APRN Practice & Professional Advocacy in Texas Lynda Woolbert, MSN, RN, CPNP-PC, FAANP APRN Consultant 1 Overview APRN Consensus Model & LACE (Module I: Unit 1) • APRN Practice in Texas, Scope of Practice & Licensure • (Module I: Units 1 & 2) Prescriptive Authority (Module I: Unit 2) • Texas Legislative & Regulatory Process (Module II) • Advocating Effectively (Module II) • Scope of Practice Review & BON Disciplinary Issues • (Module I) • CNAP & Texas Nurse PAC (Module II) Read notes in “normal” view 2 Why study APRN practice legislation & regulation now? • Must adhere to the law from the first day you practice as an APRN • Evaluate & learn throughout clinical experiences • Know resources to stay current • Avoid being featured on 10 o’clock news as two NPs were for dispensing controlled substances to treat obesity. 3 Consensus Model for APRN Regulation aligns Licensure, Accreditation, Certification and Education (LACE) 4 APRN Consensus Model: LACE Accreditation Organizations Educational Programs Certification Organizations Boards of Nursing (BON is the state agency that licenses APRNs to protect the public.) 5 Consensus Model for APRN Regulation: Licensure POPULATION FOCUS AREAS (FOCI) Family (Lifespan) Adult Gerontology Neonatal Acute or Primary Nurse Anesthetist CRNA NurseMidwife CNM APRN ROLES Pediatrics Acute or Primary Women’s Health (Gender Related) Clinical Nurse Specialist CNS & Psychiatric Mental Health Nurse Practitioner CNP* 6 Licensing Titles CRNA CNM CNS NP AGCNS AGNP ACAGNP FCNS FNP NCNS NNP PCNS PNP ACPNP PMHCNS PMHNP WHCNS WHNP 7 Scope of Practice (SOP) • Professional SOP – based on APRN education and certification SOP statements by professional organizations • Personal SOP – based on personal competency • State SOP – based on occupational licensing laws in the state 8 Elements Determining Scope of Practice (SOP) *Education *Certification Competency • SOP is not determined by: Pre-NP specialization as an RN; or Setting • While an employer may limit SOP, an employer can never expand SOP beyond that legally permitted. Source: NONPF. (2012). Statement on acute care and primary care certified nurse practitioner practice. 9 Scope of Practice References • BON Guidelines for Determining Scope of Practice with FAQs on Scope of Practice www.bon.texas.gov/practice_scope_of_practice_aprn.asp www.bon.texas.gov/faq_practice_aprn.asp#t5 • Professional organizations representing the APRN role and population focus. Examples – AANP: scope and standards applicable to all NPs – AACN: scope and standards applicable to acute care NPs – NAPNAP: scope of practice for pediatric nursing from RN through primary care and acute care PNPs. 10 Review What is the difference between certification organizations; professional organizations; and licensing boards? Certification and licensure: Know the difference. 11 Statutory and Regulatory Basis of APRN Practice in Texas 12 Statutory – Laws passed by the state legislature (Nursing Practice Act) Regulatory – Rules passed by state agencies based on authority granted by the state legislature (BON Rules) 13 What is the purpose of regulating health professionals? 14 Consensus Model for APRN Regulation Role & population determine licensure. BONs do not regulate specialization. POPULATION FOCUS AREAS (FOCI) Family or Individual (Lifespan) Adult Gerontology Neonatal Pediatrics Women’s Health Psychiatric (Gender Related) Mental Health APRN ROLES Nurse Anesthetist CRNA NurseMidwife CNM Clinical Nurse Specialist CNS Nurse Practitioner (Acute or Primary) CNP* 15 Advanced Practice Titles in Texas BON Rule 221.2 Nurse Anesthetists (CRNAs) Nurse-Midwives (CNMs) Nurse Practitioners (NPs) Clinical Nurse Specialists (CNSs) NCSBN. (2014). APRNs in the U.S. https://www.ncsbn.org/170.htm 16 BON Rules & Regulations for APRNs § 219 APRN Education § 221 APRN Licensure and Practice (expect revisions in 2017-2018) § 222 Prescriptive Authority (new rules adopted November 15, 2013) http://www.bon.texas.gov/laws_and_rules_ru les_and_regulations.asp 17 Population Foci Titles • Nurse Practitioners • • • • • • • • • • • BON Rule 221.2 & BON Policy Acute Care Adult Clinical Nurse Specialists Acute Care Adult/Gero Adult Health / MS Acute Care Pediatric Adult/Gerontology Adult Adult/Gerontology Community Health Nursing Family Critical Care Nursing Gerontological Gerontological Nursing Neonatal Pediatric Pediatric Nursing Psychiatric/Mental Health Psychiatric/Mental Health Women’s Health Nursing. Advanced Practice Titles in Texas BON Rule 221.2 • Current Rule - Advanced Practice Registered Nurse (APRN) is umbrella term and not a title to use after your name. • NPA was amended in 2013, and BON issues APRN licenses. • When BON revises rules in Chapter 221, BON will propose licensure and titling consistent with the Consensus Model. 19 BON Rules & Regulations for APRNs § 219 APRN Education § 221 APRN Licensure and Practice § 222 Prescriptive Authority REMEMBER… All BON Rules apply to APRN practice. 20 All BON Rules Apply to APRNs Particularly Note: Chapter 217 § 217.11 Standards of Nursing Practice § 217.12 Unprofessional Conduct § 217.14 Registered Nurses Performing Radiologic Procedures § 217.18 RNs that First Assist at Surgery 21 First Assisting at Surgery • §217.18 requires RNs that first assist: – Complete a RNFA program (listed on CCI Website, www.cc-institute.org/crnfa/certification/steps/programs). – CNOR certified; or APRN licensed - Limits RNFA scope to APRN Population Focus. 22 ALL BON Rules Apply to APRNs In addition to Chapter 217, Note: Chapters 216, 224, and 228 Chapter 216 – Continuing Competency Chapter 224 – Delegation to unlicensed personnel in acute care setting Chapter 228 – Pain Management Rules BON identifies as particularly relevant to APRNs are listed on the Advanced Practice Information webpage. 23 Other BON Resources • Position Statements • Texas Board of Nursing Bulletin • APRN Practice webpage http://www.bon.texas.gov/practice_nursing_practice_aprninfo.asp 24 BON Rules require RNs follow all state & federal rules that apply to their practices. Examples: Texas Medical Board (TMB) Texas State Board of Pharmacy (TSBP) Texas Health & Human Services Commission – Medicaid & CHIP Federal Center for Medicare & Medicaid Services (CMS) 25 APRN Licensure & Renewal 26 APRN Licensure in Texas • • • • • BON Rule 221.4 2nd license in addition to RN license APRN license – AP###### Verify APRN license on BON website New application required for each role and/or population focus Requirements – New graduate and national certification; or – 400 hours practice and current national certification 27 New Graduate APRN License (BON Rule 221.4) with Prescriptive Authority (BON Rule 222.2) 1. Complete & submit licensure and Rx Authority applications (online preferred); 2. Submit additional documents; 3. Pass a certification exam recognized by the BON; and 4. Notify BON 5. Receive APRN License & verify Rx Authority Number online. 28 Remember Until BON notification or verification on BON website of full APRN licensure, • Do not use APRN skills except under direct supervision; and • Do not use or claim an APRN title (including Graduate FNP, etc.) 29 Remember Do not sign a prescription until: • Prescriptive authority number is verified on BON website, and • Physician delegates prescriptive authority & signs Prescriptive Authority Agreement (PAA) or Facility-Based Protocols (as applicable to the type of practice). 30 Interim Approval (Not an option for new graduates and no interim approval is consistent with Consensus Model) BON Rule 221.6 • Short term approval until all documents received and reviewed. • Up to 120 days, no extensions • Interim approval granted only 1 time per APRN role & population focus area • No prescriptive authority 31 Applicants for Texas APRN License Currently Licensed in Other States • Must have unencumbered Texas RN license or be a resident of a RN Licensure Compact state with a privilege to practice in other Compact states • No interstate APRN Compact option - must complete the full application process for Licensure and Prescriptive Authority • BON expected to eliminate option for Interim Approval in 2017-2018. 32 Maintaining APRN Licensure BON Rules 216.3 & 221.8 • Renew APRN license in conjunction with RN license attesting requirements were met. – Current national certification in the role & population focus area; – 400 hours of current practice; – 2 hours jurisprudence/ethics CE in past 6 years; – 2 hours of CE in caring for older adults; and – APRNs with Rx authority must have 5 hours of pharmacotherapeutics CE within the past 2 years . Those with Rx authority for controlled substances (CSs), need an additional 3 hours related to CSs. 33 How to Sign Your Name (current rules) • “RN” identifies licensure • Identify APRN role & population focus, e.g. FNP, ACNP, CNM, ACNS • Multiple APRN role / population foci -- use the title that applies. Lynda Woolbert, RN, PNP Lynda Woolbert, MSN, RN, CPNP-PC 34 Likely Signature Requirements in 2018 • RN or APRN could identify licensure. • Identify APRN role & population focus, e.g. FNP, ACAGNP, AGNP • Multiple APRN role / population foci -- use the title that applies. Lynda Woolbert, APRN, PNP Lynda Woolbert, MSN, APRN, CPNP-PC In accordance with current statute but not BON rules 35 APRN Practice: Autonomous vs. Delegated Elements of APRN Scope of Practice in Texas 36 Delegation • Transferring authority from one person to another • Delegation always implies supervision • Ordering a service to be provided by a licensed individual is NOT delegation. • Physicians have broad delegatory authority. • RNs and APRNs have limited delegatory authority based on BON Rules in Chapters 224 and 225. 37 APRN Practice: What is Autonomous? • Assessments – Histories & physical exams – Ordering diagnostic exams – Interpreting diagnostic tests • Recommending OTC Drugs • Establishing treatment plans in the APRN’s scope of practice (excludes Rx & other functions specifically requiring physician delegation) • Referrals, Consultation, Coordination of Care 38 Texas APRN Practice: What is Delegated? • Based on definition of Professional Nursing in the NPA & no exclusion for APRNs – Medical diagnosis; and – Prescribing & ordering drugs, medical devices and durable medical equipment are delegated. • Based on Provisions in Other Texas Laws – Signing medical verifications for disabled parking placards – Ordering Orthotics and Prosthetics • Medicaid Rules can Limit Scope of Practice 39 Medical Aspects of Care BON Rule 221.13 (d) Medical Aspects of Care are acts that require physician delegation through a written document. Either a: • 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) 40 What are the physician’s liability implications for delegated acts? • Except when subject to other provisions in the law and/or mitigating circumstances, the professional delegating responsibility is liable. • • The Medical Practice Act (statute) and TMB Rule 193.5 include a partial exemption for physicians delegating prescriptive authority. TMB Rule 193.5(b) states: “…delegating physicians remain responsible to the Board and to their patients for acts performed under the physician's delegated authority.” 41 When performing medical aspects of care, is the APRN practicing medicine or nursing? • All health care professionals have overlapping scopes of practice. • Professional practice acts recognize this by including a provision exempting other health professionals. • When a nurse performs “medical acts,” the nurse is practicing NURSING. 42 Overlapping Scopes of Practice NP · PA · MD · DO Pharmacists Therapists Dentists Optometrists Radiology Techs, etc…. All health professionals have SOPs that overlap in some way. 43 Facts about Physician Assistants (PAs) • Regulated by the Physician Assistant Board • Licensing Statute is in Medical Practice Act (Subtitle B, Chapter 204, Texas Occupations Code). • PA rules are in Chapter 185 of the TMB Rules. • Education is similar to 3rd year medical school. • Scope of practice is based on supervising physician. • All aspects of PA practice are delegated by the supervising physician. • In Texas, PA & APRN prescriptive authority are identical. 44 Terminology Referring to APRNs & PAs • Best to call professionals by their names, e.g., Nurse Practitioner Physician Assistant • When a collective term is used: Avoid mid-level provider or practitioner Exception: DEA and DPS Better: Advanced Practice Providers (APP) or advanced practice practitioners. 45 Prescriptive Authority in Texas Nursing Statutes: Sections 301.152 & 301.168, NPA BON Rules: Chapter 222 Medical Statutes: Sec. 157. 051 – 157. 060, MPA TMB Rules: 193.5 – 193.14 and Applicable Definitions in TMB Rule 193.2 46 Definitions Prescribing vs. Ordering • Prescribing – Prescription filled at outpatient pharmacy – Must have prescriptive authority to sign a Rx – Includes orders written in long-term care facilities • Ordering – Medications dispensed from inpatient pharmacy for administration – Must be consistent with facility policy and “Protocol, PAA or other written authorization” 47 Definitions Two Broad Drug Categories in Law Dangerous Drugs - Drugs & medical devices that require a prescription, excluding controlled substances. Controlled Substances (with limitations) – Drugs deemed to have abuse potential and subject to additional regulation. Controlled substances are divided into 5 schedules. 48 Controlled Substances (CSs) Schedules are based on abuse potential & medical use. I - highest abuse with no medical use II - high abuse with recognized medical use III - moderate abuse potential IV - moderate to low abuse potential V - some abuse potential www.deadiversion.usdoj.gov/schedules/#define Schedules III-V subject to less regulation than Schedules I and II. www.deadiversion.usdoj.gov/schedules/ 49 A Universal Limitation on APRN Prescriptive Authority Scope of Practice In any state, prescriptions are limited to the scope of practice authorized by state law and the state’s board of nursing. 50 Limitations on APRN Rx Authority in Texas • Delegated & Supervised • No Schedule II Controlled Substances in most practices 51 MD may delegate ordering & prescribing: Dangerous Drugs – Any category Controlled Substances (CS)- Limitations • Schedules III – V • 90-day Rx (or refills equal 90-day supply) • Prior authorization required for: –Refills beyond 90-days –Any CS for Children Under 2 yrs. • Schedule II to APRNs treating: – patients in hospital ER (APRN must be facility-based) – Inpatients (APRN must be facility-based); or – Hospice patients 52 Rx Authority Delegation • MD or DO • Witten delegation document: – Protocol if facility-based; or – Prescriptive Authority Agreement (PAA). • Physicians register APRNs & PAs to whom they delegate Rx authority through a PAA. • Physician & APRN must keep records until 2 years from the date the PAA is terminated. Resources: CNAP’s Sample Prescriptive Authority Agreement CNAP’s Sample Facility-Based Protocols A Guide for APRN Practice in Texas FAQs on TMB and BON Websites 53 Prescribing Controlled Substances (CSs) DPS and DEA Registrations 1.Must have delegated prescriptive authority for CSs. 2.Before 9/1/16, request permit application from Texas Department of Public Safety (DPS) tppcsr@txdps.state.tx.us a. Physician must register delegation for CSs with TMB b. Physician must sign DPS CSs registration application 3. Apply for DEA# online www.deadiversion.usdoj.gov/drugreg/index.html 4. Report DEA # to DPS until 9/1/16; then TSBP. 54 Rx Authority Review An APRN from a nurse licensure compact state is going to practice in Texas for four months. What licenses must the APRN have before prescribing dangerous drugs in Texas? (Check all that apply) a) Texas APRN license b) Texas APRN prescriptive authority number c) Texas DPS Controlled Substances registration d) Texas RN license 55 Texas Prescriptive Authority Law Special Practice Designations exempt practices from certain restrictions • Do not submit site changes to BNE or the Texas Medical Board (TMB) 56 Prescriptive Authority Two Types of Practice Designations • Practice serving a medically underserved population • Facility-based practice or site 57 Medically Underserved • Medically Underserved Population (MUP) Definition – 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 designation as a site serving a MUP prior to March 1, 2013. 58 Medically Underserved • PAA requirements same as other sites • Advantage - No physician to APRN/PA ratio • Physician limited to delegating at no more than 3 MUP practices = 150 hrs./wk. 59 Facility-Based Sites • Licensed Hospital – Only delegated by certain physicians – Limited to 1 hospital (under facilitybased hospital provisions) • Long-term Care Facility – Only delegated by medical director – Limited to 2 facilities 60 Facility-Based Sites: Advantages • Licensed Hospital – No delegation ratio – May use protocols or PAA • Long-term Care Facility – 1 physician to 7 APRN/PA ratio (no advantage) – May use protocols or PAA • Physicians delegating under facility-based provisions may delegate to 7 additional APRNs/PAs through a PAA. 61 Protocols BON Rule 221.13 (d) • Preferred written delegation document in facility-based practices • Protocol should promote the exercise of professional judgment commensurate with: – APRN’s education and experience; and – Complexity of patient’s condition. • Advantage – No specific QAI requirements that are specified in the PAA. 62 Prescriptive Authority Agreement (PAA) • Written document through which a physician delegates the authority to order and prescribe drugs and/or devices in all practices except facility-based. • Remains an option for facility-based. 63 Requirements for Parties to the PAA • Physicians are limited to delegating Rx authority to no more than 7 APRNs and/or PAs (FTEs) • 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. 64 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 65 QAI Plan Requirements • Chart review - Number determined jointly • Purpose/content of QAI monthly meetings – share information about patient care & treatment, – changes in treatment plans and – issues relating to referrals • 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. • Document implementation method & compliance 66 Prescription Form 1. patient's name and address; 2. name, strength, and quantity of the dangerous drug or controlled substance; 3. directions to the patient regarding taking the drug and the dosage; 4. intended use of the drug, if appropriate; 5. name, address, and telephone number of the delegating physician; continued 67 Prescription Form – cont’d 6. APRN’s prescriptive authority # 7. address & telephone # of site; 8. date of issuance; 9. number of refills permitted; and 10. If a controlled substance: – DEA # for APRN & MD/DO – DEA # for APRN BON Rule 222.4(b) & TSBP Rule 291.34 (b)(7)(A) 68 ? Would a NP be able to prescribe dangerous drugs or medical devises without DPS and DEA registrations? 69 Prescribing Standards: Writing a Prescription • Avoid abbreviations on The Joint Commission’s “Do Not Use” list • Refer to Stewart & DeNisco 70 Prescribing Standards: Generic Substitution • Requires written and faxed prescriptions designate “brand medically necessary” or “brand necessary” in the prescriber’s handwriting. • Rules allow electronic prescriptions designated on the prescription. TSBP Rule 309.3 71 Prescribing Standards: BON • FDA approved • Off label use permitted only if: – Part of a research protocol approved by IRB or Expanded Access authorized clinical trial – Within the current standard of care and supported by evidence-based research • Patient-practitioner relationship must exist – Do not prescribe for self, friends or family • May treat STDs for partners of established patient after examining the patient 72 Prescribing Controlled Substances • Schedule III-V Controlled Substances may be prescribed on a standard prescription form. • CSs may be prescribed electronically • Essential Resources if prescribing CSs – BON Prescribing Controlled Substances Rule, 22 TAC §222.8 – Pain Management Rules – BON Chapter 228 & TMB Chapter 170 – DPS (Before September 1, 2016) http://www.txdps.state.tx.us/RSD/ControlledSubstances/index.htm – TSBP – Resources on Abuse & Misuse (including TMB links) http://www.tsbp.state.tx.us/sb144.htm 73 “Official Prescription Form” • Term for the form required when prescribing Schedule II Controlled Substances (triplicate) • Schedule II Controlled Substances may be prescribed electronically • DPS requires that the delegating physician sign the APRN’s application for DPS controlled substances registration. (This will not be a requirement after 8/31/16.) 74 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 1) delegates authority, 2) signs PAA or Protocol 4. Register delegation on TMB website within 30 days. 5. May not prescribe controlled substances until have DPS # (CSR) (until 9/1/16) and DEA #. 6. May not prescribe for yourself, friends or family. 75 ? What Texas state agencies regulate the information included on a prescription form when the APRN signs a prescription for a controlled substance? (Check all that apply.) a) Board of Nursing (BON) b) Department of Public Safety (DPS) c) Texas Medical Board (TMB) d) Texas State Board of Pharmacy (TSBP) 76 Advocacy and the Texas Legislative Process 77 Barriers to Practice • Federal Level – Some Medicare reimbursement policies – APRN not allowed to order home health in Medicare & Medicaid • State Level – Definition of Professional Nursing in the NPA – Physician delegation – Limitations on controlled substances – Provisions in the Insurance Code – Some Medicaid reimbursement policies 78 Texas Legislative Basics • Begins with Interim Charges. • Stakeholders take part in hearings. • Session starts the 2nd Tuesday in January. • Bills are filed by legislators until 60th day. • Companion bills – Same bill filed in House & Senate • The same bill number must pass House & Senate • The Regular Session lasts 140 days • Governor may call a 30-day Special Session for specific purpose/s (The Call) 79 Texas Legislative Session Cycle 2016 • Interim Charges issued fall 2015 – 1/16 • Elections – 3/1, 5/24, 11/1 2018 • Interim Reports – 11/1 – 12/1 • Begin Pre-filing bills 85th Legislature • 85th Session Begins 1/10 2017 • Bill filing deadline 3/11 • Session Ends 5/29 Special Session 2017 • Governor calls • Special Purpose – “The Call” • 30-day Legislative Process: Bill to Statute • • • • • • • • Bill Introduced & Referred to Committee Committee Hearing → Committee Report Floor Vote → Engrossed Received in 2nd Chamber & Referred Committee Hearing → Committee Report Floor Vote → Enrolled Sent to Governor → Signed Statute (Law) 81 Legislation to Regulation 82 Legislation • Texas Legislature passes a bill. • Governor signs into law. • Statute directs state agency to implement. Regulation • State agency proposes & adopts rules • Agency takes action within statutory authority against regulated persons / entities that violate rules. 83 Advocacy Basics • What is the difference between legislation and regulation? • Does the Texas Legislature meet in Regular Session every year? • Does your congressman work in Austin or in Washington, D.C.? • How do you address your state legislators? • How do you find your legislators’ names? Who represents you in Austin & D.C.? 84 Following Bills through Legislative Process How to Find and Read a Bill http://cnaptexas.com/texas-legislation Finding a Bill www.capitol.state.tx.us How a Bill Becomes Law www.tlc.state.tx.us/gtli/legproc/process.html 85 APRN Legislative Priorities Remove unnecessary restrictions that prevent & delay care. • Contract directly with insurance providers and serve as primary care providers whether the delegating physician is in-network or not. • Authorize physicians to delegate prescribing Schedule II medications (especially to psychiatric APRNs and APRNs providing palliative care). Handouts: http://www.texasnp.org/?84LegSession 2015 Legislative Summary http://www.texasnurses.org/?page=SessionUpdates#ID 86 Visits with Legislators • Lobbying is education – Identify purpose & 3 goals • Flow of the visit – Getting to know you – finding commonalities – Listen before telling. Find out what the legislator /staff knows about your issue/s. www.house.state.tx.us for info on representatives www.senate.state.tx.us for into on senators – Give the information the legislator needs. – End on time with your request. • Follow-up with a letter to the legislator & staff. 87 Visiting/Writing Legislators • Research the issue & ask for help as needed. APRN state & national organizations and Policy Institutes: www.texaspolicy.com & www.cppp.org • Address the right issue to the right legislator • Limit to 1 page – Use enclosures as necessary • Use correct forms of address – “The Honorable Donald Doorman” to address the envelop – “Dear Representative Doorman:” to open the letter • Include your card / your contact information. 88 Writing Legislators by Email • Be sure the email will be read by asking if email is a preferred form of communication. • Write it like a letter - Include a salutation & closing • Edit very carefully • Remember how easily emails are forwarded • Never put anything in an email you would not want the public to read. 89 Relationships with Legislators • Be a regular – At least 3 - 4 contacts a year – Meet with legislators in home district – Always be polite, even when you disagree • Visit when you need no favors • Write notes – Handwritten notes are good – Congratulatory – Items or articles of interest • Volunteer and donate • Attend fundraisers 90 Responding to Action Alerts • • • • • • • • Read the entire alert carefully. Clarify if needed. Verify the alert is from a reputable source. Respond if appropriate in time frame requested. Read & Follow directions/guidelines exactly. Put your response in your own words. Edit carefully. Close the loop. Let requestor know you responded. Responding through an organization’s automated response system 91 Becoming an Effective Advocate • Join and attend professional meetings • Get informed & organized – – – – Register or Join to receive professional org.’s updates Organize so everyone plays to their strengths Recruit colleagues Do what you can, when you can • Join your statewide professional organizations TNA, TNP, and CNAP. • Contribute to Texas Nurse PAC • Form relationships with your legislators & staff. 92 APRN Legislative Day Monday, February 22, 2016 Location: Bullock Museum in Austin Register at bit.ly/APRNday By February 15th $50 Registration fee 93 Reasons the BON Disciplines APRNs Scope of Practice Review What To Do If a Complaint is Filed BON Disciplinary Options 94 Administrative Violations of the NPA • Fails to: – Obtain APRN Licensure – Renew APRN Licensure – Renew RN License – Maintain National Certification – Attain or maintain records of CE – Sign name properly identifying APRN role & population – Solicit / inform patients ethically or in accordance with HIPPA 95 APRNs Practice Violations • Fail to: – Maintain or annually sign /date Rx authority written documentation – Document – Assess or monitor – Maintain a safe environment for patient – Refer to a physician or others – Prescribe and/or administer drug appropriately 96 Mistakes Resulting in Serious Outcomes • APRN Practicing as RN without proper orientation – Practicing as APRN in primary care does not maintain high tech RN skills. • Practicing when fatigued / over 12 hours or too many days in a row. (See the Texas BON Bulletin, April 2015.) 97 Mistakes Resulting in Serious Outcomes • Violating APRN Scope of Practice most common cause for: – disciplinary action R/T practice error – bad outcomes 98 May APRNs provide any service or perform any procedure delegated by a physician? NO Must fall within formal APRN education: • Population of patients • Type of services 99 Scope of Practice Review Is a primary care educated NP permitted to practice in a specialty? YES 100 Scope of Practice Review Is a primary care educated NP permitted to practice in a hospital? YES, But limited to the level of care included in APRN educational program. 101 What to do if a Complaint is Filed • • • • Notice means BON opened an investigation. You have 20 days to respond. Use the time wisely. Identity of complainant is confidential. Fail to respond, the case moves forward without your side of the story. • Consult an attorney and colleagues. • If you have prescriptive authority through a PAA, notify delegating physician and other parties. Resources: BON Website & A Guide for APRN Practice in Texas, Chapter 9.102 BON Disciplinary Process: Chapter 213 Disciplinary Options The BON may issue a Board Order taking any of the following actions against the RN/APRN license: • Warning (can be deferred) • Reprimand • Restrict • Suspend • Revoke 103 BON Disciplinary Options SB 1415 (2009) & SB 1058 (2013) • “Corrective Action” – BON finds nurse committed a minor violation of the Nursing Practice Act or BON Rule. – A non-disciplinary, administrative action. – May count as a disciplinary action in future sanctions • Not reported to National Data Bank • Not disclosed to public 104 Corrective Action • Determined by BON Executive Director • First offense for: – Delinquent license less than 6 months – Noncompliance with CE – Inaccurate answers R/T criminal history, etc. – Fails to report new name or address to BON – Fails to assure credentials for personnel – Does not maintain peer review plan • Fine is $500 Rules 211.7 & 213.32 adopted on 11-6-09 105 BON Disciplinary Options • Deferred Disciplinary Action – Cases are eligible if a warning or lesser discipline proposed (not a license reprimand, suspension or revocation). – If nurse completes requirements, BON removes public record of the infraction after 5 years. – May count as a disciplinary action in future sanctions • Reported to National Data Bank but modified five years after completing. 106 More about the Coalition for Nurses in Advanced Practice (CNAP), Texas Nurses Association, & Texas Nurse PAC 107 CNAP Mission 1. Educate APRNs and stakeholders about the legal aspects of APRN practice; 2. Educate APRNs about advocating for their practices; and 3. Promote regulations that allow APRNs to reach their full potential to improve the health and well-being of all Texans. 108 CNAP APRN Group Members CTCNM Consortium of Texas Certified NurseMidwives Tx Tx Texas Texas ANNP CNS NAPNAP PAPNs Texas Clinical Nurse Specialists Greater Texas, Houston Area & South Texas Chapters of the National Association of Pediatric NPs Psychiatric Advanced Practice Nurses : Austin Houston San Antonio Texas Association of Neonatal Nurse Practitioners GCAPNA Gulf Coast Gerontological APN Association TNA is taking a lead role in coordinating the APRN legislative agenda through its Advanced Practice Nursing Advisory Committee, the Texas Team and the APRN Alliance. http://www.texasnurses.org/?page=TxTeam 110 Texas Nurse PAC 111 PAC – Political Action Committee 112 PACs contribute money to support political candidates Incorporated organizations may not make political contributions Texas Nurse PAC 113 Texas RN PAC became RN/APRN PAC in 1995 Administered by TNA, CNAP and TANA Became the Texas Nurse PAC in 2015 Contributes to candidates for state office When I give $$ to the Texas RN/APRN PAC, am I giving to a professional group that hires lobbyists? NO PACs must be separate from prof. organizations, e.g., TNA, TNP & CNAP 114 Do Your Fair Share Contribute $30 /mo. for professional organizations $15 /month to Texas Nurse PAC ( Total = 1 hour of your salary / month) Visit your legislators 7 times Spread the word and recruit 4 colleagues to do the same 115 Thanks for Joining CNAP Questions? Contact Lynda Woolbert lynda.woolbert@gmail.com (979) 345-5974 (512) 750-3747 116