Title: Law and Order: What is Your Role
1Law and Order What is Your Role?
- How is our practice regulated?
- Where can I go to find the regulations?
2Definitions
- LAW a system of rules, usually enforced through
a set of institutions, used to underpin civil
obedience, politics, economics and society in
numerous ways. Wikipedia.com - Statute a formal written enactment of a
legislative authority that governs a country,
state, city or county.
3Statutes
- Typically, statutes command or prohibit
something, or declare policy. - The word statute is often used to distinguish
law made by legislative bodies from judicial
decisions of the common law and the regulations
issued by Government Agencies. - Before a statute becomes a law, it must be agreed
upon by the highest executive in the government
and published as part of a code. In Missouri,
that executive would be Governor Blunt.
4- Legislation law which has been promulgated (or
enacted) by a legislature or other governing
body. - (Before an item of legislation becomes law, it
may be known as a bill, which is typically also
known as legislation while it remains under
active consideration.
5- Bill a proposed new law introduced within a
legislature that has not been ratified, adopted
or received assent. Bills have a sponsor and
most times, a cosponsor or cosponsors. - After a bill is passed and signed by the
governor, many times a set of Rules Regulations
are written to help regulate the new law.
6Rules Regulations
- Rules can only be written if a statute
authorizes a state agency to write a rule
pertaining to a particular subject. There are a
few rules that are authorized by the Missouri
Constitution, but the vast majority of rules
exist by statutory authority. - How are rules created?
- 1. An agency writes a rule, based on authority
from specific statutes in the Missouri Revised
Statutes. Once the rule is written by the agency,
the remaining required paperwork is compiled. The
agency is then ready to file the rulemaking. - 2. The second step to create a rule is to file a
proposed rule with the Administrative Rules
Division of the Office of the Secretary of State
and the Joint Committee on Administrative Rules
of the General Assembly on the same day. - 3. According to the Missouri Register publication
schedule, the Administrative Rules Division
publishes the proposed rule 3045 days later in
the Missouri Register. Whether the rulemaking is
published at the first or the middle of each
month in the Register is determined by the filing
date of the rulemaking. - 4. Following publication, there must be a public
comment and/or public hearing period that extends
a minimum of thirty (30) days after the date of
publication of the proposed rulemaking in the
Missouri Register. The agency must act on the
rulemaking within ninety (90) days following the
close of public comment, or the agency may
withdraw the rulemaking at anytime. - 5. Once the public comment and/or public hearing
period is closed, information from the comments
and/or public hearing is compiled by the agency
and the agency writes the final order of
rulemaking for the proposed rulemaking. - 6. A copy of the final order of rulemaking for
the proposed rulemaking is next filed by the
agency only with the Joint Committee on
Administrative Rules at the Capitol. (This is
required for all agencies, except in some
instances, the Department of Conservation, the
Department of Elementary and Secondary Education,
and the Department of Labor and Industrial
Relations Commission.)
7- 7. The final order of rulemaking is retained by
the Joint Committee on Administrative Rules for a
thirty (30)-day review period. Once the thirty
(30)-day review period is completed, the agency
may then, and only then, file the final order of
rulemaking with the Administrative Rules Division
for publication in the Missouri Register. - 8. At the end of each month, the rules that are
published as final orders of rulemaking in the
Missouri Register are prepared in final form for
publication in the update to the Code of State
Regulations by the Administrative Rules Division. - 9. These rules become effective thirty (30) days
after the publication date of the update to the
Code of State Regulations. An agency, at their
discretion, may choose a later date. Exceptions
to these effective dates are set by statute. - 10. Once a rule becomes effective, it has the
force and effect of law. - 11. Agencies may amend or rescind existing rules
by going through the same process which is
outlined in the above steps.
8The Missouri Register
- The Missouri Register is published by the
secretary of state as required by section
536.015, RSMo Supp. 2006. It is published twice
each month, and organized in the format
established by the secretary of state. The
function of the Missouri Register is to encourage
and solicit public participation in the
rulemaking process. The Missouri Register is
organized into the following sections - Table of ContentsA list of agencies with rules
in the current issue, and the deadline dates for
filing and publication in the Missouri Register
and the Code of State Regulations. - Missouri Participating LibrariesList of the
locations, throughout the state, where copies of
the Missouri Register and the Code of State
Regulations are available. - Emergency RulesEmergency rulemakings promulgated
under the provisions of section 536.025, RSMo
2000. - Executive OrdersAll executive orders issued (by
the governor) are published under the provisions
of section 536.035.2, RSMo Supp. 2006. - Proposed RulesChanges to rules, new rules, or
rescissions are published under the provisions of
section 536.021, RSMo Supp. 2006. - Orders of RulemakingFinal versions of rules
adopted, amended, rescinded, or withdrawn under
the provisions of section 536.021, RSMo Supp.
2006. - In AdditionsNotices required to be published in
the Missouri Register. - Rules Under ConsiderationAn agency may solicit
comments on subject matter pursuant to section
536.026, RSMo 2000. - Free access to the Register is available on the
Internet at - http//www.sos.mo.gov/adrules/moreg/moreg.asp
9Missouri Code of State Regulations
- The Missouri Code of State Regulations is the
final product in the rulemaking process. It is
also referred to as the Code of State Regulations
or simply the Code. - The Administrative Rules Division of the Office
of the Secretary of State publishes the Missouri
Code of State Regulations. The Code is currently
published on paper in a fifteen (15)-volume loose
leaf format and on the Internet. The paper copy
is currently the official copy. The Code is
updated monthly and, although the total number of
pages changes from month-to-month, it contains
approximately ten thousand (10,000) pages. - Rules, amendments and rescissions are published
in the Code only after completing the rulemaking
process. Once a final order of rulemaking has
been published in the Missouri Register that
rulemaking is updated in Code. - Final orders that appear in both the first of the
month and middle of the month Missouri Registers
are published in the Code on the last day of that
same month. For example, all orders published in
the March 1 and March 15 issues of the Missouri
Register are published in the Code of State
Regulations update on March 31. In most cases the
rulemaking becomes effective thirty (30) days
after it is published in the Code. - http//www.sos.mo.gov/adrules/csr/csr.asp.
10What do the numbers and letters mean?
- The rules are codified in the Code of State
Regulations in this system - Title CSR
Division Chapter Rule - 25
15 5 .025 - Each department of state government is assigned a
title. Each agency or division in the department
is assigned a division number. The agency then
groups its rules into general subject matter
areas called chapters and specific areas called
rules. - Within a rule, the first breakdown is called a
section and is designated as (1). Subsection is
(A) with further breakdown into paragraphs 1.,
subparagraphs A., parts (I), subparts (a), items
I. and subitems a. - The rule is properly cited by using the full
citation, for example, 25 CSR 15-5.025
11Code of State Regulations
- In the Missouri Code of State Regulations, there
are chapters and divisions that affect our
practice. To find these, you can go to the
Secretary of States website and search for them. - The website is www.sos.mo.gov/ Click on
administrative rules. Then click on to Code
of State Regulations and click on to current
edition and go to - Title 20 Department of Insurance, Financial
Institutions and Professional Registration. The
Nurse Practice Act is in Division 2200 in
Chapter 335
12Missouri Statutes Affecting CRNA Practice
- Because we are nurses, the Nurse Practice Act,
found in Chapter 335, defines who is a CRNA, what
an advanced practice nurse is, and which Board
regulates our practice. - Found at moga.mo.gov/statutes/chapters/chap335.h
tm
1320 CSR 2200-4DEPARTMENT OF INSURANCE,FINANCIAL
INSTITUTIONS ANDPROFESSIONAL REGISTRATION
Division
2200State Board of Nursing
- (5) Scope of Practice.
- (A) Registered professional nurses recognized by
the Missouri State Board of Nursing as being
eligible to practice as advanced practice nurses
shall function clinically - 1. Within the state of Missouri Nursing Practice
Act, Chapter 335, RSMo, and all other applicable
rules and regulations and - 2. Within the professional scope and standards of
their advanced practice nursing clinical
specialty area and consistent with their formal
advanced nursing education and national
certification, if applicable, or within their
education, training, knowledge, judgment, skill,
and competence as registered professional nurses. - 20 CSR 2200-4 (5)
14Other Divisions Affecting our Practice
- Missouri Dental Board - Division 2110
- sos.mo.gov/adrules/csr/current/20csr/20c2
110-4.pdf - Missouri State Board of Registration for the
Healing Arts Division 2150 (physicians,
surgeons, physical therapists, speech-language
pathologists and audiologists, physician
assistants, perfusionists and anesthesiologist
assistants) - Department of Health and Senior Services
Division 30, Chapter 20 ---Hospital Regulations
and Licensure - sos.mo.gov/adrules/csr/current/19csr/19
c30-20.pdf - Chapter 30 ---Ambulatory Surgical Centers
- sos.mo.gov/adrules/csr/current/19csr/19
c30-30.pdf
1519 CSR 30-30.010 Definitions and Proceduresfor
Licensing Ambulatory SurgicalCenters19 CSR
30-30.010 (1)(E)
page 3
- (E) Certified nurse anesthetist. A registered
- nurse licensed under Chapter 335,
- RSMo, who has been graduated from a
- school of nurse anesthesia accredited by the
- Council on Accreditation of Educational Programs
- of Nurse Anesthesia or its predecessor,
- and is certified or is eligible for certification
- as a nurse anesthetist by the Council on
Certification - of Nurse Anesthetists.
1619 CSR 30-30.010 Definitions and Proceduresfor
Licensing Ambulatory SurgicalCenters19 CSR
30-30.010 (1)(R) page 3
- (R) Qualified anesthesia personnel.
- An anesthesiologist who is a physician with
training or experience in the administering of
anesthetics, a certified registered nurse
anesthetist or an anesthesiologist assistant.
1719 CSR 30-30.030 (E)1-2Ambulatory Surgery Rules
- (E) Anesthesia Service.
- 1. The anesthesia service shall be under the
direction of an anesthesiologist or a physician
with training or experience in the administration
of anesthetics. The clinical privileges of
qualified anesthesia personnel shall be reviewed
by the director of anesthesia service and the
medical staff and approved by the governing body. - 2. An anesthesiologist or physician with training
or experience in the administration of
anesthetics shall be on the premises and readily
accessible during the administration of
anestheticswhether local, general or intravenous
sedationand the postanesthetic recovery period
until all patients are alert or medically
discharged. Qualified anesthesia personnel shall
be present in the room throughout the conduct of
all general anesthetics, regional anesthetics and
monitored anesthesia care and shall continually
evaluate the patients oxygenation, ventilation,
circulation and temperature. Oxygen analyzers,
pulse oximeter and electrocardiography equipment
shall be available.
1819 CSR 30-30.030 (E)(6)Ambulatory Surgery Rules
- 6. All anesthetics shall be administered
by anesthesiologists, physicians with training or
experience in the administration of anesthetics,
certified registered nurse anesthetists or
anesthesiologist assistants supervised by an
anesthesiologist, except for local anesthetic
agents which may be administered by the attending
physician, dentist or podiatrist. - Notwithstanding the provisions of sections
334.400 to 334.430, RSMo, or the rules of the
Missouri State Board of Registration for the
Healing Arts, the governing body of every
ambulatory surgical center shall have full
authority to limit the functions and activities
that an anesthesiologist assistant performs in
such ambulatory surgical center. Nothing in this
paragraph shall be construed to require any
ambulatory surgical center to hire an
anesthesiologist who is not already employed as a
physician prior to August 28, 2003.
1919 CSR 30-20.001 (2)Hospital Licensing Rules
- (2) Notwithstanding any other rule in this
chapter, anesthesia in hospitals shall be
administered only by qualified anesthesiologists,
physicians or dentists trained in anesthesia,
certified nurse anesthetists, anesthesiologist
assistants or supervised students in an approved
educational program. Notwithstanding the
provisions of sections 334.400 to 334.430, RSMo,
or the rules of the Missouri State Board of
Registration for the Healing Arts, the governing
body of every hospital shall have full authority
to limit the functions and activities that an
anesthesiologist assistant performs in such
hospital. Nothing in this section shall be
construed to require any hospital to hire an
anesthesiologist who is not - already employed as a physician prior to
August 28, 2003.
2019 CSR 30-20.011 (9)Hospital Licensing Rule
- (9) Certified registered nurse anesthetistA
- registered nurse who has graduated from a
school of nurse anesthesia accredited by the
Council on Accreditation of Educational Programs
of Nurse Anesthesia or its predecessor and has
been certified or is eligible for certification
as a nurse anesthetist by the Council on
Certification of Nurse Anesthetists.
2119 CSR 30-20.0120Anesthesia Services in Hospitals
- (1) Anesthesia services, if provided, shall be
under the medical direction of a qualified
physician member of the medical staff and
appointed by the governing body. This physician
shall be responsible for implementing the rules
of the medical staff governing the quality and
scope of anesthesia care provided.
2219 CSR 30-20.120 contd
- 3) Anesthesia shall be administered only by
- qualified anesthesiologists, physicians or
dentists trained in anesthesia, certified nurse - anesthetists or supervised students in an
- approved educational program.
- (The rule goes on to describe the pre- and
post-anesthesia requirements.)
2320 CSR 2110-4.010 Definitions (Dental Rules)
- (S) Qualified sedation providerany of
- the following who have satisfied the provisions
- of this rule
- 1. A currently licensed dentist in Missouri
- with a valid permit to administer enteral
- and/or parenteral conscious sedation
- 2. A currently licensed physician
anesthesiologist - or
- 3. A currently licensed nurse anesthetist
2420 CSR 2110-4.020 (4)Dental Rules, contd
- (4) If the primary administrator of enteral
and/or parenteral conscious sedation in a dental
office is an anesthesiologist or a nurse
anesthetist, the dentist must order the
anesthesia services, is responsible for the
readiness of the dental office, preoperative
patient evaluation and appropriate medical
consultations, the coordination of and emergency
preparedness of the sedation team, and the
maintenance of appropriate records. The dentist
must evaluate the patient prior to the procedure,
remain in the dental office, and evaluate the
patient prior to discharge.
2520 CSR 2200-4.200Collaborative Practice Rule
- This is where you can find the details of the
collaborative practice rule for advanced practice
registered nurses. - sos.mo.gov/adrules/csr/current/20csr/20c2200-4.pdf
- (begins on page 15)
26Missouri State Board of Nursing Information
- Go To pr.mo.gov/nursing.asp
- Click on Advanced Practice
- This will open a page that has a number of items
that are of interest to us, including the Scope
of Practice Decision Making Tool. This can help
you answer the questions Can I do this in our
state? Am I qualified to perform this skill?
etc. -
27Revised Statutes of Missouri (RSMo)
- In the Revised Statutes of Missouri (RSMo), there
is a section about nurses giving anesthesia
(334.104). This statute describes our
supervision requirement in Missouri. Because of
this requirement, Opt-Out is not possible for us
at this time.
28moga.mo.gov/statutes/C300-399/3340000104.HTM
- 6. Notwithstanding anything to the contrary in
this section, a registered nurse who has
graduated from a school of nurse anesthesia
accredited by the Council on Accreditation of
Educational Programs of Nurse Anesthesia or its
predecessor and has been certified or is eligible
for certification as a nurse anesthetist by the
Council on Certification of Nurse Anesthetists
shall be permitted to provide anesthesia services
without a collaborative practice arrangement
provided that he or she is under the supervision
of an anesthesiologist or other physician,
dentist, or podiatrist who is immediately
available if needed.
29334.402 (6) RSMoAnesthesiologist Assistants
- 6. The anesthesiologist members of the faculty of
an anesthesiologist assistant program established
in this state shall be comprised of
board-certified or board-eligible
anesthesiologists. No faculty member of any
anesthesiologist assistants program shall
concurrently supervise more than two
anesthesiologist assistant students who are
delivering anesthesia. Certified registered nurse
anesthetists will be excluded from clinical
education of anesthesiologist assistants.
30Ready Web References
- Revised Statutes of Missouri (RSMo)
- moga.state.mo.gov/STATUTES/STATUTES.HTM
- Missouri Code of State Regulations
(CSR) - sos.mo.gov/adrules/csr/csr.asp
- Missouri State Board of Nursing
- pr.mo.gov/nursing.asp