Mo. Code Regs. tit. 20 § 2200-4.100

Current through Register Vol. 49, No. 9, May 1, 2024

Section 20 CSR 2200-4.100 - [Effective until 5/31/2024] Advanced Practice Registered Nurse

PURPOSE: This amendment brings the regulation in line with current statutory language, equalizes the requirements for maintenance of the Document of Recognition for the uncertified APRNs and updates titling with national standards.

(1) Definitions.

(A) Accredited college or university-An institution of learning awarded accreditation status by the appropriate regional accreditation body for higher education certified by the Council on Post Secondary Accreditation to conduct such accreditations.

(B) Advanced-Means content and competency at a level beyond that of a baccalaureate prepared nurse.

(C) Advanced nursing education program-

1. Prior to July 1, 1998, completion of a formal post-basic educational program from or formally affiliated with an accredited college, university, or hospital of at least one (1) academic year, which includes advanced nursing theory and clinical nursing practice, leading to a graduate degree or certificate with a concentration in an advanced practice nursing clinical specialty area.

2. From and after July 1, 1998, completion of a graduate degree from an accredited college or university with a concentration in an advanced practice nursing clinical specialty area, which includes advanced nursing theory and clinical nursing practice. From and after January 1, 2009, the program shall provide a minimum of five hundred (500) faculty supervised clinical hours.

(D) Advanced pharmacology course-A course that offers content in pharmacokinetics and pharmacodynamics, pharmacology of current/commonly-used medications, and the application of drug therapy to the treatment of disease and/or the promotion of health;

(E) Advanced practice registered nurse (APRN)-As defined in section 335.016, RSMo.

(F) Advanced practice nursing role-A recognized advanced body of nursing knowledge and specialized acts of advanced professional nursing practice categorized into one

(1) of these four (4) roles: certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), certified clinical nurse specialist (CNS) and certified nurse practitioner (CNP).

(G) Certificate of controlled substance prescriptive authority-Eligibility granted by the Missouri State Board of Nursing (MSBN) to an APRN to apply with the Missouri Bureau of Narcotics and Dangerous Drugs (BNDD) and the federal Drug Enforcement Agency (DEA) for authority to prescribe controlled substances from Schedules III-V as delegated in a collaborative practice arrangement between a collaborating physician and a collaborating APRN.

(H) Nationally recognized certifying body-A non-governmental agency approved by the MSBN that validates by examination, based on pre-determined standards, an individual nurse's qualifications and knowledge for practice in a defined functional or clinical area of nursing.

(I) Nationally recognized professional nursing organization-A membership entity for registered professional nurses (RNs) in the United States whose intention is national in scope and exists, in part, for the ongoing purposes of-

1. Fostering high standards for professional nursing practice;

2. Promoting the professional development and general welfare of registered professional nurses;

3. Improving the health and well-being of individuals, families, and communities in collaboration with other health care providers; and

4. Engaging in action at the national level on matters of professional policy and national health policy.

(J) Population focus-Describes the type of patients that the APRN has been educated to provide care for, i.e. family/individual across the lifespan, adult-gerontology, pediatrics, neonatal, women's health/gender-related or psych/mental health.

(K) Preceptorial experience-A designated portion of a formal educational program that is offered in a healthcare setting and affords students the opportunity to integrate theory and role in both the clinical specialty/practice area and advanced nursing practice through direct patient care/client management.

(L) Qualified preceptor-An APRN with a current unrestricted RN license who has a scope of practice which includes prescribing and has met the requirements for prescriptive authority; a licensed practitioner of medicine or osteopathy with unrestricted prescriptive authority.

(2) To Obtain APRN Recognition.

(A) After June 30, 1997, the MSBN will maintain an up-to-date roster of RNs recognized as eligible to practice as an APRN.

1. Temporary recognition-available to new graduate APRNs only-An RN who is a graduate registered nurse anesthetist, graduate nurse midwife, graduate nurse practitioner, or graduate clinical nurse specialist and desires to begin practice in their advanced practice role prior to the successful completion of their certification examination must be recognized by the MSBN and-

A. Hold a current unencumbered license to practice in Missouri, or another compact state as an RN;

B. Submit completed Document of Recognition application and fee to the MSBN. Incomplete application forms and evidence will be considered invalid. Fees are not refundable;

C. Provide evidence of having successfully completed an advanced nursing education program as defined in subsection (1)(B) of this rule;

D. Register to take the first available certification examination administered by a nationally recognized certifying body acceptable to the MSBN;

E. Agree to notify the MSBN and employer of results within five (5) working days of receipt of results. If notification is of unsuccessful results, then agree to cease practice as an APRN immediately;

F. Be restricted from any prescriptive authority;

G. Have never been denied certification or had any certification suspended, revoked, or cancelled by an MSBN-approved nationally-recognized certifying body; and

H. Be recognized for a period not greater than four (4) months from the date of graduation, pending a certification decision by an MSBN-approved nationally recognized certifying body.

(B) Initial Recognition-RNs who are certified registered nurse anesthetists (CRNA), certified nurse midwives (CNM), certified nurse practitioners, or certified clinical nurse specialists (CNS) applying for recognition from the MSBN for eligibility to practice as advanced practice registered nurses shall-

1. Hold a current unencumbered license to practice in Missouri or another compact state as an RN; and

2. Provide evidence of completion of appropriate advanced nursing education program as defined in subsection (1)(C) of this rule; and

3. Submit completed Document of Recognition application and appropriate fee to the MSBN. Incomplete application forms and evidence will be considered invalid. Fees are not refundable; and

4. Submit documentation of current certification in their respective advanced practice nursing population focus area of practice by an MSBN-approved nationally-recognized certifying body, meeting the requirements of this rule; or

5. Before January 1, 2010, applicants for whom there is no appropriate certifying examination shall also provide the following documentation:

A. Evidence of successful completion of three (3) graduate credit hours of pharmacology offered by an accredited college or university within the previous five (5) years prior to the date of application to the board; and

B. Evidence of a minimum of eight hundred (800) hours of clinical practice in the advanced practice nursing clinical specialty area within two (2) years prior to date of application to the board; and

6. Each applicant is responsible for maintaining and providing documentation of satisfactory, active, up-to-date certification/recertification/maintenance and/or continuing education/competency status to the MSBN.

7. To be eligible for controlled substance prescriptive authority, the APRN applicant shall submit the following:

A. Evidence of completion of an advanced pharmacology course that includes preceptorial experience in the prescription of drugs, medicines, and therapeutic devices with a qualified preceptor. Evidence shall be submitted in the form of one (1) of the following:

(I) An official final transcript from their advanced practice program; or

(II) A letter from the school describing how this was integrated into the curriculum; or

(III) Evidence of successful completion of three (3) credit hours post-baccalaureate course in advanced pharmacology from an accredited college or university within the last five (5) years; or

(IV) Evidence of successful completion of forty-five (45) continuing education units in pharmacology within the last five (5) years; and

B. Provide evidence of completion of at least three hundred (300) clock hours of preceptorial experience in the prescription of drugs, medicines, and therapeutic devices with a qualified preceptor. The APRN applicant shall complete the form provided by the MSBN and include this form with the Document of Recognition application or at such time as the APRN has completed the required hours of preceptorial experience;

C. Has had controlled substance prescriptive authority delegated in a collaborative practice arrangement under section 334.104, RSMo, with a Missouri licensed physician who has an unrestricted federal Drug Enforcement Administration (DEA) number and who is actively engaged in a practice comparable in scope, specialty, or expertise to that of the APRN. Submit the completed "Statement of Controlled Substance Delegation" form provided by the MSBN as part of the application process to the MSBN; and

D. Provide evidence of a minimum of one thousand (1,000) hours of practice in an advanced practice nursing category prior to application for a certificate of prescriptive authority. The one thousand (1,000) hours shall-

(I) Be obtained after graduation from the advanced practice nursing education program; and

(II) Include transmitting a prescription order orally, telephonically, or to an inpatient medical record from protocols developed in collaboration with and signed by a licensed physician. The APRN applicant shall complete the form provided by the MSBN and may include this form with the Document of Recognition application or at such time as the APRN has completed the required hours of practice in an advanced practice nursing category.

8. Once the APRN has received controlled substance prescriptive authority from the MSBN, he/she may apply for a BNDD registration number and a federal DEA registration number. Restrictions that may exist on the collaborative physician's BNDD registration may also result in restrictions on the BNDD registration for the APRN. The instructions and the application needed for BNDD registration can be found at www.dhss.mo.gov/BNDD. For information regarding federal DEA registration, see www.DEADiversion.usdoj.gov.

(C) Continued Recognition for Certified APRNs-In order to maintain a current Document of Recognition, the APRN shall-

1. Maintain current RN licensure in Missouri or in another compact state. An RN license placed on inactive or lapsed status will automatically expire the Document of Recognition regardless of current certification status; and

2. Notify the MSBN within five (5) working days of any change in status, documentation, or other changes that may affect their recognition as an APRN; and

3. Provide evidence of recertification by a certifying body, approved by the MSBN, to the MSBN prior to the current expiration date. It is the APRN's responsibility to be sure that their recertifica-tion credentials have been received by the MSBN; and

4. Adhere to all requirements of the BNDD and the federal DEA.

5. Failure to satisfy any of the applicable requirements of subsections (2)(A)-(C) of this rule shall result in the loss of recognition as an APRN in Missouri. Loss of recognition as an APRN results in ineligibility to call or title oneself or practice as an APRN but does not prevent the individual from practicing as an RN within his/her education, training, knowledge, judgment, skill, and competence as long as otherwise licensed to practice as an RN.

(D) Continued Recognition for Uncertified APRNs - In order to maintain a current Document of Recognition, the uncertified APRN shall-

1. Have been approved by the MSBN as noncertified prior to January 1, 2010, and every two (2) years thereafter provide evidence of-

A. A minimum of eight hundred (800) hours of clinical practice in their advanced practice nursing population focus area and in the advanced practice role; and

B. A minimum of sixty (60) contact hours in their advanced practice nursing population focus area of practice. Formally approved continuing education hours shall meet one (1) or more of the criteria listed below:

(I) Continuing nursing education (CNE) approved for nursing contact hours by an accredited provider or approver of nursing continuing education;

(II) Continuing medical education (CME) approved for CME hours;

(III) Sponsored by organizations, agencies, or educational institutions accredited or approved by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), or the Commission on Dietetic Registration;

(IV) Provided by one (1) of these accepted agencies: American Nurses Association American Academy of Family Physicians (AAFP) American Academy of Physician Assistants (AAPA) American Association of Nurse Practitioners (AANP) American College of Nurse Midwives (ACNM) American Psychiatric Association (APA) American Psychological Association (APA) American Psychiatric Nurses Association (APNA) Emergency Nurses Association (ENA) National Association of Nurse Practitioners in Women's Health (NPWH) National Association of Pediatric Nurse Associates and Practitioners (NAP-NAP);

(V) Independent study and/or e-learning approved for continuing education hours by one (1) of the accepted continuing education providers may be used for one hundred percent (100%) of the required continuing education hours (e.g. independent study programs, online courses, articles from professional journals); and

2. Maintain current RN licensure in Missouri or in another compact state. An RN license placed on inactive or lapsed status will automatically expire the Document of Recognition regardless of current certification status; and

3. Notify the MSBN within five (5) working days of any change in status, documentation, or other changes that may affect their recognition as an APRN; and

4. Adhere to all requirements of the BNDD and the federal DEA; and

5. Uncertified APRNs who fail to satisfy any of the applicable requirements of subsections (2)(A), (B), and (D) of this rule will no longer be recognized as an APRN in Missouri. Loss of recognition as an APRN results in ineligibility to call or title oneself or practice as an APRN but does not prevent the individual from practicing as an RN within his/her education, training, knowledge, judgment, skill, and competence if the RN has an active license to practice as an RN.

6. Uncertified APRNs who fail to satisfy any of the applicable requirements of subsections (2)(A), (B), and (D) of this rule will no longer be recognized as an APRN in Missouri. To regain recognition, the uncertified APRN shall complete the application process described in paragraphs (2)(B)1.-8. of this rule, which includes the requirement for certification.

(3) Titling.

(A) After June 30, 1997, only an RN meeting the requirements of this rule and recognized by the MSBN as an APRN may use any of the following titles or abbreviations in clinical practice: advanced practice registered nurse (APRN); certified advanced practice registered nurse; nurse anesthetist; certified registered nurse anesthetist (CRNA); nurse midwife; certified nurse midwife (CNM); nurse practitioner (NP); certified nurse practitioner; certified nurse specialist (CNS); or certified clinical nurse specialist.

(B) A Registered Nurse (RN) recognized as an APRN by the MSBN shall use the title APRN and may include their role and population focus (NP with population focus, CNS with population focus, CNM, or CRNA), and certification status, if applicable, for purposes of identification and documentation.

(4) Scope of Practice.

(A) RNs recognized by the MSBN as being eligible to practice as an APRN shall function clinically-

1. Within the state of Missouri Nursing Practice Act, Chapter 335, RSMo, and all other applicable rules and regulations;

2. Within the professional scope and standards of their advanced practice nursing role and population focus and consistent with their formal advanced nursing education and national certification, if applicable, or within their education, training, knowledge, judgment, skill, and competence as an RN; and

3. Within the regulations set forth by the BNDD and the federal DEA if deemed eligible to prescribe controlled substances by the MSBN.

(5) Certifying Body Criteria.

(A) In order to be a certifying body acceptable to the MSBN for APRN status, the certifying body must meet the following criteria:

1. Be national in the scope of its credentialing;

2. Have no requirement for an applicant to be a member of any organization;

3. Have formal requirements that are consistent with the requirements of the APRN rule;

4. Have an application process and credential review that includes documentation that the applicant's advanced nursing education, which included theory and practice, is in the advanced practice nursing clinical specialty area being considered for certification;

5. Use psychometrically sound and secure examination instruments based on the scope of practice of the advanced practice nursing clinical specialty area;

6. Issue certification based on passing an examination and meeting all other certification requirements;

7. Provide for periodic recertification/maintenance options which include review of qualifications and continued competence; and

8. Have an evaluation process to provide quality assurance in its certification, recertification, and continuing competency components.

(B) Each listed certifying body and/or its policies and procedures for certification shall be subject to at least annual review by the MSBN to determine whether criteria for recognition under this rule are being maintained.

(C) The MSBN will identify, keep on file, and make available to the public the current list of nationally-recognized certifying bodies acceptable to the board of nursing. Nationally-recognized certifying bodies may be added or deleted from the board of nursing's list of nationally-recognized certifying bodies based on the criteria set forth in this rule. A copy of the current list may be obtained by contacting the Missouri State Board of Nursing.

20 CSR 2200-4.100

AUTHORITY: sections 335.016(2) and 335.036, RSMo Supp. 2009.* This rule originally filed as 4 CSR 200-4.100. Original rule filed Nov. 15, 1991, effective March 9, 1992. Rescinded and readopted: Filed Oct. 25, 1995, effective June 30, 1996. Emergency amendment filed May 1, 1997, effective May 12, 1997, expired Nov. 7, 1997. Amended: Filed May 1, 1997, effective Oct. 30, 1997. Amended: Filed June 16, 2003, effective Dec. 30, 2003. Moved to 20 CSR 2200-4.100, effective Aug. 28, 2006. Amended: Filed Aug. 11 , 2006, effective March 30, 2007. Amended: Filed June 27, 2008, effective Dec. 30, 2008. Rescinded and readopted: Filed April 30, 2010, effective Nov. 30, 2010.

Amended by Missouri Register November 15, 2018/Volume 43, Number 22, effective 12/31/2018

*Original authority: 335.016(2), RSMo 1975, amended 1993, 1995, 1999, 2002, 2004, 2007, 2008 and 335.036, RSMo 1975, amended 1981, 1985, 1993, 1995, 1999, 2007, 2008.