Transcript APRN Practice in Texas

APRN Practice in Texas
Kathy Shipp
MSN, APRN, FNP
Disclosures
• President, Texas Board of Nursing (BON)
• Presentation was prepared with the assistance of BON staff
• It is the policy of the BON to ensure balance, independence,
objectivity and scientific rigor in all of its continuing
nursing education activities
• No conflicts of interest to disclose
• Discussions today do not imply endorsement of any
commercial product or off-label use of any product for
which it was approved by the FDA
Objectives
• Discuss the Nursing Practice Act (NPA) and
BON Rules and Regulations as they apply to
advanced practice registered nurses (APRNs)
• Differentiate the roles and function of the
BON from those of nursing and healthcare
specialty associations
Objectives
• Discuss the 83rd Legislative Session, new legislation and
Continuing Competency Requirements
• Discuss New BON Rules and Regulations
• Discuss physician delegation of prescriptive authority and
SB406
Board of Nursing
Agency Mission
To protect and promote the welfare of
the people of Texas by ensuring that
each person holding a license as a
nurse in the State of Texas is
competent to practice safely
Role of the Board
• Regulation of Nursing Practice
• Approval of nursing education
programs
• Licensing qualified applicants
• Investigating complaints
• Corrective Action / Discipline
Texas
(December 2013)
APRN
• 98,056 LVNs (26%)
• 260,717 RNs (69%)
• 17,597 APRNs (5%)
Total 376,370
LVN
RN
 Board of Nursing
 Organizations & Associations
• Responsible to the
• Responsible to their
public
members
• No authority in
• Serve the individual
employment related
interests of nurses
issues, i.e. facility
• May lobby legislature and
policies and procedures
Governor
• Prohibited by law from
lobbying legislature
Board Members
• 13 members
• Nursing Education
1 – LVN education
1 – ADN education
1 – BSN education
• Consumers - 4
•
Representing:
Nursing Practice
3 – LVN in active
practice
2 – RN in active
practice
1 – Advanced
Practice RN
(APRN) in active
practice
Board Meetings
• Quarterly meetings (January, April, July, &
October)
• Dates posted on website and Bulletin
• Meetings open to the public
• Held in the Hobby Building in Austin
• Receive input from stakeholders
Advisory Committee
•
•
•
•
Advisory Committee on Education (ACE)
Nursing Practice Advisory Committee (NPAC)
Advanced Practice Advisory Committee (APAC)
Eligibility and Disciplinary Advisory Committee
(EDAC)
• Task Force – Delegation Task Force (DTF)
Our Practice Staff
•
•
•
•
•
•
•
•
•
Kristin Benton, MSN, RN, Director of Nursing
Jackie Ballesteros
Denise Benbow, MSN, RN
Nicole Binkley, BSN, RNC
Bonnie Cone, MSN, RN
Melinda Hester, DNP, RN
Laura Lewis
Ciara Williamson
Jolene Zych, PhD, RN, WHNP-BC
Nursing Licensure Compact
• Multistate license privilege
• Legal agreement between
states
• Texas is a Compact State
• A party state can rescind
the nurse’s multistate
licensure privilege and
report violations to nurse’s
home state
• Home state can take action
• APRNs do not have a
compact at this time
NPA, Chapter 304
Board Rules Chapter 220
Continuing Competency Requirements
• SB 1058 (Effective September 1, 2013)
• 2 Hours of CE in adults/geriatrics for those whose practice
includes adult and geriatric populations each renewal cycle
• 2 Hours of CE in Nursing Jurisprudence and Ethics each third
renewal (every 6 years)
• SB 1191 (Effective September 1, 2013)
• 2 hours of CE in forensic evidence collection for any nurse who
performs a forensic examination on a sexual assault survivor
(Not just Emergency Department nurses)
• SB 1058 (Effective September 1, 2013)
• In addition to targeted CNE - Mandatory criminal
background checks for students
• SB 945 (Effective January 1, 2014)
• Requires a health care provider in a hospital to
wear a photo identification badge clearly stating
the provider's name, department, title, type of
license held.
• If applicable, the badge must also state the
provider's status as a student, faculty, intern,
trainee, or resident.
• SB 1842 (Effective Immediately – June 14, 2013)
• In hospitals and state mental hospitals, patients
will have a face to face assessment within one
hour after initiation of a restraint or seclusion by
a RN who has special training and did not
initiate the restraint or seclusion.
• HB 705 (Effective September 1, 2013)
• Enhances penalty prescribed for an assault
committed against emergency services
personnel.
• SB 406 (Effective November 1, 2013)
• Made changes to delegative authority in
the State of Texas.
• FAQs on the website
• New Rule Chapter 222
• For additional information go the
Website; and /or contact the APRN
Department ([email protected])
UPDATE:
• New Board of Nursing Rules and Regulations
• Proposed
• Adopted by Board at Quarterly Meeting
• Jan 2014 : Chapter 216 – continuing competency
• Jan 2014 : Chapter 228 – Pain Management – minimum standards
of nursing practice for APRNs when providing pain management
services
APRN Continuing Competency Requirements
• For APRN licensure renewal:
20 contact hours of targeted continuing
education in the advanced practice role and
population focus area recognized by the BON
or
attain, maintain, or renew the national
certification recognized by the BON
APRN Continuing Competency Requirements
• For Prescriptive Authority Renewal:
+5 additional CEs in Pharmacotherapeutics within the
preceding 2 years
+3 additional hours related to prescribing controlled
substances for those who prescribe controlled
substances
The 20 CEs satisfy both the RN and APRN requirement
Category I Continuing Medical Education (CME) contact
hours will meet requirements for CE for APRNs
Prescriptive Authority
(Rx Auth)
•
APRN Licensure AND prescriptive authority
•
Texas Medical Board Delegation of Prescriptive
Authority (www.tmb.state.tx.us)
•
Texas Department of Public Safety (DPS) AND US
DEA controlled substances registration
Dangerous Drugs
• Texas Health and Safety Code, § 483
• Legend drugs
• “Caution: federal law prohibits
dispensing without prescription”
• “Rx only”
• Does not require DPS and DEA
numbers
Controlled Substances
• Code of Federal Regulations
§ 1308
• Texas Health and Safety Code
§ 481
• Defines each schedule
Controlled Substances
• Schedules III through V in any setting
• Schedule II
• Certified terminally ill patients with
qualified hospice provider
• Hospital facility based practice in
hospital emergency departments
• Hospital facility based practice for
hospitalized patients intended to stay
at least 24 hours
Controlled Substances
• No more than 90 day supply
• Collaboration and documentation for refills and for
prescriptions for children less than two years
• DPS and DEA registrations required
Additional Clarifications
• Nonprescription drugs
• Durable medical equipment (DME)
• Order or prescribe in most cases
• CRNAs not required to have
prescriptive authority
Mechanisms for Delegation of
Prescriptive Authority
• Protocols or other written authorization
• Facility based practices only
• Prescriptive authority agreement
Prescriptive Authority
Agreement
An agreement entered into by a physician and an
advanced practice registered nurse or physician
assistant through which the physician delegates to
the advanced practice registered nurse or
physician assistant the act of prescribing or
ordering a drug or device.
Before Executing A Prescriptive
Authority Agreement
• Current APRN license and prescriptive authority in
good standing
• Not prohibited by Board of Nursing
• Disclosure of any prior discipline
What Has to Be Included?
• Signed and dated by the parties to the agreement &
reviewed/resigned at least annually;
• Name, address, and all professional license numbers of
the parties to the agreement;
• State the nature of the practice, practice locations, or
practice settings;
• Identify the types or categories of drugs or devices that
may be prescribed OR the types or categories of drugs
or devices that may not be prescribed;
Requirements for Prescriptive
Authority Agreement
• Provide a general plan for addressing consultation and
referral;
• Provide a plan for addressing patient emergencies;
• State the general process for communication and the
sharing of information between the physician and the
APRN or PA to whom the physician has delegated
prescriptive authority related to the care and treatment
of patients;
• Designate one or more alternate physicians
Quality Assurance
& Improvement Plan
Document a quality assurance and improvement
plan and specify methods for implementation of
the plan to include:
• Chart review
• Periodic face to face meetings
Face to Face Meetings
• At least monthly until the 3rd
anniversary of the date the
agreement is executed;
• At least quarterly after the 3rd
anniversary of the date the
agreement is executed, with monthly
meetings held between the quarterly
meetings by means of a remote
electronic communications system,
including videoconferencing
technology or Internet;
Face to Face Meetings
During the 7 years preceding the date the agreement is
executed the APRN or PA for at least 5 years was in a
practice that included the exercise of prescriptive authority
with required physician supervision:
• At least monthly until the 1st anniversary of the date the
agreement is executed; and
• At least quarterly after the 1st anniversary of the date the
agreement is executed, with monthly meetings held
between the quarterly meetings by means of a remote
electronic communications system, including
videoconferencing technology or the Internet
Credit for
Rx Authority Experience
The calculation under Chapter 157, Texas Occupations
Code, of the amount of time an APRN or PA has practiced
under the delegated prescriptive authority of a physician
under a prescriptive authority agreement shall include the
amount of time the APRN or PA practiced under the
delegated prescriptive authority of that same physician prior
to November 1, 2013. You must be practicing with the same
physician you practiced with prior to November 1, 2013 in
order to get credit under this provision.
Additional Content
• Other mutually agreed upon provisions
• Need not describe exact steps
• Promote exercise of professional judgment
• Keep copy of agreement for 2 years
• Cannot nullify, void or waive requirements by
contract
APRN to Physician Ratio
• In many cases:
• 1 Physician
• 7 Full time equivalent APRNs/PAs
• No limits in facility-based practices in hospitals or
practices serving a medically underserved
population
Investigations & Discipline
• Notify other parties to agreement if investigation is
opened
• Make agreement available to the board(s) not later than
the 3rd business day after receipt of a request
• Boards of nursing, medicine and physician assistants
notify each other if investigation opened involving
prescriptive authority and final disposition.
• Open investigation based on notice from other boards
• Publish list of APRNs prohibited from entering
prescriptive authority agreement
• Texas Medical Board onsite inspection authority
FAQs on BON Website
and TMB Website
Also provided to you as a handout.
Board Rules Applied to APRNs
• Rule 217.11 Standards of Nursing Practice
• Rule 217.12 Unprofessional Conduct
• Rule 221.13 Core Standards for Advanced
Practice
• Rule 222.4 Minimum Standards for Signing
Prescriptions
Rule 217.11
• Four subsections:
• (1) applies to all nurses at all levels of licensure
• (2) applies to LVNs
• (3) applies to RNs
• (4) applies to APRNs
• Subsections (1), (3) and (4) are applicable to APRNs
(1)(B)
Implement measures to promote a safe environment
(1)(C)
Know the rationale for and effects of medications and
treatments and shall correctly administer the same
For APRNs, this also means knowing the rationale for
and effects of medications and treatments that are
ordered or prescribed.
Rights of Medication
Administration
•
•
•
•
•
Patient
Medication
Dose
Route
Time

•
•
•
•
•
Documentation
Reason/Diagnosis
Assessment
Patient education
Patient response
Refuse medication
(1)(T)
Accept only those nursing
assignments that take into
consideration client safety and that
are commensurate with the nurse’s
educational preparation, experience,
knowledge, and physical and
emotional ability.
217.11(3) and (4)
• Rule 217.11(3) includes standards related to
a systematic approach to patient care and
addresses delegation to unlicensed
personnel
• Rule 217.11(4) requires APRNs to practice
and prescribe in accordance with the role
and population focus of licensure
217.12 Unprofessional Conduct
• Applies to all nurses
• Describes unprofessional or
dishonorable behaviors
• Public protection
217.12(1)(A) and (4)
• 217.12(1)(A)
• Carelessly failing, repeatedly failing, or
exhibiting an inability to perform vocational,
registered or advanced practice nursing in
conformity with the standards of minimum
acceptable level of nursing practice. . . .
• 217.12(4)
• Careless or repetitive conduct that may
endanger a client’s life, health or safety. Actual
injury to a client need not be established.
Other Behaviors Include:
• Failure to supervise students
appropriately
• Failure to practice within a modified
scope
• Inability to practice safely
• Misconduct—falsification, abuse,
boundary violations, threatening
behavior
• Criminal conduct
Rule 221.13
• Core standards to be followed by all
APRNs
• Not role specific
• Not intended to replace standards of
patient care set by the profession
• Not intended to replace the Standards of
Nursing Practice (Rule 217.11)
221.13(b)
• The advanced practice nurse shall practice
within the specialty and role appropriate to
his/her advanced educational preparation.
• Can obtain licensure to expand to a new
role/population focus area with additional
education and certification
221.13(d)
• When providing medical aspects of
care, advanced practice nurses shall
utilize mechanisms that provide
authority for that care. . .
•
•
•
•
Protocols
Practice guidelines
Collaborative agreements
*Prescriptive Authority Agreements
221.13(e)
• The advanced practice nurse shall retain
professional accountability for advanced
practice nursing care.
Rule 222.4
• Standards related to prescribing
• Not role specific
• Not intended to replace standards of
care for treatment of specific
conditions
•
•
•
•
Rule 222.4(a)
BON-issued prescriptive authority
Physician delegation
TMB Rule 193
Protocols/Prescriptive Authority
Agreements
Population-focused
Rule 222.4(b)
Information on a Prescription
• Patient information
• Medication and directions for use
• Physician information
• Name, address, telephone information
• DEA if prescribing controlled substance
• APRN information
• Name, address, telephone, & Prescriptive
authority number issued by the BON
• DEA if prescribing controlled substance
Rule 222.4(d) Partner Treatment
• Treatment of partners of
established patients is permitted
• APRNs are not required to provide
this service
Rule 222.4(e) Off Label Use
IRB approved clinical trials
~ ~ ~ ~ ~ ~ ~OR~ ~ ~ ~ ~ ~ ~
Current standard of care for treatment of
disease or condition
AND
Supported by evidenced-based research
Rule 222.8 Controlled Substances
•
•
•
•
DPS and DEA registrations required
Schedules III through V
Not to exceed 90 day supply
Consultation and documentation
required for:
• Refills after 90 days
• Children under the age of 2 years
Rule 221.8 continued
• Schedule II medications with the following
limitations:
• Certified terminally ill patients with
qualified hospice provider
• Hospital facility based practice in
hospital emergency departments
• Hospital facility based practice for
hospitalized patients intended to stay at
least 24 hours
Questions
We are also available at:
www.bon.texas.gov
[email protected]