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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: Medical Board 2018 - August - Audit Committee Minutes
Document: ... bject to the
attorney client privilege under the authority of the Open Meetings Act Section 551.071,
Government.
Ope
n
session resumed
at 1:05 p
.m. and
it was announced that no action was
taken. A certified agenda was made.
Agenda item #2,
Discussion, recommendation, and possibl ...
Description: Medical Board 2018 - August - Full Board Minutes
Document: ... ubject to the attorney client privilege under the authority of the Texas Government Code,
Section 551.071
.
Open session resumed at 10:50a.m. and it was announced that no a
ction was
taken. A certified agenda was made.
After discussion,
Dr. De Loach moved, Ms. Barnes
seconded and the motio ...
Description: Medical Board 2018 - October - Finance Committee Minutes
Document: ... 8 to fiscal year
2019 and the unexpended balance authority related to
capital budget items.
Ms. Corrales also
addressed the
status of the biennial
revenue collections
.
Agenda Item #3,
Adjourn.
There being no additional items,
Dr. Zaafran moved, Ms.
Barnes seconded, and the motion ...
Description: Medical Board 2018 - October - Licensure Committee Minutes
Document: ... sure applications
and the
applicants under the authority of The Medical Practice Act Sections
152.009 and 155.058, Occupations Code, and that while in executive session, the Board would
not take any action, make any decision, or vote with regard to any matter that may be considered
or discuss ...
Description: Acupuncture Board Education Committee Agenda
Document: ... ject to the attorney
-
client privilege under the authority of the Open Meetings Act
Section 551.071, Government Code.
b.
Deliberations concerning personnel matters under the authority of the Open Meetings Act Section 551.074,
Government
Code.
While in executive session, the Board will not ...
Description: TMB disciplines 34 physicians at October meeting, adopts rules changes
Document: ... rd approval; and shall not supervise or delegate
prescriptive authority to physician assistants and advanced practice nurses or supervise surgical assistants. The Board
found on April 2017, the DEA ordered his DEA certificate of registration revoked based on findings that Dr. Zayas issued
prescr ...
Description: Acupuncture Board Full Board Agenda
Document: ... ct to the attorney
-
client privilege under the
authority
of the Open Meetings Act Section 551.071, Government Code.
b.
Deliberations concerning personnel matters under the authority of the Open Meetings Act
Section 551.074, Government Code.
While in executive session, the Board will not t ...
Description: Medical Board Boundaries Task Force Committee Agenda
Document: ... he character and fitness of
applicants under the authority of The Medical Practice Act Sections 152.009 and
155.058, Occupations Code.
b.
Deliberations concerning disciplinary action, investigative information, peer review
informat
ion, and possible rehabilitation orders under the authority o ...
Description: PA Board 2018 November - Licensure Committee Minutes
Document: ... the character and fitness of applicants under the authority of
Chapter 204, Section
204.0585,
Occupations Code, and that while in executive session, the Board
would not take any action, make any decision, or vote with regard to any
matter that may be
considered or discussed. A certified agend ...
Description: Medical Board 2018 - December - Licensure Committee Minutes
Document: ...
concerning
licensure applications
under the
authority of The Medical Practice Act Sections 152.009 and 155.058, Occupations Code, and
that while in executive session, the Board would not take any action, make any decision, or vote
with regard to any matter that may be considered or discuss
e ...
Description: Medical Board Full Board Agenda
Document: ... the character and fitness of applicants under the authority of The Medical Practice Act Sections 152.009 and 155.058, Occupations Code.Deliberations concerning disciplinary action, investigative information, peer review information, and possible rehabilitation orders under the authority of The Medic ...
Description: TMB disciplines 36 physicians at March meeting, adopts rule changes
Document: ... rom supervising delegates and is prohibi
ted from prescriptive
delegation authority; within one year and three attempts pass the Medical Jurisprudence Exam; within one year
complete at least 24 hours of CME, divided as follows: eight hours in risk management, eight hours in medical ethics and
eig ...
Description: Medical Board 2019 - February - Licensure Committee Minutes
Document: ... he character and fitness of applicants under the
authority of The Medical Practice Act Sections 152.009 and 155.058, Occupations Code, and
that while in executive session, the Board would not take any action, make any decision, or vote
with regard to any matter that may be considered or discussed ...
Description: PA Board 2019 March - Licensure Committee Minutes
Document: ... he character and fitness of applicants under the
authority of Chapter 204, Section 204.0585, Occupations Code, and that while in executive
session, the B
oard would not take any action, make any decision, or vote with regard to any
matter that may be considered or discussed. A certified agenda of ...
Description: Medical Radiologic Technology Board Licensure Committee Minutes (February 15, 2019)
Document: ... closed for deliberations at 10:12
a.m. under the authority of
Texas Government Code Chapter 551.071
,
and that while in executive
session, the Board would not take any action, make any decision, or vote with regard to any matter that
may be considered or discussed. A certified agenda of any ex ...
“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.