1. health and fitness
2. drugs

Changes in APRN
Prescriptive Authority
SB 406
Kathy Hutto
Governmental Affairs Consultant
Jackson Walker L.L.P.
1
WHAT HAS CHANGED?
• SITE-BASED APPROACH
• MILEAGE LIMITATIONS
• DIFFERENT REQUIREMENTS FOR
SUPERVISION
2
Other Changes in Rx Authority
1. Terminology
–
–
–
“Carrying out or signing a prescription drug order “
becomes “Ordering or prescribing drugs & medical
devices”
Changes “site” to “practice”
Changes definition of a “site serving a medically
underserved population.
2. Increases delegation ratio from 4 to 7 APRN/PAs (FTE)
–
Preserves no limit in practices that had no limit previously
3. Changes “Protocol” to “Prescriptive Authority
Agreement” in most practices.
(No change for CRNAs)
3
WHAT HAS NOT CHANGED?
• Limit on Physician Liability
• Facility-Based Practices
– Hospitals (care in hospital) and long-term care facilities
– No major changes in how delegate, who delegates, etc.
– Some clarifications
• Which and number of physicians can delegate
• Facility-based physicians delegating in private
practices
• FTE limits in freestanding clinics
• CRNA Practice
4
Limit on Physician Liability - MPA
• MPA Sec. 157.060. PHYSICIAN LIABILITY FOR DELEGATED ACT.
Unless the physician has reason to believe the physician
assistant or advanced practice registered nurse lacked the
competency to perform the act, a physician is not liable for an
act of a physician assistant or advanced practice registered
nurse solely because the physician signed a standing medical
order, a standing delegation order, or another order or
protocol, or entered into a prescriptive authority agreement,
authorizing the physician assistant or advanced practice
registered nurse to administer, provide, prescribe, or order a
drug or device
5
Limit on Physician Liability – TMB Rules
§193.5. Physician Liability for Delegated Acts and Enforcement.
(a) [Content of MPA 157.060. Moves qualifier to end.]
(b) Notwithstanding subsection (a) of this section,
delegating physicians remain responsible to the Board and to their
patients for acts performed under the physician's delegated
authority.
(c) Any physician authorizing standing delegation orders or
standing medical orders which authorize the exercise of
independent medical judgment or treatment shall be subject to
having his or her license to practice medicine in the State of Texas
revoked or suspended under §§164.001, 164.052, and 164.053 of
the Act.
6
Limitations on APRN Rx Authority
in Texas
• Delegated & Supervised
• Site-based
• No Schedule II in most practices
7
MD may delegate ordering & prescribing:
 Nonprescription Drugs
 Dangerous Drugs - Drugs & medical devices that
require a prescription, excluding controlled substances
 Controlled Substances (CS)
Schedule II drugs added in limited situations
8
Limits on Schedules III-V (no change)
Physicians may also delegate ordering and prescribing Schedules IIIV Controlled Substances subject to 4 limitations.
• The duration of the prescription, including refills of the original
prescription, may not exceed 90 days;
• Continued treatment with the same controlled substance
beyond 90 days requires consultation with the delegating
physician prior to writing another prescription or refilling the
original prescription;
• Treating a child under age 2 requires prior consultation with the
delegating physician; and
• Consultation with the physician must be noted in the patient’s
medical record.
9
Where can a physician delegate prescribing
Schedule II, Controlled Substances?
1) in a hospital facility-based practice, as part of the care
provided to a patient who:
• (A) has been admitted to the hospital for an intended length
of stay of 24 hours or greater; or
• (B) is receiving services in the emergency department of the
hospital; or
(2) as part of the plan of care for the treatment of a person who
has executed a written certification of a terminal illness, has
elected to receive hospice care, and is receiving hospice
treatment from a qualified hospice provider.
10
Prescribing Controlled Substances
DPS Permit and DEA #
• Must have delegated prescriptive authority for CSs.
• Request permit application from Texas Department
of Public Safety (DPS)
– Physician must sign application
– Physician must register delegation for CSs with TMB
• Apply for DEA# online
www.deadiversion.usdoj.gov/drugreg/index.html
• Report DEA # to DPS
11
Rx Authority Delegation
• MD or DO
• Prescriptive Authority Agreement (PAA) or
Protocol
• Physicians delegating through a PAA register
delegation at TMB within 30 days
• Physician & APRN must keep records until 2
years from the date the PAA is terminated.
12
Special Practice Designations
exempt from certain restrictions
• Practice serving a medically underserved
population
• Facility-based (hospital or long-term
care)
13
Medically Underserved
• Medically Underserved Population (MUP)
– Federally designated HPSA, RHC, FQHC
– Public health or family planning clinic under
contract with HHSC or DSHS
– Designated by DSHS (Health Professions Resource
Center) www.dshs.state.tx.uschs/hprc/default.shtm
• Titles V, X, XVIII, XIX, XXI Federal funding or state-funded
– County, state or federal correctional facility
– Any practice designated as a site serving a MUP
prior to March 1, 2013.
14
Medically Underserved
• PAA requirements same as other sites
• Advantage - No physician to APRN/PA ratio
15
Facility-Based Sites
• Licensed Hospital
– Advantage - no delegation ratio
– Physician limited to 1 hospital
• Long-term Care Facility
– Only delegated by medical director
– Limited to 2 facilities
– 1 physician to 7 APRN/PA ratio
• May use current Protocol or PAA
16
Prescriptive Authority
BON Rule 221.13 (d)
Prescriptive authority requires:
• Prescriptive Authority Agreement (PAA); or
• In facility-based practice, Protocols or other
written authorizations (standing medical orders,
standing delegation orders, or other order or protocol)
– “Medical Aspects of Care” include all functions on
the next slide.
17
APRN Practice: Delegated Medical Acts
•
•
•
•
Prescribing & Ordering Drugs & Medical Devices
Ordering Durable Medical Equipment & Supplies
Establishing a Medical Diagnosis
Verifying medical eligibility for disabled parking
placard
• Ordering Orthotics and Prosthetics
• Ordering respiratory care
• Tx Medicaid – Ordering therapy services
18
Protocols
• May continue to use in facility-based
practices
• As permitted by medical staff bylaws &
policies
• Protocols are not diagnosis or condition
specific
• Must identify the drugs or categories of
drugs the APRN may, or may not, prescribe
19
Recap of Physician Delegating in Hospital
• Delegation is through protocols
• Delegate to an unlimited number of APRNs/PAs
– Does not include freestanding clinics (7 FTE limit)
• Limited to delegation in 1 hospital
• Physician may also delegate in other practices to a
maximum of 7 APRNs/PAs under a Prescriptive
Authority Agreement
20
LTC Facility-Based Practice
• Same as hospital facility-based except:
–Medical Director is only physician who
can delegate
–Physician may delegate at 2 LTC
facilities
–Seven FTE limit
21
Prescriptive Authority Agreements
• May be used in facility-based practices
– Not recommended
– Must comply with all PAA requirements
• PAA:
– All non-facility-based practices
– Requirements specified in law
22
Requirements for Parties to the PAA
All parties must disclose:
• Prior disciplinary action by the licensing board before
executing the PAA.
• Investigation by the licensing board while a party to
the PAA.
All parties must cooperate with TMB and BON staff
during an inspection or audit relating to the PAA and
its implementation.
23
PAA Requirements
•
•
•
•
•
In writing, signed and dated by all parties
Name, address & professional license # of parties
Nature of the practice, locations, or settings
Categories of drugs that may or may not be prescribed
Plans for:
–
–
–
–
Consultation & referral
Addressing patient emergencies
Communicating & sharing information related to treatment
Quality assurance and improvement (QAI) that includes chart
review, meetings, & documenting implementation of QAI
24
QAI Plan Requirements
• Chart review - Number determined jointly
• Purpose/content of QAI monthly meetings
– share information about patient care & treatment
– changes in treatment plans
– issues relating to referrals
– discussion of patient care improvement
• Document implementation method & compliance
25
QAI MEETING REQUIREMENTS
• QAI monthly in-person meetings
– Location, day and time determined jointly
– Face-to-face 1 year for APRNs who prescribed for 5 of past 7
yrs.
– Face-to-face for 3 years for APRNs with less experience
• Thereafter, meet quarterly in-person & monthly in between
by electronic means.
NOTE: TMB Rules [Sec. 193.8(11)(C), TAC] authorizes APRNs who prescribed for 5 of
the past 7 yrs with the SAME physician with whom the PAA is being entered to go
immediately to quarterly in-person meetings & monthly in between by electronic
means. However, BON Rules [Sec. 222.5(d)(2)(B)] requires all APRNs who prescribed
for 5 of the past 7 yrs to meet face-to-face for 1 year, even if working with the same
physician. Unfortunately, one has to abide by this more restrictive regulation.
26
Cook Books Not Required
• The prescriptive authority agreement need not describe the
exact steps that an APRN must take with respect to each
specific condition, disease, or symptom.
• The prescriptive authority agreement should promote the
exercise of professional judgment by the APRN commensurate
with the APRN’s education and experience and the
relationship between the APRN and the physician.
• This section shall be liberally construed to allow the use of
prescriptive authority agreements to safely and effectively
utilize the skills and services of APRNs.
27
Other Key Provisions
• The prescriptive authority agreement and any amendments
must be reviewed at least annually, dated, and signed by the
parties to the agreement.
• The prescriptive authority agreement and any amendments
must be made available to the board, the Texas Board of
Nursing, or the Texas Physician Assistant Board not later than
the third business day after the date of receipt of request, if
any.
• A party to a prescriptive authority agreement must retain a
copy of the agreement until the 2nd anniversary of the date
the agreement is terminated.
28
Disclosure Requirements
• Before executing the prescriptive authority agreement,
the physician and the APRN shall disclose to the other
prospective party to the agreement any prior disciplinary
action by the Texas Medical Board or the Texas Board of
Nursing, as applicable.
• If a party to a prescriptive authority agreement is notified
that the individual is the subject of an investigation by
the Texas Medical Board or the Texas Board of Nursing,
the individual shall immediately notify the other party to
the prescriptive authority agreement.
29
Number of APRNs/PAs to whom a
physician may delegate Rx authority?
• 7 FTEs in most practices
• UNLIMITED in
– hospitals (not including free-standing
clinics) or
– practices serving a medically underserved
population (MUP)
30
A Universal Limitation on APRN
Prescriptive Authority
Scope of Practice
In any state, prescriptions are
limited to the scope of practice
authorized by the state board of
nursing.
31
What APRNs Must Know about Rx Authority
1. Apply for a prescriptive authority number when
applying for license to practice as an APRN.
2. Separate Prescriptive Authority required for each
APRN role & population-focus area.
3. May not write prescriptions until a physician (A)
delegates authority, & (B) signs PAA or Protocol
4. Register delegation on TMB website within 30 days.
5. May not prescribe controlled substances until have
DPS # (CSR) and DEA #.
6. May not prescribe for yourself, friends or family. 32
Sample Practice Prescriptive Authority
Agreement &
APRN Guide to Practice, 4th Edition
AVAILABLE AT
WWW.CNAPTEXAS.ORG
33