SS/HB 402 - This act modifies several provisions relating to health care, including: (1) Rare Kidney Disease Awareness Month; (2) emergency services; (3) do-not-resuscitate orders; (4) patient examinations; (5) health care advisory committees; (6) health professional loans and grants; (7) the Missouri Parkinson's Disease Registry Act; (8) voluntary nonopioid directive forms; (9) licensing of certain health care professionals; (10) prescription labeling requirements; (11) pharmacy settlements; (12) rural emergency hospitals; (13) at-risk behavioral health patients; (14) surgical smoke plume; (15) county or township-owned nursing homes; (16) supplemental welfare assistance; (17) fentanyl testing; (18) mental health services for vulnerable persons; (19) notarization requirements for certain mental health detentions; and (20) lead poisoning. RARE KIDNEY DISEASE AWARENESS MONTH (Section 9.384) This act establishes March of each year as "Rare Kidney Disease Awareness Month" in Missouri. This provision is substantially similar to a provision in the truly agreed to and finally passed HCS/SS/SCS/SB 106 (2023) and the truly agreed to and finally passed CCS/HCS/SS/SCS/SBs 45 & 90 (2023) EMERGENCY SERVICES (Sections 67.145, 105.500, 190.100, 190.103, 190.142, 190.147, 192.2405, 208.1032, 285.040, 321.225, 321.620, 537.037, 650.320, 650.340, and the repeal of Section 190.134) This act repeals references to ambulance attendants, drivers, emergency medical technician paramedics, mobile emergency medical technicians, emergency medical technician basic, and EMT intermediate and adds references to paramedics in various statutes relating to emergency medical services. These provisions are identical to provisions in the truly agreed to and finally passed SS/HB 402 (2023), the truly agreed to and finally passed CCS/HCS/SB 186 (2023), the truly agreed to and finally passed HCS/SS/SB 24 (2023), and SB 625 (2023). Under current law, emergency medical dispatchers shall complete an emergency medical dispatcher course that meets or exceeds the national curriculum of the U.S. Department of Transportation. This act modifies that training requirement and instead requires emergency medical dispatchers to complete training courses approved by the Missouri 911 Service Board. Additionally, the Service Board shall develop rules and regulations, in collaboration with the State EMS Medical Director's Advisory Committee, relating to the medical aspects of pre-arrival medical instructions. This act makes several technical changes to the emergency medical dispatcher statutes. These provisions are identical to provisions in the truly agreed to and finally passed HCS/SS/SB 24 (2023) and the truly agreed to and finally passed CCS/HCS/SB 186 (2023), SB 449 (2023), and HB 1143 (2022) and substantially similar to HB 2381 (2022). Currently, paramedic training programs used as part of an emergency medical technician license shall be accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP) or hold a CAAHEP letter of review. This act repeals this accreditation requirement and such programs shall instead be accredited as required by the National Registry of Emergency Medical Technicians. This provision is identical to a provision in the truly agreed to and finally passed HCS/SS/SB 24 (2023), the truly agreed to and finally passed CCS/HCS/SB 186 (2023), and SB 534 (2023). DO-NOT-RESUSCITATE ORDERS (Sections 190.600-190.613) This act modifies the "Outside the Hospital Do-Not-Resuscitate Act" by expanding the provisions to cover persons under 18 years of age who have do-not-resuscitate orders issued on their behalf by a parent or legal guardian or by a juvenile or family court under a current provision of law. Such orders shall function as outside the hospital do-not-resuscitate orders unless specifically stated otherwise. Persons who are not subject to civil, criminal, or administrative liability for certain actions taken upon the discovery of an adult outside the hospital do-no-resuscitate orders shall not be subject to such liability in the case of a minor child's do-not-resuscitate order. Emergency services personnel shall be authorized to comply with the minor child's do-not-resuscitate order, except when the minor child, either parent, the legal guardian, or the juvenile or family court expresses to such emergency services personnel in any manner, before or after the onset of a cardiac or respiratory arrest, the desire for the patient to be resuscitated. Under this act, do-not-resuscitate orders from other states or territories, or Transportable Physician Orders for Patient Preferences/Physician Orders for Life-Sustaining Treatment (TPOPP/POLST) forms containing specific do-not-resuscitate provisions, as described in the act, shall be accepted under this section and may be revoked by the patient or patient's representative at any time and by any means. These provisions are identical to SS/SCS/SB 228 (2023), HCS/HB 594 (2023), SCS/HCS/HB 1015 (2023), HCS/SS/SB 198 (2023), HCS/SS/SB 213 (2023), and SS/SCS/SB 228 (2023), substantially similar to provisions in the truly agreed to and finally passed CCS/HCS/SS/SCS/SBs 45 & 90 (2023) and HCS/SS/SCS/SB 106 (2023), and similar to HB 2741 (2022). PATIENT EXAMINATIONS (Section 191.240) Under this act, no health care provider, or any student or trainee under the supervision of a health care provider, shall perform a patient examination, defined as a prostate, anal, or pelvic examination, upon an anesthetized or unconscious patient in a health care facility, unless: (1) the patient or person authorized to make health care decisions for the patient gives specific informed consent for nonmedical purposes, (2) the patient examination is necessary for diagnostic or treatment purposes, (3) the collection of evidence through a forensic examination for a suspected sexual assault is necessary because the evidence will be lost or the patient is unable to give informed consent due to a medical condition, or (4) emergency implied consent, as described in the act, is present. A health care provider shall notify a patient of certain examinations performed. A health care provider who violates the provisions of this act, or who supervises a student or trainee who violates the provisions of this act, shall be subject to disciplinary action by the provider's licensing board. This provision is identical to a provision in the truly agreed to and finally passed CCS/HCS/SS/SCS/SBs 45 & 90 (2023) and substantially similar to provisions in HCS/SS/SB 198 (2023), SCS/HB 283 (2023), the truly agreed to and finally passed HCS/SS/SCS/SB 106 (2023), HB 406 (2023), HB 1031 (2023), HCS/HB 1742 (2022), and SB 746 (2022). HEALTH CARE ADVISORY COMMITTEES (Sections 191.305, 192.745, and 194.300) This act modifies the "Missouri Genetic Advisory Committee", the "Missouri Brain Injury Advisory Council", and the "Organ Donation Advisory Committee", by authorizing the Director of the Department of Health and Senior Services to appoint committee members instead of the Governor. This act also makes a technical changes to the Missouri Brain Injury Advisory Council membership provision. These provisions are identical to SB 494 (2023). HEALTH PROFESSIONAL LOANS AND GRANTS (Sections 191.430-191.450, 191.500-191.550, 191.600, 191.828, 191.831, and 335.203-335.257) The act repeals current law relating to student loans for certain health professional students and establishes the "Health Professional Loan Repayment Program". Under this program, the Department of Health and Senior Services shall provide forgivable loans in order to repay existing loans for eligible educational expenses for health professional students. The Director of the Department shall have the discretion to select the health professionals who are eligible for the forgivable loans in accordance with the greatest need in the best interest of the public. Individuals receiving loans under this program shall agree to serve at least 2 years in an area of defined need as a condition of receipt of the funds, among other criteria that must be met as delineated in the act. An individual who fails to uphold the loan agreement shall be liable for the amount paid to the individual by the Department under this program. Furthermore, if an individual breaches a written contract executed pursuant to this provision by failing to begin or complete his or her service obligation, the state shall be entitled to recover from such person an amount equal to: · The total amount of the loan awarded by the Department or, if the Department had already awarded partial forgiveness at the time of the breach, the amount of the loan not yet forgiven; · The interest on the amount that would be payable if at the time the loan was awarded it was a loan bearing interest at the maximum prevailing rate as determined by the Treasurer of the United States; · An amount equal to any damages incurred by the Department as a result of the breach; and · Any legal fees or associated costs incurred by the Department or the state of Missouri in the collection of damages. The act additionally creates the Health Professional Loan Incentive Fund for the purpose of allowing the Department to provide loans under this provision. The fund will consist of funds appropriated to it by the General Assembly. These provisions are identical to provisions in the truly agreed to and finally passed CCS/HCS/SS/SCS/SBs 45 & 90 (2023), the truly agreed to and finally passed HCS/SS/SCS/SB 106 (2023), the truly agreed to and finally passed CCS/HCS/SS/SCS/SB 157 (2023), the truly agreed to and finally passed HCS/SS/SCS/SB 70 (2023), and HB 542 (2023) and substantially similar to SB 555 (2023). The act modifies the Nursing Education Incentive Program. Under current law, grant awards made under the program are limited to $150,000. This act repeals that limit. Additionally, the State Board of Nursing is required to collect, at the time of any license application or license renewal application, a Nursing Education Incentive Program surcharge from each person licensed or relicensed as a nurse under Missouri law. Such surcharge shall be equal to $1 for practical nurses and $5 for registered professional nurses. The act repeals the Nursing Student Loan Program and the Nursing Student Loan Repayment Program. These provisions are identical to provisions in the truly agreed to and finally passed CCS/HCS/SS/SCS/SBs 45 & 90 (2023), the truly agreed to and finally passed SS/SCS/HCS/HB 417 (2023), the truly agreed to and finally passed HCS/SS/SCS/SB 70 (2023), the truly agreed to and finally passed HCS/SS/SCS/SB 106 (2023), the truly agreed to and finally passed CCS/HCS/SS/SCS/SB 157 (2023), HB 775 (2023), and SB 552 (2023). THE MISSOURI PARKINSON'S DISEASE REGISTRY ACT (Section 191.1820-191.1855) This act establishes the "Missouri Parkinson's Disease Registry Act". Beginning January 1, 2024, the University of Missouri, or any medical research university in a memorandum of understanding with the University, shall establish a Parkinson's disease registry in order to collect data on the incidence of Parkinson's disease in Missouri, as well as other epidemiological data, as described in the act. All patients with Parkinson's disease or similar symptoms shall be given the opportunity to opt out of participation in the registry. The University shall establish an advisory committee in order to assist in the development of the registry and to determine the data to be collected. Beginning August 28, 2024, all cases of Parkinson's disease and similar symptoms diagnosed or treated in Missouri shall be reported to the registry, as described in the act. The University may enter into agreements to share information in the registry with other states, the federal government, local health agencies, or researchers; provided, that the confidentiality of the information is maintained. The registry shall not contain any identifying information about patients. Finally, the University shall provide a report to the General Assembly before January 1 of each year summarizing the year's incidence of the disease by county and other demographic information. This provision is identical to SB 553 (2023) and substantially similar to HB 822 (2023). VOLUNTARY NONOPIOID DIRECTIVE FORM (Section 192.530) Under this act, a patient may execute and file a voluntary nonopioid directive form, developed by the Department of Health and Senior Services, with a health care provider stating that an opioid shall not be administered or prescribed to that patient. The directive may be waived at any time in writing or orally. A health care provider acting in good faith shall not be subject to criminal or civil liability as described in the act. This provision is substantially similar to HB 1286 (2023) and similar to SB 663 (2023). LICENSING OF CERTAIN HEALTH CARE PROFESSIONALS (Sections 195.070, 334.036, 334.104, 334.735, 334.747, 335.016, 335.019, 335.036, 335.046, 335.051, 335.056, 335.076, 335.086, and 335.175) Currently, a requirement for licensure as an assistant physician is that the applicant must be a graduate of any medical school. This act provides that the applicant must be a graduate of a medical school accredited by certain organizations listed in the act. This act repeals a provision of law that authorizes an assistant physician collaborative practice arrangement in any pilot project areas established in which assistant physicians may practice. Additionally, this act authorizes a collaborative practice arrangement between a physician assistant and a physician to delegate prescriptive authority to physician assistant for Schedule II controlled substances for hospice patients and limits prescriptions for Schedule III narcotics to a 5-day supply without refill, as described in the act. This act modifies licensing and collaborative practice arrangements for advanced practice registered nurses (APRNs). Under this act, an APRN may prescribe Schedule II controlled substances for hospice patients, as described in the act. Additionally, collaborative practice arrangements between the APRN and the collaborating physician may waive geographic proximity requirements, as described in the act, including when the arrangement outlines the use of telehealth and when the APRN is providing services in a correctional center. Collaborating physicians or designated physicians shall be present with the APRN for sufficient periods of time, at least once every two weeks, to participate in chart reviews and supervision. Currently, an APRN shall practice with the collaborating physician continuously present for a one-month period when entering into an arrangement with the physician. This act waives that requirement when a primary care or behavioral health physician enters into an arrangement with a primary care or behavioral health APRN, the physician is new to the patient population, and the APRN is familiar with the patient population. Currently, a nurse may be licensed to practice professional or practical nursing. This act adds a license to practice advanced practice nursing and modifies the definitions of APRN and the practice of professional nursing. Additionally, this act specifies the requirements for the advanced practice nursing license, including the requirement that an applicant first hold a current registered professional nurse license, and have completed certain graduate-level programs and certifications, or hold a document of recognition to practice as an APRN that is current as of August 28, 2023. License renewals for APRN licenses and registered professional nurse licenses shall occur at the same time and failure to renew and maintain the registered professional nurse license or failure to provide evidence of an active required certification shall result in the expiration of the APRN license. This act further modifies the names of the specific certifying organizations for nursing specialties. Under this act, the State Board of Registration for the Healing Arts shall make information publicly available about which physicians and other health care providers have entered into collaborative practice arrangements. These provisions are identical to provisions of the truly agreed to and finally passed CCS/HCS/SS/SCS/SB 157 (2023), HCS/SS/SCS/SB 70 (2023), and SS/HCS/HBs 115 & 99 (2023), substantially similar to SCS/SB 79 (2023) and HCS/HB 271 (2023), and similar to provisions in HB 1578 (2022) and HB 693 (2019). PRESCRIPTION LABELING REQUIREMENTS (Sections 195.100 and 334.735) Currently, the name of the collaborating physician for an advanced practice registered nurse or physician assistant shall be included on any label of a controlled substance sold or dispensed by a pharmacist. This act repeals this requirement and only the name of the prescribing health care provider is needed. These provisions are identical to provisions of the truly agreed to and finally passed CCS/HCS/SS/SCS/SB 157 (2023), HCS/SS/SCS/SB 70 (2023), and SS/HCS/HBs 115 & 99 (2023), substantially similar to SCS/SB 79 (2023) and HCS/HB 271 (2023), and similar to provisions in HB 1578 (2022) and HB 693 (2019). PHARMACY SETTLEMENTS (Section 196.1050) This act adds proceeds from opioid settlements with pharmacies to the Opioid Addiction Treatment and Recovery Fund. This provision is identical to a provision in the truly agreed to and finally passed CCS/HCS/SS/SCS/SBs 45 & 90 (2023) and SCS/HCS/HBs 117, 343, & 1091 (2023) and substantially similar to a provision in the truly agreed to and finally passed HCS/SS/SCS/SB 106 (2023). RURAL EMERGENCY HOSPITALS (Sections 197.005 and 197.020) This act modifies the term "hospital" for purposes of licensure to include facilities designated as rural emergency hospitals by the Centers for Medicare and Medicaid Services. This provision is identical to a provision in the truly agreed to and finally passed CCS/HCS/SS/SCS/SBs 45 & 90 (2023), the truly agreed to and finally passed HCS/SS/SB 24 (2023), the truly agreed to and finally passed HCS/SS/SCS/SB 106 (2023), and SB 420 (2023). AT-RISK BEHAVIORAL HEALTH PATIENTS (Section 197.145) Under this act, when an at-risk behavioral health patient receives treatment at a hospital, the treating physician may temporarily hold the patient for further behavioral health assessment and, if necessary, transfer to an appropriate facility, if the physician has reason to believe that the patient is at imminent serious risk of harming themselves or others. A physician employing a temporary hold under this provision, and any other health care professional or other personnel at the hospital working to treat or transfer the patient, as well as any emergency services personnel or law enforcement officers who may be acting to detain or transport the patient under this act shall not be civilly liable for the temporary hold, treatment, or transport of a patient if such actions are carried out in good faith and without gross negligence for a purpose authorized under this act. SURGICAL SMOKE PLUME (Section 197.185) This act requires each hospital and ambulatory surgical center accredited by the Joint Commission that performs procedures that produce surgical smoke plume, on or before January 1, 2026, to adopt and implement policies and procedures required by the Joint Commission to ensure the evacuation of surgical smoke plume by use of a surgical smoke plume evacuation system for each procedure that generates surgical smoke plume from the use of energy-based devices, including, but not limited to, electrosurgery and lasers. This provision is substantially similar to SB 212 (2023), SB 1000 (2022), and HB 1711 (2022). COUNTY OR TOWNSHIP-OWNED NURSING HOMES (Sections 205.375 and 205.377) Currently, county or township-owned nursing homes may be rented or leased for the purpose of operating a nursing home. This act authorizes the county commission or township board to rent or lease the nursing home for the purpose of operating any other health care facility located within the county or township providing nursing care or other medical services to patients, including residents of the county or township. Additionally, this act authorizes county commissions to sell county-owned nursing homes. The proceeds of the sale shall be used to pay any outstanding indebtedness incurred in the purchase, construction, additions, or renovation of the nursing home. If the proceeds of the sale are insufficient to pay the outstanding debt, the county commission shall continue to provide for the collection of an annual tax on tangible property sufficient to pay the principal and interest of the debt. Any remaining proceeds from the sale shall be placed to the credit of the county's general fund to be used to provide health care services in the county. Any purchasers of the nursing home shall be limited to those who plan to offer medical services in the community for a period of at least 10 years. These provisions are identical to SCS/SB 349 (2023). SUPPLEMENTAL WELFARE ASSISTANCE (Section 208.030) Under current law, certain persons may be eligible for up to $156 a month in supplemental welfare assistance for home care in licensed residential care facilities. This act removes that monthly cap and makes such assistance subject to appropriations. This provision is identical to a provision in the truly agreed to and finally passed HCS/SS/SCS/SB 106 (2023), SB 336 (2023), and SB 1192 (2022) and similar to provisions in CCS/HCS/SS/SB 690 (2022) and HCS/HB 2727 (2022). FENTANYL TESTING (Section 579.088) Under this act, it shall not be unlawful to manufacture, possess, sell, deliver, or use any device, equipment, or other material for the purpose of analyzing controlled substances for the presence of fentanyl. This provision is identical to a provision in the truly agreed to and finally passed SS/SCS/SBs 189, 36, & 37 (2023), the truly agreed to and finally passed HCS/SS/SCS/SB 70 (2023), the truly agreed to and finally passed HCS/SS/SB 24 (2023), the truly agreed to and finally passed CCS/HCS/SS/SCS/SBs 45 & 90 (2023), SB 480 (2023), HB 927 (2023), HB 250 (2023), and SCS/HCS/SBs 117, 343, & 1091 (2023). MENTAL HEALTH SERVICES FOR VULNERABLE PERSONS (Section 630.1150) Under this act, the Department of Mental Health (DMH) and the Department of Social Services shall oversee and implement a collaborative project to assess the continued hospitalization without medical justification of foster children and DMH clients due to a lack of post-discharge placement options or because they are awaiting screening for appropriateness of residential treatment services, as well as to develop recommendations to ensure these patients receive treatment in the most cost-effective and efficacious settings consistent with federal and state standards for treatment in the least restrictive environment. The Departments shall solicit information from specified persons and entities and shall issue interim reports by December 31, 2023, and July 1, 2024, before issuing a final report by December 1, 2024. The provisions of this act shall expire on January 1, 2025. This provision is identical to SB 419 (2023) and SCS/SB 1168 (2022). NOTARIZATION REQUIREMENTS FOR CERTAIN MENTAL HEALTH DETENTIONS (Section 632.305) Under this act, no notarization requirement shall be required for an application for civil detention for evaluation and treatment or for any affidavits, declarations, or other documents supporting an application. However, such application, affidavits, declarations, or other documents shall be made under penalty of perjury. This provision is identical to a provision in the truly agreed to and finally passed HCS/SS/SCS/SB 106 (2023) and SB 564 (2023). LEAD POISONING (Sections 701.336-701.348) Currently, the Department of Health and Senior Services, in collaboration with the Department of Social Services and other health care organizations, shall develop an educational strategy to increase the number of children who are tested for lead poisoning under the Medicaid program. This act repeals a provision describing the goals and timelines of the educational strategy. Under this act, every medical provider serving children shall annually provide education to all parents and guardians of children under 4 years of age regarding lead hazards and provide the option to test every child under 4 years of age with the consent of the parent or guardian. This act repeals the requirement that parents or guardians provide a written statement refusing lead testing. This act repeals provisions requiring all children less than 6 years of age who reside or spend more than 10 hours a week in a high risk area to be annually tested for lead poisoning. Instead, every child under 6 years of age shall be annually assessed for lead poisoning risk and may be tested with the consent of the child's parent or guardian. Finally, every child care facility located in a geographic area of high risk for lead poisoning shall, within 30 days of enrollment of a child age 12 months of age or older and under 5 years of age, require the child's parents or guardians to provide evidence of lead poisoning testing or a statement of refusal of such testing. These provisions are identical to the provisions in the truly agreed to and finally passed HCS/SS/SCS/SB 106 (2023), HCS/SS/SB 198 (2023), the perfected HCS/HB 906 (2023), and SCS/SB 507 (2023). SARAH HASKINS