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.

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.)

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.

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. 

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. 

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.

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.

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.