A BILL TO BE ENTITLED
AN ACT to deliver safe, accessible, value directed and excellent (SAVE) health care throughout north carolina by modernizing nursing regulations.
The General Assembly of North Carolina enacts:
SECTION 1.  G.S. 90‑171.20 reads as rewritten:
"§ 90‑171.20.  Definitions.
As used in this Article, unless the context requires otherwise:
(1)	Advanced assessment. – An advanced practice registered nurse taking the history, physical, and psychological assessment of a patient's signs, symptoms, pathophysiologic status, and psychosocial variations in the determinations of differential diagnoses and treatment.
(1a)	Advanced practice registered nurse or APRN. – An individual licensed by the Board as an advanced practice registered nurse within one of the following four roles:
a.	Nurse practitioner or NP.
b.	Certified nurse midwife or CNM.
c.	Clinical nurse specialist or CNS.
d.	Certified registered nurse anesthetist or CRNA.
(1b)	Board. – The North Carolina Board of Nursing.
(2)	Health care provider. – Any licensed health care professional and any agent or employee of any health care institution, health care insurer, health care professional school, or a member of any allied health profession. For purposes of this Article, a person enrolled in a program that prepares the person to be a licensed health care professional or an allied health professional shall be deemed a health care provider.
(3)	License. – A permit issued by the Board to practice nursing as an advanced practice registered nurse, as a registered nurse, or as a licensed practical nurse, including a renewal or reinstatement thereof.
(3a)	Nurse anesthesia activities. – Consist of the following activities, including clinical activities:
a.	Preanesthesia preparation and evaluation of the client, including the following:
1.	Performing a preoperative health assessment.
2.	Recommending, requesting, and evaluating pertinent diagnostic studies.
3.	Selecting and administering preanesthetic medications.
b.	Anesthesia induction, maintenance, and emergence of the client, including the following:
1.	Securing, preparing, and providing safety checks on all equipment, monitors, supplies, and pharmaceutical agents used for the administration of anesthesia.
2.	Selecting, implementing, and managing general anesthesia; monitored anesthesia care; and regional anesthesia modalities, including administering anesthetic and related pharmaceutical agents, consistent with the client's needs and procedural requirements.
3.	Performing tracheal intubation and extubation and providing mechanical ventilation.
4.	Providing perianesthetic invasive and noninvasive monitoring, recognizing abnormal findings, implementing corrective action, and requesting consultation with appropriately qualified health care providers as necessary.
5.	Managing the client's fluid, blood, electrolyte, and acid‑base balance.
6.	Evaluating the client's response during emergence from anesthesia and implementing pharmaceutical and supportive treatment to ensure the adequacy of client recovery from anesthesia.
c.	Postanesthesia care of the client, including the following:
1.	Providing postanesthesia follow‑up care, including evaluating the client's response to anesthesia, recognizing potential anesthetic complications, implementing corrective actions, and requesting consultation with appropriately qualified health care professionals as necessary.
2.	Initiating and administering respiratory support to ensure adequate ventilation and oxygenation in the immediate postanesthesia period.
3.	Initiating and administering pharmacological or fluid support of the cardiovascular system during the immediate postanesthesia period.
4.	Documenting all aspects of nurse anesthesia care and reporting the client's status, perianesthetic course, and anticipated problems to an appropriately qualified postanesthetic health care provider who assumes the client's care following anesthesia consistent with 21 NCAC 36 .0224(f).
5.	Releasing clients from the postanesthesia care or surgical setting as per established agency policy.
d.	Other clinical activities for which the qualified registered nurse anesthetist may accept responsibility, including all of the following:
1.	Inserting central vascular access catheters and epidural catheters.
2.	Identifying, responding to, and managing emergency situations, including initiating and participating in cardiopulmonary resuscitation.
3.	Providing consultation related to respiratory and ventilator care and implementing such care according to established policies within the practice setting.
4.	Initiating and managing pain relief therapy utilizing pharmaceutical agents, regional anesthetic techniques and other accepted pain relief modalities according to established policies and protocols within the practice setting.
Nurse anesthesia activities do not constitute the prescribing of a medical treatment regimen or the making of a medical diagnosis.
(4)	Nursing. – A dynamic discipline which includes the assessing, caring, counseling, teaching, referring and implementing of prescribed treatment in the maintenance of health, prevention and management of illness, injury, disability or the achievement of a dignified death. It is ministering to; assisting; and sustained, vigilant, and continuous care of those acutely or chronically ill; supervising patients during convalescence and rehabilitation; the supportive and restorative care given to maintain the optimum health level of individuals, groups, and communities; the supervision, teaching, and evaluation of those who perform or are preparing to perform these functions; and the administration of nursing programs and nursing services. For purposes of this Article, the administration of required lethal substances or any assistance whatsoever rendered with an execution under Article 19 of Chapter 15 of the General Statutes does not constitute nursing.
(5)	Nursing program. – Any educational program in North Carolina offering to prepare persons to meet the educational requirements for licensure under this Article as a registered nurse or a licensed practical nurse.
(6)	Person. – An individual, corporation, partnership, association, unit of government, or other legal entity.
(6a)	Population focus. – With respect to APRN practice, includes one of the following areas of focus:
a.	The family or the individual across the life span.
b.	Adult gerontology.
c.	Neonatal.
d.	Pediatrics.
e.	Women's health or gender‑related issues.
f.	Psychiatric or mental health.
(6b)	Practice of nursing as an advanced practice registered nurse or APRN. – In addition to the RN scope of practice and within the APRN role and population foci, also consists of the following six components:
a.	Conducting an assessment.
b.	Delegating and assigning therapeutic measures to assistive personnel.
c.	Performing other acts that require education and training consistent with professional standards and commensurate with the APRN's education, certification, demonstrated competencies, and experience.
d.	Complying with the requirements of this Article and rendering quality advanced nursing care.
e.	Recognizing limits of knowledge and experience.
f.	Planning for the management of situations beyond the APRN's expertise.
(6c)	Practice of nursing as a certified nurse midwife or CNM. – In addition to the RN scope of practice and within the APRN role and population foci, also consists of the following four components:
a.	The management, diagnosis, and treatment of women's primary health care, including pregnancy, childbirth, postpartum period, care of the newborn, family planning, partner care management relating to sexual health, and gynecological care of women across the life span.
b.	Ordering, performing, supervising, and interpreting diagnostic studies.
c.	Prescribing pharmacologic and nonpharmacologic therapies.
d.	Consulting with or referring to other health care providers as warranted by the needs of the patient.
(6d)	Practice of nursing as a certified registered nurse anesthetist or CRNA. – In addition to the RN scope of practice and within the APRN role and population foci, also consists of the performance of nurse anesthesia activities and related services, in collaboration with a physician, podiatrist, or other lawfully qualified health care provider, including the following:
a.	Selecting, ordering, and administering drugs and therapeutic devices to facilitate diagnostic, therapeutic, and surgical procedures.
b.	Ordering, performing, supervising, and interpreting diagnostic studies.
c.	Consulting with or referring to other health care providers as warranted by the needs of the patient.
(6e)	Practice of nursing as a clinical nurse specialist or CNS. – In addition to the RN scope of practice and within the APRN role and population foci, also consists of the following eight components:
a.	The diagnosis and treatment of health and illness states.
b.	Disease management.
c.	Prescribing nonpharmacologic therapies.
d.	Ordering, performing, supervising, and interpreting diagnostic studies.
e.	Preventing of illness and risk behaviors.
f.	Nursing care for individuals, families, and communities.
g.	Consulting with or referring to other health care providers as warranted by the needs of the patient.
h.	Integrating care across the continuum to improve patient outcomes.
(6f)	Practice of nursing as a nurse practitioner or NP. – In addition to the RN scope of practice and within the APRN role and population foci, also consists of the following six components:
a.	Health promotion, disease prevention, health education, and counseling.
b.	Providing health assessment and screening activities.
c.	Diagnosing, treating, and facilitating patients' management of their acute and chronic illnesses and diseases.
d.	Ordering, performing, supervising, and interpreting diagnostic studies.
e.	Prescribing pharmacologic and nonpharmacologic therapies.
f.	Consulting with or referring to other health care providers as warranted by the needs of the patient.
(7)	Practice of nursing by a registered nurse. – Consists of the following 10 components:
a.	Assessing the patient's physical and mental health, including the patient's reaction to illnesses and treatment regimens.
b.	Recording and reporting the results of the nursing assessment.
c.	Planning, initiating, delivering, and evaluating appropriate nursing acts.
d.	Teaching, assigning, delegating to or supervising other personnel in implementing the treatment regimen.
e.	Collaborating with other health care providers in determining the appropriate health care for a patient.
f.	Implementing the treatment and pharmaceutical regimen prescribed or ordered by any person authorized by State law to prescribe or order the regimen.
g.	Providing teaching and counseling about the patient's health.
h.	Reporting and recording the plan for care, nursing care given, and the patient's response to that care.
i.	Supervising, teaching, and evaluating those who perform or are preparing to perform nursing functions and administering nursing programs and nursing services.
j.	Providing for the maintenance of safe and effective nursing care, whether rendered directly or indirectly.
(8)	Practice of nursing by a licensed practical nurse. – Consists of the following seven components:
a.	Participating in the assessment of the patient's physical and mental health, including the patient's reaction to illnesses and treatment regimens.
b.	Recording and reporting the results of the nursing assessment.
c.	Participating in implementing the health care plan developed by the registered nurse and/or prescribed by any person authorized by State law to prescribe such a plan, by performing tasks assigned or delegated by and performed under the supervision or under orders or directions of a registered nurse, physician licensed to practice medicine, dentist, or other person authorized by State law to provide the supervision.
c1.	Assigning or delegating nursing interventions to other qualified personnel under the supervision of the registered nurse.
d.	Participating in the teaching and counseling of patients as assigned by a registered nurse, physician, or other qualified professional licensed to practice in North Carolina.
e.	Reporting and recording the nursing care rendered and the patient's response to that care.
f.	Maintaining safe and effective nursing care, whether rendered directly or indirectly."
SECTION 2.  G.S. 90‑18(c) reads as rewritten:
"(c)	The following shall not constitute practicing medicine or surgery as defined in this Article:
…
	
…
(14a)	The practice of nursing by a certified registered nurse anesthetist or CRNA as defined in G.S. 90‑171.20.
…."
SECTION 3.  G.S. 90‑29(b) reads as rewritten:
"(b)	A person shall be deemed to be practicing dentistry in this State who does, undertakes or attempts to do, or claims the ability to do any one or more of the following acts or things which, for the purposes of this Article, constitute the practice of dentistry:
…
(6)	Administers an anesthetic of any kind in the treatment of dental or oral diseases or physical conditions, or in preparation for or incident to any operation within the oral cavity; provided, however, that this subsection shall not apply to a certified registered nurse anesthetist who administers such anesthetic in collaboration with a licensed dentist pursuant to G.S. 90‑171.20.
…."
SECTION 4.  G.S. 90‑171.23(b) reads as rewritten:
"(b)	Duties, powers. The Board is empowered to:
…
(14)	Grant prescribing, ordering, dispensing, and furnishing authority to holders of the advanced practice registered nurse license pursuant to G.S. 90‑171.20.
…."
SECTION 5.  G.S. 90‑171.27(b) reads as rewritten:
"§ 90‑171.27.  Expenses payable from fees collected by Board.
(b)	The schedule of fees shall not exceed the following rates:
Application for license as advanced practice registered nurse…	$100.00
Renewal of license to practice as advanced practice registered nurse (two‑year period)	…………………………………100.00
Reinstatement of lapsed license to practice as advanced practice registered nurse and renewal fee…………………….......	180.00
Application for examination leading to license as registered nurse	75.00
Application for license as registered nurse by endorsement	150.00
Application for each re‑examination leading to license as registered nurse	75.00
Renewal of license to practice as registered nurse (two‑year period)	100.00
Reinstatement of lapsed license to practice as a registered nurse and renewal fee	180.00
Application for examination leading to license as licensed practical nurse by examination	75.00
Application for license as licensed practical nurse by endorsement	150.00
Application for each re‑examination leading to license as licensed practical nurse	75.00
Renewal of license to practice as a licensed practical nurse (two‑year period)	100.00
Reinstatement of lapsed license to practice as a licensed practical nurse and renewal fee	180.00
Application fee for retired registered nurse status or retired licensed practical nurse status	………………………………………50.00
Reinstatement of retired registered nurse to practice as a registered nurse or a retired licensed practical nurse to practice as a licensed practical nurse (two‑year period)	100.00
Reasonable charge for duplication services and materials.
A fee for an item listed in this schedule shall not increase from one year to the next by more than twenty percent (20%)."
SECTION 6.  Article 9A of Chapter 90 of the General Statutes is amended by adding new sections to read:
"§ 90‑171.36B.  Advanced practice registered nurse licensure.
(a)	No advanced practice registered nurse shall practice as an advanced practice registered nurse unless the nurse is licensed by the Board under this section.
(b)	An applicant for a license to practice as an APRN shall apply to the Board in a format prescribed by the Board and pay a fee in an amount determined under G.S. 90‑171.27.
(c)	To be eligible for licensure, an applicant shall meet all of the following criteria:
(1)	Must hold a current North Carolina registered nurse license.
(2)	Must not hold an encumbered license as a registered nurse or advanced practice registered nurse in any state or territory.
(3)	Must have completed a graduate level APRN program accredited by a nursing or nursing‑related accrediting body that is recognized by the United States Secretary of Education or the Council for Higher Education Accreditation as acceptable to the Board. The education must be in one of the four APRN roles and at least one population focus.
(4)	Must be currently certified by a national certifying body recognized by the Board in the APRN role and population focus appropriate to educational preparation.
(5)	Must report any criminal conviction, nolo contendere plea, Alford plea, or other plea arrangement in lieu of conviction.
(6)	Must not have committed any acts or omissions that are grounds for disciplinary action in another jurisdiction or, if these acts have been committed and would be grounds for disciplinary action in this State, the Board has found, after investigation, that sufficient restitution has been made.
"§ 90‑171.36C.  Advanced practice registered nurse licensure; grandfathering exceptions.
(a)	The Board shall issue an APRN license to an applicant who does not meet the education requirements of G.S. 91‑171.36B(c)(3) if the applicant is recognized by the Board or approved to practice as an APRN in this State on December 31, 2019.
(b)	The Board shall issue a license to an applicant who meets the education requirements of G.S. 90‑171.36B(c)(3) but who is unable to meet the certification requirements of G.S. 90‑171.36B(c)(4) if the applicant's education and certification are substantially similar to the requirements set forth in G.S. 90‑171.36B.
(c)	An advanced practice registered nurse licensed under this section shall maintain all practice privileges provided to licensed advanced practice registered nurses under this Chapter.
"§ 90‑171.36D.  Advanced practice registered nurse licensure renewal; reinstatement.
(a)	APRN licenses issued under this Article shall be renewed according to the frequency and schedule established by the Board. An applicant for APRN license renewal shall do all of the following:
(1)	Submit a renewal application in the manner prescribed by the Board and remit the required fee.
(2)	Maintain national certification in the appropriate APRN role and at least one population focus, authorized by licensure, through an ongoing certification maintenance program nationally recognized by the Board unless subject to the grandfather provision in G.S. 90‑171.36C.
(3)	Meet all other requirements as set forth in statute and rule.
Failure to renew the APRN license before the expiration date shall result in automatic forfeiture of the right to practice nursing as an APRN in North Carolina until such time as the license has been reinstated.
(b)	An APRN licensee who has allowed his or her license to lapse by failure to renew as herein provided may apply for reinstatement in a manner prescribed by the Board. The Board shall require the applicant to return the completed application along with the required fee and a statement of the reason for failure to apply for renewal prior to the deadline."
SECTION 7.  G.S. 90‑171.43 reads as rewritten:
"§ 90‑171.43.  License required.
(a)	No person shall practice or offer to practice as an advanced practice registered nurse, registered nurse, or licensed practical nurse, or use the word "nurse" as a title for herself or himself, or use an abbreviation to indicate that the person is an advanced practice registered nurse, registered nurse, or licensed practical nurse, unless the person is currently licensed as an advanced practice registered nurse, registered nurse, or licensed practical nurse as provided by this Article. If the word "nurse" is part of a longer title, such as "nurse's aide", a person who is entitled to use that title shall use the entire title and may not abbreviate the title to "nurse". This Article shall not, however, be construed to prohibit or limit the following:
(1)	The performance by any person of any act for which that person holds a license issued pursuant to North Carolina law;
(2)	The clinical practice by students enrolled in approved nursing programs, continuing education programs, or refresher courses under the supervision of qualified faculty;
(3)	The performance of nursing performed by persons who hold a temporary license issued pursuant to G.S. 90‑171.33;
(4)	The delegation to any person, including a member of the patient's family, by a physician licensed to practice medicine in North Carolina, a licensed dentist or registered nurse of those patient‑care services which are routine, repetitive, limited in scope that do not require the professional judgment of a registered nurse or licensed practical nurse;
(5)	Assistance by any person in the case of emergency.
Any person permitted to practice nursing without a license as provided in subdivision (2) or (3) of this section shall be held to the same standard of care as any licensed nurse.
(b)	The abbreviations for the APRN designation of a certified nurse midwife, a clinical nurse specialist, a certified registered nurse anesthetist, and a nurse practitioner shall be APRN, plus the role title, i.e., CNM, CNS, CRNA, and NP.
(c)	It shall be unlawful for any person to use the title "APRN" or "APRN" plus their respective role titles, the role title alone, authorized abbreviations, or any other title that would lead a person to believe the individual is an APRN, unless permitted by this act.
(d)	The Board shall have the authority to promulgate rules to enforce the provisions of this section."
SECTION 8.  G.S. 90‑171.43A reads as rewritten:
"§ 90‑171.43A.  Mandatory employer verification of licensure status.
(a)	Before hiring an advanced practice registered nurse, a registered nurse, or a licensed practical nurse in North Carolina, a health care facility shall verify that the applicant has a current, valid license to practice nursing pursuant to G.S. 90‑171.43.
(b)	For purposes of this section, "health care facility" means:
(1)	Facilities described in G.S. 131E‑256(b).
(2)	Public health departments, physicians' offices, ambulatory care facilities, and rural health clinics."
SECTION 9.  G.S. 90‑171.44 reads as rewritten:
"§ 90‑171.44.  Prohibited acts.
It shall be a violation of this Article, and subject to action under G.S. 90‑171.37, for any person to:
(1)	Sell, fraudulently obtain, or fraudulently furnish any nursing diploma or aid or abet therein.
(2)	Practice nursing under cover of any fraudulently obtained license.
(3)	Practice nursing without a license. This subdivision shall not be construed to prohibit any licensed registered nurse who has successfully completed a program established under G.S. 90‑171.38(b) from conducting medical examinations or performing procedures to collect evidence from the victims of offenses described in that subsection.
(3a)	Refer to himself or herself as an advanced practice registered nurse; or refer to himself or herself as any of the four roles of advanced practice registered nurses, a registered nurse, or a licensed practical nurse; or use the abbreviations "APRN," "CNM," "CNS," "CRNA," "NP," "RN," and "LPN" without a license.
(4)	Conduct a nursing program or a refresher course for activation of a license, that is not approved by the Board.
(5)	Employ unlicensed persons to practice nursing."
SECTION 10.  Article 9A of Chapter 90 of the General Statutes is amended by adding a new section to read:
"§ 90‑171.49.  Disasters and emergencies.
In the event of an occurrence that the Governor of the State of North Carolina has declared a state of emergency, or in the event of an occurrence for which a county or municipality has enacted an ordinance to deal with states of emergency under G.S. 166A‑19.31, or to protect the public health, safety, or welfare of its citizens under Article 22 of Chapter 130A of the General Statutes, G.S. 160A‑174(a) or G.S. 153A‑121(a), as applicable, the Board may waive the requirements of this Article in order to permit the provision of emergency health services to the public."
SECTION 11.  G.S. 90‑171.28 and Article 10A of Chapter 90 of the General Statutes are repealed.
SECTION 12.  This act becomes effective January 1, 2020, and applies to licenses applied for or renewed on or after that date.