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“... r tests, and prescribe.
Supervision and Prescriptive Authority Registrations: waived the requirement of physicians having to register with the TMB their supervision and prescriptive authority for PAs and APRNs.For more information on this requirement, visit: https://www.tmb.state.tx.us/pag ... ”
“At this time, the Online Supervision and Prescriptive Delegation Registration system is not set up to accept delegation locations outside of Texas.
Any physician, PA or APRN who does not have a TX practice address and needs to register prescriptive delegation, please contact the Registration Departm ... ”
“... cal director?
Do delegates who have prescribing authority have to apply for their own waiver or are they covered by the supervising physician’s waiver?
Do I need a waiver for each of my practice locations?
How can someone determine if a practitioner has a waiver?
How long w ... ”
Description: PA Board 2006 February, Licensure
Document: ... on and/or possible rehabilitation order under the authority of the Open Meetings Act, GOV'T CODE, §551.071; and the Medical Practice Act, TEX. OCC. CODE ANN., §152.009; and the Physician Assistant Licensing Act, TEX. OCC. CODE ANN., §§204.208, 204.254, 204.305, and 204.306; and Attorney General's Op ...
Description: PA Board 2008 February, Disciplinary Ethics
Document: ... ns, and/or possible disciplinary action under the authority of the Open Meetings Act, GOVERNMENT CODE, 551.071; and the Physician Assistant Licensing Act, TEXAS OCCUPATIONS CODE ANNOTATED, 204.208 and 204.254; and Attorney Generals Opinion No. H-484. Open session resumed at 11:17a.m. and it was anno ...
Description: PA Board 2008 February, Licensure Committee
Document: ... on and/or possible rehabilitation order under the authority of the Open Meetings Act, GOVT CODE, 551.071; and the Medical Practice Act, TEX. OCC. CODE ANN., 152.009; and the Physician Assistant Licensing Act, TEX. OCC. CODE ANN., 204.208, 204.254, 204.305, and 204.306; and Attorney Generals Opinion ...
Description: PA Board 2002 January, Disc Min
Document: ... ns, and/or possible disciplinary action under the authority of the Open Meetings Act, GOVERNMENT CODE, 551.071; and the Physician Assistant Licensing Act, TEXAS OCCUPATIONS CODE ANNOTATED , 204.208 and 204.254; and Attorney Generals Opinion No. H-484. Open session resumed at 11:18 a.m. and it was an ...
Description: PA Board 2002 January, Full Board Min
Document: ... he proposed rule change relating to delegation of prescriptive authority at alternate sites and stated that the comments had been reviewed by the Long Range Planning Committee. Based on the comments, staff recommended incorporating additional amendments to the rule. Dr. Patrick and Ms. Shackelford e ...
Description: PA Board 2002 January, Lic Min
Document: ... on and/or possible rehabilitation order under the authority of the Open Meetings Act, GOV'T CODE, §551.071; and the Medical Practice Act, TEX. OCC. CODE ANN., §152.009; and the Physician Assistant Licensing Act, TEX. OCC. CODE ANN., §§204.208, 204.254, 204.305, and 204.306; and Attorney General's Op ...
Description: PA Board 2002 January, Long Range Plan Min
Document: ... he proposed rule change relating to delegation of prescriptive authority at alternate sites. Based on the comments, staff recommended incorporating additional amendments to the rule. Dr. Patrick and Ms. Shackelford explained that this was an informational item only and that the rule would be conside ...
Description: PA Board 2009 July, Disciplinary Ethics
Document: ... subject to the attorneyclient privilege under the authority of the Open Meetings Act, Section 551.071, GOVERNMENT CODE. Open session resumed at 11:27 a.m. and it was announced that no action was taken during executive session. A certified agenda of the executive session was made. Agenda Item #6. Rev ...
Description: PA Board 2009 July, Full Board
Document: ... and SB532 relating to a physician's delegation of prescriptive authority to physician assistants. After discussion, the board directed staff to research and draft guidelines to address the supervision of a physician assistant when the physician assistant is the employer of the physician. Agenda item ...
Description: PA Board 2009 July, Licensure Committee
Document: ... of the Board. Mr. Rahr then asked if the issue of prescriptive authority of PAs on temporary licenses for out of practice issues be discussed. It was determined that the Committee would evaluate the issue on a case by case basis.
Michael A. Mitchell, D.O. entered the meeting.
Agenda Item 2 Discuss ...
Description: PA Board 2004 July, Discipline and Ethics
Document: ... ns, and/or possible disciplinary action under the authority of the Open Meetings Act. GOVERNMENT CODE, 551.071; and the Physician Assistant Licensing Act, TEXAS OCCUPATIONS CODE ANNOTATED, 204.208 and 204.254; and Attorney Generals Opinion No. H-484. Open session resumed at 10:00 a.m. and it was ann ...
Description: PA Board 2004 July, Full Board
Document: ... edical Board meeting concerning electromyography, prescriptive medical devices, and the scope of practice in the area for physician assistants. The Board directed staff to present their expressed concerns with 193.12 at the next Medical Board meeting.
Agenda item #4, report regarding the Prescripti ...
Description: PA Board 2004 July, Licensure
Document: ... on and/or possible rehabilitation order under the authority of the Open Meetings Act, GOV'T CODE, §551.071; and the Medical Practice Act, TEX. OCC. CODE ANN., §152.009; and the Physician Assistant Licensing Act, TEX. OCC. CODE ANN., §§204.208, 204.254, 204.305, and 204.306; and Attorney General's Op ...
Description: PA Board 2005 July, Discipline and Ethics
Document: ... ns, and/or possible disciplinary action under the authority of the Open Meetings Act. GOVERNMENT CODE, 551.071; and the Physician Assistant Licensing Act, TEXAS OCCUPATIONS CODE ANNOTATED, 204.208 and 204.254; and Attorney General Opinion No. H-484. Open session resumed at 10:35 a.m. and it was anno ...
Description: PA Board 2005 July, Full Board
Document: ... ns, and/or possible disciplinary action under the authority of the Open Meetings Act, Government Code 551.071; and the Medical Practice Act, Texas Occupations Code Annotated, 152.009; and the Physician Assistant Licensing Act, Texas Occupations Code Annotated, 204.208 and 204.254; and Attorney Gener ...
“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 ... ”
Is a prescriptive authority agreement required in a hospital or long term care facility-based practice?
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. ”
At how many facilities can one physician delegate prescriptive authority through protocols?
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. &n ... ”
Who may delegate prescriptive authority in a hospital facility-based practice?
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. ”
Who may delegate prescriptive authority in a long term care facility based practice?
In a long term care facility based practice, delegation is by the medical director.
“... 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 ... ”
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.)
“... as an eligible site for delegation of schedule II authority. The physician may only delegate authority to prescribe controlled substances in schedules III through V in this setting. Authority to prescribe dangerous drugs, nonprescription drugs and devices may be delegated in any setting. ... ”
Can schedule II authority be delegated in a free standing emergency department that is affiliated with a hospital?
No. A free standing emergency department is not located within the hospital anddoes not qualify as an eligible site for delegation of schedule II authority. The physician may only delegate authority to prescribe controlled substances in schedules III through V in this setting. Authority to prescribe dangerous drugs, nonprescription drugs and devices may be delegated in any setting.
“Yes. Nothing changed for delegation of prescriptive authority for controlled substances in schedules III through V. ”
Can APRNs and PAs in hospital-based clinics continue to prescribe drugs in schedules III through V?
Yes. Nothing changed for delegation of prescriptive authority for controlled substances in schedules III through V.
“... rried out by the Texas Board of Nursing under the authority of the Nursing Practice Act. Ultimate responsibility and accountability for the medical management of a patient under anesthesia remains with the delegating physician who may be subject to discipline for improper delegation dependent ... ”
Is a CRNA under a valid delegation order, subject to discipline by the Texas Medical Board under the Medical Practice Act for a violation of the standard of care in the selection and administration of anesthesia or the care of an anesthetized patient?
No, while the selection and administration of anesthesia is a medical act, if such an act was validly delegated to a CNRA by a physician, the act is considered to be within the practice of nursing and governed by the Nursing Practice Act. Any discipline for a violation of the standard of care by a CRNA would be carried out by the Texas Board of Nursing under the authority of the Nursing Practice Act. Ultimate responsibility and accountability for the medical management of a patient under anesthesia remains with the delegating physician who may be subject to discipline for improper delegation dependent upon the facts and circumstances of each case, and how state statutes and regulations apply in those situations.
“... ed nurse anesthetist does not possess independent authority to administer anesthesia without delegation by a physician.” (Page 5). Since the selection and administration of anesthesia is a medical act, CRNAs must be properly delegated this act by a physician. A CRNA who administers ... ”
Are CRNA’s authorized to practice independent of physician supervision and delegation?
No, neither the Medical Practice Act nor the Nursing Practice Act authorize independent practice by a CRNA. Additionally, Texas Attorney General Opinion No. KP-0266 found “A certified registered nurse anesthetist does not possess independent authority to administer anesthesia without delegation by a physician.” (Page 5). Since the selection and administration of anesthesia is a medical act, CRNAs must be properly delegated this act by a physician. A CRNA who administers anesthesia without proper delegation from a physician would be liable for the unlicensed practice of medicine.
“... to beginning to practice under the employment or prescriptive authority agreement. They are also required to notify the Board within 30 days of any change to the scope of the delegation. APRNs should look to guidance provided by the Texas Board of Nursing for how to register their delega ... ”
Do I have to let the Medical Board know about my delegates/supervising physicians?
Yes, if you are a physician or a physician assistant.
Physicians are required to register all PAs and APRNs that they supervise prior to the delegates beginning to work for them. If there is a change to the scope of the delegation, physicians must notify the Board within 30 days of this change.
PAs are likewise required to register their supervising physicians with the Board prior to beginning to practice under the employment or prescriptive authority agreement. They are also required to notify the Board within 30 days of any change to the scope of the delegation.
APRNs should look to guidance provided by the Texas Board of Nursing for how to register their delegating physicians, as the Medical Board does not have licensing authority for nurses.
“... other qualified and licensed individual delegated authority to check the PMP may do so on behalf of the prescriber. Ultimately though, it is the prescriber’s responsibility to ensure that the PMP has been checked and that they have reviewed and taken into account any relevant information ... ”
Is only the prescriber allowed to check the PMP, or can someone else check on behalf of the physician?
A physician, their delegated midlevel provider, or any other qualified and licensed individual delegated authority to check the PMP may do so on behalf of the prescriber. Ultimately though, it is the prescriber’s responsibility to ensure that the PMP has been checked and that they have reviewed and taken into account any relevant information prior to issuing a prescription.
“... the prescribing delegate is prescribing under the authority of a physician who has been granted a waiver, then the prescribing delegate may use non-electronic prescribing means. If a prescribing delegate is issuing a prescription under the authority of a physician who does not have a waiver, t ... ”
Do delegates who have prescribing authority have to apply for their own waiver or are they covered by the supervising physician’s waiver?
If the supervising physician has a waiver, then the prescribing delegate is also covered under that waiver. So long as the prescribing delegate is prescribing under the authority of a physician who has been granted a waiver, then the prescribing delegate may use non-electronic prescribing means. If a prescribing delegate is issuing a prescription under the authority of a physician who does not have a waiver, then the prescribing delegate must issue the prescription via e-prescribing.
If an individual wants to look up whether a prescribing delegate has a waver they can do so as listed below:
For physician assistants: A PA’s waiver status will not be viewable on their TMB public profile. Each PA’s public profile has a link to their supervising physician’s profile page. The physician’s profile page will list the waiver status.
For nurse practitioners: APRN waivers are determined by the Texas Board of Nursing. Information on the waiver process for the APRNs is available on the Texas Board of Nursing Website.