“... y as:
(A) a hospital that is licensed pursuant to Chapter 241, Health and Safety Code or the Texas Mental Health Code (Articles 5547-100, Vernon's Texas Civil Statutes);
(B) an entity, including a health maintenance organization, group medical practice, nursing home, health science center, universit ... ”
“... he Texas Controlled Substances Registration under Chapter 481.061 of the Health and Safety Code.
Physicians and PAs will continue to be required to hold registration from the U.S. Drug Enforcement Administration in order to prescribe controlled substances and to register prescriptive delegatio ... ”
“... empt from registration. Those are listed in Chapter 168 of the Texas Occupations Code. Exemptions must be supported with documentation to prove qualification for the exemption. If you are claiming a clinic location is exempt, please request an exemption worksheet from Registrations@ ... ”
“... can Academy of Medical Acupuncture and the Austin Chapter of the Texas Pain Society. Additionally, he is a member of the American Society of Addiction Medicine, the American Society of Interventional Pain Physicians, and the American Association of Naturopathic Physicians. Ximenes received ... ”
“... n violation the Texas Occupations Code (Chapter 205) and/or the Board's rules; and exercising the authority to cancel, revoke, restrict, suspend or otherwise limit the license of any acupuncturist upon proof of violation.
Mission
The Texas State Board of Acupuncture Examiners’ m ... ”
“... to the requirements of the Texas Government Code, Chapter 2114, “Customer Service” (Compact with Texans). The Compact provides information for the public, consumers, and customers on the agency’s mission, programs, principles and standards of customer service, and helpful con ... ”
“... COLLEGE, FUZHOU, CHINA
1077
HAI PHONG CITY CHAPTER OF EAST MED RES ASSN
1078
CLINICA PANAMERICANA, CD JUAREZ, MEXICO
1079
COLLEGE OF TRAD AC, LEAMINGTON, SPA, ENGLAND
1080
HAI DIAN HEALTH TRAINING SCH, BEIJING, CHINA
1081
HYUN DAI ACUP RESEARCH SOCIETY, SEOUL, KOREA
... ”
“... ated as part of the licensure application.
Chapter 168 of the Board’s rules addresses criminal history evaluation letters. These rules can be viewed in the Board Rules section of our web site.
You must download and complete the application below, and submit it to the Board a ... ”
“... althcare facilities. (*Statutory Citations: Chapter 324, Texas Health and Safety Code; Chapter 154, Texas Occupations Code).
http://www.dshs.state.tx.us/thcic/consumerguide/consumerguide.shtm
Consumer Guide to Health Care Billing
A guide created by the Texas Department of Insur ... ”
“... state.tx.us/, under Laws, Rules & Guidelines, Chapter 183.20. Here are highlights of some of the requirements:
Providers must obtain approval of different course submissions on an annual basis for three consecutive years
Providers must have no history of complaints or reprimands.
Provider ... ”
“... ode Highlights:
Physicians
Medical Practice Act
Chapter 151 -
General Provisions: HTML | PDF | Word
Chapter 152 -
Organization of Board: HTML | PDF | Word
Chapter 153 -
General Powers and Duties of Board: HTML | PDF | Word
Cha ... ”
“... s concerning nonprofit certification are found in Chapter 177 of the Board Rules.
List of 162.001(b) Non-Profit Health Organizations
List of 162.001(c) Non-Profit Charitable Health Centers
The first and most prevalent type is referred to in chapter 162.001(b) of the Texas Occupations C ... ”
“... s concerning nonprofit certification are found in Chapter 177 of the Board Rules.
List of 162.001(b) Non-Profit Health Organizations
List of 162.001(c) Non-Profit Charitable Health Centers
The first and most prevalent type is referred to in chapter 162.001(b) of the Texas Occupations C ... ”
“... currently serves as vice president of the Austin chapter of the Construction Specification Institute. In addition, he is an allied member of the American Institute of Architects. McElhany received a Bachelor of Science in Telecommunication Media Studies from Texas A&M University.
Gregory Ro ... ”
“... n violation the Texas Occupations Code (Chapter 204, the Physician Assistant Licensing Act) and/or the Board's rules; and exercising the authority to cancel, revoke, restrict, suspend or otherwise limit the license of any physician assistant upon proof of violation.
Mission
The Texas ... ”
Description: TMB Bulletin Fall 2000
Document: ... f Acupuncture Examiners. Acupuncture Rule Changes Chapter 183, Acupuncture: rule review and amendments to 183.1-183.5, repeal of 183.6-183.23 and new 183.6-183.21. For copies of rule changes, write the Board at MC 901, P.O. Box 2018, Austin, TX 78768-2018; e-mail pat.wood@tmb.state.tx.us or on the w ...
Description: TMB Bulletin Fall 2006
Document: ... te.tx.us/rules/rules/bdrules_toc.php and included Chapter 163, Licensure; Chapter 166, Physician Registration; Chapter 171, Postgraduate Training Permits; and Chapter 172, Temporary Licenses. Enforcement Stakeholder Group Another stakeholder group was formed to address rulemaking for enforcement and ...
Description: TMB Bulletin Fall 2002
Document: ... hanges that were published in the Texas Register: Chapter 161, General Provisions: Amendments to §161.6 regarding the committees of the board. The amendments relate to the status and duties of the Non-Profit Health Organizations Committee and the Licensure Committee. Chapter 163, Licensure: Amendmen ...
Description: TMB Bulletin Fall 2001
Document: ... hanges that were published in the Texas Register: Chapter 161, General Provisions: relating to return to active status following retired status, updates to Occupations Code cites, and compliance with Americans with Disabilities Act requirement s. Chapter 163, Licensure, relating to relicensure requi ...
Description: TMB Bulletin Fall 2004
Document: ... hanges that were published in the Texas Register: Chapter 163, Licensure: Rule review and amendments to §§163.1-163.7, 163.11 and 163.12 concerning eligibility for licensure and general cleanup of the rules. Amendments to §§163.1-163.3, 163.5, 163.6 and repeal of §§163.8 and 163.9 concerning Definit ...
Description: TMB Bulletin Fall 2009
Document: ... ical Practice Act, Texas Occupa
-
tions Code, and Chapter 193 of the Board rules,
physicians may delegate prescriptive authority to
PAs and APNs. This authority includes prescrib
-
ing dangerous drugs and Schedules III, IV and V
controlled substances.
As the delegating physician you remain respo ...
Description: TMB Bulletin Fall 2007
Document: ... www.tmb.state.tx.us/rules/rules/bdrules_toc.php . Chapter 161, General Provisions, amending to 161.3, Organization and Structure, regarding standards of conduct for Board members, including prohibiting expert testimony by board members in cases in which a licensee is a party and in which the expert ...
Description: TMB Bulletin Fall 2010
Document: ... ir final form in the
Texas Regis-
in September:
Chapter 161. General Provisions:
Provides that adoption of committee
minutes are to be approved by the full board rather than by
the individual committees.
Chapter 163. Licensure:
§163.6 Examinations Accepted
for Licensure.
Amendment clarifies ...
Description: TMB Bulletin Fall 2008
Document: ... mittee, chairman of the Ad Hoc Committee to Study Chapter 192 and as a member of the Executive Committee, the Disciplinary Process Review Committee and the Ad Hoc Committee for Scope of Practice. At the October board meeting, board members thanked Dr. Anderson for his service and presented him with ...
Description: TMB Bulletin Fall 1997
Document: ... pective legal counsel. Medical Board Rule Changes Chapter 163: Licensure Implementation of statutory changes relating to licensure for the Fifth Pathway. Section 163.14 relating to the temporary licensure of primary care physicians for practice in rural counties or medically underserved areas in Tex ...
Description: TMB Bulletin Fall 1998
Document: ... nate Bill Distribution Sam Houston Building, Room 190 201 E. 14th St. Austin, TX 78701 (512) 463-0252 Texas State Board of Physician Assistant Examiners Governor George W. Bush has appointed three new members to the Texas
State Board of Physician Assistant Examiners for terms running until Februar ...
Description: TMB Bulletin Fall 1999
Document: ... nate Bill Distribution Sam Houston Building, Room 190 201 E. 14th St. Austin, TX 78701 (512) 463-0252 Texas State Board of Physician Assistant Examiners Governor George W. Bush has appointed three new members to the Texas
State Board of Physician Assistant Examiners for terms running until Februar ...
Description: TMB Bulletin Fall 2005
Document: ... ical Acupuncture; and Vice President of the Texas Chapter of the AAMA. Dr. Counts also serves as a Clinical Assistant Professor of Family Practice for UTMB Galveston in Austin. He received his formal training in acupuncture from UCLA in 1991. Dr. Counts has been a family practitioner in Austin since ...
Description: TMB Bulletin June-July 2003
Document: ... er, 2002, through the June, 2003, board meetings: Chapter 163, Licensure. Amendments to §§163.1, 163.3-.5, and 163.10 regarding definitions, examinations accepted by the board, and relicensure requirements. Amendment to §163.3 regarding cleanup of language concerning the definition of "graduate of a ...
Description: TMB Bulletin March 2013
Document: ... ave staff review impairment issues as part of the Chapter 161. GENERAL PROVISIONS: The amend- applica on process. ment to §161.3 establishes that board members may not appear at disciplinary or licensure hear- The amendment to §171.6 changes a single referings on behalf of licensure applicants or li ...
“... quirements is available under Board Rules Section Chapter 183, Section 183.4 Procedural Rules for Licensure Applicants. The following is paraphrased from that rule. We encourage you to read the entire rule. Submit an application online for licensure and pay the $305 applicat ... ”
What are the basic requirements to be licensed as an acupuncturist in Texas?
Information on licensure requirements is available under Board Rules Section Chapter 183, Section 183.4 Procedural Rules for Licensure Applicants. The following is paraphrased from that rule. We encourage you to read the entire rule.
“The authority to delegate is found in Chapter 157 of the Texas Occupations Code, and Title 22 of the Texas Administrative Code, Section 193. A physician is allowed to delegate certain duties to a qualified and properly trained person acting under the physician’s supervision:1) if in the opinio ... ”
What are the general rules related to AAs/CRNAs?
The authority to delegate is found in Chapter 157 of the Texas Occupations Code, and Title 22 of the Texas Administrative Code, Section 193. A physician is allowed to delegate certain duties to a qualified and properly trained person acting under the physician’s supervision:
1) if in the opinion of the delegating physician the act can be properly and safely performed by the person to whom the medical act is delegated;
2) the act is performed in its customary manner; and
3) the performance of the act by the delegate is not in violation of any other statute.
It is clear that AAs can be delegated certain tasks under Chapter 157. The question is the extent allowable of such delegation. The key provision that needs to be examined is likely “not in violation of any other statute.”
Although the Nursing Act describes what a CRNA can do in regard to anesthesia, there is overlap of regulation of CRNAs between the Medical Board and Nursing Board. CRNAs are subject to physician delegation under the Medical Practice Act. The delegating physician can limit what a CRNA is allowed to provide under a Prescriptive Authority Agreement (PAA) or Standing Order, despite what may be allowed under Nursing Board rules and regulations.
The level of supervision required for any AA (or any delegated provider) is determined based on training, knowledge, and experience, as determined by the physician. For CRNAs, whether any level of physician supervision is required will depend upon those same factors, in addition to applicable federal and state statutes, regulations, bylaws, and ethical standards, if any. However, AAs and CRNAs cannot practice independently and require physician delegation. A hospital or facility can set their own standards, policies, etc., related to delegation and supervision as long as it does not violate Chapter 157, board rules, or other applicable federal and state statutes and regulations. Although AAs most commonly work under an anesthesiologist physician, any physician may supervise and delegate to AAs; however, the standard of care must be met and the delegating physician remains responsible for the AA’s actions.
One difference between an AA and CRNA is the ability to order and prescribe dangerous and controlled substances to patients for anesthesia and anesthesia-related services. Under section 157.058, a CRNA pursuant to the physician’s order and in accordance with facility policies or bylaws may select, obtain, and administer those drugs appropriate to accomplish the order. The physician’s order for anesthesia or anesthesia-related services is not required to specify a drug, dose, or administration technique.
As previously stated, the Nursing Act describes what a CRNA can do in regard to anesthesia. However, the delegating physician or facility can limit what a CRNA is allowed to provide under a PAA or Standing Order, despite what may be allowed under Nursing Board rules and regulations.
While AAs are not allowed to select drugs, determine dose, or administration technique for anesthesia or anesthesia-related services without specification by the supervising physician through an order, they perform many of the other same key duties performed by CRNAs. These duties include conducting preoperative physical exams, administering medications, evaluating and responding to life-threatening situations, setting up external and internal monitors, and implementing general and site-specific anesthetic techniques.
Another area of concern relates to handing-off patient care from CRNAs to AAs. RNs have the authority to delegate certain nursing tasks to unlicensed individuals; however, a CRNA and AA do not have any specific delegation authority concerning anesthesia tasks. A physician has the authority to delegate the process of anesthesia-related patient care, including the transfer or hand-off of care from a CRNA to an AA through an order (standing or patient-specific) or protocol. A CRNA or AA cannot set-up or independently delegate a hand-off or step-down process.
While the Nursing Act places responsibility for patient hand-off on a CRNA, if the physician orders a hand-off process from CRNA to AA, and this is memorialized in orders, protocols, etc., then the CRNA does not have the authority to determine the AA is not competent. The reason is that the physician has already made the determination of competency under Chapter 157.001.
Because the CRNA’s authority also arises through the delegating physician, and is not independent of that physician, a CRNA cannot override a physician Order related to this hand-off scenario. If this hand-off became an issue, the CRNA would have a defense (absolute) because the physician has already determined the competency of the AA to accept this patient.
“... erification database. The Texas Occupations Code, Chapter 154.006 requires that information be made available through the physician profile system. In addition to the statutorily required information, the TMB has adopted rules (Chapter 173) regarding the contents of the physician profile system. Due ... ”
What information is available on a physician’s Profile?
Statutory regulations require the TMB to maintain a profile on each licensed physician. This profile information is gathered in conjunction with the license registration and is available to the public through our online verification database. The Texas Occupations Code, Chapter 154.006 requires that information be made available through the physician profile system. In addition to the statutorily required information, the TMB has adopted rules (Chapter 173) regarding the contents of the physician profile system. Due to concern expressed by licensees regarding identity theft and the public disclosure of exact dates of birth, the TMB no longer includes exact dates of birth in our data products, online verification databases or verbal verifications. We do however continue to include birth year.
“... health organization certified by the board under Chapter 177 of this title (relating to Certification of Non-Profit Health Organizations); a clinic owned or operated by a physician who treats patients within the physician's area of specialty who personally uses other forms of treatment, including s ... ”
Who does not need to register a pain management clinic?
Regulations regarding the registration and operation of pain management clinics do not apply to the following settings:
Note: The TMB cannot give legal advice. Please consult an attorney if you have questions regarding whether or not your clinic meets one of the exemptions listed above. However, the Board does have inspection authority, and owners of clinics that have not been properly registered can be investigated.
“... et.seq. and the Texas Controlled Substances Act, Chapter 481 of the Texas Health and Safety Code, relating to the prescribing and dispensing of controlled substances. The medical director of a pain management clinic must, on an annual basis, ensure that all personnel: • are properly licensed, ... ”
Who can own or operate a pain management clinic?
A pain management clinic may not operate in Texas unless the clinic is owned and operated by a medical director who: • is a physician who practices in Texas • has an unrestricted medical license • holds a certificate of registration for that pain management clinic In addition, the owner/operator of a pain management clinic, an employee of the clinic, or a person with whom a clinic contracts for services may not: • have been denied, by any jurisdiction, a license issued by the Drug Enforcement Agency or a state public safety agency under which the person may prescribe, dispense, administer, supply, or sell a controlled substance; • have held a license issued by the Drug Enforcement Agency or a state public safety agency in any jurisdiction, under which the person may prescribe, dispense, administer, supply, or sell a controlled substance, that has been restricted; or • have been subject to disciplinary action by any licensing entity for conduct that was a result of inappropriately prescribing, dispensing, administering, supplying, or selling a controlled substance A pain management clinic may not be owned wholly or partly by a person who has been convicted of, pled nolo contendere to, or received deferred adjudication for: • an offense that constitutes a felony; or • an offense that constitutes a misdemeanor, the facts of which relate to the distribution of illegal prescription drugs or a controlled substance as defined by Texas Occupations Code Annotated §551.003(11) The medical director of a pain management clinic must operate the clinic in compliance with Drug Prevention and Control Act, 21 U.S.C.A. 801 et.seq. and the Texas Controlled Substances Act, Chapter 481 of the Texas Health and Safety Code, relating to the prescribing and dispensing of controlled substances. The medical director of a pain management clinic must, on an annual basis, ensure that all personnel: • are properly licensed, if applicable, • are trained including 10 hours of continuing medical education related to pain management, and • are qualified for employment.
“... ules I through V or Penalty Groups 1 through 4 of Chapter 481, Health and Safety Code (Texas Controlled Substances Act). The term includes a device or drug that bears, or is required to bear, the legend: “Caution: federal law prohibits dispensing without prescription” or “Rx only&r ... ”
What is a dangerous drug? Are these legend drugs?
Texas is one of just a few states that use the term “dangerous drugs.” The Dangerous Drug Act defines a dangerous drug as a device or drug that is unsafe for self-medication and that is not included in Schedules I through V or Penalty Groups 1 through 4 of Chapter 481, Health and Safety Code (Texas Controlled Substances Act). The term includes a device or drug that bears, or is required to bear, the legend: “Caution: federal law prohibits dispensing without prescription” or “Rx only” or another legend that complies with federal law. Many other states use the term “legend drugs.”
“... physician who issues a standing delegation under chapter 203 generally “is not liable in connection with an act performed under that standing delegation order”). Thus, we cannot conclude that the liability of a physician delegating the administration of anesthesia to a CRNA is limited s ... ”
Are physicians potentially subject to discipline for violations of the standard of care by CRNAs to whom they have delegated the selection or administration of anesthesia or the care of an anesthetized patient?
Yes, potentially. Although physicians are not required to supervise CRNA’s for delegated tasks, they nonetheless remain subject to potential liability for violations of the standard of care by CRNAs, depending on federal and state statutes and regulations. The degree to which a physician is required to supervise a CRNA during the performance of a task in anesthesia services is left to the “physician’s professional judgment in light of other relevant federal and state laws, facility policies, medical staff bylaws, and ethical standards.” (Texas Attorney General Opinion No. JC-0117). However, physician supervision during the medical management of a patient while undergoing an anesthetic may require supervision dependent on federal and state statutes and regulations.
Additionally, Texas Attorney General Opinion No. KP-0353 found “In authorizing physicians to delegate the administration of anesthesia to CRNAs, the Legislature did not expressly limit the liability of the delegating physician. See TEX. OCC. CODE § 157.058; cf. id. § 157.004(c) (providing that in specified circumstances a physician who issues a standing delegation under chapter 203 generally “is not liable in connection with an act performed under that standing delegation order”). Thus, we cannot conclude that the liability of a physician delegating the administration of anesthesia to a CRNA is limited solely to the determination of competency. Questions of physician liability in any specific context are highly factual and not an appropriate determination for the opinion process. See Tex. Att’y Gen. Op. No. GA-0446 (2006) at 18 (“Questions of fact are not appropriate to the opinion process.”) (Page 4 with emphasis added.)
“... KP-0353 also found “…the language of chapter 157 is not the only relevant authority to consider in addressing the question of physician supervision over acts delegated to a CRNA. Federal regulations limiting Medicare coverage and conditioning hospital participation in Medicare and ... ”
When is Physician supervision of a CRNA required?
Regardless of the circumstances when supervision is or is not required, it is important to remember that the delegating physician must abide by all required federal and state statutes and regulations regarding delegation. The physician retains responsibility of the medical management of the patient. Therefore, the delegating physician must consider the delegatee’s education, training, and experience prior to delegating. Additionally, delegation may be revoked by the delegating physician at any time.
The Texas Attorney General has issued three opinions on CRNA supervision. The latest opinion found that although physician supervision of a CRNA is not required in Texas Occupations Code Sec. 157.058, other federal and state statutes and regulations may require physician supervision of a CRNA, a CRNA may not administer an anesthetic that is a controlled substance outside the presence of a physician, and the Legislature did not expressly limit the liability of the delegating physician.
Specifically, Texas Attorney General Opinion KP-0353 found “Section 157.058 of the Occupations Code does not, by itself, require a physician who properly delegates anesthesia-related tasks to a certified registered nurse anesthetist (“CRNA”) to supervise the performance of those acts.” (Page 5)
However, KP-0353 also found “…the language of chapter 157 is not the only relevant authority to consider in addressing the question of physician supervision over acts delegated to a CRNA. Federal regulations limiting Medicare coverage and conditioning hospital participation in Medicare and Medicaid programs require physician supervision of a CRNA when administering anesthesia in certain circumstances. See, e.g., 42 C.F.R. §§ 416.42(b)(2), 482.52(a)(4), 485.639(c)(1)(v), (2) (requiring a CRNA to operate under a physician’s supervision when administering anesthesia in certain circumstances). Furthermore, a CRNA may not administer an anesthetic that is a controlled substance outside the presence of a physician. See TEX. HEALTH & SAFETY CODE §§ 481.002(1)(A) (defining “administer” to require agent to apply controlled substance in presence of physician), .071(a) (prohibiting physician from causing controlled substance to be administered under physician’s “direction and supervision” except for valid medical purpose and in course of medical practice). And a CRNA may not obtain an anesthetic that is a dangerous drug unless a physician has listed that CRNA as the physician’s designated agent. See id. §§ 483.001(4) (defining “designated agent”), .022(a) (requiring physician to name each designated agent in writing). (Page 3 with emphasis added.)
Finally, KP-0353 found “Whether and the extent to which physician supervision is required for an act delegated to a CRNA will depend on the specific act delegated, the type of facility in which the CRNA performs the act, and any relevant regulations of that facility. And while section 157.058 authorizes a physician to delegate to a CRNA, a physician is never required to do so. If a physician is concerned about a CRNA’s ability to perform a delegated act or desires to limit the delegation, the physician retains the authority to refrain from delegating, to limit the delegation, or to supervise the delegation to whatever extent the physician determines necessary. In sum, the authority to delegate provided by section 157.058 of the Occupations Code does not eliminate the need to comply with all other applicable statutes, regulations, bylaws, ethical standards, and a physician’s own professional judgment. See TEX. OCC. CODE § 157.007 (“An act delegated by a physician under [chapter 157] must comply with other applicable laws.”). (Page 4 with emphasis added.)
“... urse approved by the board. In all settings under Chapter 192, at a minimum, at least two persons, including the surgeon or anesthesiologist, shall maintain current competency in basic life support. ”
What are the standards for anesthesia services relating to OBA?
Physicians and anesthesiologists shall maintain current competency in ACLS, PALS, or a course approved by the board. In all settings under Chapter 192, at a minimum, at least two persons, including the surgeon or anesthesiologist, shall maintain current competency in basic life support.
“... ces, must still meet all other requirements under Chapter 192. ”
Who does not need to register for office-based anesthesia?
OBA registration does not apply to physicians who practice in the following settings:
Note: physicians that provide only level I services, must still meet all other requirements under Chapter 192.