Yes.  SB 406 clarified that it is necessary to have prescriptive authority to order these devices.  In the past, it was not clear to DME suppliers that APRNs and PAs had this authority.  The changes to the law as a result of the passage of SB 406 clearly indicate that APRNs and PAs may order or prescribe this equipment provided all requirements for delegation of prescriptive authority are met.  

SB 406 eliminated site based prescriptive authority.  The law is silent regarding the practice location of the physician and its proximity to the practice site of the APRN or PA. That said, there has been no change in the law that requires that a physician must provide adequate supervision of delegates. In any given case, the distance between a physician’s primary practice and the practice site at which the physician’s delegates provide medical services may be an important factor in determining the quality of the physician’s supervision. 

All prescriptive delegation requires adequate supervision under the Medical Practice Act.  As such, a physician delegating to an APRN or PA must adequately supervise those individuals.  An individual physician may serve in both the supervising and delegating role and does not need to be physically present at all times to be considered to have adequate supervision.

APRNs and PAs are required to have delegated authority from a licensed physician in order to provide medical aspects of patient care. Historically, this delegation has occurred through a protocol or other written authorization. Rather than requiring multiple documents, delegation protocols can now be included in one document the prescriptive authority agreement. The prescriptive authority agreement need not describe the exact steps that an advanced practice registered nurse or physician assistant must take with respect to each specific condition, disease, or symptom, however.

No.  Free standing clinics, centers or other medical practices that are owned or operated by or associated with a hospital or long term care facility that are not physically located within the hospital or long term care facility are not considered facility based practices.  Prescriptive authority agreements are required in these settings.

Although it is possible to use a prescriptive authority agreement in a hospital or long term care facility based practice, it is not required.  You may continue to practice under protocols in these settings.  APRNs and PAs must exercise prescriptive authority under one of these delegation mechanisms.

A physician may delegate prescriptive authority via facility based protocol at no more than one licensed hospital or no more than two long term care facilities.  

In a hospital facility based practice, the delegating physician may be the medical director, the chief of medical staff, the chair of the credentialing committee, a department chair, or a physician who consents to the request of the medical director or chief of the medical staff to delegate.  

In a long term care facility based practice, delegation is by the medical director.

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.)

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.)

APRNs or PAs may prescribe schedule II drugs in the following situations:

(1) in a hospital facility-based practice, in accordance with policies approved by the hospital's medical staff or a committee of the hospital's medical staff as provided by the hospital's bylaws to ensure patient safety and as part of care provided to a patient who:

(A) has been admitted to the hospital for an intended length of stay of 24 hours or greater; or

(B) is receiving services in the emergency department of the hospital; or

(2) as part of the plan of care for the treatment of a person who has executed a written certification of a terminal illness, has elected to receive hospice care, and is receiving hospice treatment from a qualified hospice provider.

 APRNs and PAs must consult with the delegating physician for refills of a prescription for controlled substances after the initial 90 day supply.  Consultation is also required when prescribing controlled substances for children under the age of two years.  In both cases, the consultation must be documented in the patient’s medical record.

For physicians only:

If another state board requires your examination grades, please be advised that most physicians will have to contact the Federation of State Medical Boards to obtain examination scores.

Federation of State Medical Boards
400 Fuller Wiser Rd.
Suite 300
Euless, TX 76039-3855
Tel. (817) 868-4000

A small percentage of physicians can obtain verification of examination scores from TMB.

• If you were licensed before 1976 and
• you took the Texas State Board Medical Exam,

please call the Pre-Licensure, Registration and Consumer Services at (512) 305-7030 to confirm the location of your scores.

There is no fee for this verification.

The 76th Legislature passed HB 692, which states in part: "The social security number of an applicant for or holder of a license, certificate of registration, or other legal authorization issued by a licensing agency to practice in a specific occupation or profession that is provided to the licensing agency is confidential and is not subject to disclosure under the open records law."

The law was passed in the House on March 18 and in the Senate on May 17 and went into effect after being signed by Governor George W. Bush on May 29, 1999.