Kathy Shipp MSN, APRN, FNP

Kathy Shipp MSN, APRN, FNP
APRN Practice in Texas Kathy Shipp MSN, APRN, FNP Good morning. Welcome to our webinar. My name is Jolene Zych, and I am a consultant for advanced practice here at the Board. Before we start our discussion on the standards, we want to take care of a few housekeeping items.

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 These are the objectives we will cover in today’s presentation. You will see these again in your evaluation of today’s webinar.

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 A mission statement is the statement of the purpose and guides the actions of the Board of Nursing. Agency Mission The mission of the Texas Board of Nursing (BON or Board) is to protect and promote the welfare of the people of Texas by ensuring that each person holding a license as a nurse in this state is competent to practice safely. Our mission, derived from the NPA, supersedes the interest of any individual, the nursing profession, or any special interest group.

Role of the Board Regulation of Nursing Practice
Approval of nursing education programs Licensing qualified applicants Investigating complaints Corrective Action / Discipline The Board fulfills its mission through the regulation of the practice of nursing and the approval of nursing educational programs. Currently we have in excess of 100 RN programs and LVN programs in Texas. You can find a current list of approved nursing programs in Texas…..they are included on our website, the NURSING EDUCATION. We have 4 Nurse Education Consultants who are very busy working with these schools throughout the state Licensing qualified applicants Our enforcement department investigates complaints and corrective action and/or disciplinary action in taken as necessary. Remember the Role of the Board is to protect the public.

Texas (December 2013) 98,056 LVNs (26%) 260,717 RNs (69%)
APRN 98,056 LVNs (26%) 260,717 RNs (69%) 17,597 APRNs (5%) Total 376,370 LVN RN So yes we are busy. This number continues to increase as do the number of students who enroll in nursing programs.

Responsible to the public
Board of Nursing Responsible to the public No authority in employment related issues, i.e. facility policies and procedures Prohibited by law from lobbying legislature Organizations & Associations Responsible to their members Serve the individual interests of nurses May lobby legislature and Governor The mission and purpose of the BON differ significantly from a professional organization. The Board of Nursing, is a government agency, is responsible to the public whereas ……………professional organizations are responsible to their members and serve the interests of their members including lobbying the legislature. If asked… by the legislature we can provide information, otherwise we cannot lobby. BON does not have jurisdiction regarding facility policy, employer-employee issues: hiring, firing, employee discipline or labor disputes BON nor as consultants can we provide legal advice or consultation or discuss personal issues

Board Members 13 members Representing: 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 MOVE TO THE NEXT SLIDE……

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 The Board Members serve 6 year terms. They can rotate on and off at different intervals so they will not be new at the same time. And a great reward is they benefit from each other as we also benefit from their areas of expertise.

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 The board meets 4 times a year in January, April, July and October Meetings are posted on the BON events page and published in the BON Bulletin and AND THEY ARE Open to the public so if you are in Austin, you are welcome to attend Board members also are active in representing the BON on various committees, meetings, hearings and in their communities They travel to Austin; do not receive pay; and are integral part in helping to advance the profession of nursing. As New Board members join, they are featured in BON Newsletters

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) Advisory Committees and the Delegation Task Force consist of representatives from the public, professional organizations, associations, employers, state agencies. They are determined by the BON. Each committee has a Board Member as well as nursing practice consultants or nursing education consultants participate in each. Depending if the committee is convened related to education or practice. The participants, approved by the Board, represent various stakeholders and are not compensated The committees make recommendations i.e., rule changes, position statements Once the committee has met and formulated recommendations, The Board then considers the recommendations and determines if they will be adopted

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 In addition to Nicole, Melinda and I who are here in the room, we have a number of other staff whose names you might see or hear in response to an or telephone call.

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 Much like a driver’s license, nurses who hold a compact license, they can practice in another compact state. The compact privilege is applicable to RNs and LVNs. APRNs do not have compact privileges yet. There are currently 24 states that recognize NLC. You will find not only our website by also multiple documents for nurses and their employers related to NLC. NPA, Chapter 304 Board Rules Chapter 220

Continuing Competency Requirements
NEW LEGISLATION 83rd Legislative Session Continuing Competency Requirements SB (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 (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)

83rd Legislative Session
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 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 1842 – while this bill does amend the NPA, it does affect nurses so we wanted to share. S.B adds RNs to the list of health care professionals authorized to conduct these evaluations. S.B amends current law relating to restraint and seclusion procedures and reporting at certain facilities. HB 705 – again, this bill does amend the NPA, it does affect nurses so we wanted to share. H.B. 705 amends current law relating to the definition of emergency services personnel for purposes of the enhanced penalty prescribed for an assault committed against a person providing services in that capacity.

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 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

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 The January, 2014 Board meeting was held recently and adopted the following rules. Rules changes will be added to the Rule Books and available on line. Nurses are encouraged to go to the website and review these new rules. Chapter 216 – pertaining to CONTINUING COMPETENCY. The new rules reflect the requirements for CNE passed during the 83rd Legislative Session – (SB 1058) mandatory NJE every 3 renewal cycle; and older adult/geriatric populations . In addition, (SB1191) requires individuals who perform a forensic examination on a sexual assault survivor to have at least basic forensic evidence collection training. Chapter 228 – pertaining to PAIN MANAGEMENT. This adds a new chapter to our existing rules. Following the 83rd Legislative Session and born out of the concern surrounding the issuance of controlled substances and the regulation of persons engaged in pain management , This new chapter provides minimum standards of nursing practice for APRNs when providing pain management services. Chapter 225 – pertaining to DELEGATION IN THE INDEPENDENT LIVING ENVIRONMENTS. The new rule includes corrections to outdated references and legal citations; improved the definition of nurse delegation; expanded the list of tasks and the RNs discretion to identify HMAs not specifically listed; and clarification of minimum standards when delegating. You will hear more about delegation later today. Position Statements – are reviewed annually and approved every January. You will have the benefit of learning more about these later on.

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 ( Texas Department of Public Safety (DPS) AND US DEA controlled substances registration In order to obtain prescriptive authority, you must have full licensure as an APRN. You must also have evidence that you have met the education requirements for prescriptive authority and be nationally certified if you are required to hold such certification for licensure. Once the Board determines that you have met the requirements, a prescriptive authority number will be issued. This is not your APRN license number, it is a prescription ID number. The Nursing Practice Act requires the board to issue a prescription ID number, and this is the number that must go on all prescriptions. Once you have a prescription ID number, you and your delegating physician must go to the Texas Medical Board’s website and register the delegation of prescriptive authority. I provided you with their web address for your convenience. This is a two part process, and the physician must complete his/her parts of the registration before the delegation becomes effective. For those APRNs who have disciplinary action against their licenses but still have prescriptive authority, you will not be able to register online. You must obtain a hard copy of the prescriptive delegation form from the Texas Medical Board and submit that for staff review. TMB staff will review your agreed order to confirm that you are permitted to continue to order or prescribe drugs and devices under the terms of the order before approving the delegation. Once that process is complete, you are eligible to begin ordering and prescribing categories of dangerous drugs. Dangerous drugs require a prescription but do not include controlled substances. They are often referred to as legend drugs in other states. Texas law uses dangerous drugs as the term for these categories of medications, and we use that term in Board Rules to be consistent. If you want to prescribe controlled substances, you must register with both the Texas Department of Public Safety and the US Drug Enforcement Administration. For those nurses who move to Texas and already have a DEA number, you will not be able to transfer your DEA registration until you obtain a Texas DPS registration. You must have both to prescribe controlled substances in Texas.

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 With your prescriptive authority from the BON and registration of delegation of prescriptive authority on the TMB website, you can begin prescribing dangerous drugs. Chapter 483 of the Texas Health and Safety Code is otherwise known as the Dangerous Drug Act. As I mentioned with the last slide, other states use the term legend drugs because the drugs are required to bear a legend that says something like Caution: federal law prohibits dispensing without prescription or something else of a similar nature. These are medications and certain prescription devices that require a prescription drug order or medication order. Categories of dangerous drugs include medications such as antibiotics, diuretics, insulin. The term dangerous drugs does not include controlled substances. If you are prescribing only medications and devices that fall under the category of dangerous drugs, you are not required to have DPS and DEA numbers. Let me say that one more time because there has been a lot of confusion over this. If you only prescribe categories of dangerous drugs, you are not required to have DPS and DEA numbers. I also put it in writing for you on your slides just in case you need to share this with an employer or another interested party.

Controlled Substances
Code of Federal Regulations § 1308 Texas Health and Safety Code § 481 Defines each schedule Controlled substances are identified in both state and federal law, and we’ve provided you with the legal citations for both. The law defines what goes into each schedule. The Board of Nursing has no authority to determine what schedule a controlled substance is in nor do we have authority to determine what schedules APRNs can and cannot prescribe. It is important to be mindful of what is in each schedule. It is also important to keep in mind that medications can be added to the schedule. Medications can also be moved from one schedule to another. It is important to know whether the medications you are prescribing are controlled substances and if they are, what schedule of controlled substances they are in. We will talk about this more in just a moment.

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 Since 2003, APRNs in Texas have been able to prescribe controlled substances in schedules III through V with the appropriate delegated authority from a physician. Some limitations apply, and we will discuss those momentarily. As of November 1, 2013, APRNs now have limited authority to prescribe medications that are in Schedule II. Schedule II includes medications such as morphine, methadone, and stimulants such as adderall. APRNs may only prescribe these medications in one of three practice settings. APRNs who work with patients who have been certified as terminal and admitted to the services of a qualified hospice provider may order or prescribe medications that are included in schedule II. Both criteria—certification of terminal illness and admission to hospice services--must be met before writing for the schedule II medication. APRNs who practice in hospital emergency departments as well as APRNs whose practice is hospital based if they are ordering or prescribing this medication for patients who are intended to stay in the hospital at least 24 hours. If they are admitted for observation for less than 24 hours, you would not have schedule II authority. Some other questions regarding schedule II authority have arisen since this law became effective in November. For those of you who work in clinics that are part of the hospital, you will not have schedule II authority because your patients have not been admitted for a minimum 24 hour stay—they are clinic patients. For those of you in free standing emergency rooms, you will not have schedule II authority. The emergency department must be the emergency department that is physically located within the hospital. We know there are a large number of you who need to be able to prescribe Schedule II medications but you are not practicing in one of these settings. Only a legislative change to Texas law will get you that authority. This is not something that can be changed by the Board.

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 Now for the limitations on controlled substance authority that I mentioned a few moments ago. You may prescribe controlled substances for a quantity not to exceed 90 days. You cannot write another prescription for the same medication at the end of the 90 days and consider that a new prescription. You can prescribe controlled substances for a total of 90 days. Once the 90 days is up, you will need to consult with the physician and document your consultation in the patient’s medical record. Once that consultation has occurred and has been documented, you may write another prescription for up to a 90 day supply based on your discussion with the physician. This documentation is very important. Likewise, for those of you in pediatric settings or who may encounter pediatric patients in your practice setting, consultation and documentation of the consultation is required for prescriptions for children who are less than two years old. DPS and DEA registrations are required if you are writing prescriptions for controlled substances. Do NOT write prescriptions for any controlled substance without current registrations from both agencies. You must have your own DPS and DEA registrations. It is not lawful to write those prescriptions using the physician’s registrations.

Additional Clarifications
Nonprescription drugs Durable medical equipment (DME) Order or prescribe in most cases CRNAs not required to have prescriptive authority Some additional clarifications that were added to the law in November 2013 are that APRNs may order or prescribe nonprescription drugs. That seems like it should be obvious, but some APRNs were having difficult in this area prior to this statement being added to the law. In inpatient settings, orders are required for non-prescription drugs. This clarifies that this is part of the APRN’s prescriptive authority. In outpatient settings, APRNs may recommend that patients purchase nonprescription drugs. However, some patients are requesting prescriptions for non-prescription drugs for insurance reasons. Therefore, having this language in the law is helpful. This clarifies that this is part of the APRN’s prescriptive authority. The law also clarifies that APRNs with prescriptive authority may order durable medical equipment. In the past, there has been some confusion about this, and some suppliers have refused to fill the order. This clarifies that it is permissible for APRNs to order this type of equipment provided they have prescriptive authority. One other clarification that has been made is that prescriptive authority is required when ordering medications in an inpatient setting. In the past, prescriptive authority was only related to prescription drug orders. One caveat here involves CRNAs. CRNAs are not required to have prescriptive authority. CRNAs practice in accordance with facility policy and bylaws. A physician delegates the authority to order drugs/devices to provide anesthesia or anesthesia-related services and the CRNA obtains an order to provide the anesthetic or appropriately related service. The laws regarding CRNA practice have not changed in this regard. Physicians delegate the authority to order medications and devices through the CRNA’s clinical privileges. CRNAs only need prescriptive authority if they are writing prescription drug orders.

Mechanisms for Delegation of Prescriptive Authority
Protocols or other written authorization Facility based practices only Prescriptive authority agreement So how is prescriptive authority delegated for the rest of us who are not CRNAs? For those APRNs who practice in facility-based practices, meaning a licensed hospital or long term care facility, you may continue to order and prescribe under protocols as you always have done. The Medical Practice Act spells out who may be the delegating physician in each site. Be sure your delegating physician is eligible to fulfill this role in compliance with the Medical Practice Act. For those of you who have facility-based practices in long term care facilities, the medical director may delegate prescriptive authority to up to seven full time equivalent APRNs or PAs. It is important for you to know that physicians may be the delegating physician for one hospital facility-based practice or two long term care facility-based practices. For anyone who is not in a facility-based practice, you are now required to use a 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. So what is a prescriptive authority agreement? The definition of a prescriptive authority agreement that you see on the screen was added to the Medical Practice Act by SB As you can see, the agreement is needed for ordering or prescribing a drug or device. So the next question to ask is what do I need to do to have a prescriptive authority agreement.

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 There are some criteria that must be met in order to enter into a prescriptive authority agreement. Some of these are new items that were added with SB 406 that were not a requirement under the old site-based prescriptive authority model. Current licensure and prescriptive authority have always been required. Physicians cannot delegate prescriptive authority to an APRN who does not have prescriptive authority from the Texas Board of Nursing—with the exception of delegation to CRNAs that we mentioned earlier. What has been added to this particular requirement is that your license must be in good standing. APRNs can be prohibited from entering into a prescriptive authority agreement by the BON. This refers to APRNs who have disciplinary orders that prohibit them from using their prescriptive authority or prohibit them from entering new prescriptive authority agreements without approval from the board. The Board can also limit their ability to use prescriptive authority—for example, no authority to prescribe or order controlled substances. If you recall when we talked about the TMB earlier, I mentioned that APRNs with current discipline against their licenses cannot register delegation of prescriptive authority online. This is why TMB staff review the Board order before approving the delegation. The other requirement is that you must disclose prior disciplinary actions, even if your license has been cleared. As APRNs, you should know that this is also required of physicians and PAs. You have the right to know if the other parties to the agreement have had any prior disciplinary action from their respective licensing board and you should be sure to ask about this before signing on the dotted line as a party to an agreement. This disclosure is required by law.

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; We always get a lot of questions about what needs to be in a prescriptive authority agreement or requests for sample documents. We have never had sample documents because of variations in practice settings and in individual circumstances, although I believe some of the professional organizations may have some samples available. This is a written agreement that needs to be signed and dated by all parties to the agreement. It needs to contain names, addresses and license numbers for each party to the agreement. This is not optional, it is required by law. You must review and re-sign the agreement at least annually The agreement needs to describe the nature of the practice and clearly indicate key information about the practice, such as the location. The agreement may identify either: the types or categories of drugs or devices that you are authorized to prescribe OR the types or categories of drugs or devices that you are not authorized to prescribe. You must have one statement or the other. It can be a very broad statement rather than having to identify specific drugs or devices.

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 The agreement is required to provide a general plan for addressing consultation and referral of patients. It is better to plan for this issue up front rather than waiting until the situation arises. Likewise, it is just as important to have a plan in place to address patient emergency situations. This is something you may have already had in place, but now it is required by law as part of the prescriptive authority agreements. It is important that all parties are in agreement as to how they will communicate with one another and how information will be shared. Will electronic medical records be used and all parties will have access? Will the parties communicate via , telephone, text, or some other format? When considering what mechanisms will be utilized, staff would offer a word of caution. Be cautious about transmission of personal health information in order to avoid an unintended HIPAA violation. If alternate physicians will serve in the absence of the primary delegating physician, you may put that information in the prescriptive authority agreement. The agreement can identify who the alternate physician(s) is and also indicate the alternate physician’s role in the quality assurance and improvement meetings.

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 There is room for some flexibility with regard to the quality assurance and improvement plan that you and the physician put in place. However, there are two things that are non-negotiable to some extent. The first is chart review. The physician must review some of your charts. How many charts or what percentage of your charts is where there is some flexibility. You and the physician(s) should discuss and negotiate a number or percentage that is reasonable to both of you. Keep in mind that many factors will influence what constitutes a reasonable number or percentage. A brand new graduate APRN may require more of his/her charts to be reviewed than a seasoned APRN. A physician who is new to working with APRNs may not feel as comfortable as a physician who has extensive experience with APRNs and may want to review a larger number of charts. The patient population, the length of time the particular physician and APRN have worked together, past experience, and any other number of factors can influence these numbers. There is also a requirement that you meet with the physician periodically. These are required to be face to face meetings at a mutually agreed upon location. The purpose is to discuss patient care and the need for change in treatment plans and also to discuss any issues that may arise related to referrals. It is also a chance to discuss quality improvement. It is an opportunity for all of us to discuss and find ways to improve the care we provide. If you are practicing with a physician group practice, alternate physicians can be appointed to conduct the monthly meetings. Again, these meetings can take place at a mutually agreed upon location. As with the communication plan, we would offer a word of caution with regard to confidential health information and your meeting location with the delegating physician. Be cautious of who may overhear your discussions or be able to see your documents.

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; And that raises a question of how often these meetings need to occur. According to the law, at least monthly for the first three years, and then quarterly thereafter. When the decision is made to move to quarterly face to face meetings after the first three years, then it is important to note that you must still have monthly meetings, and these can occur via videoconference or internet technology. If you want to continue with monthly face to face meetings after the three year period has lapsed, there is nothing that would prohibit this. We would recommend that you document these meetings just in case you are ever asked to provide evidence that the meetings took place.

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 For those of you who are seasoned APRNs who have been writing prescriptions or ordering medications for many years, there is an alternate provision. You must have been practicing for at least five years out of the last seven in a practice that included exercising prescriptive authority under physician delegation. If you meet this criterion, then you can have monthly face to face meetings for the first year and move to quarterly face to face meetings thereafter. You are still required to have the monthly meetings via remote electronic communications systems.

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, You must be practicing with the same physician you practiced with prior to November 1, 2013 in order to get credit under this provision. For seasoned APRNs, credit can be given for time you have already worked with your physician. You must enter a prescriptive authority agreement with the same physician you practiced with prior to November 1, If you are practicing with a different physician, you must meet the monthly face to face meeting requirements we discussed on the previous two slides.

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 The prescriptive authority agreement may contain other provisions that you and the physician agree upon. So for example, if you are providing medical aspects of care that require physician delegation, you can include that content in your prescriptive authority agreement if both of you are willing to do so. Just as was the case with the protocols, a prescriptive authority agreement need not describe the exact steps you are required to take with regard to each specific condition, disease or symptom and should promote the exercise of professional judgment by the APRN based on education and experience. All parties to the prescriptive authority agreement are required to maintain a copy of the agreement for at least two years. You may keep it longer than that if you wish. If you have questions regarding whether you should keep it longer than the required two years, we would recommend you contact your own legal counsel or perhaps your professional organization for advice. Board staff cannot advise you on this matter. Cannot develop a contract to get around the requirements associated with the prescriptive authority agreement.

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 Another thing that has changed is the ratio of APRNs and PAs to whom one physician may delegate prescriptive authority. In the recent past, that ratio was 1 physician to four full time equivalent APRNs and/or PAs. That has now been increased to 1 physician to seven full time equivalent APRNs and/or PAs. We’ve highlighted the words full time equivalent because this is an important factor to consider when considering whether the physician has met his/her ratio. If you have two APRNs in the same practice setting, and one APRN works 30 hours a week while the other works only 10 hours, together they are one full time equivalent. It isn’t seven individuals—it is seven full time equivalents. Another thing to note is that there is nothing that requires all seven FTE APRNs/PAs to be in the same practice setting. So one physician might be the delegating physician for four FTE APRNs and PAs at an urgent care center and still delegate to three other APRNs/PAs in an office based practice. For those of you who are practicing in facility-based hospital practices or you are in practices that serve a medically underserved population, you are not bound by the one to seven ratio.

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 All parties to a prescriptive authority agreement are required to notify one another if they become the subject of an investigation. This requirement applies to physicians as well as APRNs and PAs. Please note that this is required if you are subject to an investigation, not just if you have been disciplined. If one of the respective licensing boards requests a copy of the prescriptive authority agreement, you are required to provide it to them by the third business day after you receive that request. Keep in mind that each board may request the agreement and you must provide it to each. The boards are required to notify one another when we open an investigation that involves prescriptive authority and also to provide each other with notification of the final disposition of the case. What this also means is that when we receive notice from another board that it has opened an investigation on one of its licensees, we may open a case against an APRN based solely upon receipt of the notice that another party to the prescriptive authority agreement is under investigation. So here is an example—if the Texas Medical Board notifies the BON that they have opened an investigation against a physician, the BON can open a case on any APRNs that were party to the prescriptive authority agreement based on the notice from the TMB. We are working with the other boards to publish a list of APRNs who are prohibited from entering a prescriptive authority agreement. The key word there is prohibited. This list will include APRNs who have been disciplined and are prohibited by the disciplinary order from exercising prescriptive authority. We are required by law to publish this list, similar to the requirement to publish our list of disciplinary actions. Texas Medical Board was also given authority to do on site inspections in locations in which a prescriptive authority agreement has been executed. The Board of Nursing is still able to do an onsite investigation as part of an ongoing investigation. APRNs are required to cooperate with the TMB should they do an inspection.

FAQs on BON Website and TMB Website
Also provided to you as a handout. There are FAQs on our website as well as the TMB website. You have those same FAQs as a handout for this webinar. The FAQs on the BON and TMB websites are identical. Staff of each agency worked together to develop these and agreed to put the same questions and answers on both websites. So you will notice that some of the questions and responses are directed to physicians. Please be sure to review these FAQs and share them with your delegating physicians, employers, etc. Keep checking back on our website as we may add more questions as everyone gains more experience working with prescriptive authority agreements.

Board Rules Applied to APRNs
Rule Standards of Nursing Practice Rule Unprofessional Conduct Rule Core Standards for Advanced Practice Rule Minimum Standards for Signing Prescriptions Licensure responsibility to be familiar with the Nursing Practice Act and all BON rules When considering scope questions or whether to accept a specific assignment or provide a certain service, look at the four rules listed here. Notice I listed the unprofessional conduct rule in addition to the Standards in , 221 and When you are considering question related to scope or whether to perform specific patient care activities, reviewing the unprofessional conduct rule and understanding behaviors that the Board believes are dishonorable for nurses can provide some additional insights to assist in your decision. All rules can be reviewed on the BON website in their entirety. Will list that website at the end of the presentation.

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 Rule is broken into four subsections, with (1) being the largest. Keep in mind, that APRNs have 2 licenses—the RN license as well as APRN, so it is necessary to be familiar with subsection 3 as well as 4 We’re not going to address every standard in their entirety—going to address a few that are cited frequently and use our case files to illustrate the concepts.

Implement measures to promote a safe environment
(1)(B) Implement measures to promote a safe environment (1)(B) Implement measures to promote a safe environment for clients and others. This is one of the most frequently cited standards. Establishes the nurse’s duty to his/her patients. I have an example that is from a case involving an RN. Although it is not an APRN case, it is our best example of the importance of (1)(B) Patient and a friend were traveling through Texas. The patient began experiencing chest pains, so they sought assistance at a rural hospital. When they entered the hospital, the friend went in search of help while the patient waited in the waiting room. The friend found the RN and they went back to the waiting room to find the patient with extreme discomfort, diaphoretic, nausea. The RN went back and found the physician and told him that a patient had arrived in the waiting room with chest pain. She did not describe any further symptoms or assessment findings to the physician. After talking with the physician (who did not ever see the patient) she returned and instructed the friend to drive the patient to a larger hospital that was equipped to handle such situations. The rural hospital only had one cardiac monitor that was in use on another patient. The larger hospital was 24 miles away. The nurse indicated that the physician had given her an order for the patient to go to the other hospital and that this was the policy in place at this rural hospital facility. Was this an appropriate course of action for this nurse? Poll Question 2 – what should she do? (follow order…send on in private vehicle; follow order…send in ambulance; assess and report; assess, to treatment room, advocate through communication with physician) Landmark case: Lunsford vs. the Board of Nurse Examiners. Mrs. Lunsford should have done everything in her power to have the physician in the rural hospital see and evaluate the patient. The patient was not stable, and sending them to another facility 24 miles away was not an appropriate course of action. When she gave instructions to the friend regarding taking the patient to the other hospital, she asked the friend if she knew CPR. She also instructed her to drive as fast as possible. This indicates that Mrs. Lunsford recognized the critical nature of the patient’s condition. The patient succumbed to a fatal MI approximately 5 miles away from the rural facility. The Board maintained that by virtue of her nursing education and licensure, Mrs. Lunsford had the knowledge to intervene and should have done so. Mrs. Lunsford contended that she had both a physician order and facility policy that prevented her from taking any other course of action. The courts sided with the Board, ruling that the nurse knew or should have known that the patient was at risk for harm leaving the facility. Further, the nurse’s duty to the patient cannot be superseded by facility policies or a physician’s order.

(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. We all learned the five rights of medication administration in nursing school. There are more than that now. Right patient, medication, dose, route and time are the five we all remember. Now add with the right documentation, for the right reason/diagnosis, accompanied by the right assessment and right patient education, and followed by the right evaluation of patient response. Can also add the patient’s right to refuse medication.

Rights of Medication Administration
Patient Medication Dose Route Time Documentation Reason/Diagnosis Assessment Patient education Patient response Read the list quickly, so here they are in bullet format. I don’t see anything on this list that does not apply to writing a medication order or prescribing. Do you? An adult nurse practitioner working in a clinic had been employed in this setting for just over a year. He had been a nurse practitioner for 16 years at the time of the patient visit and was working with a brand new nurse practitioner student on the day of the patient visit. The patient was seeking a refill on her synthroid and also wanted something for her depression that had gradually been getting worse. The patient’s thyroid panel was reviewed. The lab values were appreciable for a decreased level of thyroid stimulating hormone. The assessment of the patient also revealed an appreciable level of depression that may benefit from an antidepressant. Poll Question 3 & 4 What should the ANP have done with the synthroid dose? [Answer--lower] Is it appropriate to let a brand new NP student at a first clinical site write a prescription for an antidepressant? [Answer--maybe with proper oversight by the ANP] What happened? The ANP doubled the patient’s dose of synthroid which could have resulted in hormone imbalance with symptoms of tachycardia, dysrhythmia, dyspnea, hypertension, possible cardiac decompensation due to hormonal imbalances. The ANP allowed the student to write the prescription for an antidepressant and then signed the prescription without reviewing what the student had written. So he missed that the student had prescribed an amount of medication that was twice the recommended daily dose. This could have further impacted the endocrine disorder. It also appeared that none of this information was documented in the patient’s medical record until after the ANP received notice of investigation. Situation was mitigated in that the ANP was experiencing significant personal distress at the time of the incident as a result of the loss of a child. Also, the pharmacist noted the error on the prescription for the antidepressant and called the delegating physician because the ANP was out of the office when the patient went to fill the prescription, so the patient never received the excessive dose of antidepressant. There is nothing in the order that indicates when the error regarding the synthroid dose was discovered and whether the patient took the excessive dose. The ANP received the sanction of remedial education to include courses in jurisprudence, ethics, and documentation This case also illustrates standard (1)(D) related to accurate and complete documentation. 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. Along with (1)(B) relating to the safe environment, (1)(T) is the other most frequently cited standard. See this in scope of practice cases: e.g., CNS in pediatric nursing providing routine primary care to adult patients, Scope of education/experience seems obvious, although it can be difficult to determine when someone practices on the fringe areas of their practice. Judging physical and emotional ability can be more difficult. A clinical nurse specialist was licensed to practice in psychiatric/mental health nursing. At the time of the incident, she was practicing in an advanced practice role in an oncology setting. Without knowing any more about the situation, do you think it was acceptable for this CNS to practice in this setting? Poll Question 5 Oncology patients are experiencing difficult situations and may benefit from mental health counseling and support. It is reasonable to consider that they may be appropriately assessed and treated for conditions such as depression or anxiety. If the CNS in psych/mental health is providing those services, she would have been well within her scope of practice. Unfortunately, this CNS was ordering chemotherapy, radiation treatments, and medically managing the patient’s cancer treatments and medical side effects of those treatments based on on the job training provided by the physician. At the time this practice was reported to the Board, she had been in this position for more than 15 years. Because she was practicing outsider her scope of practice by practicing beyond the scope of her APRN education, she also failed to meet the APRN renewal requirements for 400 hours of practice in the advanced practice role and population focus area. This CNS elected to voluntarily surrender her CNS license. She never sought reinstatement nor did she return to school to seek additional education that would have prepared her to provide advanced practice nursing care to patients in this practice setting.

217.11(3) and (4) Rule (3) includes standards related to a systematic approach to patient care and addresses delegation to unlicensed personnel Rule (4) requires APRNs to practice and prescribe in accordance with the role and population focus of licensure Could spend days talking about the Standards in (1). But my teenagers tell me that nobody wants to listen to me talk that long. So we will move on. Briefly, (3) (A) reminds all RNs that they are expected to utilize a systematic approach to patient care—nursing process (3)(B) reminds RNs that delegation to unlicensed personnel must comply with Rules 224 and Cannot delegate tasks requiring nursing judgment. The same delegation rules apply for all RNs, including APRNs. Subsection (4) reiterates that APRNs must practice in the role and population focus area for which they have been licensed. If you are licensed as in adult health, you cannot provide advanced practice nursing care to neonates. Likewise, your prescriptive authority is limited to the area of licensure for which you have been granted prescriptive authority. For example, if you are licensed as both an ANP and FNP but only have prescriptive authority as an ANP, you cannot write prescriptions for children. Must apply for prescriptive authority in each role/population focus.

217.12 Unprofessional Conduct
Applies to all nurses Describes unprofessional or dishonorable behaviors Public protection Applies to all licensure levels Identifies nursing behaviors that the board believes are likely to deceive, defraud or injure patients or the public if a nurse engages in these behaviors. Not every situation rises to the level of unprofessional conduct. Part of the evaluation of any scope situation is not only asking yourself whether you can do something but also whether you should. Or does the issue cross the line into something that would not be appropriate for a nurse. Concerns regarding incompetent nurses as well as unethical or illegal behaviors are addressed in

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. 217.12(1) describes unsafe practices to include failure to conform to Not every violation of is unprofessional conduct. This gets at behaviors that are careless or repetitive as well as incompetence. 217.12(4) gets at risk for harm. Over the course of a two year period, a CRNA failed to ensure he had the appropriate medications and equipment necessary for emergency situations prior to the start of anesthesia cases. An example of the CRNA’s conduct that was cited in the order is that he failed to perform a complete assessment and therefore did not recognize the patient had eaten prior to an emergency case. As a result, the patient vomited during the procedure and aspirated. The CRNA was not prepared to respond appropriately to the patient.

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 This is not an exhaustive list. Those in faculty/preceptor role must supervise students appropriately. Similar language for CNO to ensure standards are met for administration as well as oversight of nursing services for which the CNO is responsible. Modified scope relates to disciplinary orders. Limited license, supervision/monitoring requirements, that must be met. Actual or potential for unsafe practice due to use of drugs, alcohol, mood altering substances, due to illness, etc. Misconduct—boundary crossings means inappropriate relationships with patients, not scope boundaries. Threatening behavior includes threatening or violent behavior in the work place.

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 ) We know when you go looking for information on the BON website, whether it is scope or standards, you are looking for something specific to your APRN role. We do not have specific rules for each APRN role—rather, one rule that is applicable to all APRNs with few exceptions for certain sections of the rule. So the standards included in Rule 221 are not a replacement for standards of patient care. The Board evaluates APRN practice against the national standard for patient care. It is important to stay up to date when standards change as new medications, procedures, diagnostic and laboratory testing becomes available. You must comply with these standards in addition to, not in lieu of the Standards in Rule Intended to provide further guidance for APRNs with scope of practice issues and patient care dilemmas.

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 APRNs are limited to practicing at the advanced practice level in the role/population for which they were educated. This means that an NP cannot practice as a nurse-midwife unless s/he obtains the appropriate education/licensure. This also holds true for adding care of different population focus areas—e.g. adult expanding to include full scope of family. A GNP accepted a position working with an internal medicine physician that included responsibilities in which he rounded on patients in long term care and rehab facilities, including the care of young adults and older adolescents who were in the rehab facility. He later accepted a position in a correctional health setting where he provided care to male inmates across the full spectrum of adult health that included the care of younger patients. Is there a way the GNP could have practiced in these settings and stayed within the gero scope? Yes if limits care to older adults. Can provide care to younger patients if limits self to RN role. In this case, the GNP identifies himself only as an APN (did not list RN or GNP credential) and wrote prescriptions, including at least one controlled substance, without prescriptive authority or DPS/DEA numbers. He had been a GNP for five years at the time the incidents occurred. Sanction—warning with stipulations to include courses in jurisprudence and ethics, documentation. $2500 fine, employer notification of the order, monitored practice X1 year with 2x/month meetings and quarterly reports from the monitor to the BON

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 Under Texas law as set forth by the legislature, APRNs cannot practice entirely independently. We can provide nursing aspects of care independently, but we must have a mechanism in place to grant authority to provide medical aspects of patient care. The law uses the term Protocol or other written authorization. Must be a written document, agreed upon and signed by the physician and APRN and reviewed and re-signed at least annually. Verbal agreements do not meet this requirement. The Board has disciplined APRNs for not having protocols or other written authorization to provide medical aspects of patient care. The level of the sanction varies based on whether other violations occurred and the length of time there was no protocol in place. Can be as low as a fine and remedial education to include a course in nursing jurisprudence to a higher level sanction if the length of time was extensive, if it was willful (intent to practice without), or other violations were involved.

221.13(e) The advanced practice nurse shall retain professional accountability for advanced practice nursing care. APRNs are responsible for their actions, their patient care decisions, and knowing the scope of their practice and education. If an APRN accepts an assignment that is beyond his/her scope, s/he is accountable. There was a case several years ago in which an APRN performed a procedure on a patient. It was found that the NP was not knowledgeable regarding patient selection criteria and contraindications for the procedure. So she did not know that the patient should have been referred to a specialist for a different procedure. The APRN knew how to perform the procedure, but was unaware of special considerations that needed to be considered for this particular patient. Consequently, she performed the procedure incorrectly and complications resulted. Incorrect performance of the procedure resulted in unexpected complications that the APRN was unprepared to manage. Ultimately, the patient had to be transported to the hospital by EMS, she had emergency surgery that day and required additional surgeries to correct the complications that occurred as a result of performing the original procedure incorrectly. The nurse received a reprimand with stips. This standard makes you feel a little like Atlas. If remember your Greek mythology, Atlas had to carry the weight of the sky on his shoulders as a punishment from Zeus after the Titans revolted against Zeus and the Olympians.

Standards related to prescribing Not role specific
Rule 222.4 Standards related to prescribing Not role specific Not intended to replace standards of care for treatment of specific conditions Standards for prescribing medications. For those new to Texas, we do not have independent prescribing authority. Requires legislative change to get to that point. Like , not role specific

BON-issued prescriptive authority Physician delegation TMB Rule 193
Rule 222.4(a) BON-issued prescriptive authority Physician delegation TMB Rule 193 Protocols/Prescriptive Authority Agreements Population-focused Before writing prescriptions, you must have prescriptive authority from the board. APRNs have issued prescriptions without valid prescriptive authority, and disciplinary action is the result. Keep in mind, APRNs with interim approval are NOT issued prescriptive authority. Texas law requires that a physician delegate prescriptive authority to an APRN. Physician delegation of prescriptive authority must be registered with the Texas Medical Board. Can be done online. BON Rules do not include requirements for physicians—BON does not have authority to regulate physician licensure and practice. Need to be familiar with 193 of the TMB’s rules. Delegation of prescriptive authority occurs through protocols or prescriptive authority agreements. Depending on your practice site. Protocols may be used in facility based practices. In all other settings, a prescriptive authority agreement must be in place. If you are using very specific protocols or prescriptive authority agreements, be cautious. We have had situations in which APRNs had more specific protocols, and then wrote prescriptions for medications or classes of medications that were not authorized by that specific protocol. Be mindful of what your protocol or prescriptive authority agreement says. Prescriptive authority is population focused. Can only write prescriptions for those patients with those disease processes or conditions that are within the scope of your practice. If you are licensed in more than one category, that does not mean you are necessarily authorized to prescribe in all categories. If want prescriptive authority linked to each title, need to apply for it with each. A psych/mental health CNS with prescriptive authority returns and completes a post-master’s CNS in adult health nursing program. If the psych/mental health CNS does not apply for prescriptive authority with the CNS in adult health nursing license, his/her prescriptive authority is limited to prescribing for the mental health patient population only.

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 Patient information of course. Technically includes both name and address of patient Medication name and directions for use. Discussed the various rights of medication administration earlier under Rule , so won’t repeat that information here. Be cognizant of the rights because they are as applicable to prescribing as they are to medication admin. If appropriate, try to document the intended use of the medication. Helps patients remember why they are taking a particular medication. Times when not appropriate, so use caution. Example might be desmopressin. If prescribing for treatment of diabetes insipidus, could be fine to identify. If you are prescribing for 13 year old with bedwetting issues, putting the intended use on the bottle could be an embarrassment to the patient. Great deal of confusion over the need for physician information. Texas law still requires the name and contact information for the physician on all prescriptions. The physician’s DEA number is also required if the prescription is for a controlled substance. Pharmacist can and should refuse to fill the prescription if this information is not included—risk violating Pharmacy Act and Pharmacy Board Rules=> disciplinary action for the pharmacist/pharmacy. Your own information also needs to be there.

Rule 222.4(d) Partner Treatment
Treatment of partners of established patients is permitted APRNs are not required to provide this service Those of you in public health settings and of course in OB/Gyn settings are aware of the issues related to STIs and treatment of patient’s partner or partners. Conflict for the APRN in these settings, because there are inherent risks to writing prescriptions for individuals we may never have met. We don’t know about allergies or health conditions that may contraindicate prescribing the drug of choice and necessitate an alternate treatment choice. We also have concerns about patient education—lack of access to the partner means we rely on the patient to share what they’ve learned. On the other side of the conflict, the public health community sees the need for partner treatment. Left untreated, significant sequelae. The rule clarifies that APRNs may choose to issue prescriptions for treatment of their patient’s partner(s). Must be an established patient—can’t just write a prescription without having an established relationship with the patient. Board also wanted APRNs to have the option to refuse to treat partners if they are uncomfortable with doing so. Therefore, by rule, the APRN is not required to do so. Allows the APRNs to make their own decisions regarding whether they are comfortable with treating partners.

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 General expectation has always been FDA approved medications and uses. However, need for off-label prescribing. IRB approved research clinical trials are acceptable. Be sure you are familiar with the research protocol and ask about things like the IRB approval, the research question, what data is being recorded and how. Several years ago, we had some APRNs who were working in what they believed to be a clinical research study. Unfortunately, there was no evidence that this was a bona fide research study nor was there an IRB approval. Could not find evidence of what data was being collected. If not in research, off label prescribing may still be appropriate. Current standard of care and supported by evidence 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 Must have DPS and DEA registrations to prescribe controlled substances. Not legal to use another provider’s (including a physician’s) DEA/DPS. Coming from another jurisdiction that does not have a state process similar to DPS—the DEA number is not valid in Texas without getting DPS. There are different rules applied to prescriptions for schedule II medications than for Schedules III through V. We have had authority to prescribe III through V medications for about 10 years now. So this information is really just a reminder. No more than 90 days (including refills). Beyond 90 days-need physician’s consult. Also needed for children under the age of two. All requirements are set in state law. The Board cannot change these limitations—only the legislature can make such changes.

Rule 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 What is new as of November 1, 2013 is limited authority to prescribe Schedule II medications. These limits are in addition to the limits noted previously regarding the 90 day supply and children under the age of two years. There are only certain APRNs who can prescribe schedule II medications. If you are working with patients who have been certified as terminally ill and they are admitted for services by a qualified hospice provider, you may prescribe schedule II medications. If you are in a hospital facility based practice and practicing in the emergency department, you may prescribe schedule II. There is a caveat that I need to mention—the emergency department must be a physical part of the hospital. APRNs who practice in freestanding ERs are not eligible for Schedule II authority. If you are in a hospital facility based practice and caring for hospitalized patients who are intended to stay at least 24 hours, you may have schedule II authority. If you are working in a clinic of the hospital, even if it is physically located within the hospital building, you are not eligible for schedule II authority. Your patients are not intended to stay for at least 24 hours in your clinic. We need to also clarify that schedule II authority does not extend to long term care facility based practices. The law is very specific with regard to schedule II. I know many of you are in settings where you need authority to order/prescribe these medications that are not one of the three listed here. Again, only the Texas legislature can make this type of change.

We are also available at: www.bon.texas.gov aprn@bon.texas.gov
Questions We are also available at: I am happy to answer any questions you may have. ____________________ do we have any questions?

Kathy Shipp MSN, APRN, FNP

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Kathy Shipp MSN, APRN, FNP

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