AB154: Bill Text

LRB-2341/1

JPC&MED:amn

2023 - 2024 LEGISLATURE

2023 Assembly BILL 154

April 10, 2023 - Introduced by Representatives Magnafici, Armstrong, Behnke, Bodden, Dittrich, Donovan, Green, Gundrum, Gustafson, S. Johnson, Kitchens, Krug, Kurtz, Macco, Murphy, Novak, Rodriguez, Schmidt, Schraa, Schutt, Sortwell, Steffen, Tittl, Tusler, Wichgers and Nedweski, cosponsored by Senators Testin, Cabral-Guevara, Roys, Ballweg, Cowles, Felzkowski, Jacque, Marklein, Nass, Quinn, Stroebel and Taylor. Referred to Committee on Health, Aging and Long-Term Care.

AB154,3,2 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), 450.01 (1m) and 655.001 (9); to renumber 655.001 (1); 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 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), 146.615 (1) (a), 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) and (7), 252.11 (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., 440.077 (1) (a), 440.077 (2) (c), 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), 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), 655.002 (1) (a), 655.002 (1) (b), 655.002 (1) (c), 655.002 (1) (d), 655.002 (1) (e), 655.002 (1) (em), 655.002 (2) (a), 655.002 (2) (b), 655.003 (1), 655.003 (3), 655.005 (2) (a), 655.005 (2) (b), 655.23 (5m), 655.27 (3) (a) 4., 655.27 (3) (b) 2m., 655.275 (2), 655.275 (5) (b) 2., 961.01 (19) (a) and 961.395; to repeal and recreate 155.01 (1g) (b), 251.01 (1c) 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) 47r., 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, 441.092 and 655.001 (1g) 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 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, 2024, 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.

Under the bill, all APRNs, except APRNs with a certified nurse-midwife specialty designation, must practice in collaboration with a physician or dentist. However, under the bill, an APRN may practice without being supervised by a physician or dentist if the Board of Nursing verifies that the APRN has completed 3,840 clinical hours of advanced practice registered nursing practice in their recognized role while working with a physician or dentist during those 3,840 hours of practice. APRNs with a certified nurse-midwife specialty designation are instead required, if they offer to deliver babies outside of a hospital setting, to file and keep current with the board a proactive plan for involving a hospital or a physician who has admitting privileges at a hospital in the treatment of patients with higher acuity or emergency care needs, as further described below. Additionally, under the bill, an APRN may provide pain management services only while working in a collaborative relationship with a physician or, if the APRN has qualified to practice independently, in a hospital or clinic associated with a hospital.

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, 2024, 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.

Malpractice liability insurance

The bill requires all APRNs to maintain malpractice liability insurance in coverage amounts specified under current law for physicians and nurse anesthetists except for APRNs whose employer has in effect malpractice liability insurance that provides the same amount of coverage for the APRN. Additionally, the bill requires APRNs who have qualified to practice independently and who practice outside a collaborative or employment relationship, but not including those APRNs who only practice as a certified nurse-midwife, to participate in the Injured Patients and Families Compensation Fund. The Injured Patients and Families Compensation Fund provides excess medical malpractice coverage for health care providers who participate in the fund and meet all other participation requirements, which includes maintaining malpractice liability insurance in coverage amounts specified under current law.

Other changes

The bill makes numerous other changes throughout the statutes relating to APRNs, including various terminology changes.

For further information see the state fiscal estimate, which will be printed as an appendix to this bill.

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

AB154,1 Section 1 . 29.193 (1m) (a) 2. (intro.) of the statutes is amended to read:

AB154,5,6 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:

AB154,2 Section 2 . 29.193 (2) (b) 2. of the statutes is amended to read:

AB154,6,6 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.

AB154,3 Section 3 . 29.193 (2) (c) 3. of the statutes is amended to read:

AB154,6,19 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.

AB154,4 Section 4 . 29.193 (2) (cd) 2. b. of the statutes is amended to read:

AB154,7,2 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.

AB154,5 Section 5 . 29.193 (2) (cd) 2. c. of the statutes is amended to read:

AB154,7,8 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.

AB154,6 Section 6 . 29.193 (2) (e) of the statutes is amended to read:

AB154,7,19 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.

AB154,7 Section 7 . 29.193 (3) (a) of the statutes is amended to read:

AB154,7,24 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.

AB154,8 Section 8 . 45.40 (1g) (a) of the statutes is amended to read:

AB154,8,5 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.

AB154,9 Section 9 . 46.03 (44) of the statutes is amended to read:

AB154,8,16 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).

AB154,10 Section 10 . 50.01 (1b) of the statutes is repealed.

AB154,11 Section 11 . 50.08 (2) of the statutes is amended to read:

AB154,8,23 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.

AB154,12 Section 12 . 50.09 (1) (a) (intro.) of the statutes is amended to read: