Law and Order: What is Your Role

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Law and Order What is Your Role?

• How is our practice regulated?
• Where can I go to find the regulations?

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Definitions

• 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.

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Statutes

• 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.

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• 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.

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• 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.

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Rules 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.)

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• 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.

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The 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

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Missouri 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.

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What 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

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Code 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

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Missouri 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

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20 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)

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Other 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

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19 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.

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19 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.

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19 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.

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19 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.

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19 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.

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19 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.

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19 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.

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19 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.)

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20 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

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20 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.

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20 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)

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Missouri 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.

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Revised 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.

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moga.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.

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334.402 (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.

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Ready 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