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“... nvestigation status, or the issuance of any Board orders?
No. To receive additional information a new request will need to be submitted for review.
”
“... a non-patient-specific prescription pursuant to a standing order, approved protocol for drug therapy, collaborative drug management, or comprehensive medication management, in response to a public health emergency or in other circumstances in which the practitioner may issue a non-patient-specific p ... ”
“... have access to a team of support representatives standing by ready to answer questions by email at support@cebroker.com or by chat via our Help Center, help.cebroker.com.Help CenterCE Broker’s Help Center is accessible anytime, anywhere, providing assistance even outside of reg ... ”
Description: Medical Board 2007 - August - Licensure Committee Meeting Minutes
Document: ... tion and consideration of possible rehabilitation orders under the authority of the Open Meetings Act, GOVERNMENT CODE, 551.071; and the Medical Practice Act, TEXAS OCCUPATIONS CODE ANNOTATED, 152.009, 155.058, 160.006, 164.007 and 164.203; and Attorney Generals Opinion No. H-484.
There was no fina ...
Description: Medical Board 2007 - February - Minutes of the Disciplinary Process Review Committee
Document: ... p.m. for consideration of possible rehabilitation orders under the authority of the Open Meetings Act, GOVERNMENT CODE, §551.071; and the Medical Practice Act, TEXAS OCCUPATIONS CODE ANNOTATED, §§152.009, 160.006, 164.007, and 164.203; and Attorney General's
Opinion No. H-484. Open session resumed ...
Description: Medical Board 2007 - February - Full Board Committee Meeting Minutes
Document: ... eration and Approval of Non-Public Rehabilitation Orders and Modification Request/Termination Request of Non-Public Rehabilitation Orders.
After discussion, Dr. Price moved, Dr. Benavides seconded, and the motion passed to approve the orders Non-Public Rehabilitation Orders and Modification Request ...
Description: Medical Board 2007 - February - Licensure Committee Meeting Minutes
Document: ... tion and consideration of possible rehabilitation orders under the authority of the Open Meetings Act, GOVERNMENT CODE, 551.071; and the Medical Practice Act, TEXAS OCCUPATIONS CODE ANNOTATED, 152.009, 155.058, 160.006, 164.007 and 164.203; and Attorney Generals Opinion No. H-484.
There was no fina ...
Description: Medical Board 2007 - June - Minutes of the Disciplinary Process Review Committee
Document: ... and for consideration of possible rehabilitation orders under the authority of the Open Meetings Act, GOVERNMENT CODE, 551.071; and the Medical Practice Act, TEXAS OCCUPATIONS CODE ANNOTATED, 152.009, 160.006, 164.007, and 164.203; and Attorney Generals Opinion No. H-484. Open session resumed at 1: ...
Description: Medical Board 2007 - June - Full Board Committee Meeting Minutes
Document: ... eration and Approval of Non-Public Rehabilitation Orders and Modification Request/Termination Request of Non-Public Rehabilitation Orders.
After discussion, Ms. Blackwell moved, Dr. Arambula seconded, and the motion passed to approve Non-Public Rehabilitation Order #434 with discussed comments dele ...
Description: Medical Board 2007 - June - Licensure Committee Meeting Minutes
Document: ... one.
Agenda Item 5 Reports on:
Item 5a Proposed orders for restriction of physician licensure and physician in training permit applicants Ms. Garanflo reported on two orders for physician in training permit holders who applied for full licensure and will be offered orders with similar terms and co ...
Description: Medical Board 2007 - June - Standing Orders Committee Meeting Minutes
Document: TEXAS MEDICAL BOARD STANDING ORDERS COMMITTEE MEETING MINUTES June 07, 2007
The meeting was called to order at 9:35 a.m. by Chair, Annette Raggette. Committee members present were Larry Anderson, M.D., Melinda Fredricks, Amanullah Khan, M.D., Margaret C. McNeese, M.D., and Irvin E. Zeitler, Jr., D. ...
Description: Medical Board 2007 - November - Minutes of the Disciplinary Process Review Committee
Document: ... sion for consideration of possible rehabilitation orders under the authority of the Open Meetings Act, Government Code, 551.071; and the Medical Practice Act, TEXAS OCCUPATIONS CODE ANNOTATED, 152.009, 160.006, 164.007, and 164.203; and Attorney Generals Opinion No. H-484. Open session
resumed at ...
Description: Medical Board 2007 - November - Full Board Committee Meeting Minutes
Document: ... eration and Approval of Non-Public Rehabilitation Orders and Modification Request/Termination Request of Non-Public Rehabilitation Orders.
After discussion, Mr. Turner moved, Ms. Blackwell seconded, and the motion passed to approve all of the Non-Public Rehabilitation Orders as written. Dr. Kalafut ...
Description: Medical Board 2007 - November - Licensure Committee Meeting Minutes
Document: ... tion and consideration of possible rehabilitation orders under the authority of the Open Meetings Act, GOVERNMENT CODE, 551.071; and the Medical Practice Act, TEXAS OCCUPATIONS CODE ANNOTATED, 152.009, 155.058, 160.006, 164.007 and 164.203; and Attorney Generals Opinion No. H-484. There was no final ...
Description: Medical Board 2008 - April - Licensure Committee Action Item Agenda Item 2c Applicant #329 Executive Director Proposed Public Non-Disciplinary Rehabilitation Order April 10, 2008
Document: ... ved to recommend to the full Board that all eight orders be approved. Dr. Benavides seconded. All voted in favor and the motion passed.
Description: Medical Board 2008 - April - Licensure Committee Action Item Agenda Item 2c Applicant #333 Executive Director Proposed Public Non-Disciplinary Rehabilitation Order April 10, 2008
Document: ... ved to recommend to the full Board that all eight orders be approved. Dr. Benavides seconded. All voted in favor and the motion passed.
Description: Medical Board 2008 - April - Licensure Committee Action Item Agenda Item 2c Applicant #409 Executive Director Proposed Non-Public Non-Disciplinary Rehabilitation Order April 10, 2008
Document: ... ved to recommend to the full Board that all eight orders be approved. Dr. Benavides seconded. All voted in favor and the motion passed.
Description: Medical Board 2008 - April - Licensure Committee Action Item Agenda Item 2c Applicant #626 Executive Director Proposed Non-Public Non-Disciplinary Rehabilitation Order April 10, 2008
Document: ... ved to recommend to the full Board that all eight orders be approved. Dr. Benavides seconded. All voted in favor and the motion passed.
TERMS AND CONDITIONS LENGTH OF ORDER: PSYCHIATRIC: 7. [ INDEPENDENT PSYCHIATRIC EVALUATION] Submit to IPE by psychiatrist appointed by ED and follow recommendations ...
“The prescriptive authority agreement designates who may serve as an alternate physician if alternate physician supervision will be utilized. If an alternate physician(s) will participate in the quality assurance and improvement meetings with the APRN or PA, this information must be included in ... ”
What if an alternate physician is involved in delegation of prescriptive authority on a temporary basis?
The prescriptive authority agreement designates who may serve as an alternate physician if alternate physician supervision will be utilized. If an alternate physician(s) will participate in the quality assurance and improvement meetings with the APRN or PA, this information must be included in the prescriptive authority agreement.
“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 au ... ”
If I work in a clinic owned by the hospital, is this considered a facility-based practice?
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.
“... xercise prescriptive authority under one of these delegation mechanisms. ”
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.
“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.
“... 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 anesthe ... ”
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.)
“... eral 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 ... ”
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.)
“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 ... ”
Who can prescribe Schedule II drugs under physician delegation?
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.
“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. Auth ... ”
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.
“... ian 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. ”
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.
“... endent 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 ... ”
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.
“... m. 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. ... ”
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.