Mo. Code Regs. tit. 20 § 2200-4.100

Current through Register Vol. 49, No. 8, April 15, 2024

Section 20 CSR 2200-4.100 - [Effective 5/31/2024] Advanced Practice Registered Nurse

PURPOSE: This amendment changes the recognition to a license.

PURPOSE: This rule specifies the criteria necessary for registered professional nurses to be licensed by the Missouri State Board of Nursing and, therefore, eligible to practice as advanced practice registered nurses and use certain advanced practice registered nurse titles.

(1) Definitions.

(A) Accredited college or university-An institution of learning awarded accreditation status by the appropriate regional or national accreditation body for higher education.

(B) Advanced-Means content and competency at a level beyond that of a baccalaureate prepared nurse.

(C) Advanced nursing education program-

1. Prior to July 1, 1998, completion of a formal post-basic educational program from or formally affiliated with an accredited college, university, or hospital of at least one (1) academic year, which includes advanced nursing theory and clinical nursing practice, leading to a graduate degree or certificate with a concentration in an advanced practice nursing clinical specialty area.

2. From and after July 1, 1998, completion of a graduate level degree from a college or university accredited by a nursing accrediting body that is recognized by the U.S. Secretary of Education and/or the Council for Higher Education Accreditation (CHEA), or an accrediting organization as acceptable by the Missouri State Board of Nursing (MSBN). From and after January 1, 2009, the program shall provide a minimum of five hundred (500) faculty supervised clinical hours.

(D) Advanced pharmacology course-A course that offers content in pharmacokinetics and pharmacodynamics, pharmacology of all broad categories of agents, with preceptorial experience in the prescription of drugs, medicines, and therapeutic devices.

(E) Advanced practice registered nurse (APRN)-As defined in section 335.016, RSMo.

(F) Advanced practice nursing role-A recognized advanced body of nursing knowledge and specialized acts of advanced professional nursing practice categorized into one (1) of these four (4) roles: certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), certified clinical nurse specialist (CNS) and certified nurse practitioner (CNP).

(G) Certificate of controlled substance prescriptive authority-Eligibility granted by the MSBN to an APRN to apply with the Missouri Bureau of Narcotics and Dangerous Drugs (BNDD) and the federal Drug Enforcement Agency (DEA) for authority to prescribe controlled substances from Schedules II-V as delegated in a collaborative practice arrangement pursuant to 334.104, RSMo, between a collaborating physician and a collaborating APRN.

(H) Nationally recognized certifying body-A non-governmental agency approved by the MSBN that validates by examination, based on pre-determined standards, an individual nurse's qualifications and knowledge for practice in a defined functional or clinical area of nursing.

(I) Nationally recognized professional nursing organization-A membership entity for registered professional nurses (RNs) and APRNs in the United States whose intention is national in scope and exists, in part, for the ongoing purposes of-

1. Fostering high standards for professional nursing practice;

2. Promoting the professional development and general welfare of registered professional and advanced practice nurses;

3. Improving the health and well-being of individuals, families, and communities in collaboration with other health care providers; and

4. Engaging in action at the national level on matters of professional policy and national health policy.

(J) Population focus-Describes the type of patients that the APRN has been educated to provide care for, i.e. family/individual across the lifespan, adult-gerontology, pediatrics, neonatal, women's health/gender-related or psych/mental health.

(K) Preceptorial experience-A designated portion of a formal educational program that is offered in a healthcare setting and affords the nurse the opportunity to integrate theory and role in both the clinical specialty/practice area and advanced nursing practice through direct patient care/client management.

(L) Qualified preceptor-An APRN with a current unrestricted RN and APRN license who has a scope of practice which includes prescribing and has met the requirements for prescriptive authority; a licensed practitioner of medicine or osteopathy with unrestricted prescriptive authority.

(M) Unencumbered license-A license that authorizes a nurse to engage in the full and unrestricted practice of nursing.

(2) APRN Licensure.

(A) Any RN who is a certified registered nurse anesthetist (CRNA), certified nurse midwife (CNM), certified nurse practitioner (CNP), or certified clinical nurse specialist (CNS) may apply for a license as an advanced practice registered nurse. The requirements for licensure are-

1. A current unencumbered license or current multistate privilege to practice in Missouri as an RN;

2. Evidence of completion of an appropriate advanced nursing education program as defined in subsection (1)(C) of this rule;

3. Completed APRN licensure application with attestation that all information contained in, or referenced by, the application is complete and accurate and is not false or misleading and appropriate fee. Incomplete application forms and evidence will be considered invalid. Fees are not refundable. Any application for licensure submitted to the MSBN is valid for one (1) year from the date the application was submitted. After the expiration of one (1) year, an applicant shall submit a new application;

4. An official final transcript from an accredited APRN program either directly from the accredited APRN program or MSBN-approved electronic transcript service. The transcript must verify the date of graduation; credential conferred; completion of three (3) separate graduate level courses in advanced physiology and pathophysiology; advanced health assessment; advanced pharmacology that includes pharmacodynamics, pharmacokinetics, and pharmacotherapeutics of all broad categories of agents; and role and population focus area of the education program;

5. Verification of national certification as an APRN in the role and population focus, if applicable, directly from the board-approved national certifying body;

6. Verification of active unencumbered APRN licensure/ authority to practice in another jurisdiction directly from the national coordinated licensure information system or the licensing authority. Not applicable if never licensed as an APRN;

7. State and federal fingerprint criminal background checks or other biometric criminal background checks as administered through the Missouri State Highway Patrol (MSHP) completed no earlier than two (2) months prior to the application; and

8. Evidence of United States citizenship or alien status as specified in 8 U.S.C.A. section 1621 or lawful presence as specified in section 208.009, RSMo.

(B) An applicant for APRN licensure who answers yes to one (1) or more of the questions on the application or the fingerprint checks reveal charges and/or convictions which relate to possible grounds for denial of licensure under section 335.066, RSMo, shall submit copies of appropriate documents, as requested by the MSBN, related to that answer or the fingerprint check before his/her application will be considered complete. The copies shall be certified if they are records of a court or administrative government agency. An applicant for licensure who the executive director, or his/her designee, determines may not meet the requirements for licensure shall be reviewed by the members of the MSBN at its next regular scheduled meeting following receipt of all requested documents. The MSBN shall notify any individual who is denied licensure. At the time of notification, this individual shall be made aware of his/her avenue to appeal through the Missouri Administrative Hearing Commission (AHC).

(C) An internationally educated applicant for licensure as an APRN in Missouri shall-

1. Hold an unencumbered RN license in Missouri or hold a current multistate privilege to practice in Missouri;

2. Complete the same required credentials review and evidence of English-language proficiency as required for new internationally educated RN applicants as defined in 20 CSR 2200-4.020(7)(A) 4.;

3. Verification of national certification as an APRN in the role and population focus directly from the board-approved national certifying body; and

4. Meet all other APRN licensure criteria required of applicants educated in the U.S.

(D) Temporary permit.

1. A temporary permit may be secured for a limited period of time of six (6) months if otherwise eligible pursuant to Chapter 335, RSMo, and these regulations, until licensure is granted or denied by the MSBN or until the temporary permit expires, whichever comes first.

2. A temporary permit is only granted upon request to an APRN applicant who has submitted all required documents, has started the state and federal fingerprint criminal background checks, but whose license is delayed solely due to pending receipt of the state and federal criminal background checks.

3. A temporary permit is not available to an APRN applicant of whom the MSBN discovers facts or allegations which relate to possible grounds for denial of licensure under section 335.066, RSMo.

(E) Change of name, address, or both. Each Missouri licensed APRN shall notify the MSBN within (30) thirty days of each name, address, and/or email address change.

(F) Each APRN is required to notify the MSBN within five (5) business days of any discipline or expiration of the APRN national certification.

(G) Additional certifications.

1. An APRN who has completed a post-masters education program for an additional nursing specialty may-

A. Submit a request for permission to practice in the new certification area;

B. Provide verification of national certification as an APRN in the role and population focus, if applicable, directly from the board-approved national certifying body; and

C. Provide an official final transcript from an accredited APRN program directly from the accredited APRN program or MSBN-approved electronic transcript service. The transcript must verify the date of graduation; credential conferred; completion of three (3) separate graduate level courses in advanced physiology and pathophysiology; advanced health assessment; advanced pharmacology that includes pharmacodynamics, pharmacokinetics, and pharmacotherapeutics of all broad categories of agents; and role and population focus area of the education program.

(3) With an application for controlled substance prescriptive authority, the APRN applicant shall submit the following:

(A) Evidence of completion of an advanced pharmacology course as defined in subsection (1)(D) of this rule. Evidence shall be submitted in the form of one (1) of the following:

1. An official final transcript from their advanced practice program, if not already on file with the MSBN, as defined in paragraph (2)(A)4. of this rule; or

2. A letter from the school describing how this was integrated into the curriculum; or

3. Evidence of successful completion of three (3) credit hours post-baccalaureate course in advanced pharmacology from an accredited college or university within the last five (5) years; or

4. Evidence of successful completion of forty-five (45) continuing education units in pharmacology within the last five (5) years; and

(B) Provide evidence of completion of at least three hundred (300) clock hours of preceptorial experience in the prescription of drugs, medicines, and therapeutic devices with a qualified preceptor. The APRN applicant shall complete the form provided by the MSBN and include this form with the APRN licensure application or at such time as the APRN has completed the required hours of preceptorial experience;

(C) Has had controlled substance prescriptive authority delegated in a collaborative practice arrangement under section 334.104, RSMo, with a Missouri licensed physician who has an unrestricted federal Drug Enforcement Administration (DEA) number and who is actively engaged in a practice comparable in scope, specialty, or expertise to that of the APRN. Submit the completed "Statement of Controlled Substance Delegation" form provided by the MSBN as part of the application process to the MSBN; and

(D) Provide evidence of a minimum of one thousand (1,000) hours of practice in an advanced practice nursing category prior to application for a certificate of prescriptive authority. The one thousand (1,000) hours -

1. Shall be obtained after graduation from the advanced practice nursing education program; and

2. May include transmitting a prescription order orally, telephonically, or to an inpatient medical record from protocols developed in collaboration with and signed by a licensed physician. The APRN applicant shall complete the form provided by the MSBN and may include this form with the APRN licensure application or at such time as the APRN has completed the required hours of practice in an advanced practice nursing category.

(4) Once the APRN has received controlled substance prescriptive authority from the MSBN, he/she may apply for a BNDD registration number and a federal DEA registration number. Restrictions that may exist on the collaborative physician's BNDD registration may also result in restrictions on the BNDD registration for the APRN. The instructions and the application needed for BNDD registration can be found at www.health.mo.gov/BNDD. For information regarding federal DEA registration, see www.DEADiversion.usdoj.gov.

(5) APRN License Renewal.

(A) For Certified APRNs, renewal periods shall be for one (1), two (2), or three (3) years as determined by the MSBN and run concurrent with the Missouri or other multistate RN license-In order to renew an APRN license, the APRN shall-

1. Maintain a current unencumbered RN license or current multistate privilege to practice in Missouri. An RN license placed on inactive or lapsed status will automatically lapse the APRN license;

2. Provide information related to the nurse's practice and demographics at least five (5) business days prior to the expiration date of the RN and/or APRN license and fee, if appropriate. Failure to do so may result in the license becoming lapsed, which will require the nurse to complete a petition for license reinstatement;

3. Notify the MSBN within five (5) working days of any change in status, documentation, or other changes that may affect their license as an APRN;

4. Provide primary source evidence of recertification by a certifying body, approved by the MSBN, to the MSBN prior to the current expiration date. It is the APRN's responsibility to be sure that their recertification credentials have been received by the MSBN;

5. Adhere to all requirements of the BNDD and the federal DEA; and

6. Failure to satisfy any of the requirements of paragraphs (5)(A)1. and 4. of this rule shall result in the lapse of the APRN license in Missouri. Loss of licensure as an APRN results in ineligibility to call or title oneself or practice as an APRN, but does not prevent the individual from practicing as an RN within his/her education, training, knowledge, judgment, skill, and competence as long as otherwise licensed to practice as an RN.

(B) For Uncertified APRNs-In order for an uncertified APRN to renew an APRN license approved by the MSBN as noncertified prior to January 1, 2010, and every two (2) years thereafter, an uncertified APRN shall provide evidence of-

1. A minimum of eight hundred (800) hours of clinical practice in their advanced practice nursing population focus area and in the advanced practice role; and

2. A minimum of sixty (60) contact hours in their advanced practice nursing population focus area of practice. Formally approved continuing education hours shall meet one (1) or more of the criteria listed below:

A. Continuing nursing education (CNE) approved for nursing contact hours by an accredited provider or approver of nursing continuing education;

B. Continuing medical education (CME) approved for CME hours;

C. Sponsored by organizations, agencies, or educational institutions accredited or approved by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), or the Commission on Dietetic Registration;

D. Provided by one (1) of these accepted agencies: American Nurses Association, American Academy of Family Physicians (AAFP), American Academy of Physician Assistants (AAPA), American Association of Nurse Practitioners (AANP), American College of Nurse Midwives (ACNM), American Psychiatric Association (APA), American Psychological Association (APA), American Psychiatric Nurses Association (APNA), Emergency Nurses Association (ENA), National Association of Nurse Practitioners in Women's Health (NPWH), or the National Association of Pediatric Nurse Associates and Practitioners (NAPNAP);

E. Independent study and/or e-learning approved for continuing education hours by one (1) of the accepted continuing education providers may be used for one hundred percent (100%) of the required continuing education hours (e.g., independent study programs, online courses, articles from professional journals); and

3. Maintain current unencumbered RN licensure or current multistate privilege to practice in Missouri and provide appropriate fee, if applicable;

4. Notify the MSBN within five (5) working days of any change in status, documentation, or other changes that may affect their licensure as an APRN;

5. Adhere to all requirements of the BNDD and the federal DEA; and

6. Uncertified APRNs who fail to satisfy any of the applicable requirements of paragraphs (5)(B)1.-3. and 5. of this rule will no longer be licensed as an APRN in Missouri. To regain licensure, the uncertified APRN shall complete the application process described in paragraphs (2)(A)1.-8. of this rule, which includes the requirement for certification and a graduate degree.

(6) Inactive APRN Licenses.

(A) Any nurse possessing a current license to practice as an APRN in Missouri may place that license on inactive status by submitting a request for inactive status with the MSBN. An inactive license shall be deemed expired. No person shall practice as an APRN or hold him/herself out as an APRN in Missouri while his/her license is inactive.

(B) An individual wishing to reactivate an APRN license shall complete an application for APRN license reinstatement containing data and documents required by the MSBN and attest that all information contained in, or referenced by, the application is complete and accurate and is not false or misleading. Any application for licensure reinstatement submitted to the MSBN is valid for one (1) year from the date the application is submitted. After the expiration of one (1) year, an applicant shall submit a new application, along with the required fee. The requirements include-

1. Hold an unencumbered RN license in Missouri or hold a current multistate privilege to practice in Missouri;

2. State and federal fingerprint or other biometric criminal background checks as administered through the MSHP no earlier than two (2) months prior to the application;

3. Verification of national certification as an APRN in the role and population focus, if applicable, directly from the MSBN-approved national certifying body;

4. Verification of active unencumbered APRN licensure/ authority to practice in another jurisdiction directly from the national coordinated licensure information system or the licensing authority, if applicable; and

5. Evidence of United States citizenship or alien status as specified in 8 U.S.C.A. section 1621 or lawful presence as specified in section 208.009, RSMo.

(C) If an APRN did practice as an APRN while the license was inactive, the APRN must disclose how long and where the practice of advanced practice nursing occurred. If the nurse was practicing as an APRN in Missouri at the time his/her license was inactive, he/she also must submit a statement to the MSBN indicating whether and when he/ she ceased working as soon as he/she realized that the license was inactive. In addition, the nurse must cause his/ her employer, if applicable, to submit a statement on the employer's letterhead stationery indicating whether and when the nurse ceased working as soon as he/she realized that the license was inactive and the APRN will not resume practice until duly licensed.

(D) An APRN who applies for renewal of an inactive license who answers yes to one (1) or more of the questions on the application which relate to possible grounds for denial of renewal under section 335.066, RSMo, shall submit copies of appropriate documents and/or evidence of rehabilitation related to that answer, as requested by the MSBN, before his/her application will be considered complete. The copies shall be certified if they are records of a court or administrative government agency. If an APRN requesting reinstatement of his/her inactive license is denied by the MSBN based upon the fact that the nurse is subject to disciplinary action under any provisions of Chapter 335, RSMo, the nurse will be notified of the statutory right to file a complaint with the AHC.

(E) An uncertified APRN is not eligible to reinstate an inactive APRN license.

(7) Lapsed APRN Licenses.

(A) Pursuant to sections 335.056 and 335.061, RSMo, a license issued by the MSBN to an APRN is lapsed if the nurse fails to renew that license prior to the expiration date. A lapsed license is deemed expired. No person shall practice as an APRN or hold him/herself out as an APRN in Missouri while his/her license is lapsed.

(B) An individual wishing to reinstate a lapsed APRN license shall file an application for APRN license reinstatement containing data and documents required by the MSBN and attest that all information contained in, or referenced by, the application is complete and accurate and is not false or misleading. Any application for APRN licensure reinstatement submitted to the MSBN is valid for one (1) year from the date the application was submitted. After the expiration of one (1) year, an applicant shall submit a new application, along with the required fee. The requirements include-

1. Hold an unencumbered RN license in Missouri or hold a current multistate privilege to practice in Missouri;

2. State and federal fingerprint or other biometric criminal background checks as administered through the MSHP no earlier than two (2) months prior to the application;

3. Verification of national certification as an APRN in the role and population focus, if applicable, directly from the MSBN-approved national certifying body;

4. Verification of active unencumbered APRN licensure/ authority to practice in another jurisdiction directly from the national coordinated licensure information system or the licensing authority, if applicable; and

5. Evidence of United States citizenship or alien status as specified in 8 U.S.C.A. section 1621 or lawful presence as specified in section 208.009, RSMo.

(C) If an APRN did practice as an APRN while the license was lapsed, the APRN must disclose how long and where the practice of advanced practice nursing occurred. If the nurse was practicing as an APRN in Missouri at the time his/her license was lapsed, he/she also must submit a statement to the MSBN indicating whether and when he/she ceased working as soon as he/she realized that the license was lapsed. In addition, the nurse must cause his/ her employer, if applicable, to submit a statement on the employer's letterhead stationery indicating whether and when the nurse ceased working as soon as he/she realized that the license was lapsed and the APRN will not resume practice until duly licensed.

(D) An APRN who applies for reinstatement of a lapsed license who answers yes to one (1) or more of the questions on the application which relate to possible grounds for denial of renewal under section 335.066, RSMo, shall submit copies of appropriate documents and/or evidence of rehabilitation related to that answer, as requested by the MSBN, before his/her application will be considered complete. The copies shall be certified if they are records of a court or administrative government agency. If an APRN requesting reinstatement of his/her lapsed license is denied by the MSBN based upon the fact that the nurse is subject to disciplinary action under any provisions of Chapter 335, RSMo, the nurse will be notified of the statutory right to file a complaint with the AHC.

(E) An uncertified APRN is not eligible to reinstate a lapsed APRN license.

(8) Titling.

(A) Only an RN meeting the requirements of this rule and licensed by the MSBN as an APRN may use any of the following titles or abbreviations in clinical practice: advanced practice registered nurse (APRN); nurse anesthetist; certified registered nurse anesthetist (CRNA); certified nurse midwife (CNM); nurse practitioner (NP); certified nurse practitioner (CNP); or certified clinical nurse specialist (CNS).

(B) A Registered Nurse (RN) licensed as an APRN by the MSBN shall use the title APRN and may include their role and population focus (NP with population focus, CNS with population focus, CNM, or CRNA), and certification status, if applicable, for purposes of identification and documentation.

(C) APRNs will be held accountable by the MSBN for representing themselves accurately and fully to the public, their employers, and other health care providers.

(9) Scope of Practice.

(A) RNs licensed by the MSBN as being eligible to practice as an APRN shall function clinically-

1. Within the state of Missouri Nursing Practice Act, Chapter 335, RSMo, and all other applicable rules and regulations;

2. Within the professional scope and standards of their advanced practice nursing role and population focus and consistent with their formal advanced nursing education and national certification, if applicable, or within their education, training, knowledge, judgment, skill, and competence as an RN; and

3. Within the regulations set forth by the BNDD and the federal DEA if deemed eligible to prescribe controlled substances by the MSBN.

(10) Certifying Body Criteria.

(A) In order to be a certifying body acceptable to the MSBN for APRN status, the certifying body must meet the following criteria:

1. Be national in the scope of its credentialing;

2. Have no requirement for an applicant to be a member of any organization;

3. Have formal requirements that are consistent with the requirements of the APRN rule;

4. Have an application process and credential review that includes documentation that the applicant's advanced nursing education, which included theory and practice, is in the advanced practice nursing clinical specialty area being considered for certification;

5. Use psychometrically sound and secure examination instruments based on the scope of practice of the advanced practice nursing clinical specialty area;

6. Issue certification based on passing an examination and meeting all other certification requirements;

7. Provide for periodic recertification/maintenance options which include review of qualifications and continued competence; and

8. Have an evaluation process to provide quality assurance in its certification, recertification, and continuing competency components.

(B) Each listed certifying body and/or its policies and procedures for certification shall be subject to at least annual review by the MSBN to determine whether criteria for recognition under this rule are being maintained.

(C) The MSBN will identify, keep on file, and make available to the public the current list of nationally recognized certifying bodies acceptable to the board of nursing. Nationally recognized certifying bodies may be added or deleted from the board of nursing's list of nationally recognized certifying bodies based on the criteria set forth in this rule. A copy of the current list may be obtained by contacting the Missouri State Board of Nursing.

20 CSR 2200-4.100

AUTHORITY: sections 335.016(2) and 335.036, RSMo Supp. 2009.* This rule originally filed as 4 CSR 200-4.100. Original rule filed Nov. 15, 1991, effective March 9, 1992. Rescinded and readopted: Filed Oct. 25, 1995, effective June 30, 1996. Emergency amendment filed May 1, 1997, effective May 12, 1997, expired Nov. 7, 1997. Amended: Filed May 1, 1997, effective Oct. 30, 1997. Amended: Filed June 16, 2003, effective Dec. 30, 2003. Moved to 20 CSR 2200-4.100, effective Aug. 28, 2006. Amended: Filed Aug. 11 , 2006, effective March 30, 2007. Amended: Filed June 27, 2008, effective Dec. 30, 2008. Rescinded and readopted: Filed April 30, 2010, effective Nov. 30, 2010.

Amended by Missouri Register November 15, 2018/Volume 43, Number 22, effective 12/31/2018

Amended by Missouri Register April 15, 2024/volume 49, Number 08, effective 5/31/2024.

*Original authority: 335.016(2), RSMo 1975, amended 1993, 1995, 1999, 2002, 2004, 2007, 2008 and 335.036, RSMo 1975, amended 1981, 1985, 1993, 1995, 1999, 2007, 2008.