Amendment SSA1-SB394

LRBs0225/1

KP/MED/TJD:emw

2021 - 2022 LEGISLATURE

SENATE SUBSTITUTE AMENDMENT 1, TO SENATE BILL 394

November 10, 2021 - Offered by Senator Testin.

SB394-SSA1,2,20 An Act to repeal 50.01 (1b), 77.54 (14) (f) 3., 118.2925 (1) (b), 146.89 (1) (r) 8., 252.01 (1c), 440.03 (13) (b) 3., 440.03 (13) (b) 42., 440.08 (2) (a) 4m., 440.08 (2) (a) 50., 441.11 (title), 441.11 (1), 441.11 (3), 441.15, 441.16, 441.19, 448.035 (1) (a) and 450.01 (1m); to renumber and amend 146.89 (1) (r) 3., 253.13 (1), 255.06 (1) (d), 441.06 (7) and 441.11 (2); to amend 14.87 (title), 29.193 (1m) (a) 2. (intro.), 29.193 (2) (b) 2., 29.193 (2) (c) 3., 29.193 (2) (cd) 2. b., 29.193 (2) (cd) 2. c., 29.193 (2) (e), 29.193 (3) (a), 45.40 (1g) (a), 46.03 (44), 50.08 (2), 50.09 (1) (a) (intro.), 50.09 (1) (f) 1., 50.09 (1) (h), 50.09 (1) (k), 50.49 (1) (b) (intro.), 51.41 (1d) (b) 4., 70.47 (8) (intro.), 77.54 (14) (f) 4., 97.59, 102.13 (1) (a), 102.13 (1) (b) (intro.), 1., 3. and 4., 102.13 (1) (d) 1., 2., 3. and 4., 102.13 (2) (a), 102.13 (2) (b), 102.17 (1) (d) 1. and 2., 102.29 (3), 102.42 (2) (a), 106.30 (1), 118.15 (3) (a), 118.25 (1) (a), 118.29 (1) (e), 118.2925 (3), 118.2925 (4) (c), 118.2925 (5), 146.343 (1) (c), 146.82 (3) (a), 146.89 (1) (r) 1., 146.89 (6), 154.01 (1g), 252.07 (8) (a) 2., 252.07 (9) (c), 252.10 (7), 252.11 (2), (4), (5), (7) and (10), 252.15 (3m) (d) 11. b. and 13., (5g) (c), (5m) (d) 2. and (e) 2. and 3. and (7m) (intro.) and (b), 252.16 (3) (c) (intro.), 252.17 (3) (c) (intro.), 253.07 (4) (d), 253.115 (4), 253.115 (7) (a) (intro.), 253.15 (2), 255.06 (2) (d), 255.07 (1) (d), 257.01 (5) (a) and (b), 341.14 (1a), (1e) (a), (1m) and (1q), 343.16 (5) (a), 343.51 (1), 343.62 (4) (a) 4., 440.094 (1) (c) 1., 440.094 (2) (a) (intro.), 440.981 (1), 440.982 (1), 440.987 (2), 441.01 (3), 441.01 (4), 441.01 (7) (a) (intro.), 441.01 (7) (b), 441.06 (3), 441.06 (4), 441.07 (1g) (intro.), (a), (c) and (e), 441.10 (7), 441.18 (2) (a) (intro.), 441.18 (2) (b), 441.18 (3), subchapter II (title) of chapter 441 [precedes 441.51], 441.51 (title), 448.03 (2) (a), 448.035 (2) to (4), 448.56 (1) and (1m) (b), 448.62 (2m), 448.67 (2), 448.956 (1m), 450.01 (16) (h) 2., 450.01 (16) (hr) 2., 450.03 (1) (e), 450.11 (1g) (b), 450.11 (1i) (a) 1., 450.11 (1i) (b) 2. b., 450.11 (7) (b), 450.11 (8) (e), 450.13 (5) (b), 450.135 (7) (b), 462.04, 655.001 (7t), 655.001 (9), 655.005 (2) (a), 961.01 (19) (a) and 961.395; to repeal and recreate 155.01 (1g) (b) and 441.06 (title); and to create 253.115 (1) (f), 253.13 (1) (a), 253.15 (1) (em), 255.06 (1) (f) 2., 440.03 (13) (b) 39m., 440.08 (2) (a) 47., 441.001 (1c), 441.001 (3c), 441.001 (3g), 441.001 (3n), 441.001 (3r), 441.001 (3w), 441.001 (5), 441.01 (7) (c), 441.09 and 441.092 of the statutes; relating to: advanced practice registered nurses, extending the time limit for emergency rule procedures, providing an exemption from emergency rule procedures, and granting rule-making authority.

Analysis by the Legislative Reference Bureau

Nursing practice and licensure

This bill makes various changes to practice, licensure, and certification requirements for nurses, which are administered by the Board of Nursing.

Licensure of advanced practice registered nurses

Under current law, a person who wishes to practice professional nursing must be licensed by the Board of Nursing as a registered nurse (RN). This bill creates an additional system of licensure for advanced practice registered nurses (APRNs), to be administered by the board. Under the bill, in order to apply for an APRN license, a person must 1) hold, or concurrently apply for, an RN license; 2) have completed an accredited graduate-level or postgraduate-level education program preparing the person to practice as an APRN in one of four recognized roles and hold a current national certification approved by the board; 3) possess malpractice liability insurance in an amount determined as provided in the bill; 4) pay a fee determined by the Department of Safety and Professional Services; and 5) satisfy certain other criteria specified in the bill. The bill also allows a person who has not completed an accredited education program described above to receive an APRN license if the person 1) on January 1, 2022, is both licensed as an RN in Wisconsin and practicing in one of the four recognized roles; and 2) satisfies additional practice or education criteria established by the board. The bill also, however, automatically grants licenses to certain RNs, as further described below. The four recognized roles, as defined in the bill, are 1) certified nurse-midwife; 2) certified registered nurse anesthetist; 3) clinical nurse specialist; and 4) nurse practitioner. The bill requires the board, upon granting a person an APRN license, to also grant the person one or more specialty designations corresponding to the recognized role or roles for which the person qualifies.

The holder of an APRN license may append the title “A.P.R.N." to his or her name, as well as a title corresponding to whichever specialty designations that the person possesses. The bill prohibits any person from using the title “A.P.R.N.," and from otherwise indicating that he or she is an APRN, unless the person is licensed by the board as an APRN. The bill also prohibits the use of titles and abbreviations corresponding to a recognized role unless the person has a specialty designation for that role. However, the bill allows an APRN to delegate a task or order to another clinically trained health care worker if the task or order is within the scope of the APRN's practice, the APRN is competent to perform the task or issue the order, and the APRN has reasonable evidence that the health care worker is minimally competent to perform the task or issue the order under the circumstances. The bill requires an APRN to adhere to professional standards when managing situations that are beyond the APRN's expertise.

Under the bill, when an APRN renews his or her APRN license, the board must grant the person the renewal of both the person's RN license and the person's APRN license. The bill requires all APRNs to complete continuing education requirements each biennium in clinical pharmacology or therapeutics relevant to the APRN's area of practice and to satisfy certain other requirements when renewing a license.

Practice of nurse-midwifery

This bill repeals licensure and practice requirements specific to nurse-midwives and the practice of nurse-midwifery, including specific requirements to practice with an obstetrician. Under the bill, “certified nurse-midwife" is one of the four recognized roles for APRNs, and a person who is licensed as a nurse-midwife under current law is automatically granted an APRN license with a certified nurse-midwife specialty designation. The bill otherwise allows nurse-midwives to be licensed as APRNs if they satisfy the licensure requirements, except that the bill also requires that a person applying for a certified nurse-midwife specialty designation be certified by the American Midwifery Certification Board. The bill also requires an APRN with a specialty designation as a certified nurse-midwife to file with the board, and obtain the board's approval of, a plan for ensuring appropriate care or care transitions in treating certain patients if the APRN offers to deliver babies outside of a hospital setting.

Prescribing authority

Under current law, a person licensed as an RN may apply to the board for a certificate to issue prescription orders if the person meets certain requirements established by the board. An RN holding a certificate is subject to various practice requirements and limitations established by the board and must possess malpractice liability insurance in an amount determined by the board.

The bill eliminates certificates to issue prescription orders and generally authorizes APRNs to issue prescription orders. A person who is certified to issue prescription orders under current law is automatically granted an APRN license with his or her appropriate specialty designation. RNs who are practicing in a recognized role on January 1, 2022, but who do not hold a certificate to issue prescription orders on that date and who are granted an APRN license under the bill may not issue prescription orders. As under current law, an APRN issuing prescription orders is subject to various practice requirements and limitations established by the board.

The bill repeals a provision concerning the ability of advanced practice nurses who are certified to issue prescription orders and who are required to work in collaboration with or under the supervision of a physician to obtain and practice under a federal waiver to dispense narcotic drugs to individuals for addiction treatment.

Other changes

The bill makes numerous other changes throughout the statutes relating to APRNs, including various terminology changes and technical changes relating to the Nurse Licensure Compact.

The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:

SB394-SSA1,1 Section 1 . 14.87 (title) of the statutes is amended to read:

SB394-SSA1,4,2 14.87 (title) Enhanced nurse Nurse licensure compact.

SB394-SSA1,2 Section 2 . 29.193 (1m) (a) 2. (intro.) of the statutes is amended to read:

SB394-SSA1,5,5 29.193 (1m) (a) 2. (intro.) Has a permanent substantial loss of function in one or both arms or one or both hands and fails to meet the minimum standards of any one of the following standard tests, administered under the direction of a licensed physician, a licensed physician assistant, a licensed chiropractor, or a certified licensed advanced practice registered nurse prescriber:

SB394-SSA1,3 Section 3 . 29.193 (2) (b) 2. of the statutes is amended to read:

SB394-SSA1,5,12 29.193 (2) (b) 2. An applicant shall submit an application on a form prepared and furnished by the department, which shall include a written statement or report prepared and signed by a licensed physician, a licensed physician assistant, a licensed chiropractor, a licensed podiatrist, or a certified licensed advanced practice registered nurse prescriber prepared no more than 6 months preceding the application and verifying that the applicant is physically disabled.

SB394-SSA1,4 Section 4 . 29.193 (2) (c) 3. of the statutes is amended to read:

SB394-SSA1,5,25 29.193 (2) (c) 3. The department may issue a Class B permit to an applicant who is ineligible for a permit under subd. 1., 2. or 2m. or who is denied a permit under subd. 1., 2. or 2m. if, upon review and after considering the physical condition of the applicant and the recommendation of a licensed physician, a licensed physician assistant, a licensed chiropractor, a licensed podiatrist, or a certified licensed advanced practice registered nurse prescriber selected by the applicant from a list of licensed physicians, licensed physician assistants, licensed chiropractors, licensed podiatrists, and certified licensed advanced practice nurse prescribers registered nurses compiled by the department, the department finds that issuance of a permit complies with the intent of this subsection. The use of this review procedure is discretionary with the department and all costs of the review procedure shall be paid by the applicant.

SB394-SSA1,5 Section 5. 29.193 (2) (cd) 2. b. of the statutes is amended to read:

SB394-SSA1,6,7 29.193 (2) (cd) 2. b. The person has a permanent substantial loss of function in one or both arms and fails to meet the minimum standards of the standard upper extremity pinch test, the standard grip test, or the standard nine-hole peg test, administered under the direction of a licensed physician, a licensed physician assistant, a licensed chiropractor, or a certified licensed advanced practice registered nurse prescriber.

SB394-SSA1,6 Section 6 . 29.193 (2) (cd) 2. c. of the statutes is amended to read:

SB394-SSA1,6,13 29.193 (2) (cd) 2. c. The person has a permanent substantial loss of function in one or both shoulders and fails to meet the minimum standards of the standard shoulder strength test, administered under the direction of a licensed physician, a licensed physician assistant, a licensed chiropractor, or a certified licensed advanced practice registered nurse prescriber.

SB394-SSA1,7 Section 7 . 29.193 (2) (e) of the statutes is amended to read:

SB394-SSA1,6,24 29.193 (2) (e) Review of decisions. An applicant denied a permit under this subsection, except a permit under par. (c) 3., may obtain a review of that decision by a licensed physician, a licensed physician assistant, a licensed chiropractor, a licensed podiatrist, or a certified licensed advanced practice registered nurse prescriber designated by the department and with an office located in the department district in which the applicant resides. The department shall pay for the cost of a review under this paragraph unless the denied application on its face fails to meet the standards set forth in par. (c) 1. or 2. A review under this paragraph is the only method of review of a decision to deny a permit under this subsection and is not subject to further review under ch. 227.

SB394-SSA1,8 Section 8 . 29.193 (3) (a) of the statutes is amended to read:

SB394-SSA1,7,4 29.193 (3) (a) Produces a certificate from a licensed physician, a licensed physician assistant, a licensed optometrist, or a certified licensed advanced practice registered nurse prescriber stating that his or her sight is impaired to the degree that he or she cannot read ordinary newspaper print with or without corrective glasses.

SB394-SSA1,9 Section 9 . 45.40 (1g) (a) of the statutes is amended to read:

SB394-SSA1,7,10 45.40 (1g) (a) “Health care provider" means an advanced practice registered nurse prescriber certified who may issue prescription orders under s. 441.16 441.09 (2), an audiologist licensed under ch. 459, a dentist licensed under ch. 447, an optometrist licensed under ch. 449, a physician licensed under s. 448.02, or a podiatrist licensed under s. 448.63.

SB394-SSA1,10 Section 10 . 46.03 (44) of the statutes, as affected by 2021 Wisconsin Act 23, is amended to read:

SB394-SSA1,7,22 46.03 (44) Sexually transmitted disease treatment information. Prepare and keep current an information sheet to be distributed to a patient by a physician, a physician assistant, or certified an advanced practice registered nurse prescriber who may issue prescription orders under s. 441.09 (2) providing expedited partner therapy to that patient under s. 441.092, 448.035 , or 448.9725. The information sheet shall include information about sexually transmitted diseases and their treatment and about the risk of drug allergies. The information sheet shall also include a statement advising a person with questions about the information to contact his or her physician, advanced practice registered nurse, pharmacist, or local health department, as defined in s. 250.01 (4).

SB394-SSA1,11 Section 11. 50.01 (1b) of the statutes is repealed.

SB394-SSA1,12 Section 12 . 50.08 (2) of the statutes, as affected by 2021 Wisconsin Act 23, is amended to read:

SB394-SSA1,8,5 50.08 (2) A physician, an advanced practice registered nurse prescriber certified who may issue prescription orders under s. 441.16 441.09 (2), or a physician assistant who prescribes a psychotropic medication to a nursing home resident who has degenerative brain disorder shall notify the nursing home if the prescribed medication has a boxed warning under 21 CFR 201.57.

SB394-SSA1,13 Section 13 . 50.09 (1) (a) (intro.) of the statutes is amended to read:

SB394-SSA1,8,14 50.09 (1) (a) (intro.) Private and unrestricted communications with the resident's family, physician, physician assistant, advanced practice registered nurse prescriber, attorney, and any other person, unless medically contraindicated as documented by the resident's physician, physician assistant, or advanced practice registered nurse prescriber in the resident's medical record, except that communications with public officials or with the resident's attorney shall not be restricted in any event. The right to private and unrestricted communications shall include, but is not limited to, the right to:

SB394-SSA1,14 Section 14 . 50.09 (1) (f) 1. of the statutes is amended to read:

SB394-SSA1,8,20 50.09 (1) (f) 1. Privacy for visits by spouse or domestic partner. If both spouses or both domestic partners under ch. 770 are residents of the same facility, the spouses or domestic partners shall be permitted to share a room unless medically contraindicated as documented by the resident's physician, physician assistant, or advanced practice registered nurse prescriber in the resident's medical record.

SB394-SSA1,15 Section 15 . 50.09 (1) (h) of the statutes is amended to read:

SB394-SSA1,8,25 50.09 (1) (h) Meet with, and participate in activities of social, religious, and community groups at the resident's discretion, unless medically contraindicated as documented by the resident's physician, physician assistant, or advanced practice registered nurse prescriber in the resident's medical record.

SB394-SSA1,16 Section 16. 50.09 (1) (k) of the statutes is amended to read:

SB394-SSA1,9,13 50.09 (1) (k) Be free from mental and physical abuse, and be free from chemical and physical restraints except as authorized in writing by a physician, physician assistant, or advanced practice registered nurse prescriber for a specified and limited period of time and documented in the resident's medical record. Physical restraints may be used in an emergency when necessary to protect the resident from injury to himself or herself or others or to property. However, authorization for continuing use of the physical restraints shall be secured from a physician, physician assistant, or advanced practice registered nurse prescriber within 12 hours. Any use of physical restraints shall be noted in the resident's medical records. “ Physical restraints" includes, but is not limited to, any article, device, or garment that interferes with the free movement of the resident and that the resident is unable to remove easily, and confinement in a locked room.

SB394-SSA1,17 Section 17 . 50.49 (1) (b) (intro.) of the statutes is amended to read:

SB394-SSA1,9,23 50.49 (1) (b) (intro.) “Home health services" means the following items and services that are furnished to an individual, who is under the care of a physician, physician assistant, or advanced practice registered nurse prescriber, by a home health agency, or by others under arrangements made by the home health agency, that are under a plan for furnishing those items and services to the individual that is established and periodically reviewed by a physician, physician assistant, or advanced practice registered nurse prescriber and that are, except as provided in subd. 6., provided on a visiting basis in a place of residence used as the individual's home:

SB394-SSA1,18 Section 18 . 51.41 (1d) (b) 4. of the statutes is amended to read:

SB394-SSA1,10,10 51.41 (1d) (b) 4. A psychiatric mental health advanced practice registered nurse who is suggested by the Milwaukee County board of supervisors. The Milwaukee County board of supervisors shall solicit suggestions from organizations including the Wisconsin Nurses Association for individuals who specialize in a full continuum of behavioral health and medical services including emergency detention, inpatient, residential, transitional, partial hospitalization, intensive outpatient, and wraparound community-based services. The Milwaukee County board of supervisors shall suggest to the Milwaukee County executive 4 psychiatric mental health advanced practice registered nurses for this board membership position.

SB394-SSA1,19 Section 19 . 70.47 (8) (intro.) of the statutes, as affected by 2021 Wisconsin Act 23, is amended to read:

SB394-SSA1,10,25 70.47 (8) Hearing. (intro.) The board shall hear upon oath all persons who appear before it in relation to the assessment. Instead of appearing in person at the hearing, the board may allow the property owner, or the property owner's representative, at the request of either person, to appear before the board, under oath, by telephone or to submit written statements, under oath, to the board. The board shall hear upon oath, by telephone, all ill or disabled persons who present to the board a letter from a physician, physician assistant, or advanced practice registered nurse prescriber certified under s. 441.16 (2) licensed under ch. 441 that confirms their illness or disability. At the request of the property owner or the property owner's representative, the board may postpone and reschedule a hearing under this subsection, but may not postpone and reschedule a hearing more than once during the same session for the same property. The board at such hearing shall proceed as follows:

SB394-SSA1,20 Section 20. 77.54 (14) (f) 3. of the statutes is repealed.

SB394-SSA1,21 Section 21 . 77.54 (14) (f) 4. of the statutes is amended to read:

SB394-SSA1,11,4 77.54 (14) (f) 4. An advanced practice registered nurse who may issue prescription orders under s. 441.09 (2).

SB394-SSA1,22 Section 22 . 97.59 of the statutes is amended to read: