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 reads as rewritten:
"§ 90‑1.1.  Definitions.
The following definitions apply in this Article:
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(4d)	Team‑based setting. – Any of the following:
a.	A medical practice organized pursuant to G.S. 55B‑14(c)(3).
b.	A physician‑owned medical practice where the physician owner has consistent and meaningful participation in the design and implementation of health services to patients.
c.	Licensed 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.
d.	For the purposes of this Article, the term "team‑based setting" shall not include a medical practice that specializes in pain management.
(5)	The practice of medicine or surgery. – Except as otherwise provided by this subdivision, the practice of medicine or surgery, for purposes of this Article, includes any of the following acts:
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e.	Using the designation "Doctor," "Doctor of Medicine," "Doctor of Osteopathy," "Doctor of Osteopathic Medicine," "Physician," "Surgeon," "Physician and Surgeon," "Dr.," "M.D.," "D.O.," "Physician Assistant," "PA," or any combination thereof in the conduct of any occupation or profession pertaining to the prevention, diagnosis, or treatment of human disease or condition, unless the designation additionally contains the description of or reference to another branch of the healing arts for which the individual holds a valid license in this State or the use of the designation "Doctor" or "Physician" is otherwise specifically permitted by law.
f.	The performance of any act, within or without this State, described in this subdivision by use of any electronic or other means, including the Internet or telephone.
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 the practice of medicine or surgery."
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.
	
(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 practice as a physician assistant.
(a)	A physician assistant shall execute and maintain a written or electronic supervisory arrangement with a physician unless the physician assistant meets all of the following conditions:
(1)	The physician assistant practices in team‑based settings, as defined in G.S. 90‑1.1(4d).
(2)	The physician assistant has more than 4,000 hours of practice experience as a licensed physician assistant and more than 1,000 hours of practice within the specific medical specialty of practice with a physician in that specialty.
(b)	The written or electronic supervisory arrangement shall be made available to the Board immediately upon request and shall describe with specificity, at a minimum, all of the following:
(1)	The terms of clinical oversight.
(2)	An onboarding or orientation process.
(3)	Quality measures to be achieved.
(4)	Scope of delegate duties.
(5)	Plan for interval expansion.
(c)	Physician assistants who are subject to written or electronic supervisory arrangements shall submit an "Intent to Practice Notification Form" to the Board before initiating the practice of medical acts, tasks, or functions as a physician assistant, which shall include the name, address, and telephone number of the physician who will supervise the physician assistant in the relevant medical practice setting.
(d)	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. A physician assistant is responsible for the care they provide.
(e)	Notwithstanding any other provision of this Chapter, a 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 who is subject to supervisory arrangements shall submit an "Intent to Practice Notification Form" to the Board 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.
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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." A person who meets the qualifications for licensure as a physician assistant under this Chapter may use the title "physician assistant" or "PA," but shall not act or practice as a physician assistant unless licensed under this Chapter. 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)	If the physician assistant is subject to a supervisory arrangement, 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.
(5)	A physician assistant who prescribes a targeted controlled substance as defined in Article 5 of this Chapter shall personally consult with a physician 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 or advertises in any medium for any type of pain management services.
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 physician in the practice at least once every 90 days to verify that the prescription remains medically appropriate for the patient.

	
	
(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)	A physician assistant may prescribe, dispense, compound, order, administer, and procure drugs and medical devices. Physician assistants may 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 such as 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. The term "diagnostic imaging" includes all plain film radiographs, computed tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, positron emission tomography (PET), mammography, and ultrasound goods and services. Final interpretations must be provided by a physician licensed in this State, who is subject to the supervision of the North Carolina Medical Board.
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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, if subject to supervisory arrangement requirements, a current Intent to Practice form with the Board.
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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), or 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.  This act becomes effective January 1, 2022.