“... Texas Administrative Code, Title 22, Part 9, Chapter 194, Subchapter A, Rule 194.7(c), adopted to be effective September 16, 2018, located here.
Non-certified radiologic technicians (NCT) need to complete a minimum of 12 hours of continuing education (CE) every 2 ... ”
“... the Texas Administrative Code, Title 22, Part 9, Chapter 160, Rule 160.16, located here.
Medical physicists need to complete at least 24 credits of continuing education (CE) every 24 months (24 month timeline goes by the biennial registration period, not the calendar year). A permit holder m ... ”
“... the Texas Administrative Code, Title 22, Part 9, Chapter 188, Rule 188.24, located here.
A permit holder must report during registration if she or he has completed the required CE during the previous two years (biennial registration period).
New Human Trafficking Preventio ... ”
“... Texas Administrative Code, Title 22, Part 9, Chapter 186, Rule 186.10, located here.
Respiratory care practitioners need to complete at least 24 credits/hours of continuing education (CE) every 24 months (24 month timeline goes by the biennial registration period, not the calendar year). ... ”
“... acilities. (*Statutory Citations: Chapter 324, Texas Health and Safety Code; Chapter 154, Texas Occupations Code).
http://www.dshs.state.tx.us/thcic/consumerguide/consumerguide.shtm
”
“... on as required by the Licensed Perfusionists Act, Chapter 603, Occupations Code.
Perfusionist Licensure Advisory Committee Member Listing & Terms
What is a perfusionist?
A Perfusionist is an individual who operates extracorporeal (outside the body) circulation and autotransfusion equipm ... ”
“... edical Radiologic Technologist Certification Act, Chapter 601, Occupations Code.
Medical Radiologic Technology Board Member Biographies
Medical Radiologic Technology Board Committees
Medical Radiologic Technology Board Member Listing & Terms Adobe® Portable Document Format (PDF) ... ”
“... g the practice of respiratory care as required by Chapter 604, Occupations Code.
Respiratory Care Board Member Biographies
Respiratory Care Board Committees
Respiratory Care Board Member Listing & Terms Adobe® Portable Document Format (PDF) File
What is a respiratory care pract ... ”
“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. More information is ... ”
“... guilt of a felony under:
(A) Chapter 481 or 483, Health and Safety Code (relating to offenses involving controlled substances and dangerous drugs);
(B) Section 485.033, Health and Safety Code (relating to offenses involving inhalant paraphernalia); or
... ”
“... the Texas Administrative Code, Title 22, Part 9, Chapter 194, Subchapter A, Rule 194.7(c), adopted to be effective November, 2019, located here.
Radiologist assistants need to complete a minimum 24 hours of continuing education (CE) every 24 months (24 month timeline goes by the biennia ... ”
Description: Acupuncture 2013 - October - Full Board Meeting Minutes
Document: ... hange, including proposed amendments to 22 T.A.C. Chapter 183.
M
r
. Freshour presented a summary
of the petition for a rule change
. After discussion
,
Ms.
Siegel
moved,
Mr.
Graham seconded, and the motion passed to forward proposed amendments to
22 T.A.C. Chapter 183 to the Medical B ...
Description: Acupuncture 2011 - May - Full Board Meeting Minutes
Document: ... adoption of proposed rule chan
g
es to 22 T.A.C. Chapter 183.
§183.
20
Continuing Acupuncture Education
§183.
24
Procedure
Ms.
Kaufman gave a brief summary. Oral com
ments we
re received from Ms. Lisa Lin.
Written commen
ts were received and reviewed.
After discussion,
Dr. Rasc ...
Description: PA Board 2013 November - Full Board Minutes
Document: ... uding adoption of proposed amendment to 22 T.A.C. Chapter 185,
Physician
Assistants.
§185.29 Report of Impairment on Registration Form
Ms. Tuthill gave a brief
summary of proposed amendments to Chapter 185. No written comments were received.
After discussion,
Mr. Rush moved, Dr. Baptiste ...
Description: PA Board 2014 March - Licensure Committee Minutes
Document: ... strative Code, Title
22, Part 9
Proposed Changes
Chapter 1
85
Proposed to Board
Physician Assistants
Page
1
of
1
(c) In order to be determined eligible for a temporary license, app
licant must:
(1) be supervised by a physician who:
(A)
is currently licensed as a physician in this s ...
Description: TMB Bulletin March 2014
Document: ... requirements that apply.
Under Board Rules,
Chapter 190.8(1)(m)
-
Violaon Guidelines
, the
rule states:
(M) inappropriate prescripon of dangerous drugs or con-
trolled substances to oneself, family members, or others in
which there is a close personal rela ...
Description: ... ed with the Texas Medical Board as required under Chapter 194 of the board rules. The physician must also be registered with the board to supervise the non-certified technician.
Document:
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",, \r \n \n
...
Description: Medical Board 2014 - May - Licensure Committee Minutes
Document: ...
2
REINSTATEMENT
0
0
0
0
TOTAL:
190
22
0
212
PUBLIC HEALTH
REGULAR
0
0
0
0
RELICENSURE
0
0
0
0
REINSTATEMENT
0
0
0
0
TOTAL:
0
0
0
0
TELEMEDICINE
REGULAR
1
0
0
1
RELICENSURE
0
0
0
0
RE ...
Description: Medical Board Telemedicine Committee Agenda (June 2016)
Document: ... le 22 of the Texas Administrative Code:
ï‚·
Chapter 174 Telemedicine
§174.11 On
-
Call Services
ï‚·
Chapter 177
Business Organizations
,
New Subchapter E, Physician Call Coverage Medical Services
§§177.18
-
177.20
3.
Presentation
.
4.
Adjourn
.
...
Description: Medical Board 2014 - May - Disciplinary Process Review Committe Minutes
Document: ... tle 22 of the Texas Administrative Code:
A.
Chapter 184
,
Surgical Assistants, §184.16
.
Discipline of Surgical Assistants
B.
Chapte
r 187, Procedural Rules, §187.26
.
Service in SOAH Proceeding
s, §187.28.
Discovery, §187.29. Mediated Settlement Conferences
C.
Chapter 190
, ...
Description: Medical Board 2014 - February - Full Board Minutes
Document: ...
petition for proposed rule changes to 22 T.A.C. Chapter 183, Acupuncture.
Was deferred to
the next board meeting
.
(See reconsideration below)
Consent
Agenda
Discussion/Action Items
–
to be considered at any time the full board is in session:
1.
Consideration and approval of t ...
Description: TMB disciplines 61 physicians at May meeting, adopts rule changes
Document: ... in
FY14 to
2,396
.
RULE CHANGES ADOPTED
CHAPTER 175. FEES AND PENALTIES
§175.1
,
Application and Administrative Fees
The amendments to 175.1, relating to
Application and Administrative Fees
, i
ncreases application fees in accordance with
the 2014
-
2015 General Appropriations Ac ...
Description: Rule Changes Effective July 19, 2018
Document: ... _view=3&ti=22&pt=9
RULE CHANGES ADOPTED
CHAPTER
185. PHYSICIAN ASSISTANT
The amendments to
§
185.4
,
concerning
Procedural Rules for Licensure Applicants
, eliminates the
requirement for applicants to have good moral character and adds l
anguage requiring applicants to
submit to a ...
Description: Rule Changes Effective July 22, 2018
Document: ... _view=3&ti=22&pt=9
RULE CHANGES ADOPTED
CHAPTER
190.
DISCIPLINARY GUIDELINES
The amendments to
§
190.8(6)(B)
, concerning
Violation Guidelines
,
amends the rule to clarify that the
Board will consider a misdemeanor to be a misdemeanor of moral turpitude if that type of misdemeanor ...
Description: Form L - PA Professional Evaluation
Document: ... nformation furnished by you is further subject to Chapter 160.010, of the Medical Practice Act, Immunity fromCivil Liability.
Program Directors
Please fill out this box
in addition to
the rest of the form
UNUSUAL
CIRCUMSTANCES
IN PA SCHOOL
Please attach an
explanation for any
...
Description: Form L - Physician Licensure Evaluation Verification of Postgraduate Training and Professional Evaluation
Document: ... nformation furnished by you is further subject to Chapter 160.010, of the Medical Practice Act, Immunity fromCivil Liability.
FOR TRAINING POSITIONS Completion of the Verification of Post Graduate Training andthe Verification of
Professional History sections are required.
FOR NONTRAINING POSITIONS ...
“... 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.