligible for] Maintains a license as a registered nurse [licensure] in this state, as provided by section 20-93 or 20-94; (2) holds and maintains current certification as [either] a nurse practitioner, a clinical nurse specialist [,] or a nurse anesthetist from one of the following national certifying bodies [which] that certify nurses in advanced practice: The American Nurses' Association, the Nurses' Association of the American College of Obstetricians and Gynecologists Certification Corporation, the National Board of Pediatric Nurse Practitioners and Associates or the American Association of Nurse Anesthetists, their successors or other appropriate national certifying bodies approved by the board of examiners for nursing; (3) has completed thirty hours of education in pharmacology for advanced nursing practice; and (4) if first certified by one of the foregoing certifying bodies after December 31, 1994, holds a master's degree in nursing or in a related field recognized for certification as either a nurse practitioner, a clinical nurse specialist, or a nurse anesthetist by one of the foregoing certifying bodies. No license shall be issued under this section to any applicant against whom professional disciplinary action is pending or who is the subject of an unresolved complaint.

Sec. 3. Section 20-101c of the general statutes is repealed and the following is substituted in lieu thereof:

All prescription forms used by advanced practice registered nurses and nurse-midwives shall contain the name, address and telephone number of the [physician (1) under whose direction the] advanced practice registered nurse [is prescribing or (2) with whom the nurse-midwife has a clinical practice relationship. Nothing in this section shall be construed to preclude such form from also containing the name of the advanced practice registered nurse] or the nurse-midwife. The form may also contain the name of the collaborating physician.

Sec. 4. Section 20-94b of the general statutes is repealed and the following is substituted in lieu thereof:

An advanced practice registered nurse licensed pursuant to section 20-94a, as amended by this act, and maintaining current certification from the American Association of Nurse Anesthetists may prescribe, dispense and administer drugs, including controlled substances in schedule II, III, IV, or V. An advanced practice registered nurse licensed pursuant to section 20-94a, as amended by this act, who does not maintain current certification from the American Association of Nurse Anesthetists may prescribe, dispense, and administer drugs, including controlled substances in schedule IV or V, except that such an advanced practice registered nurse may also prescribe controlled substances in schedule II or III [to an inpatient in a short-term hospital as defined in the regulations of Connecticut state agencies and licensed pursuant to subsection (a) of section 19a-491, provided the physician under whose direction the advanced practice registered nurse is prescribing shall cosign the order for a controlled substance in schedule II or III not later than twenty-four hours thereafter] that are expressly specified in written collaborative agreements pursuant to subsection (b) of section 20-87a, as amended by this act.

Sec. 5. Subdivision (6) of subsection (b) of section 20-9 of the general statutes is repealed and the following is substituted in lieu thereof:

(6) Any person rendering service as (A) an advanced practice registered nurse if such service is rendered[under the direction of] in collaboration with a licensed physician, or (B) an advanced practice registered nurse maintaining classification from the American Association of Nurse Anesthetists if such service is under the direction of a licensed physician.

Sec. 6. (NEW) (a) Each person licensed as an advanced practice registered nurse under the provisions of section 20-94a of the general statutes who provides direct patient care services shall maintain professional liability insurance or other indemnity against liability for professional malpractice. The amount of insurance that each such person shall carry as insurance or indemnity against claims for injury or death for professional malpractice shall not be less than five hundred thousand dollars for one person, per occurrence, with an aggregate of not less than one million five hundred thousand dollars.

(b) Each insurance company that issues professional liability insurance, as defined in subdivisions (1), (6), (7), (8), (9) or (10) of subsection (b) of section 38a-393 of the general statutes, as amended by this act, shall on and after January 1, 2000, render to the Commissioner of Public Health a true record of the names and addresses, according to classification, of cancellations of and refusals to renew professional liability insurance policies and the reasons for such cancellation or refusal to renew said policies for the year ending on the thirty-first day of December next preceding.

Sec. 7. Section 38a-393 of the general statutes is repealed and the following is substituted in lieu thereof:

(a) Each insurance company doing business in this state shall, annually, on or before the first day of March, render to the Insurance Commissioner a true record of the number, according to classification, of cancellations of and refusals to renew professional liability insurance policies for the year ending on the thirty-first day of December next preceding.

(b) For purposes of sections 38a-393 to 38a-395, inclusive, "professional liability insurance" means professional liability contracts for: (1) Physicians and surgeons, (2) hospitals, (3) lawyers, (4) dentists, (5) architects and engineers, (6) osteopathic physicians, (7) chiropractors, (8) licensed natureopaths, [and] (9) podiatrists, and (10) advanced practice registered nurses and such other categories as the Insurance Commissioner, in [his] the commissioner's discretion, shall adopt by regulations in accordance with chapter 54.

http://www.cga.state.ct.us/ps99/act/pa/pa168.htm


Attorney General Ruling Regarding Public Act 99-168

The following is a response to your request for advice on the interpretation of Public Act 99-168, An Act Concerning Advanced Practice Nursing.

Your initial inquiry, dated August 4, 1999, was whether Section 2 of the Act, which amends Conn. Gen. State 20-94a(a), is applicable only to individuals obtaining their licenses for the first time, or whether it is also applicable to APRNs who are renewing their licenses. Subsequently, on September 7, 1999, you forwarded a supplemental inquiry as to whether Public Act 99-168 affected the current practice allowing for registered nurses to administer a medical regimen when ordered by an APRN.

I

Conn. Gen. Stat. 20-94a(a) formerly provided that a license could be issued to an applicant who, in addition to satisfying other requirements, was "eligible for registered nurse licensure in this state . . . ." (Emphasis supplied.) Section 2 of the Act replaces the former subsection (a) with revised criteria for licensure, including a requirement that an applicant [m]aintains a license as a registered nurse in this state. You noted in your inquiry that the legislature intended to require that all APRNs, including those licensed prior to passage of the Act who are renewing their licenses, to maintain RN licensure. However, you also noted that no amendment was made to Conn. Gen. State 19a-88c(2).

Conn. Gen. Stat. 19a-88c(2) details the process of annual licensure renewal by advance practice registered nurses and provides that

[n]o such license shall be renewed unless the department is satisfied that the person maintains current certification as either a nurse practitioner, a clinical nurse specialist or a nurse anesthetist...

Thus, 19a-88c(2) speaks to certification from national accrediting bodies, not licensure requirements. The Act, on the other hand, changes the licensure requirements. Accordingly, we do not perceive any conflict between 19a-88c(2) and the Act.

Further, we have examined the legislative history of Public Act 99-168 and agree that it was the legislature’s clear intent to require all APRNs to maintain current APRN licensure. Public Health Proc., 1999 Sess. p.30 (Remarks of Nancy Bafundo, Chairman of the Board of Examiners for Nursing.) Ms. Bafundo, testifying in support of the bill, noted that "the revisions to this bill enforces the fact that the APRN has to maintain a current RN licensure in the State of Connecticut and that doesn’t occur right now." Id.

In interpreting statutes, our Supreme Court has held that the "fundamental objective is to ascertain and give effect to the apparent intent of the legislature . . . . In seeking to discern that intent, we look to the words of the statute itself, to the legislative history and circumstances surrounding its enactment, to the legislative policy it was designed to implement, and to its relationship to existing legislation and common law principles governing the same general subject matter." Poulos v. Pfizer, Inc., 244 Conn. 598, 605, 711 A.2d 688(1998).

Moreover, "[s]tatutes are to be construed consistently with other relevant statutes, because we presume that the legislature intended to create a coherent body of law." (Internal quotation marks omitted.) In re Bruce R., 234 Conn. 194, 207, 662 A.2d 107 (1995). Specifically, in reconciling apparently conflicting statutory provisions, we presume that subsequent enactments were enacted in light of already existing relevant statutes as part of a consistent body of law. Caulkins v Petrillo, 200 Conn. 713, 718, 513 A.2d 43 (1986).

Here, the clear legislative intent was to require all APRNs, whether seeking initial licensure or licensure renewal, to maintain RN licensure. It is apparently current Department practice to require APRNs seeking renewal of their licensure to maintain eligibility for RN licensure, per the former 20-94a(a), even though there is no specific reference to maintaining eligibility in 19a-88(c)(2), which, again, discusses certification from national accrediting bodies. Accordingly, it would be consistent wand would effectuate legislative intent to require maintenance of RN licensure in accordance with the Act.

II

With respect to the issue of whether the Act changes the current practice allowing for RNs to administer a medical regimen when ordered by an APRN, we have concluded that the Act may in fact change that practice.

One of the primary changes implemented by the Act is replacement throughout of the language in Conn. Gen. Stat. 20-87a(b), which defines the scope of APRN practice, that APRNs practice "under the direction of a physician" with language indicating that APRNs practice "in collaboration" with a physician.

"Collaboration" means a

mutually agreed upon relationship between an advanced practice registered nurse and a physician . . . . [t]he collaboration shall address a reasonable and appropriate level of consultation and referral, coverage for the patient in the absence of the advanced practice registered nurse . . .P.A. 99-168, Section 1(b).

The scope of RN practice is defined by Conn. Gen. Stat. 20-87a(a), which states that RNs execute medical regimen "under the direction of a licensed physician or dentist." In accordance with the "under the direction of" language in the former 20-87a(b), APRNs were considered to be physician "extenders" and, accordingly, 20-87a(a) was interpreted to mean that RNs could carry out patient care orders under an APRN as a physician extender.

Nothing in the legislative history of the Act indicates that any portion of it was intended to limit the practice of APRNs; rather, much testimony was given to the effect that the Act was intended to reflect the reality of current practice of APRNs. See, e.g., House Proc., 1999 Sess., 5/28-29,pp.3432-3445.

However, no change was made to 20-87a(a), the statue defining the scope of the RN practice. Notwithstanding the Act’s passage, RNs are still only authorized to execute medical regimen "under the direction of a licensed physician or dentist." The new language in the Act providing that APRNs now work in collaboration with physicians, rather than under their direction, suggests that APRNs can no longer be presumed to be physician extenders. Accordingly, absent an indication in the collaboration agreement that an APRN is in fact working under the direction of a physician, and therefore, can be considered a physician extender, RNs may not execute medical regimen at the direction of an APRN. In other words, a collaboration agreement should specifically address RN supervision by the APRN and the physician’s direction thereof.

Section 20-87a(a) must be amended to allow RNs to execute medical regimen under the direction of a licensed physician or dentist or advanced practice registered nurse in order for the current practice to continue under the Act absent specific provision in the collaboration agreement. Otherwise, the RNs would be acting outside of their scope of practice.

The foregoing constitutes the informal advice of the undersigned Assistant Attorney General which believed to be reliable but which does not necessarily constitute the formal opinion of the Attorney General

Tanya Feliciano

Assistant Attorney General

cc: Cynthia Deene, Bureau Chief

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