81st TEXAS REGULAR LEGISLATIVE SESSION (2009)
BRIEF SUMMARY OF ENACTED BILLS THAT AFFECT APNs & THEIR PATIENTS
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A – Author
S – Sponsor
CoA -- Coauthor
BON – Board of Nursing
CE – Continuing Education
DADS – Department of Aging and Disability Services
DSHS – Department of State Health Services (formerly TDH)
FQHC – Federally Qualified Health Center
FTE – Full Time Equivalent
GR – General Revenue (Texas State Funds)
HCP – health care practitioner or provider
HHSC – Health & Human Services Commission – the state agency with sole authority to administer the Texas Medicaid and CHIP programs
MCO – managed care organization
MPA – Medical Practice Act
NPA – Nursing Practice Act
RHC – Rural Health Clinic
TDI – Texas Department of Insurance
TMB – Texas Medical Board
TSH – Texas Health Steps (Texas Medicaid Well-Child Care/EPSDT)
SECTION or SEC. – section of a bill
§ - Section / §§ - Sections of a statute or rule
Yellow highlighted text indicates CNAP’s action resulted in a positive outcome for APNs
Blue highlighted text indicates a new advisory committee, workgroup or task force
Red print indicates a change is needed in the language or follow-up is needed.
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Legislation Directly Impacting APNsBill # & Link / Author & Sponsor / Provision Impacting APNs – General Description & Implications for APNs / What Does the Provision Do?
Resulted from Actions by CNAP / Effective Date/s
SB 532 / A: Sen. Dan Patrick (R-Houston, SD #5)
S: Rep. Garnet Coleman (D-Houston, HD #147) / Amends §§157.0511, 157.053, 157.054, 157.0541, 157.0542, and 157.059, Occupations Code (certain sections of the MPA under which physicians may delegate prescriptive authority). The entire bill addresses delegated prescriptive authority for APNs and PAs. The bill reduces some physician supervisory requirements, particularly in alternate practice sites, and makes minor improvements in certain sites. It increases the quantity of Schedule III – V drugs an APN may prescribe.
APNs with delegated prescriptive authority in primary practice, alternate, and long-term care facility-based practices should determine if any of these provisions would have a positive impact for their practices. If so, discuss the change with the delegating physician and, if approved, change the practice agreement protocol accordingly. Then sign and date the revised protocol. / 1. Allows physician delegation of Schedules III-V, Controlled Substances, to include 90 day supply (up from 30 days).
2. Requires a physician to register with the Texas Medical Board (TMB) the name & license # of the APN or PA to whom the physician delegates prescriptive authority.
3. In primary practice, alternate and long-term care sites, physicians will be permitted to delegate to four full-time equivalent APNs and/or PAs (increased from 3).
4. In addition to current sites, adds a new site under the category of primary practice that is defined as a practice location where a PA or APN practices on-site with the physician more than 50 percent of the time and who provides:
(a) health services for established patients;
(b) voluntary charity health care services at a clinic run or sponsored by a nonprofit organization; or
(c) voluntary health care services at a temporary facility operated or sponsored by a governmental entity or non-profit organization during a declared disaster or emergency.
5. Makes several changes to the restrictions on alternate sites including:
(a) allowing the alternate site to be 75 miles from the delegating physician's primary practice site or residence. (Now the alternate site must be within 60 miles of the physician’s practice.)
(b) requiring the physician to be on site 10% of the "hours of operation of the site each month that the PA or APN is acting with delegated prescriptive authority." (Currently, the requirement is 20% of the time each APN or PA is at that site.); and
(c) allowing the 10% chart review to be done electronically at a remote site.
6. Adds to the TMB’s authority to waive certain supervision requirements. If the TMB determines the types of services provided at the alternate site are limited in nature and duration (the types of services offered in a retail clinic, but may apply to other sites such as practices that only offer Texas Health Step exams or manages a limited range of conditions), and patient health care will not be adversely affected, the TMB may modify or waive the mileage limit, some supervision requirements, and raise the limit on the number of PAs or APNs to whom a physician may delegate to as many as a 6 to 1 ratio. / 9/1/09 TMB has until 1/31/2010 to adopt rules
SB 1415 / A: Sen. Glenn Hegar (R-Katy, SD #18)
S: Rep. Jim McReynolds (D-Lufkin, HD #12) / Adds §301.1607 establishing a pilot program to defer disciplinary action in cases involving minor infractions of the NPA. Adds a new Subchapter N to the NPA permitting the BON to impose corrective action by imposing a fine or remedial education that would not be subject to the same disclosure and reporting rules as disciplinary action imposed by the BON.
APNs charged with violating the NPA on or after 9/1/09 should be aware of this option for the BON to impose corrective action rather than taking disciplinary action that must be subject to public disclosure. / Currently, when a nurse violates a BON Rule, no matter how minor, the BON must impose disciplinary action. This means the BON must report the action against the RN or APRN license to one of the national practitioner databanks, having an adverse effect on credentialing and privileging the APN in the future. SB 1415 provides a mechanism for the BON to take corrective action that would not require the BON to report to the national databank. In addition, the bill authorizes a pilot program to be completed by September 1, 2014, that allows the BON to defer disciplinary action pending completion of remedial education, payment of fines, etc. Once the nurse completes the BON stipulations, the BON may dismiss the action or complaint and it will not be accessible to the public in the future. However, should the nurse have another violation in the future, the BON would still be permitted to consider the previous deferred disciplinary action when determining appropriate disciplinary actions for subsequent violations. / 9/1/09
BON determines pilot feasibility by 2/1/10. If conducted, implement pilot by 2/1/11 and complete by 9/1/14.
SB 1984 / A: Sen. Carlos Uresti (D-San Antonio, SD #19)
CoA: Sen. Glenn Hegar (R-Katy, SD #18)
S: Rep. Tracy O. King (R-Weatherford, HD #61) / Amends §681.003, Transportation Code permitting APNs and PAs to verify a person is legally blind or has a mobility problem that qualifies the individual to receive an initial temporary parking placard if the individual lives in a county with a population of 125,000 or less.
APNs must know: 1) the limitations on APNs who can sign medical verifications for disable parking placards, 2) which counties in their area have a population of 125,000 or less, and 3) the mobility limitations that qualify a person to have a disabled parking placard. / For patients living in counties with a population of 125,000 or less, APNs may sign a notarized statement or write a prescription to accompany an initial application for a temporary disabled parking placard. The placard allows persons to park in parking spaces reserved for handicapped individuals. According to Transportation Code definitions, the following impairments qualify a person for a disabled parking placard.
(1)cannot walk 200 feet without stopping to rest
(2)cannot walk without the use of or assistance from an assistance device, including a brace, a cane, a crutch, another person, or a prosthetic device
(3)cannot ambulate without a wheelchair or similar device;
(4)is restricted by lung disease to the extent that the person's forced respiratory expiratory volume for one second, measured by spirometry, is less than one liter, or the arterial oxygen tension is less than 60 millimeters of mercury on room air at rest
(5)uses portable oxygen
(6)has a cardiac condition to the extent that the person's functional limitations are classified in severity as Class III or Class IV according to standards set by the American Heart Association
(7)is severely limited in the ability to walk because of an arthritic, neurological, or orthopedic condition;(H)has a disorder of the foot that, in the opinion of a person licensed to practice podiatry in this state or in a state adjacent to this state, limits or impairs the person's ability to walk
(8)has another debilitating condition that, in the opinion of a physician licensed to practice medicine in this state or a state adjacent to this state, or authorized by applicable law to practice medicine in a hospital or other health facility of the Veterans Administration, limits or impairs the person's ability to walk / Immediate 6/19/09
HB 1487 / A: Rep. Jim Pitts (R-Waxahachie, HD #10) & Rep. Ryan Guillen (D-Rio Grande Valley, HD #31)
S: Sen. Jane Nelson (R-Lewisville, SD #12) / Adds §531.099, Government Code, requiring HHSC to align written order procedures for diabetic equipment and supplies for the Texas Medicaid Program with those of Medicare.
APNs who manage diabetic patients on Medicaid need to be aware they will be able to sign the forms after HHSC implements the policy changes. / It is expected this bill will result in policy changes that will permit APNs and other appropriate “medical practitioners” to sign forms ordering diabetic supplies and equipment.
CNAP obtained an amendment in the original version of the bill to include CNMs, as well as NPs and CNSs as providers who could order diabetic equipment & supplies. The bill was ultimately revised and eliminated references to specific ordering practitioners, but still has language that includes all APNs. / 9/1/09
Prescribing or Dispensing Drugs & Medical Devices / Regulation of Pain Management Clinics
Bill # & Link / Author & Sponsor / Provision Impacting APNs – General Description & Implications for APNs / What Does the Provision Do?
Resulted from Actions by CNAP / Effective Date
SB 904 / A: Sen. Tommy Williams (R-The Woodlands, SD #4)
S: Rep. Jim McReynolds (D-Lufkin, HD #12) / Amends §§481.074 and 481.0761, Health & Safety Code (Controlled Substances Act) permitting prescribers to write a total 90-day supply of Schedule II controlled substance by issuing three 30-day prescriptions.
Amends §481.037 making carisoprodol (Soma) a Schedule IV controlled substance.
APNs may not write prescriptions for Soma unless they have DPS and DEA numbers. Although APNs may NOT write prescriptions for Schedule II drugs, but should be aware of the option for a 90-day supply if patients require longer-term treatments with a Schedule II drug. / Physicians may now write prescriptions of a 90-day supply of a Schedule II drug, but must do so by writing 3 separate prescriptions that are successively dated for the earliest date the prescription may be filled. Specifies the prescribing practitioner may only write multiple prescriptions if this does not create an undue risk of diversion or abuse. The issuance of multiple prescriptions must be in compliance with other state and federal laws.
Requires DSHS to classify carisoprodol as a Schedule IV controlled substance. / Immediate6/19/09
SB 911 / A: Sen. Tommy Williams (R-The Woodlands, SD #4)
S: Rep. Mike “Tuffy” Hamilton (R-Mauriceville, HD #19) / Adds Chapter 167, Occupations Code, to the MPA. Requires the TMB to regulate certain clinics or practices that meet the definition of pain management clinics. The purpose is to enable the state to have more authority to identify “pill mills”, especially those that might be owned by out of state physicians or other unregulated persons.
APNs owning or operating a practice in which more than 50% of patients are prescribed opiods, benzodiazepines, barbiturates or carisoprodol would be regulated by the TMB unless the APN treats patients within the APN specialty using other forms of treatment with the issuance of prescriptions for patients or practices in another location that is exempted. / Defines a pain management clinic as a “publicly or privately owned facility for which a majority of patients are issued on a monthly basis a prescription for opioids, benzodiazepines, barbiturates, or cariosoprodol, but not including suboxone.”
Exempts several types of facilities and practices including 1) medical or dental schools, 2) hospitals, including outpatient clinics, 3) hospices, 4) facilities operated by the state of Texas or the United States, 5) clinics owned by a physician or APN who treats patients in their areas of specialty and also uses other forms of treatment.
CNAP obtained the amendment to exempt APNs who might meet the definition of owning or operating a pain management clinic. (see page 2, lines 6 – 9 for specific language).
TMB must adopt rules to regulate pain management clinics and the TMB may inspect the clinics. The TMB must investigate complaints.
Pain management clinics must obtain a certificate from the TMB to operate and renew the certificate periodically. These clinics may only be owned and operated by a medical director who practices in Texas under an unrestricted license. The physician must review at least 33% of patient charts and be onsite at least 33 % of the clinic’s total number of operating hours. / 9/1/09
TMB must adopt rules by 3/1/10 and clinics must obtain certifi-cates by 9/1/10.
SB 532 / See SB 532 under Bills Directly Impacting APNs