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AB-852 Nurse practitioners: scope of practice: practice without standardized procedures.(2021-2022)

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Date Published: 04/21/2021 09:00 PM
AB852:v98#DOCUMENT

Amended  IN  Assembly  April 21, 2021

CALIFORNIA LEGISLATURE— 2021–2022 REGULAR SESSION

Assembly Bill
No. 852


Introduced by Assembly Member Wood

February 17, 2021


An act to amend Sections 1206.5, 2242.2, 2571, 2620.1, 2837.103, 2837.104, 3703, 4024, 4040, 4060, 4061, 4170, and 4174 of the Business and Professions Code, and to amend Section 1157 of the Evidence Code, relating to nursing.


LEGISLATIVE COUNSEL'S DIGEST


AB 852, as amended, Wood. Nurse practitioners: scope of practice: practice without standardized procedures.
(1) Existing law, the Nursing Practice Act, provides for the certification and regulation of nurse practitioners by the Board of Registered Nursing. Existing law authorizes a nurse practitioner who meets certain education, experience, and certification requirements to perform, in certain settings or organizations, specified functions without standardized procedures, including, but not limited to, conducting an advanced assessment; ordering, performing, and interpreting diagnostic procedures, as specified; and prescribing, administering, dispensing, and furnishing controlled substances.
Existing law, beginning January 1, 2023, authorizes a nurse practitioner to perform the functions described above without standardized procedures outside of the specified settings or organizations, in accordance with certain conditions and requirements, if the nurse practitioner holds an active certification issued by the board. Existing law requires those nurse practitioners to obtain physician consultation as specified in the individual protocols and under certain circumstances, including acute decompensation of patient situation. Existing law also requires those nurse practitioners to establish a referral plan for complex medical cases and emergencies to a physician and surgeon or other appropriate healing arts provider that addresses various circumstances, circumstances and conditions, including a patient that has acute decomposition or rare condition.
This bill would refer to practice protocols protocols, as defined, instead of individual protocols and would delete the requirement to obtain physician consultation in the case of acute decompensation of patient situation. The bill would revise the requirement to establish a referral plan, as described above, and would require the referral plan by requiring it to address the circumstance situation of a patient that has acute and unexpected decompensation or rare condition. who is acutely decompensating in a manner that is not consistent with the progression of the disease and corresponding treatment plan.
This bill would include references and incorporate nurse practitioners who function pursuant to the above-described provisions without standardized procedures into various provisions of law regulating healing arts licensees.
(2) Existing law exempts from discovery as evidence the proceedings and records of specified organized committees of health care professionals and review committees having the responsibility of evaluation and improvement of the quality of care.
This bill would extend this exemption, for purposes of civil proceedings only, to the proceedings and records of nurse practitioner organized committees and review committees, as specified.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: NO  

The people of the State of California do enact as follows:


SECTION 1.

 Section 1206.5 of the Business and Professions Code is amended to read:

1206.5.
 (a) Notwithstanding subdivision (b) of Section 1206 and except as otherwise provided in Sections 1206.6 and 1241, no person shall perform a clinical laboratory test or examination classified as waived under CLIA unless the clinical laboratory test or examination is performed under the overall operation and administration of the laboratory director, as described in Section 1209, including, but not limited to, documentation by the laboratory director of the adequacy of the qualifications and competency of the personnel, and the test is performed by any of the following persons:
(1) A licensed physician and surgeon holding a M.D. or D.O. degree.
(2) A licensed podiatrist, a licensed dentist, or a licensed naturopathic doctor, if the results of the tests can be lawfully utilized within the licensee’s practice.
(3) A person licensed under this chapter to engage in clinical laboratory practice or to direct a clinical laboratory.
(4) A person authorized to perform tests pursuant to a certificate issued under Article 5 (commencing with Section 101150) of Chapter 2 of Part 3 of Division 101 of the Health and Safety Code.
(5) A licensed physician assistant if authorized by a supervising physician and surgeon in accordance with Section 3502 or 3535.
(6) A person licensed under Chapter 6 (commencing with Section 2700).
(7) A person licensed under Chapter 6.5 (commencing with Section 2840).
(8) A perfusionist if authorized by and performed in compliance with Section 2590.
(9) A respiratory care practitioner if authorized by and performed in compliance with Chapter 8.3 (commencing with Section 3700).
(10) A medical assistant, as defined in Section 2069, if the waived test is performed pursuant to a specific authorization meeting the requirements of Section 2069.
(11) A pharmacist, as defined in Section 4036, if ordering drug therapy-related laboratory tests in compliance with paragraph (2) of subdivision (a) of Section 4052.1 or paragraph (2) of subdivision (a) of Section 4052.2, or if performing skin puncture in the course of performing routine patient assessment procedures in compliance with Section 4052.1.
(12) A naturopathic assistant, as defined in Sections 3613 and 3640.2, if the waived test is performed pursuant to a specific authorization meeting the requirements of Sections 3613 and 3640.2.
(13) A licensed optometrist as authorized under Chapter 7 (commencing with Section 3000).
(14) Other health care personnel providing direct patient care.
(15) Any other person performing nondiagnostic testing pursuant to Section 1244.
(b) Notwithstanding subdivision (b) of Section 1206, no person shall perform clinical laboratory tests or examinations classified as of moderate complexity under CLIA unless the clinical laboratory test or examination is performed under the overall operation and administration of the laboratory director, as described in Section 1209, including, but not limited to, documentation by the laboratory director of the adequacy of the qualifications and competency of the personnel, and the test is performed by any of the following persons:
(1) A licensed physician and surgeon holding a M.D. or D.O. degree.
(2) A licensed podiatrist or a licensed dentist if the results of the tests can be lawfully utilized within the licensee’s practice.
(3) A person licensed under this chapter to engage in clinical laboratory practice or to direct a clinical laboratory.
(4) A person authorized to perform tests pursuant to a certificate issued under Article 5 (commencing with Section 101150) of Chapter 2 of Part 3 of Division 101 of the Health and Safety Code.
(5) A licensed physician assistant if authorized by a supervising physician and surgeon in accordance with Section 3502 or 3535.
(6) A person licensed under Chapter 6 (commencing with Section 2700).
(7) A perfusionist if authorized by and performed in compliance with Section 2590.
(8) A respiratory care practitioner if authorized by and performed in compliance with Chapter 8.3 (commencing with Section 3700).
(9) A person performing nuclear medicine technology if authorized by and performed in compliance with Article 6 (commencing with Section 107150) of Chapter 4 of Part 1 of Division 104 of the Health and Safety Code.
(10) Any person if performing blood gas analysis in compliance with Section 1245.
(11) (A) A person certified or licensed as an “Emergency Medical Technician II” or paramedic pursuant to Division 2.5 (commencing with Section 1797) of the Health and Safety Code while providing prehospital medical care, a person licensed as a psychiatric technician under Chapter 10 (commencing with Section 4500) of Division 2, as a vocational nurse pursuant to Chapter 6.5 (commencing with Section 2840), or as a midwife licensed pursuant to Article 24 (commencing with Section 2505) of Chapter 5, or certified by the department pursuant to Division 5 (commencing with Section 70001) of Title 22 of the California Code of Regulations as a nurse assistant or a home health aide, who provides direct patient care, if the person is performing the test as an adjunct to the provision of direct patient care by the person, is utilizing a point-of-care laboratory testing device at a site for which a laboratory license or registration has been issued, meets the minimum clinical laboratory education, training, and experience requirements set forth in regulations adopted by the department, and has demonstrated to the satisfaction of the laboratory director that they are competent in the operation of the point-of-care laboratory testing device for each analyte to be reported.
(B) Prior to being authorized by the laboratory director to perform laboratory tests or examinations, testing personnel identified in subparagraph (A) shall participate in a preceptor program until they are able to perform the clinical laboratory tests or examinations authorized in this section with results that are deemed accurate and skills that are deemed competent by the preceptor. For the purposes of this section, a “preceptor program” means an organized system that meets regulatory requirements in which a preceptor provides and documents personal observation and critical evaluation, including review of accuracy, reliability, and validity, of laboratory testing performed.
(12) Any other person within a physician office laboratory if the test is performed under the supervision of the patient’s physician and surgeon or podiatrist who shall be accessible to the laboratory to provide onsite, telephone, or electronic consultation as needed, and shall: (A) ensure that the person is performing test methods as required for accurate and reliable tests; and (B) have personal knowledge of the results of the clinical laboratory testing or examination performed by that person before the test results are reported from the laboratory.
(13) A pharmacist, if ordering drug therapy-related laboratory tests in compliance with paragraph (2) of subdivision (a) of Section 4052.1 or paragraph (2) of subdivision (a) of Section 4052.2.
(c) Notwithstanding subdivision (b) of Section 1206, no person shall perform clinical laboratory tests or examinations classified as of high complexity under CLIA unless the clinical laboratory test or examination is performed under the overall operation and administration of the laboratory director, as described in Section 1209, including, but not limited to, documentation by the laboratory director of the adequacy of the qualifications and competency of the personnel, and the test is performed by any of the following persons:
(1) A licensed physician and surgeon holding a M.D. or D.O. degree.
(2) A licensed podiatrist or a licensed dentist if the results of the tests can be lawfully utilized within the licensee’s practice.
(3) A person licensed under this chapter to engage in clinical laboratory practice or to direct a clinical laboratory if the test or examination is within a specialty or subspecialty authorized by the person’s licensure.
(4) A person authorized to perform tests pursuant to a certificate issued under Article 5 (commencing with Section 101150) of Chapter 2 of Part 3 of Division 101 of the Health and Safety Code if the test or examination is within a specialty or subspecialty authorized by the person’s certification.
(5) A licensed physician assistant if authorized by a supervising physician and surgeon in accordance with Section 3502 or 3535.
(6) A perfusionist if authorized by and performed in compliance with Section 2590.
(7) A respiratory care practitioner if authorized by and performed in compliance with Chapter 8.3 (commencing with Section 3700).
(8) A person performing nuclear medicine technology if authorized by and performed in compliance with Article 6 (commencing with Section 107150) of Chapter 4 of Part 1 of Division 104 of the Health and Safety Code.
(9) Any person if performing blood gas analysis in compliance with Section 1245.
(10) Any other person within a physician office laboratory if the test is performed under the onsite supervision of the patient’s physician and surgeon or podiatrist who shall: (A) ensure that the person is performing test methods as required for accurate and reliable tests; and (B) have personal knowledge of the results of clinical laboratory testing or examination performed by that person before the test results are reported from the laboratory.
(d) Clinical laboratory examinations classified as provider-performed microscopy under CLIA may be personally performed using a brightfield or phase/contrast microscope by one of the following practitioners:
(1) A licensed physician and surgeon or nurse practitioner practicing pursuant to Section 2837.103 or 2837.104 using the microscope during the patient’s visit on a specimen obtained from their own patient or from a patient of a group medical practice of which the physician or nurse practitioner is a member or employee.
(2) A nurse practitioner practicing pursuant to Section 2837.103 or 2837.104 using the microscope during the patient’s visit on a specimen obtained from their own patient or from a patient of a group nurse practitioner practice of which the nurse practitioner is a member or employee.

(2)

(3) A nurse midwife holding a certificate as specified by Section 2746.5, a licensed nurse practitioner as specified in Section 2835.5, or a licensed physician assistant acting under the supervision of a physician pursuant to Section 3502 using the microscope during the patient’s visit on a specimen obtained from their own patient or from the patient of a clinic, group medical practice, or other health care provider of which the certified nurse midwife, licensed nurse practitioner, or licensed physician assistant is an employee.

(3)

(4) A licensed dentist using the microscope during the patient’s visit on a specimen obtained from the dentist’s own patient or from a patient of a group dental practice of which the dentist is a member or an employee.

SEC. 2.

 Section 2242.2 of the Business and Professions Code is amended to read:

2242.2.
 Notwithstanding any other law, a physician and surgeon, a nurse practitioner acting within the scope of Section 2837.103 or 2837.104, a registered nurse acting in accordance with Section 2725.2, a certified nurse-midwife acting within the scope of Section 2746.51, a nurse practitioner acting within the scope of Section 2836.1, a physician assistant acting within the scope of Section 3502.1, and a pharmacist acting within the scope of Section 4052.3 may use a self-screening tool that will identify patient risk factors for the use of self-administered hormonal contraceptives by a patient, and, after an appropriate prior examination, prescribe, furnish, or dispense, as applicable, self-administered hormonal contraceptives to the patient. Blood pressure, weight, height, and patient health history may be self-reported using the self-screening tool that identifies patient risk factors.

SEC. 3.

 Section 2571 of the Business and Professions Code is amended to read:

2571.
 (a) An occupational therapist licensed pursuant to this chapter and approved by the board in the use of physical agent modalities may apply topical medications prescribed by the client’s physician and surgeon, certified nurse-midwife pursuant to Section 2746.51, nurse practitioner pursuant to Section 2836.1, or nurse practitioner practicing pursuant to Section 2837.103 or 2837.104, or physician assistant pursuant to Section 3502.1, if the licensee complies with regulations adopted by the board pursuant to this section.
(b) The board shall adopt regulations implementing this section, after meeting and conferring with the Medical Board of California, the California State Board of Pharmacy, and the Physical Therapy Board of California, specifying those topical medications applicable to the practice of occupational therapy and protocols for their use.
(c) Nothing in this section shall be construed to authorize an occupational therapist to prescribe medications.

SEC. 4.Section 2620.1 of the Business and Professions Code is amended to read:
2620.1.

(a)In addition to receiving those services authorized by Section 2620, a person may initiate physical therapy treatment directly from a licensed physical therapist if the treatment is within the scope of practice of physical therapists, as defined in Section 2620, and all of the following conditions are met:

(1)If, at any time, the physical therapist has reason to believe that the patient has signs or symptoms of a condition that requires treatment beyond the scope of practice of a physical therapist or the patient is not progressing toward documented treatment goals as demonstrated by objective, measurable, or functional improvement, the physical therapist shall refer the patient to a person holding a physician and surgeon’s certificate issued by the Medical Board of California or by the Osteopathic Medical Board of California, to a person licensed to practice dentistry, podiatric medicine, or chiropractic, or to a nurse practitioner practicing pursuant to Section 2837.103 or 2837.104.

(2)The physical therapist shall comply with Section 2633, and shall disclose to the patient any financial interest the physical therapist has in treating the patient and, if working in a physical therapy corporation, shall comply with Article 6 (commencing with Section 650) of Chapter 1.

(3)With the patient’s written authorization, the physical therapist shall notify the patient’s physician and surgeon, if any, that the physical therapist is treating the patient.

(4)The physical therapist shall not continue treating the patient beyond 45 calendar days or 12 visits, whichever occurs first, without receiving, from a person holding a physician and surgeon’s certificate from the Medical Board of California or the Osteopathic Medical Board of California or from a person holding a certificate to practice podiatric medicine from the Podiatric Medical Board of California and acting within their scope of practice, a dated signature on the physical therapist’s plan of care indicating approval of the physical therapist’s plan of care. Approval of the physical therapist’s plan of care shall include an in-person patient examination and evaluation of the patient’s condition and, if indicated, testing by the physician and surgeon or podiatrist.

(b)The conditions in paragraph (4) of subdivision (a) do not apply to a physical therapist under either of the following circumstances:

(1)When the physical therapist is only providing wellness physical therapy services to a patient as described in subdivision (a) of Section 2620.

(2)Pursuant to Section 56363 of the Education Code or Section 7572 of the Government Code, when the physical therapist is providing physical therapy services as part of an individualized family service plan or an individualized education plan pursuant to the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and the individual receiving those services does not have a medical diagnosis.

(c)(1)This section does not expand or modify the scope of practice for physical therapists set forth in Section 2620, including the prohibition on a physical therapist diagnosing a disease.

(2)This section does not restrict or alter the scope of practice of any other health care professional.

(d)Nothing in this section shall be construed to require a health care service plan, insurer, workers’ compensation insurance plan, employer, or state program to provide coverage for direct access to treatment by a physical therapist.

(e)When a person initiates physical therapy treatment services directly, pursuant to this section, the physical therapist shall not perform physical therapy treatment services without first providing the following notice to the patient, orally and in writing, in at least 14-point type and signed by the patient:

“Direct Physical Therapy Treatment Services

You are receiving direct physical therapy treatment services from an individual who is a physical therapist licensed by the Physical Therapy Board of California.

Under California law, you may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits, whichever occurs first, after which time a physical therapist may continue providing you with physical therapy treatment services only after receiving, from a person holding a physician and surgeon’s certificate issued by the Medical Board of California or by the Osteopathic Medical Board of California, or from a person holding a certificate to practice podiatric medicine from the Podiatric Medical Board of California and acting within their scope of practice, a dated signature on the physical therapist’s plan of care indicating approval of the physical therapist’s plan of care and that an in-person patient examination and evaluation was conducted by the physician and surgeon or podiatrist.

Patient’s Signature/Date”


SEC. 4.

 Section 2837.103 of the Business and Professions Code is amended to read:

2837.103.
 (a) (1) Notwithstanding any other law, a nurse practitioner may perform the functions specified in subdivision (c) pursuant to that subdivision, in a setting or organization specified in paragraph (2) pursuant to that paragraph, if the nurse practitioner has successfully satisfied the following requirements:
(A) Passed a national nurse practitioner board certification examination and, if applicable, any supplemental examination developed pursuant to paragraph (3) (4) of subdivision (a) of Section 2837.105.
(B) Holds a certification as a nurse practitioner from a national certifying body accredited by the National Commission for Certifying Agencies or the American Board of Nursing Specialties and recognized by the board.
(C) Provides documentation that educational training was consistent with standards established by the board pursuant to Section 2836 and any applicable regulations as they specifically relate to requirements for clinical practice hours. Online educational programs that do not include mandatory clinical hours shall not meet this requirement.
(D) Has completed a transition to practice in California of a minimum of three full-time equivalent years of practice or 4600 hours.
(2) A nurse practitioner who meets all of the requirements of paragraph (1) may practice, including, but not limited to, performing the functions authorized pursuant to subdivision (c), in one of the following settings or organizations in which one or more physicians and surgeons practice with the nurse practitioner without standardized procedures:
(A) A clinic, as defined in Section 1200 of the Health and Safety Code.
(B) A health facility, as defined in Section 1250 of the Health and Safety Code, except for the following:
(i) A correctional treatment center, as defined in paragraph (1) of subdivision (j) of Section 1250 of the Health and Safety Code.
(ii) A state hospital, as defined in Section 4100 of the Welfare and Institutions Code.
(C) A facility described in Chapter 2.5 (commencing with Section 1440) of Division 2 of the Health and Safety Code.
(D) A medical group practice, including a professional medical corporation, as defined in Section 2406, another form of corporation controlled by physicians and surgeons, a medical partnership, a medical foundation exempt from licensure, or another lawfully organized group of physicians and surgeons that provides health care services.
(E) A home health agency, as defined in Section 1727 of the Health and Safety Code.
(F) A hospice facility licensed pursuant to Chapter 8.5 (commencing with Section 1745) of Division 2 of the Health and Safety Code.
(3) In health care agencies that have governing bodies, as defined in Division 5 of Title 22 of the California Code of Regulations, including, but not limited to, Sections 70701 and 70703 of Title 22 of the California Code of Regulations, the following apply:
(A) A nurse practitioner shall adhere to all applicable bylaws.
(B) A nurse practitioner shall be eligible to serve on medical staff and hospital committees.
(C) A nurse practitioner shall be eligible to attend meetings of the department to which the nurse practitioner is assigned. A nurse practitioner shall not vote at department, division, or other meetings unless the vote is regarding the determination of nurse practitioner privileges with the organization, peer review of nurse practitioner clinical practice, whether a licensee’s employment is in the best interest of the communities served by a hospital pursuant to Section 2401, or the vote is otherwise allowed by the applicable bylaws.
(b) An entity described in subparagraphs (A) to (F), inclusive, of paragraph (2) of subdivision (a) shall not interfere with, control, or otherwise direct the professional judgment of a nurse practitioner functioning pursuant to this section in a manner prohibited by Section 2400 or any other law.
(c) In addition to any other practices authorized by law, a nurse practitioner who meets the requirements of paragraph (1) of subdivision (a) may perform the following functions without standardized procedures in accordance with their education and training:
(1) Conduct an advanced assessment.
(2) (A) Order, perform, and interpret diagnostic procedures.
(B) For radiologic procedures, a nurse practitioner can order diagnostic procedures and utilize the findings or results in treating the patient. A nurse practitioner may perform or interpret clinical laboratory procedures that they are permitted to perform under Section 1206 and under the federal Clinical Laboratory Improvement Act (CLIA).
(3) Establish primary and differential diagnoses.
(4) Prescribe, order, administer, dispense, procure, and furnish therapeutic measures, including, but not limited to, the following:
(A) Diagnose, prescribe, and institute therapy or referrals of patients to health care agencies, health care providers, and community resources.
(B) Prescribe, administer, dispense, and furnish pharmacological agents, including over-the-counter, legend, and controlled substances.
(C) Plan and initiate a therapeutic regimen that includes ordering and prescribing nonpharmacological interventions, including, but not limited to, durable medical equipment, medical devices, nutrition, blood and blood products, and diagnostic and supportive services, including, but not limited to, home health care, hospice, and physical and occupational therapy.
(5) After performing a physical examination, certify disability pursuant to Section 2708 of the Unemployment Insurance Code.
(6) Delegate tasks to a medical assistant pursuant to Sections 1206.5, 2069, 2070, and 2071, and Article 2 (commencing with Section 1366) of Chapter 3 of Division 13 of Title 16 of the California Code of Regulations.
(d) A nurse practitioner shall verbally inform all new patients in a language understandable to the patient that a nurse practitioner is not a physician and surgeon. For purposes of Spanish language speakers, the nurse practitioner shall use the standardized phrase “enfermera especializada.”
(e) A nurse practitioner shall not refer to oneself in any communication, sign, business card, letterhead, or advertisement in a manner that would violate Section 2054.

(e)

(f) A nurse practitioner shall post a notice in a conspicuous location accessible to public view that the nurse practitioner is regulated by the Board of Registered Nursing. The notice shall include the board’s telephone number and the internet website where the nurse practitioner’s license may be checked and complaints against the nurse practitioner may be made.

(f)

(g) A nurse practitioner shall refer a patient to a physician and surgeon or other licensed health care provider if a situation or condition of a patient is beyond the scope of the education and training of the nurse practitioner.

(g)

(h) A nurse practitioner practicing under this section shall have professional liability insurance appropriate for the practice setting.

(h)

(i) Any health care setting operated by the Department of Corrections and Rehabilitation is exempt from this section.
(j) Nothing in this section shall authorize a nurse practitioner to administer, or monitor or order the administration of, general anesthesia or deep sedation, as those terms are defined in Section 1646.

SEC. 5.

 Section 2837.104 of the Business and Professions Code is amended to read:

2837.104.
 (a) Beginning January 1, 2023, notwithstanding any other law, the following apply to a nurse practitioner who holds an active certification issued by the board pursuant to subdivision (b):
(1) The nurse practitioner may perform the functions specified in subdivision (c) of Section 2837.103 pursuant to that subdivision outside of the settings or organizations specified under subparagraphs (A) to (F), inclusive, of paragraph (2) of subdivision (a) of Section 2837.103.
(2) Subject to subdivision (f) and any applicable conflict of interest policies of the bylaws, the nurse practitioner shall be eligible for membership of an organized medical staff.
(3) Subject to subdivision (f) and any applicable conflict of interest policies of the bylaws, a nurse practitioner member may vote at meetings of the department to which nurse practitioners are assigned.
(b) (1) The board shall issue a certificate to perform the functions specified in subdivision (c) of Section 2837.103 pursuant to that subdivision outside of the settings and organizations specified under subparagraphs (A) to (F), inclusive, of paragraph (2) of subdivision (a) of Section 2837.103, if the nurse practitioner satisfies all of the following requirements:
(A) The nurse practitioner meets all of the requirements specified in paragraph (1) of subdivision (a) of Section 2837.103.
(B) Holds a valid and active license as a registered nurse in California and a master’s degree in nursing or in a clinical field related to nursing or a doctoral degree in nursing.
(C) Has practiced as a nurse practitioner in good standing for at least three years, not inclusive of the transition to practice required pursuant to subparagraph (D) of paragraph (1) of subdivision (a) of Section 2837.103. The board may, at its discretion, lower this requirement for a nurse practitioner holding a Doctorate of Nursing Practice degree (DNP) based on practice experience gained in the course of doctoral education experience.
(2) The board may charge a fee in an amount sufficient to cover the reasonable regulatory cost of issuing the certificate.
(c) A nurse practitioner authorized to practice pursuant to this section shall comply with all of the following:
(1) The nurse practitioner, consistent with applicable standards of care, shall not practice beyond the scope of their clinical and professional education and training, including specific areas of concentration and shall only practice within the limits of their knowledge and experience and national certification.
(2) (A) The nurse practitioner shall consult and collaborate with other healing arts providers based on the clinical condition of the patient to whom health care is provided. Physician consultation shall be obtained as specified in the practice protocols and under the following circumstances:

(A)

(i) Emergent conditions requiring prompt medical intervention after initial stabilizing care has been started.

(B)

(ii) Problem which is not resolving as anticipated after ongoing evaluation and management of the situation.

(C)

(iii) History, physical, or lab findings inconsistent with the clinical perspective.

(D)

(iv) Upon request of patient.
(B) For purposes of this paragraph, “practice protocols” means a written document that includes, but is not limited to, a description of the manner of communication with and availability of the consulting physician and surgeon and any specialized circumstances under which the nurse practitioner is to communicate in a timely manner with a consulting physician concerning the patient’s condition.
(3) Nurse practitioner consultation with a physician and surgeon alone shall not create a physician-patient relationship. The nurse practitioner shall be solely responsible for the services they provide.

(3)

(4) The nurse practitioner shall establish a plan for referral of complex medical cases and emergencies to a physician and surgeon or other appropriate healing arts providers. The nurse practitioner shall have an identified referral plan specific to the practice area, that includes specific referral criteria. The referral plan shall address the following:
(A) Whenever situations arise which go beyond the competence, scope of practice, or experience of the nurse practitioner.
(B) Whenever patient conditions fail to respond to the management plan as anticipated. or the patient is acutely decompensating in a manner that is not consistent with the progression of the disease and corresponding treatment plan.
(C) Any patient with acute and unexpected decompensation or a rare condition.
(D) Any patient conditions that do not fit the commonly accepted diagnostic pattern for a disease or disorder.
(E) All emergency situations after initial stabilizing care has been started.
(d) A nurse practitioner shall verbally inform all new patients in a language understandable to the patient that a nurse practitioner is not a physician and surgeon. For purposes of Spanish language speakers, the nurse practitioner shall use the standardized phrase “enfermera especializada.”
(e) A nurse practitioner shall not refer to oneself in any communication, sign, business card, letterhead, or advertisement in a manner that would violate Section 2054.

(e)

(f) A nurse practitioner shall post a notice in a conspicuous location accessible to public view that the nurse practitioner is regulated by the Board of Registered Nursing. The notice shall include the board’s telephone number and internet website where the nurse practitioner’s license may be checked and complaints against the nurse practitioner may be made.

(f)

(g) A nurse practitioner practicing pursuant to this section shall maintain professional liability insurance appropriate for the practice setting.

(g)

(h) For purposes of this section, corporations and other artificial legal entities shall have no professional rights, privileges, or powers.

(h)

(i) Subdivision (g) (h) shall not apply to a nurse practitioner if either of the following apply:
(1) The certificate issued pursuant to this section is inactive, surrendered, revoked, or otherwise restricted by the board.
(2) The nurse practitioner is employed pursuant to the exemptions under Section 2401.

SEC. 6.

 Section 3703 of the Business and Professions Code is amended to read:

3703.
 (a) The settings in which respiratory care may be practiced include licensed health care facilities, hospitals, clinics, ambulatory or home health care, physicians’ offices, nurse practitioners’ offices, and public or community health services. Respiratory care may also be provided during the transportation of a patient, and under any circumstances where an emergency necessitates respiratory care.
(b) The practice of respiratory care shall be performed under the supervision of a medical director in accordance with a prescription of a physician and surgeon or pursuant to respiratory care protocols as specified in Section 3702.

SEC. 7.

 Section 4024 of the Business and Professions Code is amended to read:

4024.
 (a) Except as provided in subdivision (b), “dispense” means the furnishing of drugs or devices upon a prescription from a physician, nurse practitioner practicing pursuant to Section 2837.103 or 2837.104, dentist, optometrist, podiatrist, veterinarian, or naturopathic doctor pursuant to Section 3640.7, or upon an order to furnish drugs or transmit a prescription from a certified nurse-midwife, nurse practitioner, including a nurse practitioner practicing pursuant to Section 2837.103 or 2837.104, practitioner pursuant to Section 2836.1, physician assistant, naturopathic doctor pursuant to Section 3640.5, or pharmacist acting within the scope of their practice.
(b) “Dispense” also means and refers to the furnishing of drugs or devices directly to a patient by a physician, nurse practitioner practicing pursuant to Section 2837.103 or 2837.104, dentist, optometrist, podiatrist, or veterinarian, or by a certified nurse-midwife, nurse practitioner, including a nurse practitioner practicing pursuant to Section 2837.103 or 2837.104, practitioner pursuant to Section 2836.1, naturopathic doctor, or physician assistant acting within the scope of their practice.

SEC. 8.

 Section 4040 of the Business and Professions Code is amended to read:

4040.
 (a) “Prescription” means an oral, written, or electronic transmission order that is both of the following:
(1) Given individually for the person or persons for whom ordered that includes all of the following:
(A) The name or names and address of the patient or patients.
(B) The name and quantity of the drug or device prescribed and the directions for use.
(C) The date of issue.
(D) Either rubber stamped, typed, or printed by hand or typeset, the name, address, and telephone number of the prescriber, their license classification, and their federal registry number, if a controlled substance is prescribed.
(E) A legible, clear notice of the condition or purpose for which the drug is being prescribed, if requested by the patient or patients.
(F) If in writing, signed by the prescriber issuing the order, or the certified nurse-midwife, nurse practitioner, physician assistant, or naturopathic doctor who issues a drug order pursuant to Section 2746.51, 2836.1, 3502.1, or 3640.5, respectively, or the pharmacist who issues a drug order pursuant to Section 4052.1, 4052.2, or 4052.6.
(2) Issued by a physician, dentist, optometrist, podiatrist, veterinarian, nurse practitioner practicing pursuant to Section 2837.103 or 2837.104, or naturopathic doctor pursuant to Section 3640.7 or, if a drug order is issued pursuant to Section 2746.51, 2836.1, 3502.1, or 3460.5, by a certified nurse-midwife, nurse practitioner, physician assistant, or naturopathic doctor licensed in this state, or pursuant to Section 4052.1, 4052.2, or 4052.6 by a pharmacist licensed in this state.
(b) Notwithstanding subdivision (a), a written order of the prescriber for a dangerous drug, except for any Schedule II controlled substance, that contains at least the name and signature of the prescriber, the name and address of the patient in a manner consistent with paragraph (2) of subdivision (a) of Section 11164 of the Health and Safety Code, the name and quantity of the drug prescribed, directions for use, and the date of issue may be treated as a prescription by the dispensing pharmacist as long as any additional information required by subdivision (a) is readily retrievable in the pharmacy. In the event of a conflict between this subdivision and Section 11164 of the Health and Safety Code, Section 11164 of the Health and Safety Code shall prevail.
(c) “Electronic transmission prescription” includes both image and data prescriptions. “Electronic image transmission prescription” means any prescription order for which a facsimile of the order is received by a pharmacy from a licensed prescriber. “Electronic data transmission prescription” means any prescription order, other than an electronic image transmission prescription, that is electronically transmitted from a licensed prescriber to a pharmacy.
(d) The use of commonly used abbreviations shall not invalidate an otherwise valid prescription.
(e) Nothing in the amendments made to this section (formerly Section 4036) at the 1969 Regular Session of the Legislature shall be construed as expanding or limiting the right that a chiropractor, while acting within the scope of their license, may have to prescribe a device.

SEC. 9.

 Section 4060 of the Business and Professions Code is amended to read:

4060.
 A person shall not possess any controlled substance, except that furnished to a person upon the prescription of a physician, dentist, podiatrist, optometrist, veterinarian, nurse practitioner practicing pursuant to Section 2837.103 or 2837.104, or naturopathic doctor pursuant to Section 3640.7, or furnished pursuant to a drug order issued by a certified nurse-midwife pursuant to Section 2746.51, a nurse practitioner pursuant to Section 2836.1, a physician assistant pursuant to Section 3502.1, a naturopathic doctor pursuant to Section 3640.5, or a pharmacist pursuant to Section 4052.1, 4052.2, or 4052.6. This section does not apply to the possession of any controlled substance by a manufacturer, wholesaler, third-party logistics provider, pharmacy, pharmacist, physician, podiatrist, dentist, optometrist, veterinarian, naturopathic doctor, certified nurse-midwife, nurse practitioner, or physician assistant, if in stock in containers correctly labeled with the name and address of the supplier or producer.
This section does not authorize a certified nurse-midwife, a nurse practitioner pursuant to Section 2836.1, a physician assistant, or a naturopathic doctor, to order their own stock of dangerous drugs and devices.

SEC. 10.

 Section 4061 of the Business and Professions Code is amended to read:

4061.
 (a) No manufacturer’s sales representative shall distribute any dangerous drug or dangerous device as a complimentary sample without the written request of a physician, dentist, podiatrist, optometrist, veterinarian, nurse practitioner practicing pursuant to Section 2837.103 or 2837.104, or naturopathic doctor pursuant to Section 3640.7. However, a certified nurse-midwife who functions pursuant to a standardized procedure or protocol described in Section 2746.51, a nurse practitioner who functions pursuant to a standardized procedure described in Section 2836.1, or protocol, a physician assistant who functions pursuant to a protocol described in Section 3502.1, or a naturopathic doctor who functions pursuant to a standardized procedure or protocol described in Section 3640.5, may sign for the request and receipt of complimentary samples of a dangerous drug or dangerous device that has been identified in the standardized procedure, protocol, or practice agreement. Standardized procedures, protocols, and practice agreements shall include specific approval by a physician. A review process, consistent with the requirements of Section 2725, 3502.1, or 3640.5, of the complimentary samples requested and received by a nurse practitioner practicing pursuant to Section 2836.1, certified nurse-midwife, physician assistant, or naturopathic doctor, shall be defined within the standardized procedure, protocol, or practice agreement.
(b) Each written request shall contain the names and addresses of the supplier and the requester, the name and quantity of the specific dangerous drug desired, the name of the certified nurse-midwife, nurse practitioner, physician assistant, or naturopathic doctor, if applicable, receiving the samples pursuant to this section, the date of receipt, and the name and quantity of the dangerous drugs or dangerous devices provided. These records shall be preserved by the supplier with the records required by Section 4059.
(c) Nothing in this section is intended to expand the scope of practice of a certified nurse-midwife, nurse practitioner, physician assistant, or naturopathic doctor.

SEC. 11.

 Section 4170 of the Business and Professions Code is amended to read:

4170.
 (a) A prescriber shall not dispense drugs or dangerous devices to patients in the prescriber’s office or place of practice unless all of the following conditions are met:
(1) The dangerous drugs or dangerous devices are dispensed to the prescriber’s own patient, and the drugs or dangerous devices are not furnished by a nurse or physician attendant.
(2) The dangerous drugs or dangerous devices are necessary in the treatment of the condition for which the prescriber is attending the patient.
(3) The prescriber does not keep a pharmacy, open shop, or drugstore, advertised or otherwise, for the retailing of dangerous drugs, dangerous devices, or poisons.
(4) The prescriber fulfills all of the labeling requirements imposed upon pharmacists by Section 4076, all of the recordkeeping requirements of this chapter, and all of the packaging requirements of good pharmaceutical practice, including the use of childproof containers.
(5) The prescriber does not use a dispensing device unless the prescriber personally owns the device and the contents of the device, and personally dispenses the dangerous drugs or dangerous devices to the patient packaged, labeled, and recorded in accordance with paragraph (4).
(6) The prescriber, prior to dispensing, offers to give a written prescription to the patient that the patient may elect to have filled by the prescriber or by any pharmacy.
(7) The prescriber provides the patient with written disclosure that the patient has a choice between obtaining the prescription from the dispensing prescriber or obtaining the prescription at a pharmacy of the patient’s choice.
(8) A certified nurse-midwife who functions pursuant to a standardized procedure or protocol described in Section 2746.51, a nurse practitioner who functions pursuant to a standardized procedure described in Section 2836.1, or protocol, a physician assistant who functions pursuant to Section 3502.1, or a naturopathic doctor who functions pursuant to Section 3640.5, may hand to a patient of the supervising physician and surgeon a properly labeled prescription drug prepackaged by a physician and surgeon, a manufacturer as defined in this chapter, or a pharmacist.
(b) The Medical Board of California, the State Board of Optometry, the Bureau of Naturopathic Medicine, the Dental Board of California, the Podiatric Medical Board of California, the Osteopathic Medical Board of California, the Board of Registered Nursing, the Veterinary Medical Board, and the Physician Assistant Committee shall have authority with the California State Board of Pharmacy to ensure compliance with this section, and those boards are specifically charged with the enforcement of this chapter with respect to their respective licensees.
(c) “Prescriber,” as used in this section, means a person, who holds a physician’s and surgeon’s certificate, a license to practice optometry, a license to practice naturopathic medicine, a license to practice dentistry, a license to practice veterinary medicine, a certificate to practice podiatry, or is a nurse practitioner practicing pursuant to Section 2837.103 or 2837.104, and who is duly registered by the Medical Board of California, the Osteopathic Medical Board of California, the State Board of Optometry, the Bureau of Naturopathic Medicine, the Dental Board of California, the Veterinary Medical Board, the Podiatric Medical Board of California, or the Board of Registered Nursing.

SEC. 12.

 Section 4174 of the Business and Professions Code is amended to read:

4174.
 Notwithstanding any other law, a pharmacist may dispense drugs or devices upon the drug order of a nurse practitioner functioning pursuant to Section 2836.1, 2837.103, or 2837.104, or a certified nurse-midwife functioning pursuant to Section 2746.51, a drug order of a physician assistant functioning pursuant to Section 3502.1 or a naturopathic doctor functioning pursuant to Section 3640.5, or the order of a pharmacist acting under Section 4052.1, 4052.2, 4052.3, or 4052.6.

SEC. 13.

 Section 1157 of the Evidence Code is amended to read:

1157.
 (a) Neither the proceedings nor the records of organized committees of medical, medical-dental, podiatric, registered dietitian, psychological, marriage and family therapist, licensed clinical social worker, professional clinical counselor, pharmacist, or nurse practitioner, or veterinary staffs in hospitals, or of a peer review body, as defined in Section 805 of the Business and Professions Code, having the responsibility of evaluation and improvement of the quality of care rendered in the hospital, or for that peer review body, or medical or dental review or dental hygienist review or chiropractic review or podiatric review or registered dietitian review or pharmacist review or nurse practitioner review or veterinary review or acupuncturist review or licensed midwife review committees of local medical, dental, dental hygienist, podiatric, dietetic, pharmacist, nurse practitioner, veterinary, acupuncture, or chiropractic societies, marriage and family therapist, licensed clinical social worker, professional clinical counselor, or psychological review committees of state or local marriage and family therapist, state or local licensed clinical social worker, state or local licensed professional clinical counselor, or state or local psychological associations or societies or licensed midwife associations or societies having the responsibility of evaluation and improvement of the quality of care, shall be subject to discovery. For purposes of this section, “nurse practitioner” means a nurse practitioner practicing pursuant to Section 2837.103 or 2837.104 of the Business and Professions Code.
(b) Except as hereinafter provided, a person in attendance at a meeting of any of the committees described in subdivision (a) shall not be required to testify as to what transpired at that meeting.
(c) The prohibition relating to discovery or testimony does not apply to the statements made by a person in attendance at a meeting of any of the committees described in subdivision (a) if that person is a party to an action or proceeding the subject matter of which was reviewed at that meeting, to a person requesting hospital staff privileges, or in an action against an insurance carrier alleging bad faith by the carrier in refusing to accept a settlement offer within the policy limits.
(d) The prohibitions in this section do not apply to medical, dental, dental hygienist, podiatric, dietetic, psychological, marriage and family therapist, licensed clinical social worker, professional clinical counselor, pharmacist, nurse practitioner, veterinary, acupuncture, midwifery, or chiropractic society committees that exceed 10 percent of the membership of the society, nor to any of those committees if a person serves upon the committee when the person’s own conduct or practice is being reviewed.
(e) The amendments made to this section by Chapter 1081 of the Statutes of 1983, or at the 1985 portion of the 1985–86 Regular Session of the Legislature, at the 1990 portion of the 1989–90 Regular Session of the Legislature, at the 2000 portion of the 1999–2000 Regular Session of the Legislature, at the 2011 portion of the 2011–12 Regular Session of the Legislature, at the 2015 portion of the 2015–16 Regular Session of the Legislature, or at the 2021 portion of the 2021–2022 Regular Session of the Legislature, do not exclude the discovery or use of relevant evidence in a criminal action.