PACHC Memo 09-04 Applicable for: FQHC Management Team Human Resource Department Physicians Professional Nurses December 22, 2009 TO: Health Center CEOs FROM: Cheri Rinehart, President & CEO SUBJECT: Final CRNP Regulations Pennsylvania State Board of Nursing ISSUE: The Pennsylvania State Board of Nursing on December 12, 2009 published final regulations intended to permit certified registered nurse practitioners (CRNPs) to practice to the full extent of their education, skills and abilities. The regulations ease restrictions on CRNPs ability to order diagnostic tests, treat illnesses and prescribe medications to patients. The regulations became effective on publication. BACKGROUND: In 1974, the General Assembly, in amendments to the Professional Nursing Law Act and the Medical Practice Act, authorized the State Board of Nursing and the State Board of Medicine to jointly promulgate regulations that would authorize qualified nurses to perform acts of medical diagnosis and prescribe medical, therapeutic or corrective measures. These jointly promulgated regulations were published in 1977, granting CRNP status to certain professional nurses (RNs) and governing the practice of CRNPs. Further action resulted in addition regulations for CRNP practice with regard to prescribing and dispensing of drugs in 2000. In December, 2002, Pennsylvania s Professional Nursing Law (Act) was amended to give the State Board of Nursing exclusive jurisdiction over the regulation of CRNPs, changing the joint authority held previously by the State Board of Nursing and State Board of Medicine over CRNP practice. The Act was further amended by Act 48 of 2007, which expanded the CRNP scope of practice to include ordering home health and hospice care, durable medical equipment; issuing oral orders; making physical, occupational and respiratory therapy and dietician referrals; performing disability TANF assessments; issuing homebound schooling certifications; and performing and signing the initial methadone treatment assessments based on physician order. 1
The Act 48 amendments also defined the liability coverage that CRNPs must carry and made them ineligible to participate in the MCare Fund These December 12, 2009 Pennsylvania State Board of Nursing final regulations implement the 2002 and 2007 amendments to the Act. KEY PROVISIONS: Key New and Amended Definitions: Act - The Professional Nursing Law (63 P.S. && 211-225.5). Board The State Board of Nursing of the Commonwealth. Certification The authorization granted by the Board to a profession nurse who has demonstrated the qualifications for recognition as a CRNP. CRNP Certified Registered Nurse Practitioner A professional nurse licensed in this Commonwealth who is certified by the Board in a specialty and who, while functioning in the expanded role as a professional nurse, performs acts of medical diagnosis or prescription of medical therapeutic or corrective measures in collaboration with a physician licensed to practice in this Commonwealth and in accordance with the act and the subchapter (Subchapter C. Certified Registered Nurse Practitioners General Provisions). Nothing is deemed to limit or prohibit a professional nurse from engaging in those activities which constitute the practice of professional nursing as defined in section 2 of the act (63 P.S. & 212). Collaboration A process in which a CRNP works with one or more physicians to deliver health care services within the scope of the CRNP s expertise. The process includes all of the following: 1. Immediate availability of a licensed physician to a CRNP through direct communications or by radio, telephone or telecommunications. 2. A predetermined plan for emergency services. 3. A physician available to a CRNP on a regularly scheduled basis for referrals, review of the standards of medical practice incorporating consultation and chart review, drug and other medical protocols within the practice setting, periodic updating in medical diagnosis and therapeutics and cosigning records when necessary to document accountability by both parties. Collaborative agreement The written and signed agreement between a CRNP and a collaborating physician in which they agree to the details of their collaboration including the elements in the definition of collaboration. Initial certification The first certification or licensure as a nurse practitioner that an individual receives in any jurisdiction. National certification Certification by a Board-recognized national certification organization which required passing a nurse practitioner national certifying examination in a specialty. Prescriptive authority collaborative agreement The written and signed agreement between a CRNP with prescriptive authority and a collaborating physician in which they 2
agree to the details of their collaboration. (To include at least one substitute physician to act in place of the collaborating physician when unavailable.) Specialty The area of practice or population in which a CRNP is certified by the board. CRNP Practice: When acting in collaboration with a physician as set forth in a collaborative agreement and within the CRNP s specialty, a CRNP may: 1- Perform comprehensive assessments of patients and establish medical diagnoses. 2- Order, perform and supervise diagnostic tests for patients and, to the extent the interpretation of diagnostic tests is within the scope of the CRRNP s specialty and consistent with the collaborative agreement, may interpret diagnostic tests. 3- Initiate referrals to and consultations with other licensed professional health care providers, and consult with other licensed professional health care providers at their request. 4- Develop and implement treatment plans, including issuing orders to implement treatment plans. However, only a CRNP with current prescriptive authority approval may develop and implement treatment plans for pharmaceutical treatments. 5- Complete admission and discharge summaries. 6- Order blood and blood components for patients. 7- Order dietary plans for patients. 8- Order home health and hospice care. 9- Order durable medical equipment. 10- Issue oral orders to the extent permitted by the health care facility s bylaws, rules regulations or administrative policies and guidelines. 11- Make physical therapy and dietitian referrals. 12- Make respiratory therapy and occupational therapy referrals. 13- Perform disability assessments for the program providing temporary assistance to needy families (TANF). 14- Issue homebound schooling certifications. 15- Perform and sign the initial assessment of methadone treatment evaluations, provided that any order for methadone treatment is made by a physician. Authority and Qualifications for Prescribing: A CRNP who has secured prescriptive authority approval from the Board may, when acting in collaboration with a physician as set forth in a prescriptive authority collaborative agreement and within the CRNP s specialty, prescribe and dispense drugs and give written or oral orders for drugs and other medical therapeutic or corrective measures including: 1- Orders for drugs, total parenteral nutrition and lipids; 2- Disposables and devices adjunctive to a treatment plan. Drug Categories Includes antihistamines; anti-infective agents; antineoplastic agents, unclassified therapeutic agents, devices and pharmaceutical aids; autonomic drugs; blood formation, coagulation and anticoagulation drugs, and thrombolytic and antithrombolytic agents; cardiovascular drugs; central nervous system agents; contraceptives, including foams and 3
devices; diagnostic agents; disinfectants for agents used on objects other than skin; electrolytic, caloric and water balance; enzymes; antitussive, expectorants and mucolytic agents; gastrointestinal drugs; local anesthetics; eye, ear, nose and throat preparations; serums, toxoids and vaccines; skin and mucous membrane agents; smooth muscle relaxants; vitamins; hormones and synthetic substitutes; Schedule II, III or IV controlled substances (see restrictions below). Prohibited Drug Categories Includes gold compounds; heavy metal antagonists, radioactive agents; oxytocics; and Schedule I controlled substances. Prescription Pad Requirements The collaborating physician s name does not need to be imprinted on prescriptions, (Section 21.284b) but prescriptions need to bear the name, title and Pennsylvania CRNP certification number of the CRNP. CRNP-Collaborating Physician Ratio The final regulations eliminate the previously required ratio of no more than four CRNPs with prescriptive authority to one collaborating physician as CRNPs practice in the expanded role of an advanced practice nurse in collaboration with physicians. Controlled Substance Schedules and Prescribing CRNPs who hold prescriptive authority approval from the Board can now prescribe Schedule II controlled substances for up to 30 days and Schedule III and IV controlled substances for up to 90 days if specified in the collaborative agreement. CRNPs who wish to prescribe under these new time limits must file a Prescriptive Authority Change Form with the Board. CRNPs may not use the new time limits until the Change Form has been submitted and the CRNP has received a letter back from the Board. CRNPs are required to make the collaborative agreement available for inspection, including to patients, and to also provide a copy of the collaborative agreement to pharmacists and pharmacies at no charge upon request. The Board does not require physicians to attest. Oral Orders CRNPs may give oral orders, which are defined as a spoken order issued by a practitioner authorized by law and by facility policy to issue orders for medical and therapeutic measures. (Section 21.141 of the regulations). Other Provisions: Approved CRNP Tasks Section 21.282a(b) was amended to specify that a CRNP may only perform the CRNP practice listed tasks if the CRNP is acting within the scope of the CRNP s specialty and collaborative agreement. CRNP Identification Requirements The previous requirement that a patient must be informed at the time the patient makes an appointment that the patient will be seen by a CRNP has been deleted, as has the requirement that a CRNP wear a name tag with the title certified registered 4
nurse practitioner on it. CRNP is now the accepted title. The regulations require that CRNPs comply with state, federal and facility regulations regarding identification of personnel. (Section 21.286b) Collaborative Agreement CRNPs continue to be required to submit their prescriptive authority collaborative agreements on a form provided by the Board. Collaborative agreements may only be with physicians who hold current State Board of Medicine or State Board of Osteopathic Medicine licensure in Pennsylvania. Administration of Anesthesia CRNPs may administer central nervous system agents classified as general anesthetics to intubated patients in a health care facility and, when credentialed by their employer, may administer central nervous system agents classified as general anesthetics for sedation in connection with procedures being performed in a healthcare facility in collaboration with a physician trained in airway management or with the immediate availability of a CRNA anesthesiologist. Implications for Health Centers: These regulations should allow community health centers to more effectively utilize CRNPs as the competent health professionals they are. Member Action Needed: Review the final regulations and make any necessary changes to collaborative agreements, prescription pads, CRNP name tags, and policies and procedures. Please Note that federal Medicaid and Medicare law currently only allows providers of home health and hospice care to receive reimbursement for patients whose initial order and recertification order was written by a physician. Let PACHC know of any questions you have with the regulations. For More Information: Contact Cheryl Bumgardner, Clinical Services Coordinator, PACHC, at (717) 761-6443, ext. 208 or Cheryl@pachc.com. 5