ENGROSSED SUBSTITUTE HOUSE BILL 1678

ByHouse Health Care & Wellness (originally sponsored by Representatives Riccelli, Lekanoff, Stonier, Morgan, Bateman, Macri, Ormsby, Slatter, Entenman, Ramos, Peterson, Tharinger, Chopp, Ryu, Pollet, Davis, Harris, Taylor, Simmons, Kloba, and Gregerson)

AN ACT Relating to establishing and authorizing the profession of dental therapy to practice in federally qualified health centers and look-alikes; amending RCW 18.32.030, 18.32.0351, 18.120.020, 18.130.040, 18.260.010, 18.260.040, 18.260.070, 18.260.080, 18.29.050, and 69.41.010; reenacting and amending RCW 43.70.442; adding a new chapter to Title 18 RCW; creating a new section; and providing an effective date.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

Dental-related issues are a leading reason that Washingtonians seek care in hospital emergency departments, which has become the source of care for many, especially uninsured and low-income populations.

It is the intent of the legislature to expand access to oral health care for all Washingtonians through an evidence-based mid-level dental provider called a dental therapist. Dental therapy is a strategy to address racial and ethnic disparities in health and rural health care access gaps. Dental therapists are also a strategy to increase workforce diversity in health care and expand career opportunities for existing members of the dental care workforce such as dental hygienists.

It is the legislature's intent that dental therapists will meet the needs of local communities as they work under the direction of a dentist licensed in accordance with state or federal law. The legislature intends for dental therapists to be incorporated into the dental care workforce and used to effectively treat more patients.

It is the intent of the legislature to follow the national commission on dental accreditation's standards for dental therapy education. This will ensure that dental therapists are trained to the highest quality standards and provide state-to-state consistency. It is the intent of the legislature that incorporating the commission on dental accreditation's standards for dental therapy education will pave the way for Washington education institutions to become accredited programs and for students to qualify for financial aid.

It is also the intent of the legislature to provide an efficient and reasonable pathway, through a limited license, for federally certified dental health aide therapists or tribally licensed dental therapists to become a Washington state licensed dental therapist.

(1) "Close supervision of a dentist" means that a supervising dentist:

(a) Has personally examined and diagnosed the patient and has personally authorized the procedures to be performed;

(b) Is continuously on-site while the procedure in question is being performed; and

(c) Is capable of responding immediately in the event of an emergency.

(2) "Commission" means the dental quality assurance commission established in chapter 18.32 RCW.

(3) "Dental therapist" means a person licensed to practice dental therapy under this chapter.

(4) "Dental therapy" means the services and procedures specified in section 6 of this act.

(5) "Dentist" means a person licensed to practice dentistry under chapter 18.32 RCW or exempt from such licensure pursuant to Title 25 U.S.C. Sec. 1621t of the Indian health care improvement act.

(6) "Denturist" means a person licensed to engage in the practice of denturism under chapter 18.30 RCW.

(7) "Department" means the department of health.

(8) "Off-site supervision" means supervision that does not require the dentist to be personally on-site when services are provided or to previously examine or diagnose the patient.

(9) "Practice plan contract" means a document that is signed by a dentist and a dental therapist and outlines the functions the dentist authorizes the dental therapist to perform and the level and type of dentist supervision that is required.

(10) "Secretary" means the secretary of health.

(a) Pays any applicable fees established by the secretary under RCW 43.70.110 and 43.70.250;

(b) Except as provided in subsection (2) of this section, successfully completes a dental therapist program that is accredited or has received initial accreditation by the American dental association's commission on dental accreditation;

(c) Passes an examination approved by the commission; and

(d) Submits, on forms provided by the secretary, the applicant's name, address, and other applicable information as determined by the secretary.

(2) Applicants who successfully completed a dental therapist program before September 30, 2022, that was not accredited by the American dental association's commission on dental accreditation but that the commission determines is substantially equivalent to an accredited education program meet the criteria described in subsection (1)(b) of this section if the applicant also, has proof of at least 400 preceptorship hours under the close supervision of a dentist.

(3) When considering and approving the exam under subsection (1)(c) of this section, the committee must consult with tribes that license dental health aide therapists and with dental therapy education programs located in this state.

(4) The secretary in consultation with the commission must establish by rule the procedures to implement this section.

(a) Oral health instruction and disease prevention education, including nutritional counseling and dietary analysis;

(b) Comprehensive charting of the oral cavity;

(c) Making radiographs;

(d) Mechanical polishing;

(e) Prophylaxis;

(f) Periodontal scaling and root planing;

(g) Application of topical preventative or prophylactic agents, including fluoride and pit and fissure sealants;

(h) Pulp vitality testing;

(i) Application of desensitizing medication or resin;

(j) Fabrication of athletic mouth guards;

(k) Placement of temporary restorations;

(l) Fabrication of soft occlusal guards;

(m) Tissue conditioning and soft reline;

(n) Atraumatic restorative therapy and interim restorative therapy;

(o) Dressing changes;

(p) Administration of local anesthetic;

(q) Administration of nitrous oxide;

(r) Emergency palliative treatment of dental pain limited to the procedures in this section;

(s) The placement and removal of space maintainers;

(t) Cavity preparation;

(u) Restoration of primary and permanent teeth;

(v) Placement of temporary crowns;

(w) Preparation and placement of preformed crowns for patients 18 years of age or older;

(x) Indirect and direct pulp capping on primary and permanent teeth;

(y) Stabilization of reimplanted teeth;

(z) Extractions of primary teeth;

(aa) Suture removal;

(bb) Brush biopsies;

(cc) Minor adjustments and repairs on removable prostheses;

(dd) Recementing of permanent crowns;

(ee) Oral evaluation and assessment of dental disease and the formulation of an individualized treatment plan. When possible, a dental therapist must collaborate with the supervising dentist to formulate a patient's individualized treatment plan;

(ff) Identification of oral and systemic conditions requiring evaluation and treatment by a dentist, physician, or other health care provider, and management of referrals;

(gg) The supervision of expanded function dental auxiliaries, dental assistants, and dental hygienists. However, a dental therapist may supervise no more than a total of three expanded function dental auxiliaries, dental assistants, and dental hygienists at any one time in any one practice setting. A dental therapist may not supervise an expanded function dental auxiliary, dental assistant, or dental hygienist with respect to tasks that the dental therapist is not authorized to perform;

(hh) Nonsurgical extractions of erupted permanent teeth under limited conditions; and

(ii) The dispensation and oral administration of drugs pursuant to subsection (2) of this section.

(2)(a) A dental therapist may dispense and orally administer the following drugs within the parameters of the practice plan contract established in section 7 of this act: Nonnarcotic analgesics, anti-inflammatories, preventive agents, and antibiotics.

(b) The authority to dispense and orally administer drugs extends only to the drugs identified in this subsection and may be further limited by the practice plan contract.

(c) The authority to dispense includes the authority to dispense sample drugs within the categories established in this subsection if the dispensing is permitted under the practice plan contract.

(d) A dental therapist may not dispense or administer narcotic drugs as defined in chapter 69.50 RCW.

(e) A dental therapist does not have the authority to prescribe drugs.

(3) A dental therapist may only provide services and procedures in which they have been educated.

(4) A dental therapist may not provide any service or procedure that is not both authorized by this section and been authorized by the supervising dentist via inclusion in the dental therapist's practice plan contract.

(a) The level of supervision required and circumstances when the prior knowledge and consent of the supervising dentist is required;

(b) Practice settings where services and procedures may be provided;

(c) Any limitations on the services or procedures the dental therapist may provide;

(d) Age and procedure-specific practice protocols, including case selection criteria, assessment guidelines, and imaging frequency;

(e) Procedures for creating and maintaining dental records for patients treated by the dental therapist;

(f) A plan to manage medical emergencies in each practice setting where the dental therapist provides care;

(g) A quality assurance plan for monitoring care provided by the dental therapist or, including patient care review, referral follow-up, and a quality assurance chart review;

(h) Protocols for administering and dispensing medications, including the specific circumstances under which the medications may be dispensed and administered;

(i) Criteria relating to the provision of care to patients with specific medical conditions or complex medical histories, including requirements for consultation prior to the initiation of care; and

(j) Specific written protocols governing situations where the dental therapist encounters a patient requiring treatment that exceeds the dental therapist's scope of practice or capabilities and protocols for referral of patients requiring evaluation and treatment by dentists, denturists, physicians, advanced registered nurse practitioners, or other health care providers.

(2) The dental therapist shall accept responsibility for all services and procedures provided by the dental therapist or any auxiliary dental providers the dental therapist is supervising pursuant to the practice plan contract.

(3) A supervising dentist licensed under chapter 18.32 RCW who knowingly permits a dental therapist to provide a service or procedure that is not authorized in the practice plan contract, or any dental therapist who provides a service or procedure that is not authorized in the practice plan contract, commits unprofessional conduct for purposes of chapter 18.130 RCW.

(4) A dentist who enters into a written practice plan contract with a dental therapist shall:

(a) Directly provide or arrange for another dentist, denturist, or specialist to provide any necessary advanced procedures or services needed by the patient or any treatment that exceeds the dental therapist's scope of practice or capabilities;

(b) Ensure that he or she or another dentist is available to the dental therapist for timely communication during treatment if needed.

(5) A dental therapist shall perform only those services authorized by the supervising dentist and written practice plan contract and shall maintain an appropriate level of contact with the supervising dentist.

(6) A supervising dentist may supervise no more than a total of five dental therapists at any one time.

(7) Practice plan contracts must be signed and maintained by both the supervising dentist and the dental therapist.

(8) A dental therapist must submit a signed copy of the practice plan contract to the secretary at the time of licensure renewal. If the practice plan contract is revised in between license renewal, a signed copy of the revised practice plan contract must be submitted as soon as practicable after the revision is made.

(1) The practice of dental therapy by an individual otherwise licensed under this title and performing services within his or her scope of practice;

(2) The practice of dental therapy in the discharge of official duties on behalf of the United States government including, but not limited to, the armed forces, coast guard, public health service, veterans' bureau, or bureau of Indian affairs;

(3) The practice of dental therapy pursuant to an education program described in section 4 of this act;

(4) The practice of dental therapy under the supervision of a dentist necessary to meet the clinical experience or preceptorship requirements of section 4 of this act; or

(5) The practice of federally certified dental health aide therapists or tribally licensed dental health aide therapists as authorized under chapter 70.350 RCW.

(2) A dentist providing dental services at a federally qualified health center is not required to enter a practice plan contract and may not face retaliation or default on a loan repayment contract if the dentist refuses to enter into a practice plan contract or supervise a dental therapist.

(3) For purposes of this section, a "tribal federally qualified health center" means a tribal facility operating in accordance with Title XIX Sec. 1905(l)(2)(B) of the social security act and the Indian self-determination and education assistance act (P.L. 93-638) and that enrolls in Washington medicaid as a tribal federally qualified health center.

(a) Holds a valid license, certification, or recertification in another state, Canadian province, or has been certified or licensed by a federal or tribal governing board in the previous two years, that allows a substantially equivalent, but not the entire scope of practice in section 6 of this act;

(b) Is currently engaged in active practice in another state, Canadian province, or tribe;

(c) Files with the secretary documentation certifying that the applicant:

(i)(A) Has graduated from a dental therapy school accredited by the commission on dental accreditation; or

(B) Has graduated from a dental therapy education program before September 30, 2022, that the dental quality assurance commission determines is substantially equivalent to an accredited education program; and

(ii) Is licensed or certified to practice in another state or Canadian province, or has been certified or licensed by a federal or tribal governing board in the previous two years;

(d) Provides such information as the secretary deems necessary pertaining to the conditions and criteria of the uniform disciplinary act, chapter 18.130 RCW;

(e) Demonstrates to the secretary knowledge of Washington state law pertaining to the practice of dental therapy; and

(f) Pays any required fees.

(2) A person practicing with a limited license granted under this section has the authority to perform only those dental therapy procedures in section 6 of this act that he or she was licensed or certified to practice in their previous state, tribe, or Canadian province.

(3) Upon demonstration of competency in all procedures in section 6 of this act, the limited license holder may apply for licensure as a dental therapist under section 4 of this act.

(4) The term of a limited license issued under this section is the same as the term for an initial limited license issued under RCW 18.29.190.

(5) The department may adopt rules necessary to implement and administer this section.

Sec. 12. RCW 18.32.030 and 2017 c 5 s 5 are each amended to read as follows:

The following practices, acts, and operations are excepted from the operation of the provisions of this chapter:

(1) The rendering of dental relief in emergency cases in the practice of his or her profession by a physician or surgeon, licensed as such and registered under the laws of this state, unless the physician or surgeon undertakes to or does reproduce lost parts of the human teeth in the mouth or to restore or to replace in the human mouth lost or missing teeth;

(2) The practice of dentistry in the discharge of official duties by dentists in the United States federal services on federal reservations, including but not limited to the armed services, coast guard, public health service, veterans' bureau, or bureau of Indian affairs;

(3) Dental schools or colleges approved under RCW 18.32.040, and the practice of dentistry by students in accredited dental schools or colleges approved by the commission, when acting under the direction and supervision of Washington state-licensed dental school faculty;

(4) The practice of dentistry by licensed dentists of other states or countries while appearing as clinicians at meetings of the Washington state dental association, or component parts thereof, or at meetings sanctioned by them, or other groups approved by the commission;

(5) The use of roentgen and other rays for making radiographs or similar records of dental or oral tissues, under the supervision of a licensed dentist or physician;

(6) The making, repairing, altering, or supplying of artificial restorations, substitutions, appliances, or materials for the correction of disease, loss, deformity, malposition, dislocation, fracture, injury to the jaws, teeth, lips, gums, cheeks, palate, or associated tissues or parts; providing the same are made, repaired, altered, or supplied pursuant to the written instructions and order of a licensed dentist which may be accompanied by casts, models, or impressions furnished by the dentist, and the prescriptions shall be retained and filed for a period of not less than three years and shall be available to and subject to the examination of the secretary or the secretary's authorized representatives;

(7) The removal of deposits and stains from the surfaces of the teeth, the application of topical preventative or prophylactic agents, and the polishing and smoothing of restorations, when performed or prescribed by a dental hygienist licensed under the laws of this state;

(8) A qualified and licensed physician and surgeon or osteopathic physician and surgeon extracting teeth or performing oral surgery pursuant to the scope of practice under chapter 18.71 or 18.57 RCW;

(9) The performing of dental operations or services by registered dental assistants and licensed expanded function dental auxiliaries holding a credential issued under chapter 18.260 RCW when performed under the supervision of a licensed dentist, by dental therapists licensed under chapter 18.--- RCW (the new chapter created in section 23 of this act), or by other persons not licensed under this chapter if the person is licensed pursuant to chapter 18.29, 18.57, 18.71, or 18.79 RCW as it applies to registered nurses and advanced registered nurse practitioners, each while acting within the scope of the person's permitted practice under the person's license: PROVIDED HOWEVER, That such persons shall in no event perform the following dental operations or services unless permitted to be performed by the person under this chapter or chapters 18.29, 18.57, 18.71, 18.79 as it applies to registered nurses and advanced registered nurse practitioners, and 18.260 RCW:

(a) Any removal of or addition to the hard or soft tissue of the oral cavity;

(b) Any diagnosis of or prescription for treatment of disease, pain, deformity, deficiency, injury, or physical condition of the human teeth or jaws, or adjacent structure;

(c) Any administration of general or injected local anaesthetic of any nature in connection with a dental operation, including intravenous sedation;

(d) Any oral prophylaxis;

(e) The taking of any impressions of the teeth or jaw or the relationships of the teeth or jaws, for the purpose of fabricating any intra-oral restoration, appliance, or prosthesis;

(10) The performing of dental services described in RCW 18.350.040 by dental anesthesia assistants certified under chapter 18.350 RCW when working under the supervision and direction of an oral and maxillofacial surgeon or dental anesthesiologist; and

(11) The performance of dental health aide therapist services to the extent authorized under chapter 70.350 RCW.

Sec. 13. RCW 18.32.0351 and 2022 c 240 s 1 are each amended to read as follows:

The Washington state dental quality assurance commission is established, consisting of ((seventeen))21 members each appointed by the governor to a four-year term. No member may serve more than two consecutive full terms. Members of the commission hold office until their successors are appointed. All members shall be appointed to full four-year terms. Twelve members of the commission must be dentists, four members must be dental therapists licensed under chapter 18.--- RCW (the new chapter created in section 23 of this act), two members must be expanded function dental auxiliaries licensed under chapter 18.260 RCW, and three members must be public members.

Sec. 14. RCW 18.120.020 and 2020 c 80 s 22 are each amended to read as follows:

The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.

(1) "Applicant group" includes any health professional group or organization, any individual, or any other interested party which proposes that any health professional group not presently regulated be regulated or which proposes to substantially increase the scope of practice of the profession.

(2) "Certificate" and "certification" mean a voluntary process by which a statutory regulatory entity grants recognition to an individual who (a) has met certain prerequisite qualifications specified by that regulatory entity, and (b) may assume or use "certified" in the title or designation to perform prescribed health professional tasks.

(3) "Grandfather clause" means a provision in a regulatory statute applicable to practitioners actively engaged in the regulated health profession prior to the effective date of the regulatory statute which exempts the practitioners from meeting the prerequisite qualifications set forth in the regulatory statute to perform prescribed occupational tasks.

(4) "Health professions" means and includes the following health and health-related licensed or regulated professions and occupations: Podiatric medicine and surgery under chapter 18.22 RCW; chiropractic under chapter 18.25 RCW; dental hygiene under chapter 18.29 RCW; dentistry under chapter 18.32 RCW; denturism under chapter 18.30 RCW; dental anesthesia assistants under chapter 18.350 RCW; dispensing opticians under chapter 18.34 RCW; hearing instruments under chapter 18.35 RCW; naturopaths under chapter 18.36A RCW; embalming and funeral directing under chapter 18.39 RCW; midwifery under chapter 18.50 RCW; nursing home administration under chapter 18.52 RCW; optometry under chapters 18.53 and 18.54 RCW; ocularists under chapter 18.55 RCW; osteopathic medicine and surgery under chapter 18.57 RCW; pharmacy under chapters 18.64 and 18.64A RCW; medicine under chapters 18.71 and 18.71A RCW; emergency medicine under chapter 18.73 RCW; physical therapy under chapter 18.74 RCW; practical nurses under chapter 18.79 RCW; psychologists under chapter 18.83 RCW; registered nurses under chapter 18.79 RCW; occupational therapists licensed under chapter 18.59 RCW; respiratory care practitioners licensed under chapter 18.89 RCW; veterinarians and veterinary technicians under chapter 18.92 RCW; massage therapists under chapter 18.108 RCW; acupuncturists or acupuncture and Eastern medicine practitioners licensed under chapter 18.06 RCW; persons registered under chapter 18.19 RCW; persons licensed as mental health counselors, marriage and family therapists, and social workers under chapter 18.225 RCW; dietitians and nutritionists certified by chapter 18.138 RCW; radiologic technicians under chapter 18.84 RCW; nursing assistants registered or certified under chapter 18.88A RCW; reflexologists certified under chapter 18.108 RCW; medical assistants-certified, medical assistants-hemodialysis technician, medical assistants-phlebotomist, forensic phlebotomist, and medical assistants-registered certified and registered under chapter 18.360 RCW; ((and)) licensed behavior analysts, licensed assistant behavior analysts, and certified behavior technicians under chapter 18.380 RCW; and dental therapists licensed under chapter 18.--- RCW (the new chapter created in section 23 of this act).

(5) "Inspection" means the periodic examination of practitioners by a state agency in order to ascertain whether the practitioners' occupation is being carried out in a fashion consistent with the public health, safety, and welfare.

(6) "Legislative committees of reference" means the standing legislative committees designated by the respective rules committees of the senate and house of representatives to consider proposed legislation to regulate health professions not previously regulated.

(7) "License," "licensing," and "licensure" mean permission to engage in a health profession which would otherwise be unlawful in the state in the absence of the permission. A license is granted to those individuals who meet prerequisite qualifications to perform prescribed health professional tasks and for the use of a particular title.

(8) "Practitioner" means an individual who (a) has achieved knowledge and skill by practice, and (b) is actively engaged in a specified health profession.

(9) "Professional license" means an individual, nontransferable authorization to carry on a health activity based on qualifications which include: (a) Graduation from an accredited or approved program, and (b) acceptable performance on a qualifying examination or series of examinations.

(10) "Public member" means an individual who is not, and never was, a member of the health profession being regulated or the spouse of a member, or an individual who does not have and never has had a material financial interest in either the rendering of the health professional service being regulated or an activity directly related to the profession being regulated.

(11) "Registration" means the formal notification which, prior to rendering services, a practitioner shall submit to a state agency setting forth the name and address of the practitioner; the location, nature and operation of the health activity to be practiced; and, if required by the regulatory entity, a description of the service to be provided.

(12) "Regulatory entity" means any board, commission, agency, division, or other unit or subunit of state government which regulates one or more professions, occupations, industries, businesses, or other endeavors in this state.

(13) "State agency" includes every state office, department, board, commission, regulatory entity, and agency of the state, and, where provided by law, programs and activities involving less than the full responsibility of a state agency.

Sec. 15. RCW 18.130.040 and 2022 c 217 s 5 are each amended to read as follows:

(1) This chapter applies only to the secretary and the boards and commissions having jurisdiction in relation to the professions licensed under the chapters specified in this section. This chapter does not apply to any business or profession not licensed under the chapters specified in this section.

(2)(a) The secretary has authority under this chapter in relation to the following professions:

(i) Dispensing opticians licensed and designated apprentices under chapter 18.34 RCW;

(ii) Midwives licensed under chapter 18.50 RCW;

(iii) Ocularists licensed under chapter 18.55 RCW;

(iv) Massage therapists and businesses licensed under chapter 18.108 RCW;

(v) Dental hygienists licensed under chapter 18.29 RCW;

(vi) Acupuncturists or acupuncture and Eastern medicine practitioners licensed under chapter 18.06 RCW;

(vii) Radiologic technologists certified and X-ray technicians registered under chapter 18.84 RCW;

(viii) Respiratory care practitioners licensed under chapter 18.89 RCW;

(ix) Hypnotherapists and agency affiliated counselors registered and advisors and counselors certified under chapter 18.19 RCW;

(x) Persons licensed as mental health counselors, mental health counselor associates, marriage and family therapists, marriage and family therapist associates, social workers, social work associates—advanced, and social work associates—independent clinical under chapter 18.225 RCW;

(xi) Persons registered as nursing pool operators under chapter 18.52C RCW;

(xii) Nursing assistants registered or certified or medication assistants endorsed under chapter 18.88A RCW;

(xiii) Dietitians and nutritionists certified under chapter 18.138 RCW;

(xiv) Substance use disorder professionals, substance use disorder professional trainees, or co-occurring disorder specialists certified under chapter 18.205 RCW;

(xv) Sex offender treatment providers and certified affiliate sex offender treatment providers certified under chapter 18.155 RCW;

(xvi) Persons licensed and certified under chapter 18.73 RCW or RCW 18.71.205;

(xvii) Orthotists and prosthetists licensed under chapter 18.200 RCW;

(xviii) Surgical technologists registered under chapter 18.215 RCW;

(xix) Recreational therapists under chapter 18.230 RCW;

(xx) Animal massage therapists certified under chapter 18.240 RCW;

(xxi) Athletic trainers licensed under chapter 18.250 RCW;

(xxii) Home care aides certified under chapter 18.88B RCW;

(xxiii) Genetic counselors licensed under chapter 18.290 RCW;

(xxiv) Reflexologists certified under chapter 18.108 RCW;

(xxv) Medical assistants-certified, medical assistants-hemodialysis technician, medical assistants-phlebotomist, forensic phlebotomist, and medical assistants-registered certified and registered under chapter 18.360 RCW;

(xxvi) Behavior analysts, assistant behavior analysts, and behavior technicians under chapter 18.380 RCW; and

(xxvii) Birth doulas certified under chapter 18.47 RCW.

(b) The boards and commissions having authority under this chapter are as follows:

(i) The podiatric medical board as established in chapter 18.22 RCW;

(ii) The chiropractic quality assurance commission as established in chapter 18.25 RCW;

(iii) The dental quality assurance commission as established in chapter 18.32 RCW governing licenses issued under chapter 18.32 RCW, licenses and registrations issued under chapter 18.260 RCW, licenses issued under chapter 18.--- RCW (the new chapter created in section 23 of this act), and certifications issued under chapter 18.350 RCW;

(iv) The board of hearing and speech as established in chapter 18.35 RCW;

(v) The board of examiners for nursing home administrators as established in chapter 18.52 RCW;

(vi) The optometry board as established in chapter 18.54 RCW governing licenses issued under chapter 18.53 RCW;

(vii) The board of osteopathic medicine and surgery as established in chapter 18.57 RCW governing licenses issued under chapter 18.57 RCW;

(viii) The pharmacy quality assurance commission as established in chapter 18.64 RCW governing licenses issued under chapters 18.64 and 18.64A RCW;

(ix) The Washington medical commission as established in chapter 18.71 RCW governing licenses and registrations issued under chapters 18.71 and 18.71A RCW;

(x) The board of physical therapy as established in chapter 18.74 RCW;

(xi) The board of occupational therapy practice as established in chapter 18.59 RCW;

(xii) The nursing care quality assurance commission as established in chapter 18.79 RCW governing licenses and registrations issued under that chapter;

(xiii) The examining board of psychology and its disciplinary committee as established in chapter 18.83 RCW;

(xiv) The veterinary board of governors as established in chapter 18.92 RCW;

(xv) The board of naturopathy established in chapter 18.36A RCW, governing licenses and certifications issued under that chapter; and

(xvi) The board of denturists established in chapter 18.30 RCW.

(3) In addition to the authority to discipline license holders, the disciplining authority has the authority to grant or deny licenses. The disciplining authority may also grant a license subject to conditions.

(4) All disciplining authorities shall adopt procedures to ensure substantially consistent application of this chapter, the uniform disciplinary act, among the disciplining authorities listed in subsection (2) of this section.

Sec. 16. RCW 18.260.010 and 2007 c 269 s 1 are each amended to read as follows:

The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.

(1) "Close supervision" means that a supervising dentist or supervising dental therapist whose patient is being treated has personally diagnosed the condition to be treated and has personally authorized the procedures to be performed. The supervising dentist or supervising dental therapist is continuously on-site and physically present in the treatment facility while the procedures are performed by the assistive personnel and capable of responding immediately in the event of an emergency. The term does not require a supervising dentist or supervising dental therapist to be physically present in the operatory.

(2) "Commission" means the Washington state dental quality assurance commission created in chapter 18.32 RCW.

(3) "Dental assistant" means a person who is registered by the commission to provide supportive services to a licensed dentist or a licensed dental therapist to the extent provided in this chapter and under the close supervision of a dentist or close supervision of a dental therapist.

(4) "Dental therapist" means an individual who holds a license to practice as a dental therapist under chapter 18.--- RCW (the new chapter created in section 23 of this act).

(5) "Dentist" means an individual who holds a license to practice dentistry under chapter 18.32 RCW.

(((5)))(6) "Department" means the department of health.

(((6)))(7) "Expanded function dental auxiliary" means a person who is licensed by the commission to provide supportive services to a licensed dentist or dental therapist to the extent provided in this chapter and under the specified level of supervision of a dentist or dental therapist.

(((7)))(8) "General supervision" means that a supervising dentist or dental therapist has examined and diagnosed the patient and provided subsequent instructions to be performed by the assistive personnel, but does not require that the dentist or dental therapist be physically present in the treatment facility.

(((8)))(9) "Secretary" means the secretary of health.

(((9)))(10) "Supervising dental therapist" means a dental therapist licensed under chapter 18.--- RCW (the new chapter created in section 23 of this act) who is responsible for providing the appropriate level of supervision for dental assistants and expanded function dental auxiliaries.

(11) "Supervising dentist" means a dentist licensed under chapter 18.32 RCW that is responsible for providing the appropriate level of supervision for dental assistants and expanded function dental auxiliaries.

Sec. 17. RCW 18.260.040 and 2015 c 120 s 3 are each amended to read as follows:

(1)(a) The commission shall adopt rules relating to the scope of dental assisting services related to patient care and laboratory duties that may be performed by dental assistants.

(b) In addition to the services and duties authorized by the rules adopted under (a) of this subsection, a dental assistant may apply topical anesthetic agents.

(c) All dental services performed by dental assistants under (a) or (b) of this subsection must be performed under the close supervision of a supervising dentist or supervising dental therapist as the dentist or dental therapist may allow.

(2) In addition to any other limitations established by the commission, dental assistants may not perform the following procedures:

(a) Any scaling procedure;

(b) Any oral prophylaxis, except coronal polishing;

(c) Administration of any general or local anesthetic, including intravenous sedation;

(d) Any removal of or addition to the hard or soft tissue of the oral cavity;

(e) Any diagnosis of or prescription for treatment of disease, pain, deformity, deficiency, injury, or physical condition of the human teeth, jaw, or adjacent structures; and

(f) The taking of any impressions of the teeth or jaw or the relationships of the teeth or jaws, for the purpose of fabricating any intra-oral restoration, appliance, or prosthesis, other than impressions allowed as a delegated duty for dental assistants pursuant to rules adopted by the commission.

(3) A dentist or dental therapist may not assign a dental assistant to perform duties until the dental assistant has demonstrated skills necessary to perform competently all assigned duties and responsibilities.

Sec. 18. RCW 18.260.070 and 2007 c 269 s 6 are each amended to read as follows:

(1) The commission shall adopt rules relating to the scope of expanded function dental auxiliary services related to patient care and laboratory duties that may be performed by expanded function dental auxiliaries.

(2) The scope of expanded function dental auxiliary services that the commission identifies in subsection (1) of this section includes:

(a) In addition to the dental assisting services that a dental assistant may perform under the close supervision of a supervising dentist or supervising dental therapist, the performance of the following services under the general supervision of a supervising dentist or supervising dental therapist as the dentist or dental therapist may allow:

(i) Performing coronal polishing;

(ii) Giving fluoride treatments;

(iii) Applying sealants;

(iv) Placing dental x-ray film and exposing and developing the films;

(v) Giving patient oral health instruction; and

(b) Notwithstanding any prohibitions in RCW 18.260.040, the performance of the following services under the close supervision of a supervising dentist or supervising dental therapist as the dentist or dental therapist may allow:

(i) Placing and carving direct restorations; and

(ii) Taking final impressions.

(3) A dentist or dental therapist may not assign an expanded function dental auxiliary to perform services until the expanded function dental auxiliary has demonstrated skills necessary to perform competently all assigned duties and responsibilities.

Sec. 19. RCW 18.260.080 and 2007 c 269 s 7 are each amended to read as follows:

A supervising dentist or supervising dental therapist is responsible for:

(1) Maintaining the appropriate level of supervision for dental assistants and expanded function dental auxiliaries; and

(2) Ensuring that the dental assistants and expanded function dental auxiliaries that the dentist or dental therapist supervises are able to competently perform the tasks that they are assigned.

Sec. 20. RCW 18.29.050 and 2015 c 120 s 1 are each amended to read as follows:

Any person licensed as a dental hygienist in this state may remove deposits and stains from the surfaces of the teeth, may apply topical preventive or prophylactic agents, may polish and smooth restorations, may perform root planing and soft-tissue curettage, and may perform other dental operations and services delegated to them by a licensed dentist or dental therapist. Any person licensed as a dental hygienist in this state may apply topical anesthetic agents under the general supervision, as defined in RCW 18.260.010, of a dentist or a dental therapist: PROVIDED HOWEVER, That licensed dental hygienists shall in no event perform the following dental operations or services:

(1) Any surgical removal of tissue of the oral cavity;

(2) Any prescription of drugs or medications requiring the written order or prescription of a licensed dentist or physician, except that a hygienist may place antimicrobials pursuant to the order of a licensed dentist and under the dentist's or dental therapist's required supervision;

(3) Any diagnosis for treatment or treatment planning; or

(4) The taking of any impression of the teeth or jaw, or the relationships of the teeth or jaws, for the purpose of fabricating any intra-oral restoration, appliance, or prosthesis, except that a dental hygienist may take an impression for any purpose that is either allowed:

(a) For a dental assistant registered under chapter 18.260 RCW; or

(b) As a delegated duty for dental hygienists pursuant to rules adopted by the dental quality assurance commission.

Such licensed dental hygienists may perform dental operations and services only under the supervision of a licensed dentist or dental therapist, and under such supervision may be employed by hospitals, boards of education of public or private schools, county boards, boards of health, or public or charitable institutions, or in dental offices.

Sec. 21. RCW 69.41.010 and 2020 c 80 s 40 are each amended to read as follows:

As used in this chapter, the following terms have the meanings indicated unless the context clearly requires otherwise:

(1) "Administer" means the direct application of a legend drug whether by injection, inhalation, ingestion, or any other means, to the body of a patient or research subject by:

(a) A practitioner; or

(b) The patient or research subject at the direction of the practitioner.

(2) "Commission" means the pharmacy quality assurance commission.

(3) "Community-based care settings" include: Community residential programs for persons with developmental disabilities, certified by the department of social and health services under chapter 71A.12 RCW; adult family homes licensed under chapter 70.128 RCW; and assisted living facilities licensed under chapter 18.20 RCW. Community-based care settings do not include acute care or skilled nursing facilities.

(4) "Deliver" or "delivery" means the actual, constructive, or attempted transfer from one person to another of a legend drug, whether or not there is an agency relationship.

(5) "Department" means the department of health.

(6) "Dispense" means the interpretation of a prescription or order for a legend drug and, pursuant to that prescription or order, the proper selection, measuring, compounding, labeling, or packaging necessary to prepare that prescription or order for delivery.

(7) "Dispenser" means a practitioner who dispenses.

(8) "Distribute" means to deliver other than by administering or dispensing a legend drug.

(9) "Distributor" means a person who distributes.

(10) "Drug" means:

(a) Substances recognized as drugs in the official United States pharmacopoeia, official homeopathic pharmacopoeia of the United States, or official national formulary, or any supplement to any of them;

(b) Substances intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease in human beings or animals;

(c) Substances (other than food, minerals or vitamins) intended to affect the structure or any function of the body of human beings or animals; and

(d) Substances intended for use as a component of any article specified in (a), (b), or (c) of this subsection. It does not include devices or their components, parts, or accessories.

(11) "Electronic communication of prescription information" means the transmission of a prescription or refill authorization for a drug of a practitioner using computer systems. The term does not include a prescription or refill authorization transmitted verbally by telephone nor a facsimile manually signed by the practitioner.

(12) "In-home care settings" include an individual's place of temporary and permanent residence, but does not include acute care or skilled nursing facilities, and does not include community-based care settings.

(13) "Legend drugs" means any drugs which are required by state law or regulation of the pharmacy quality assurance commission to be dispensed on prescription only or are restricted to use by practitioners only.

(14) "Legible prescription" means a prescription or medication order issued by a practitioner that is capable of being read and understood by the pharmacist filling the prescription or the nurse or other practitioner implementing the medication order. A prescription must be hand printed, typewritten, or electronically generated.

(15) "Medication assistance" means assistance rendered by a nonpractitioner to an individual residing in a community-based care setting or in-home care setting to facilitate the individual's self-administration of a legend drug or controlled substance. It includes reminding or coaching the individual, handing the medication container to the individual, opening the individual's medication container, using an enabler, or placing the medication in the individual's hand, and such other means of medication assistance as defined by rule adopted by the department. A nonpractitioner may help in the preparation of legend drugs or controlled substances for self-administration where a practitioner has determined and communicated orally or by written direction that such medication preparation assistance is necessary and appropriate. Medication assistance shall not include assistance with intravenous medications or injectable medications, except prefilled insulin syringes.

(16) "Person" means individual, corporation, government or governmental subdivision or agency, business trust, estate, trust, partnership or association, or any other legal entity.

(17) "Practitioner" means:

(a) A physician under chapter 18.71 RCW, an osteopathic physician or an osteopathic physician and surgeon under chapter 18.57 RCW, a dentist under chapter 18.32 RCW, a podiatric physician and surgeon under chapter 18.22 RCW, an acupuncturist or acupuncture and Eastern medicine practitioner to the extent authorized under chapter 18.06 RCW and the rules adopted under RCW 18.06.010(1)(((j)))(m), a veterinarian under chapter 18.92 RCW, a registered nurse, advanced registered nurse practitioner, or licensed practical nurse under chapter 18.79 RCW, an optometrist under chapter 18.53 RCW who is certified by the optometry board under RCW 18.53.010, a physician assistant under chapter 18.71A RCW, a naturopath licensed under chapter 18.36A RCW, a licensed athletic trainer to the extent authorized under chapter 18.250 RCW, a pharmacist under chapter 18.64 RCW, ((or,)) when acting under the required supervision of a dentist licensed under chapter 18.32 RCW, a dental hygienist licensed under chapter 18.29 RCW, or a licensed dental therapist to the extent authorized under chapter 18.--- RCW (the new chapter created in section 23 of this act);

(b) A pharmacy, hospital, or other institution licensed, registered, or otherwise permitted to distribute, dispense, conduct research with respect to, or to administer a legend drug in the course of professional practice or research in this state; and

(c) A physician licensed to practice medicine and surgery or a physician licensed to practice osteopathic medicine and surgery in any state, or province of Canada, which shares a common border with the state of Washington.

(18) "Secretary" means the secretary of health or the secretary's designee.

Sec. 22. RCW 43.70.442 and 2020 c 229 s 1 and 2020 c 80 s 30 are each reenacted and amended to read as follows:

(1)(a) Each of the following professionals certified or licensed under Title 18 RCW shall, at least once every six years, complete training in suicide assessment, treatment, and management that is approved, in rule, by the relevant disciplining authority:

(i) An adviser or counselor certified under chapter 18.19 RCW;

(ii) A substance use disorder professional licensed under chapter 18.205 RCW;

(iii) A marriage and family therapist licensed under chapter 18.225 RCW;

(iv) A mental health counselor licensed under chapter 18.225 RCW;

(v) An occupational therapy practitioner licensed under chapter 18.59 RCW;

(vi) A psychologist licensed under chapter 18.83 RCW;

(vii) An advanced social worker or independent clinical social worker licensed under chapter 18.225 RCW; and

(viii) A social worker associate—advanced or social worker associate—independent clinical licensed under chapter 18.225 RCW.

(b) The requirements in (a) of this subsection apply to a person holding a retired active license for one of the professions in (a) of this subsection.

(c) The training required by this subsection must be at least six hours in length, unless a disciplining authority has determined, under subsection (10)(b) of this section, that training that includes only screening and referral elements is appropriate for the profession in question, in which case the training must be at least three hours in length.

(d) Beginning July 1, 2017, the training required by this subsection must be on the model list developed under subsection (6) of this section. Nothing in this subsection (1)(d) affects the validity of training completed prior to July 1, 2017.

(2)(a) Except as provided in (b) of this subsection:

(i) A professional listed in subsection (1)(a) of this section must complete the first training required by this section by the end of the first full continuing education reporting period after January 1, 2014, or during the first full continuing education reporting period after initial licensure or certification, whichever occurs later.

(ii) Beginning July 1, 2021, the second training for a psychologist, a marriage and family therapist, a mental health counselor, an advanced social worker, an independent clinical social worker, a social worker associate-advanced, or a social worker associate-independent clinical must be either: (A) An advanced training focused on suicide management, suicide care protocols, or effective treatments; or (B) a training in a treatment modality shown to be effective in working with people who are suicidal, including dialectical behavior therapy, collaborative assessment and management of suicide risk, or cognitive behavior therapy-suicide prevention. If a professional subject to the requirements of this subsection has already completed the professional's second training prior to July 1, 2021, the professional's next training must comply with this subsection. This subsection (2)(a)(ii) does not apply if the licensee demonstrates that the training required by this subsection (2)(a)(ii) is not reasonably available.

(b)(i) A professional listed in subsection (1)(a) of this section applying for initial licensure may delay completion of the first training required by this section for six years after initial licensure if he or she can demonstrate successful completion of the training required in subsection (1) of this section no more than six years prior to the application for initial licensure.

(ii) Beginning July 1, 2021, a psychologist, a marriage and family therapist, a mental health counselor, an advanced social worker, an independent clinical social worker, a social worker associate-advanced, or a social worker associate-independent clinical exempt from his or her first training under (b)(i) of this subsection must comply with the requirements of (a)(ii) of this subsection for his or her first training after initial licensure. If a professional subject to the requirements of this subsection has already completed the professional's first training after initial licensure, the professional's next training must comply with this subsection (2)(b)(ii). This subsection (2)(b)(ii) does not apply if the licensee demonstrates that the training required by this subsection (2)(b)(ii) is not reasonably available.

(3) The hours spent completing training in suicide assessment, treatment, and management under this section count toward meeting any applicable continuing education or continuing competency requirements for each profession.

(4)(a) A disciplining authority may, by rule, specify minimum training and experience that is sufficient to exempt an individual professional from the training requirements in subsections (1) and (5) of this section. Nothing in this subsection (4)(a) allows a disciplining authority to provide blanket exemptions to broad categories or specialties within a profession.

(b) A disciplining authority may exempt a professional from the training requirements of subsections (1) and (5) of this section if the professional has only brief or limited patient contact.

(5)(a) Each of the following professionals credentialed under Title 18 RCW shall complete a one-time training in suicide assessment, treatment, and management that is approved by the relevant disciplining authority:

(i) A chiropractor licensed under chapter 18.25 RCW;

(ii) A naturopath licensed under chapter 18.36A RCW;

(iii) A licensed practical nurse, registered nurse, or advanced registered nurse practitioner, other than a certified registered nurse anesthetist, licensed under chapter 18.79 RCW;

(iv) An osteopathic physician and surgeon licensed under chapter 18.57 RCW, other than a holder of a postgraduate osteopathic medicine and surgery license issued under RCW 18.57.035;

(v) A physical therapist or physical therapist assistant licensed under chapter 18.74 RCW;

(vi) A physician licensed under chapter 18.71 RCW, other than a resident holding a limited license issued under RCW 18.71.095(3);

(vii) A physician assistant licensed under chapter 18.71A RCW;

(viii) A pharmacist licensed under chapter 18.64 RCW;

(ix) A dentist licensed under chapter 18.32 RCW;

(x) A dental hygienist licensed under chapter 18.29 RCW;

(xi) An athletic trainer licensed under chapter 18.250 RCW;

(xii) An optometrist licensed under chapter 18.53 RCW;

(xiii) An acupuncture and Eastern medicine practitioner licensed under chapter 18.06 RCW; ((and))

(xiv) A dental therapist licensed under chapter 18.--- RCW (the new chapter created in section 23 of this act); and

(xv) A person holding a retired active license for one of the professions listed in (a)(i) through (((xiii)))(xiv) of this subsection.

(b)(i) A professional listed in (a)(i) through (vii) of this subsection or a person holding a retired active license for one of the professions listed in (a)(i) through (vii) of this subsection must complete the one-time training by the end of the first full continuing education reporting period after January 1, 2016, or during the first full continuing education reporting period after initial licensure, whichever is later. Training completed between June 12, 2014, and January 1, 2016, that meets the requirements of this section, other than the timing requirements of this subsection (5)(b), must be accepted by the disciplining authority as meeting the one-time training requirement of this subsection (5).

(ii) A licensed pharmacist or a person holding a retired active pharmacist license must complete the one-time training by the end of the first full continuing education reporting period after January 1, 2017, or during the first full continuing education reporting period after initial licensure, whichever is later.

(iii) A licensed dentist, a licensed dental hygienist, or a person holding a retired active license as a dentist shall complete the one-time training by the end of the full continuing education reporting period after August 1, 2020, or during the first full continuing education reporting period after initial licensure, whichever is later. Training completed between July 23, 2017, and August 1, 2020, that meets the requirements of this section, other than the timing requirements of this subsection (5)(b)(iii), must be accepted by the disciplining authority as meeting the one-time training requirement of this subsection (5).

(iv) A licensed optometrist or a licensed acupuncture and Eastern medicine practitioner, or a person holding a retired active license as an optometrist or an acupuncture and Eastern medicine practitioner, shall complete the one-time training by the end of the full continuing education reporting period after August 1, 2021, or during the first full continuing education reporting period after initial licensure, whichever is later. Training completed between August 1, 2020, and August 1, 2021, that meets the requirements of this section, other than the timing requirements of this subsection (5)(b)(iv), must be accepted by the disciplining authority as meeting the one-time training requirement of this subsection (5).

(c) The training required by this subsection must be at least six hours in length, unless a disciplining authority has determined, under subsection (10)(b) of this section, that training that includes only screening and referral elements is appropriate for the profession in question, in which case the training must be at least three hours in length.

(d) Beginning July 1, 2017, the training required by this subsection must be on the model list developed under subsection (6) of this section. Nothing in this subsection (5)(d) affects the validity of training completed prior to July 1, 2017.

(6)(a) The secretary and the disciplining authorities shall work collaboratively to develop a model list of training programs in suicide assessment, treatment, and management. Beginning July 1, 2021, for purposes of subsection (2)(a)(ii) of this section, the model list must include advanced training and training in treatment modalities shown to be effective in working with people who are suicidal.

(b) The secretary and the disciplining authorities shall update the list at least once every two years.

(c) By June 30, 2016, the department shall adopt rules establishing minimum standards for the training programs included on the model list. The minimum standards must require that six-hour trainings include content specific to veterans and the assessment of issues related to imminent harm via lethal means or self-injurious behaviors and that three-hour trainings for pharmacists or dentists include content related to the assessment of issues related to imminent harm via lethal means. When adopting the rules required under this subsection (6)(c), the department shall:

(i) Consult with the affected disciplining authorities, public and private institutions of higher education, educators, experts in suicide assessment, treatment, and management, the Washington department of veterans affairs, and affected professional associations; and

(ii) Consider standards related to the best practices registry of the American foundation for suicide prevention and the suicide prevention resource center.

(d) Beginning January 1, 2017:

(i) The model list must include only trainings that meet the minimum standards established in the rules adopted under (c) of this subsection and any three-hour trainings that met the requirements of this section on or before July 24, 2015;

(ii) The model list must include six-hour trainings in suicide assessment, treatment, and management, and three-hour trainings that include only screening and referral elements; and

(iii) A person or entity providing the training required in this section may petition the department for inclusion on the model list. The department shall add the training to the list only if the department determines that the training meets the minimum standards established in the rules adopted under (c) of this subsection.

(e) By January 1, 2021, the department shall adopt minimum standards for advanced training and training in treatment modalities shown to be effective in working with people who are suicidal. Beginning July 1, 2021, all such training on the model list must meet the minimum standards. When adopting the minimum standards, the department must consult with the affected disciplining authorities, public and private institutions of higher education, educators, experts in suicide assessment, treatment, and management, the Washington department of veterans affairs, and affected professional associations.

(7) The department shall provide the health profession training standards created in this section to the professional educator standards board as a model in meeting the requirements of RCW 28A.410.226 and provide technical assistance, as requested, in the review and evaluation of educator training programs. The educator training programs approved by the professional educator standards board may be included in the department's model list.

(8) Nothing in this section may be interpreted to expand or limit the scope of practice of any profession regulated under chapter 18.130 RCW.

(9) The secretary and the disciplining authorities affected by this section shall adopt any rules necessary to implement this section.

(10) For purposes of this section:

(a) "Disciplining authority" has the same meaning as in RCW 18.130.020.

(b) "Training in suicide assessment, treatment, and management" means empirically supported training approved by the appropriate disciplining authority that contains the following elements: Suicide assessment, including screening and referral, suicide treatment, and suicide management. However, the disciplining authority may approve training that includes only screening and referral elements if appropriate for the profession in question based on the profession's scope of practice. The board of occupational therapy may also approve training that includes only screening and referral elements if appropriate for occupational therapy practitioners based on practice setting.

(11) A state or local government employee is exempt from the requirements of this section if he or she receives a total of at least six hours of training in suicide assessment, treatment, and management from his or her employer every six years. For purposes of this subsection, the training may be provided in one six-hour block or may be spread among shorter training sessions at the employer's discretion.

(12) An employee of a community mental health agency licensed under chapter 71.24 RCW or a chemical dependency program certified under chapter 71.24 RCW is exempt from the requirements of this section if he or she receives a total of at least six hours of training in suicide assessment, treatment, and management from his or her employer every six years. For purposes of this subsection, the training may be provided in one six-hour block or may be spread among shorter training sessions at the employer's discretion.

--- END ---