AN ACT CONCERNING THE AUTHORITY AND RESPONSIBILITIES OF ADVANCED PRACTICE REGISTERED NURSES

PA 16-39—sSB 67

Public Health Committee

AN ACT CONCERNING THE AUTHORITY AND RESPONSIBILITIES OF ADVANCED PRACTICE REGISTERED NURSES

SUMMARY: This act allows advanced practice registered nurses (APRNs) to certify, sign, or otherwise document medical information in several situations that previously required a physician's signature, certification, or documentation. Examples include:

1. certifying a patient for medical marijuana use (except for glaucoma),

2. issuing “do not resuscitate” orders,

3. certifying a disability to cancel a health club contract, and

4. certifying a disability or illness for continuing education waivers or extensions for various health professions.

In a few situations not involving written documentation, the act similarly extends to APRNs authority or responsibility that previously applied only to physicians, such as requiring them to notify specified people before removal of a patient's life support.

The act extends certain reporting requirements to APRNs regarding specified types of patients or conditions, such as reporting to the Department of Rehabilitation Services (DORS) when a blind person comes under the APRN's care.

Lastly, the act allows optometrists to document vision-related information in a few situations that previously required a physician's documentation. (The act also extends this authority to APRNs. ) It also makes technical and conforming changes.

EFFECTIVE DATE: October 1, 2016, except provisions extending authority to APRNs regarding marijuana are effective January 1, 2017.

APRN CERTIFICATION OF MEDICAL INFORMATION AND RELATED AUTHORITY

The act allows APRNs to certify, sign, or otherwise document medical information in several situations. It also extends authority to APRNs in certain other contexts not involving written documentation. Thus, APRNs or physicians may certify such documents or take such other actions. Under prior law, almost all of these certifications or actions could be performed only by physicians.

The act's provisions are grouped in the following tables by categories of authority extended to APRNs.

Table 1: Certification or Other Documentation Authority Extended to APRNs Related to Employment

*Act* §	*Statute* §	*Description*
4	5-248a	Certification of a serious illness or an organ or bone marrow donation to qualify a state employee for family and medical leave
5	10-183b	Statement of health for a disability benefit application in the Teachers' Retirement System
9	14-44	Certification that an applicant for certain public passenger driver's licenses controls with medication a condition that would otherwise deem the applicant medically unqualified
10	14-73	Certification of an applicant's fitness for a driving instructor's license based on a recent medical examination
16	19a-12e	Written statement of findings after examining a health care professional under investigation for possible impairment
30 - 42	Various provisions in Title 20	Certification of a disability or illness to qualify someone in the following professions for a continuing education waiver or extension: ● acupuncturists ● audiologists ● dental hygienists ● dentists ● hearing instrument specialists ● naturopaths ● optometrists ● physical therapists ● psychologists ● radiographers ● respiratory care practitioners ● speech and language pathologists ● veterinarians

Table 2: Certification or Other Documentation Authority Extended to APRNs for Medication or Care Approval

*Act* §	*Statute* §	*Description*
6	10-212a	Order for a qualified school employee's administration of (1) glucagon using injectable equipment or (2) anti-epileptic medication
26	20-14m	Documentation in a medical record if prescribing, administering, or dispensing long-term antibiotic therapy for Lyme disease (Department of Public Health or the licensing board may not initiate a disciplinary action solely for such actions as documented in the record)
27	20-162n	Written protocols for respiratory care and direction over such care
29	20-206jj	Written protocols or standing orders for paramedics to administer controlled substances and written or oral authorization for paramedics to administer other drugs
45 & 46	21a-246 & 21a-253	License to possess and supply marijuana to treat side effects of chemotherapy (the act also makes clarifying and conforming changes)
47 – to 51	Various provisions in Chapter 420f	Certification for a patient's use of medical marijuana. This includes, among other things: ● diagnosing a patient's qualifying debilitating condition, except the act does not authorize APRNs to certify marijuana use for glaucoma; ● issuing a written certification for medical marijuana use after (1) making this diagnosis, (2) explaining the potential risks and benefits to the patient and parent or guardian of a patient lacking legal capacity, and (3) meeting other criteria; and ● extending to APRNs the same protections from civil, criminal, and disciplinary liability that already apply to physicians under the medical marijuana law.
52	22a-616	Prescription for mercury fever thermometers

Table 3: Certification or Approval Authority Extended to APRNs for Insurance Purposes

*Act* §	*Statute* §	*Description*
57 & 62	38a-489 & 38a-515	Certification of inability for self-sustaining employment because of mental or physical disability for continuation of coverage when child reaches limiting age*
58 & 63	38a-492m & 38a-518l	Document on the original prescription the need for additional quantities of prescription eye drops for insurance coverage of prescription renewal*
59 & 64	38a-493 & 38a-520	Various provisions concerning insurance coverage for home health care, such as approval of a care plan; diagnosis of a patient's terminal illness in some circumstances; and supervision of home health agency services*
60 & 65	38a-495 & 38a-522	Certification of medical necessity of home health aide services, or recommendation of additional mammograms beyond once a year, for Medicare supplement policy coverage*
61 & 67	38a-496 & 38a-524	Approval and certification of an occupational therapy care plan for insurance coverage purposes*
66	38a-523	Approval of a care plan at a comprehensive rehabilitation facility for insurance coverage purposes (applies to group policies)

* Applies to individual and group policies

Table 4: Certification or Other Documentation Authority Extended to APRNs in Other Contexts

*Act* §	*Statute* §	*Description*
2	3-39j	To the extent permitted by federal law, diagnose someone's impairment or blindness in his or her disability certification for the Achieving a Better Life Experience (ABLE) program
3	3-123aa	Certification of a service need for withdrawals from the Connecticut Home Care Trust Fund
7	10-220j	Order stating a child's need for, and capability of, performing blood glucose self-testing at school
11	14-100a	Statement of an individual's inability to wear a seat belt for exemption from seat belt requirements
12	14-286	Certification of an individual's disability and capability of riding a motor-driven cycle for a special permit
13	14-314c	Certification that a child is hearing impaired to require traffic authorities to erect a sign in the child's neighborhood alerting drivers to the child's presence
14	17b-261p	Certification of a Medicaid applicant's inability to care for self or manage affairs, when a nursing home, on a patient's behalf, seeks an extension to contest a Medicaid penalty period by claiming undue hardship
18	19a-535	Documentation in the medical record of the basis for a patient's transfer or discharge from a nursing facility, and related requirement to develop a discharge plan in certain situations
22	19a-582	Certification that criteria are met for court-ordered HIV testing if a health care provider or other worker had significant exposure to HIV from a patient (an APRN or physician must first seek the patient's voluntary consent for testing) Certification that criteria are met to require HIV testing of a prison inmate if there is no reasonable alternative and testing is needed (1) for diagnostic purposes, treatment, or related reasons or (2) because the inmate's behavior poses a significant transmission risk or has led to significant exposure to another inmate
43 & 44	21a-217 & 21a-218	Certification of an individual's disability or physical examination to cancel a health club contract
53	26-29a	Certification of an individual's intellectual disability to receive a free lifetime sport fishing license
54	26-29b	Certification of an individual's disability to receive a free lifetime hunting, sport fishing, or trapping license
68	42-282	Letter indicating that continuing a diet program is adverse to an individual's health to cancel a diet company contract
69	47-88b	Statement of a tenant's blindness or disability for laws limiting eviction in conversion condominiums under the Condominium Act
70	47a-23c	Statement of a tenant's blindness or disability for laws limiting eviction
71	51-217	Letter stating an individual's disability for permanent exemption from jury duty
72	54-204	Report of treatment or examination, as part of an application for victim compensation

Table 5: Miscellaneous Provisions Extending Authority or Responsibility to APRNs

*Act* §	*Statute* §	*Description*
1	1-350i	Determine an agent's incapacity, under the Uniform Power of Attorney Act (must be done by two physicians, two APRNs, or one APRN and one physician, and the two providers must be independent)
15	18-94	Report to a correctional facility warden or other officer in charge that an inmate with venereal disease may be released without danger to public health
19	19a-550	Various provisions in the patients' bill of rights for nursing homes, residential care homes, and chronic disease hospitals, such as: ● document in the medical record when a general right is medically contraindicated for that patient, including the right to be fully informed of his or her medical condition, communicate with persons of the patient's choice, participate in social and similar activities, use his or her own clothing and possessions, and share a room with his or her spouse; ● order the administration of psychopharmacologic drugs, or the use of restraints under certain circumstances; and ● participate in the consultative process for certain room transfers in nursing homes or rest homes with nursing supervision. The act also specifies that a patient in these facilities has the right to choose his or her own physician or APRN, not just physician
20	19a-571	Immunity from civil and criminal liability for withholding or causing the removal of a life support system under specified conditions, including that the APRN: ● based the decision on his or her best medical judgment according to medical standards; ● deemed the patient to be in a terminal condition or, in consultation with a physician qualified to make a neurological diagnosis who examined the patient, deemed the patient to be permanently unconscious; and ● considered the patient's wishes, such as in a living will or similar document. If the patient is an infant, additional provisions apply pursuant to federal regulations
21	19a-580d	Issue “do not resuscitate” orders (the act refers to required regulations)
23	19a-592	Treat a minor for HIV or AIDS without notifying the parent, after determining that (1) such notification will result in denial of treatment or (2) the minor will not pursue treatment if the parents are notified and the minor requests they not be notified (the APRN or physician must document the reasons in the medical record)
24	20-7h	Responsibility to disclose to personal injury patients (1) whether the APRN will provide services on the basis of a letter of protection issued by an attorney and (2) the estimated cost of providing an opinion letter on the cause of the injury and the patient's diagnosis, treatment, and prognosis
25	19a-580	Responsibility to make reasonable efforts to notify the patient's next of kin or other specified persons within a reasonable time before withholding or causing the removal of the patient's life support
28	20-206q	Countersign a diet order for a patient being treated by a dietitian-nutritionist in an institution

APRN REPORTING REQUIREMENTS

The act extends to APRNs certain existing requirements for physicians to report on particular types of patients or conditions, as shown in Table 6.

Table 6: Reporting Requirements Extended to APRNs

*Act* §	*Statute* §	*Description*
8 & 73	10-305 & 10-298	Report to DORS on blind patients coming into their care (existing law also requires optometrists to report) The act makes a conforming change to the existing requirement that the DORS commissioner provide a list of these patients age 16 or older to the Department of Motor Vehicles
17 & 74	19a-262 & 19a-264	Report to the Department of Public Health and the local health director on patients with, or suspected of having, tuberculosis The act also makes conforming changes to existing provisions that (1) require local health directors to give information to the reporting physician on advisable precautions for such patients' homes and (2) provide criminal penalties for physicians who willfully make false reports
55	27-140ee	Report to the Department of Veterans' Affairs, upon the patient's request, on a veteran's possible exposure to herbicides in Vietnam
56	31-40a	Report to the Labor Department on persons with certain occupational diseases (e. g. , lead poisoning)

OPTOMETRIST DOCUMENTATION

The act allows optometrists to document an individual's blindness or other vision-related information in a few situations that previously required a physician's documentation. As noted in the tables above, the act also extends this authority to APRNs.

Table 7: Documentation Authority Extended to Optometrists

*Act* §	*Statute* §	*Description*
2	3-39j	To the extent permitted by federal law, diagnose an individual's blindness for purposes of disability certification for the ABLE program
58 & 63	38a-492m & 38a-518l	Document on the original prescription the need for additional quantities of prescription eye drops for insurance coverage of prescription renewal (applies to individual and group policies)
69	47-88b	Statement of a tenant's blindness for laws limiting eviction in conversion condominiums under the Condominium Act

OLR Tracking: JO; LH; PF; cmg