A BILL TO BE ENTITLED
AN ACT to adjust the supervision arrangement of physician assistants and to make various changes to the licensure of physician assistants.
The General Assembly of North Carolina enacts:
SECTION 1.(a)  G.S. 90‑1.1 is amended by adding a new subdivision to read:
"(4d)	Team‑based setting or team‑based practice. – Any of the following:
a.	A medical practice that meets all of the following requirements:
1.	The majority of the practice is owned collectively by one or more licensed physicians.
2.	An owner who is a physician licensed under this Chapter has consistent and meaningful participation in the design and implementation of health services to patients, as defined by rules adopted by the Board.
3.	The physicians and team‑based physician assistants who provide services at the medical practice work in the same clinical practice area.
b.	Hospitals, clinics, nursing homes, and other health facilities with active credentialing and quality programs where physicians have consistent and meaningful participation in the design and implementation of health services to patients, as defined by rules adopted by the Board.
c.	For the purposes of this Article, the term "team‑based setting" or "team‑based practice" shall not include a medical practice that specializes in pain management."
SECTION 1.(b)  G.S. 90‑9.3 reads as rewritten:
"§ 90‑9.3.  Requirements for licensure as a physician assistant.
(a)	To be eligible for licensure as a physician assistant, an applicant shall submit proof satisfactory to the Board that the applicant has met all of the following:
(1)	The applicant has successfully completed an educational program for physician assistants or surgeon assistants accredited by the Accreditation Review Commission on Education for the Physician Assistant or its predecessor or successor entities.
(2)	The applicant has a current or previous certification issued by the National Commission on Certification of Physician Assistants or its successor.
(3)	The applicant is of good moral character.
(b)	Before initiating practice of medical acts, tasks, or functions as a physician assistant, the physician assistant shall provide the Board the name, address, and telephone number of the physician who will supervise the physician assistant in the relevant medical setting. This subsection shall not apply to physician assistants who meet the requirements for team‑based practice under G.S. 90‑9.3A.
(c)	The Board may, by rule, require an applicant to comply with other requirements or submit additional information the Board deems appropriate."
SECTION 1.(c)  Article 1 of Chapter 90 of the General Statutes is amended by adding a new section to read:
"§ 90‑9.3A.  Requirements for team‑based practice as a physician assistant.
(a)	In order to practice as a team‑based physician assistant, a physician assistant shall meet all of the following conditions:
(1)	Practice in team‑based settings, as defined in G.S. 90‑1.1(4d).
(2)	Have more than 4,000 hours of clinical practice experience as a licensed physician assistant and more than 1,000 hours of clinical practice experience within the specific medical specialty of practice with a physician in that specialty.
(3)	Submit proof as the Board may deem satisfactory by rule that the individual meets the requirements of subdivisions (a)(1) and (a)(2) of this section. The Board may, by rule, require the physician assistant to comply with other requirements or submit additional information the Board deems appropriate.
(b)	Team‑based physician assistants shall collaborate and consult with or refer to the appropriate members of the health care team as required by the patient's condition and as indicated by the education, experience, and competencies of the physician assistant and the standard of care. The degree of collaboration must be determined by the practice which may include decisions by the employer, group, hospital service, and the credentialing and privileging systems of a licensed facility. The Board may adopt rules to establish requirements for the determination and enforcement of collaboration, consultation, and referral. Team‑based physician assistants are responsible for the care they provide.
(c)	Notwithstanding any other provision of this Chapter, a team‑based physician assistant practicing in a perioperative setting, including the provision of surgical or anesthesia‑related services, shall be supervised by a physician."
SECTION 1.(d)  G.S. 90‑12.4 reads as rewritten:
"§ 90‑12.4.  Physician assistant limited volunteer license.
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(d)	Before initiating the performance of medical acts, tasks, or functions as a physician assistant licensed under this section, the physician assistant shall submit to the Board either an "Intent to Practice Notification Form," which shall include the name, address, and telephone number of the physician licensed under this Article who will supervise the physician assistant in the clinic specializing in the care of indigent patients, or meet the requirements for team‑based practice under G.S. 90‑9.3A.
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SECTION 1.(e)  G.S. 90‑12.4B reads as rewritten:
"§ 90‑12.4B.  Physician assistant retired limited volunteer license.
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SECTION 1.(f)  G.S. 90‑18.1 reads as rewritten:
"§ 90‑18.1.  Limitations on physician assistants.
(a)	Any person who is licensed under the provisions of G.S. 90‑9.3 to perform medical acts, tasks, and functions as a physician assistant may use the title "physician assistant" or "PA." Any other person who uses the title in any form or holds out to be a physician assistant or to be so licensed, shall be deemed to be in violation of this Article.
(a1)	Physician assistants shall clearly designate their credentials as a physician assistant in all clinical settings.
(b)	Physician assistants are authorized to write prescriptions for drugs under the following conditions:
(1)	The North Carolina Medical Board has adopted regulations governing the approval of individual physician assistants to write prescriptions with such limitations as the Board may determine to be in the best interest of patient health and safety.
(2)	The physician assistant holds a current license issued by the Board.
(3)	Repealed by Session Laws 2019‑191, s. 35, effective October 1, 2019.
(4)	The supervising physician has provided to the physician assistant written instructions about indications and contraindications for prescribing drugs and a written policy for periodic review by the physician of the drugs prescribed. This subdivision shall not apply to individuals who are practicing in a team‑based setting under G.S. 90‑9.3A.
(5)	A physician assistant shall personally consult with the supervising physician prior to prescribing a targeted controlled substance as defined in Article 5 of this Chapter when all of the following conditions apply:
a.	The patient is being treated by a facility that primarily engages in the treatment of pain by prescribing narcotic medications.
b.	The therapeutic use of the targeted controlled substance will or is expected to exceed a period of 30 days.
When a targeted controlled substance prescribed in accordance with this subdivision is continuously prescribed to the same patient, the physician assistant shall consult with the supervising physician at least once every 90 days to verify that the prescription remains medically appropriate for the patient.
(c)	Physician assistants are authorized to compound and dispense drugs under the following conditions:
(1)	The function is performed under the supervision of a licensed physician.
(2)	The physician assistant complies with all the applicable State and federal laws and rules governing compounding and dispensing.
(3)	The physician assistant holds a current license issued by the Board.
(d)	Physician assistants are authorized to order medications, tests and treatments in hospitals, clinics, nursing homes, and other health facilities under the following conditions:
(1)	The North Carolina Medical Board has adopted regulations governing the approval of individual physician assistants to order medications, tests, and treatments with such limitations as the Board may determine to be in the best interest of patient health and safety.
(2)	The physician assistant holds a current license issued by the Board.
(3)	If the physician assistant is subject to a supervisory arrangement, the supervising physician has provided to the physician assistant written instructions about ordering medications, tests, and treatments, and when appropriate, specific oral or written instructions for an individual patient, with provision for review by the physician of the order within a reasonable time, as determined by the Board, after the medication, test, or treatment is ordered.
(4)	The hospital or other health facility has adopted a written policy about ordering medications, tests, and treatments, including procedures for verification of the physician assistants' orders by nurses and other facility employees and such other procedures as are in the interest of patient health and safety.
(e)	Any prescription written by a physician assistant or order given by a physician assistant for medications, tests, or treatments shall be deemed to have been authorized by the physician approved by the Board as the supervisor of the physician assistant and the supervising physician shall be responsible for authorizing the prescription or order. This subsection shall not apply to individuals who are practicing in a team‑based setting under G.S. 90‑9.3A who may prescribe, order, administer, and procure drugs and medical devices without physician authorization. Individuals who are practicing in a team‑based setting under G.S. 90‑9.3A may also plan and initiate a therapeutic regimen that includes ordering and prescribing non‑pharmacological interventions, including durable medical equipment, nutrition, blood, blood products, and diagnostic support services, including home health care, hospice, and physical and occupational therapy.
(e1)	Physician assistants may authenticate any document, including death certificates with their signature, certification, stamp, verification, affidavit, or endorsement, if it may be so authenticated by the signature, certification, stamp, verification, affidavit, or endorsement of a physician.
(e2)	Physician assistants shall not perform final interpretations of diagnostic imaging studies. For purposes of this subsection, "diagnostic imaging" shall include computed tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, positron emission tomography (PET), mammography, and ultrasound services. Final interpretation shall be provided by a physician licensed under this Chapter. Notwithstanding any other provision of this Chapter, physician assistants conducting final interpretation of plain film radiographs shall be supervised by a physician.
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(g)	Any person who is licensed under G.S. 90‑9.3 to perform medical acts, tasks, and functions as a physician assistant shall comply with each of the following:
(1)	Maintain a current and active license to practice in this State.
(2)	Maintain an active registration with the Board.
(3)	File a current Intent to Practice form with the Board or meet the requirements for team‑based practice under G.S. 90‑9.3A.
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SECTION 1.(g)  G.S. 90‑21.81(9) reads as rewritten:
"(9)	Qualified technician. – A registered diagnostic medical sonographer who is certified in obstetrics and gynecology by the American Registry for Diagnostic Medical Sonography (ARDMS), a physician assistant with certification in obstetrical ultrasonography, or a nurse midwife or advanced practice nurse practitioner in obstetrics with certification in obstetrical ultrasonography."
SECTION 1.(h)  G.S. 58‑3‑169 reads as rewritten:
"§ 58‑3‑169.  Required coverage for minimum hospital stay following birth.
(a)	Definitions. – As used in this section:
(1)	"Attending providers" includes:
a.	The obstetrician‑gynecologists, pediatricians, family physicians, and other physicians primarily responsible for the care of a mother and newborn; and
b.	The nurse midwives, physician assistants, and nurse practitioners primarily responsible for the care of a mother and her newborn child in accordance with State licensure and certification laws.
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SECTION 1.(i)  G.S. 110‑91 reads as rewritten:
"§ 110‑91.  Mandatory standards for a license.
All child care facilities shall comply with all State laws and federal laws and local ordinances that pertain to child health, safety, and welfare. Except as otherwise provided in this Article, the standards in this section shall be complied with by all child care facilities. However, none of the standards in this section apply to the school‑age children of the operator of a child care facility but do apply to the preschool‑age children of the operator. Children 13 years of age or older may receive child care on a voluntary basis provided all applicable required standards are met. The standards in this section, along with any other applicable State laws and federal laws or local ordinances, shall be the required standards for the issuance of a license by the Secretary under the policies and procedures of the Commission except that the Commission may, in its discretion, adopt less stringent standards for the licensing of facilities which provide care on a temporary, part‑time, drop‑in, seasonal, after‑school or other than a full‑time basis.
(1)	Medical Care and Sanitation. – The Commission for Public Health shall adopt rules which establish minimum sanitation standards for child care centers and their personnel. The sanitation rules adopted by the Commission for Public Health shall cover such matters as the cleanliness of floors, walls, ceilings, storage spaces, utensils, and other facilities; adequacy of ventilation; sanitation of water supply, lavatory facilities, toilet facilities, sewage disposal, food protection facilities, bactericidal treatment of eating and drinking utensils, and solid‑waste storage and disposal; methods of food preparation and serving; infectious disease control; sleeping facilities; and other items and facilities as are necessary in the interest of the public health. The Commission for Public Health shall allow child care centers to use domestic kitchen equipment, provided appropriate temperature levels for heating, cooling, and storing are maintained. Child care centers that fry foods shall use commercial hoods. These rules shall be developed in consultation with the Department.
The Commission shall adopt rules for child care facilities to establish minimum requirements for child and staff health assessments and medical care procedures. These rules shall be developed in consultation with the Department. Each child shall have a health assessment before being admitted or within 30 days following admission to a child care facility. The assessment shall be done by: (i) a licensed physician, (ii) the physician's authorized agent who is currently approved by the North Carolina Medical Board, or comparable certifying board in any state contiguous to North Carolina, (iii) a certified nurse practitioner, (iv) a licensed physician assistant, or (v) a public health nurse meeting the Departments Standards for Early Periodic Screening, Diagnosis, and Treatment Program. However, no health assessment shall be required of any staff or child who is and has been in normal health when the staff, or the child's parent, guardian, or full‑time custodian objects in writing to a health assessment on religious grounds which conform to the teachings and practice of any recognized church or religious denomination.
Organizations that provide prepared meals to child care centers only are considered child care centers for purposes of compliance with appropriate sanitation standards.
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SECTION 2.  The North Carolina Medical Board shall adopt permanent rules necessary to implement the provisions of this act.
SECTION 3.  Section 1 of this act becomes effective when the Medical Board adopts the permanent rules required under Section 2 of this act or June 30, 2024, whichever occurs first. The Medical Board shall notify the Revisor of Statutes when the rules required under Section 2 of this act have been adopted. The remainder of this act is effective when it becomes law.