Recently Adopted Rules Impacting APRNs,
What are rules and regulations and why do they matter to you as a nurse practitioner? Every biennium, the Texas legislature considers and passes bills that amend or add to Texas law. Once a bill passes, though, this is not the end of the process. Following the passage of legislation, regulatory agencies such as the Texas Board of Nursing or the Texas Medical Board must promulgate rules to fill in the details of the law so it can be implemented and enforced. As a nurse practitioner, you are required to not only know the Nursing Practice Act and laws that pertain to your scope of practice, but you are also responsible for knowing and understanding the rules that govern your profession.
Below is a list of recently adopted rules impacting APRNs over the last year. Questions about these rules and what they mean for you? Email firstname.lastname@example.org.
Board of Nursing, 222.5 Prescriptive Authority Agreement. (ADOPTED 10/11/19) – The Board has adopted a rule that simplifies requirements related to Prescriptive Authority Agreements by eliminating face-to-face meeting, per H.B. 278 (86th Legislature).
Rubber Stamp Signatures
Board of Pharmacy, 291.34. Records (PROPOSED 10/5/18) – The amendments clarify that a rubber stamp may not be used as the signature of a practitioner on written prescription drug orders. The amendments also allow the utilization of, and specify recordkeeping requirements for, prescription drug orders dispensed for patients institutionalized in licensed health care institutions. Finally the amendments allow a pharmacist to dispense a quantity less than indicated on the original prescription at the request of the patient or patient’s agent.
Prescription Monitoring Program (PMP)
Board of Nursing, 222.8. Authority to Order and Prescribe Controlled Substances (ADOPTED 11/9/18) – This rule, along with the next three, were amended by the BON to implement Prescription Monitoring Program rules, as required by legislation from the 85th Session. The rules state that an APRN must check the PMP, and document that check, prior to prescribing opioids, benzodiazepines, barbiturates, or carisoprodol, unless the patient is receiving hospice care or is diagnosed with cancer. An APRN is not subject to discipline if the APRN makes a good faith attempt to review the PMP but is unable to, and documents that attempt. The APRN Alliance submitted comments, arguing that the BON should not discipline for failing to document, that they should clarify the meaning of a “prescription record,” as used in the amendment, and that they should include an effective date, which by law is September 1, 2019. In its adoption, the BON provided clarifications on the second point and accepted the third.
Board of Nursing, 222.10. Enforcement (ADOPTED 11/9/18) – This amendment restates the requirements from the rule above, requiring APRNs to check the PMP and document that check unless the APRN is unable to do so.
Board of Nursing, 228.2. Prescription Monitoring Program (PMP) (ADOPTED 11/16/18) – Like the rules above, this new rule requires APRNs to access the PMP prior to prescribing or dispensing opioids, benzodiazepines, barbiturates, or carisoprodol; and further authorizes, but does not require, practitioners to access the PMP prior to prescribing or dispensing any controlled substance.
Board of Pharmacy, 315.15. Access Requirements (ADOPTED 6/14/19) – Requires practitioners and pharmacists to consult the PMP to review a patient’s controlled substance history before prescribing or dispensing an opioid, benzodiazepine, barbiturate, or carisoprodol. The practitioner is not required to check if the patient has a diagnosis of cancer or is in hospice care or the practitioner is unable to access the PMP.
Medical Board, 195.3. Inspections (ADOPTED 2/9/18) – This amendment clarifies that the TMB may inspect clinics not registered as pain management clinics to ensure that they are not required to register. It also sets forth criteria establishing grounds for an inspection. Finally, it states that TMB may enforce compliance with a subpoena.
Medical Board, 170.6. Opioid Antagonist Prescription Guidelines (ADOPTED 6/29/18) – This amendment describes the individuals to whom opioid antagonists may be prescribed and provides guidelines for identifying individuals at risk of overdose.
Medical Board, 170.8. Documentation (ADOPTED 6/29/18) – Adopted in conjunction with the rule above, this rule states that physicians prescribing opioid antagonists shall document the prescription in the medical record of the person at risk of an opioid overdose.
Board of Pharmacy, 291.29. Professional Responsibility of Pharmacists (ADOPTED 9/7/18) – This rule now provides a list of “red flag factors” that pharmacists should consider when filling a opioid prescription. If a red flag factor is encountered, the pharmacist must document the rationale for dispensing to demonstrate reasonable professional responsibility. The APRN Alliance, in coordination with the Board of Nursing, requested that the rule except pain management clinics that are excluded from TMB regulation because they are owned by APRNs. The Board of Pharmacy modified its rule accordingly.
Board of Nursing, 217.24. Telemedicine Medical Service Prescriptions (ADOPTED 11/16/18) – States that a prescription issued via telemedicine is held to the same standards as those in an in-person setting. Prohibits treatment of chronic pain through telemedicine.
Medical Board, Ch. 174. Telemedicine & Mental Health Services (ADOPTED 11/17/17) – As a result of SB 1107 (85th), the TMB adjusted its telemedicine rules. The most substantial change is that an in-person meeting is no longer required to create a practitioner-patient relationship. However, the amendments also provide new definitions, requires certain notices to patients, limits the treatment of chronic pain through telemedicine medical services, and provides requirements for mental health services provided through telemedicine.
Department of State Health Services, 133.41. Hospital Functions and Services (ADOPTED 9/14/18) – During the 85th Legislative Session, the legislature passed a bill setting standards for in-hospital Do Not Resuscitate (DNR) orders, which mimics existing law for out-of-hospital DNRs. This rule amendment provides that a facility must include procedures and patient rights in their bylaws, require that DNR orders be placed into the patient’s medical record, and ensure that nursing plans of care indicate whether a physician has issued a DNR order.
Medicaid Outpatient Pharmacy Services
Health and Human Services Commission, 354.1863. Prescription Requirements (ADOPTED 12/29/17) – Pursuant to a change in federal rules, this rule now requires the prescriber of a pharmaceutical to be enrolled in Medicaid in order for the pharmacy to be reimbursed by Medicaid.
Medically Underserved Practices
Department of State Health Services, 13.31-13.35. Practice-MUP Designations (ADOPTED 8/10/18) – Prior to amendment, this rule language was based on very old APRN law, stating that designated sites would be eligible for Nurse Practitioners to “carry out” prescription drug orders. The APRN Alliance commented that the language should be updated to reflect current prescriptive authority laws. DSHS agreed, and ultimately updated the rules to better conform to current statutory language, reduce unnecessary application requirements for practices seeking designation, and increase clarity and organization.
Workers’ Compensation Work Status Reports
Department of Insurance, 129.5. Workers’ Compensation Work Status Reports (ADOPTED 10/26) – This amendment implemented HB 2546 (85th), which allows physician assistants with authority delegated from a physician to complete and sign work status reports.
Board of Nursing, 217.23. Balance Billing Dispute Resolution (ADOPTED 8/3/18) – This rule, based on a bill passed in the 85th Session, sets forth specific responsibilities of licensees related to billing mediation. It also explains the circumstances under which an insurance enrollee may request mediation for out-of-network claims. Finally, it explains the process of mediation and the factors that shall be evaluated. The APRN Alliance commented that the rule language should include the applicability limitations set out in law, state that licensees are not subject to discipline for failure to include details of the mediation process in a bill, and indicate that licensees may send a representative to mediation. The BON agreed and modified its language on the first and third points, and clarified its intent to not discipline on the second point in its adoption preamble.
Board of Nursing, 217.14. Registered Nurses Performing Radiologic Procedures (ADOPTED 8/3/18) – The BON amended this rule to make clarifying changes. However, the amendment did include one new requirement. Each registered nurse who completes a training course in radiological procedures must now maintain a record demonstrating completion and must make that documentation available to the Board upon audit.
Board of Nursing, 216.3. Continuing Competency Requirements (ADOPTED 11/30/18) – Most of the amendments to this rule were non-substantive, but the BON did remove the prescriptive requirements for the Older Adult or Geriatric Care course by making the existing requirements permissive, rather than mandatory.
Board of Nursing, 216.6. Activities that are not Acceptable as Continuing Education (ADOPTED 11/30/18) – This amendment broadens the types of courses that are acceptable for CNE. The preamble to the rule proposal states that courses focusing on compassion fatigue, moral distress, fatigue, resilience, workplace violence, and nursing satisfaction have an impact on nursing practice, patient safety, and patient outcomes, and therefore are appropriate for CNE credit.
Board of Nursing, 219.9. Program of Study (ADOPTED 12/7/18) – This amendment clarifies that an APRN program must include separate, graduate-level academic courses in advanced pharmacotherapeutics, advanced health assessment, and advanced physiology and pathophysiology.
Board of Nursing, 221.2. APRN Titles and Abbreviations (ADOPTED 02/22/19) – The BON modified its rules to align them with the APRN Consensus Model. According to the new rules, a Texas licensed APRN shall, at a minimum, use the designation "APRN" and the APRN licensure title, which consists of the current role and population focus area granted by the Board (example: APRN, FNP-BC). It will no longer be sufficient to only use the “RN” credential in combination with your role and population focus area (example: RN, FNP-BC). The amendment also clarifies that unlicensed persons may not imply that they are APRNs.
Board of Nursing, 221.3. APRN Education Requirements for Licensure (ADOPTED 02/22/19) – This rule applies to APRN programs that do not hold national accreditation. The amendment clarifies that: clinical courses must offer supervised clinical experience in a specific population focus area; preceptorships must give students the opportunity to integrate theory in both the role and population focus; programs of study must include a formal internship; and curriculums must include diagnosis and management of diseases and conditions across practice settings.
Board of Nursing, 221.4. Licensure as an APRN (ADOPTED 02/22/19) – The amendment to this rule creates a declaratory order process for APRNs who have reason to believe that they may be ineligible for licensure. It also provides clarifying language for licensure by endorsement.
Board of Nursing, 221.5. Acceptable Certification Examinations (ADOPTED 02/22/19) – This new rule codifies the BON’s current guidelines for approving national certification examinations.
Board of Nursing, 221.7. Petitions for Waiver and Exemptions (ADOPTED 02/22/19) – This amendment creates a six-month temporary license for APRNs endorsing into Texas, who are in the process of completing the advanced health assessment, advanced physiology and pathophysiology, or advanced therapeutics courses.
Board of Nursing, 221.8 APRN Licensure Renewal; 221.9. Inactive Status (ADOPTED 02/22/19) – These amendments include non-substantive, clarifying changes.
Board of Nursing, 221.10. Reactivation or Reinstatement of APRN Licensure (ADOPTED 02/22/19) – This amendment adds requirements for preceptors providing a supervised clinical component of a refresher course and specifies guidelines for those courses. It also enables APRNs who have not practiced within the past 24 calendar months to obtain a 6-month permit to complete the required 400 practice hours.
Texas Board of Nursing, 217.12 Unprofessional Conduct. (ADOPTED 10/11/19) – The Board has adopted the proposal that removed that ability for the Board to discipline persons based on a default or breach of a student loan repayment contract. This rule was required by Senate Bill 37, (86th Legislature).
Board of Nursing, 213.34. Deferred Discipline (ADOPTED 7/7/17) – After examining studies on recidivism and deferment, the BON found that making a board order confidential after three years is more appropriate than five. The BON therefore modified this rule accordingly.
Board of Nursing, 213.27. Good Professional Character (ADOPTED 2/16/18) – During the 85th Legislative Session, the Sunset Commission modified BON disciplinary statutes to ensure that disciplinary actions are based on behaviors that directly relate to the practice of nursing. The amendments to this rule reflect that legislative intent.
Board of Nursing, 213.28. Licensure of Individuals with Criminal History (ADOPTED 2/16/18) – Again as a result of the Sunset Commission recommendations, the BON went through several stakeholder meetings to ensure that their rules only allow discipline for crimes that directly relate to the practice of nursing.
Board of Nursing, 217.12. Unprofessional Conduct (ADOPTED 2/23/2018) – This rule was also amended in response to the Sunset Commission’s instructions to take disciplinary action only on conduct that directly relates to the practice of nursing. The BON removed subjective requirements and tenuous language. It also removed a reference to criminal conduct, which was superfluous in light of the criminal history rule.
Board of Nursing, 217.16 Minor Incidents (ADOPTED 5/18/2018) – The BON conducted a survey of stakeholders about the old minor incident rule, at which point they determined that the language was confusing or potentially misleading. The new rule provides clarity and avoids duplication of other rules.
Board of Nursing, 213.23. Decision of the Board (ADOPTED 2/23/18) – This rule was amended to reflect the Sunset Commission’s amendments to the Nursing Practice Act. The Board is now prohibited from modifying findings of fact or conclusions of law in a Proposal For Decision.