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Authority

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Prescriptive Authority DB

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Coalition for Nurses in Advanced Practice. (n,d,). Crafting effective letters to legislators. (See attached document)
Coalition for Nurses in Advanced Practice. (n.d.). Advocacy: How to read a bill. Retrieved from http://www.cnaptexas.org/?228
Stewart, J.G. & Denisco, S. M. (2015). Role development for the nurse practitioner, (Chapters 6, 9, 10 & 11), Burlington, MA: Jones & Bartlett Learning, LLC.
Texas Legislative Council. (2013). Section 1: The Texas legislative Process. In Guide to Texas Legislative Information, pp 1 - 10. Retrieved from http://www.tlc.state.tx.us/lege_ref.htm.
Texas Secretary of State. (n.d.).State rules and open meetings. Retrieved from http://www.sos.state.tx.us/texreg/index.shtml
Texas Secretary of State. (n.d.). Welcome to the Texas Administrative Code. Retrieved from http://www.sos.state.tx.us/tac/index.shtml

As a new APRN understanding delegated prescriptive authority will keep you out of professional and legal trouble. Refer back to Lynda Woolbert’s lecture and differentiate between facility-based and non-facility-based NP practices in Texas law. What does Texas law requires for delegation of prescriptive authority? What is a prescriptive authority agreement (PAA) and what elements should be included? What scheduled drugs can an APRN prescribe and what are the legal requirements associated with prescribing controlled substances?
Refer back to the KPRC news clinic (The Harwin Case). Analyze requirements and limitations on a physician’s authority to delegate prescriptive authority in relation to situations in which a physician is delegating prescriptive authority. What do you think the outcome was or should have been for the APRN and the MD?

Texas law has two primary limitations for delegation of prescriptive authority for APRNs; prescriptive authority must be delegated by a physician through a written document prescribed by law and certain limitations apply to prescribing controlled substances (http://www.cnaptexas.org/?page=15). Prescriptive Authority Agreements (PAA) and Facility-based protocols are the documents in which physicians delegate prescriptive authority and other medical acts to APRNs or PAs in the state of Texas (Woolbert, n.d.). According to TMB Rule 193.6 physicians may delegate ordering/prescribing nonprescription drugs, prescription drugs and medical devices to APRN’s or PA’s through a PAA. (http://www.cnaptexas.org/?page=15).
There are several items included in the PAA: the APRN must have a full and active license, and valid prescriptive authorization number in good standing. The physician must have a full license from the Texas Medical Board. Physicians are limited to delegating prescriptive authority to no more than 7 APRNs and PAs or their full time equivalent (50 hours per provider) with the exception of the underserved population or a facility-based practice (Coalition for Nurses in Advanced Practice, 2014). The PAA required elements include in writing, signed and dated by all parties: name, address and professional license number of all parties. Nature of the practice including location and settings. Categories of drugs that may or may not be prescribed (Woolbert, n.d.). A consultation plan, patient emergency plan and a plan for chart reviews, monthly meetings and signatures for all involved parties must be obtained (Coalition for Nurses in Advanced Practice, 2014).
There are limitations on prescribing controlled substances within the PAA. The APRN must comply with all federal laws/regulations related to the ordering and prescribing of controlled substances in Texas as well as those by the Texas Department of Safety and the United States Drug Enforcement Administration. Limitations for most APRNs and PA’s include schedule III-V. In 2013 SB 406 began permitting facility-based APRNs and PAs who are treating ED/ or inpatient population for a 24 hour or more stay to prescribe Schedule II drugs when delegated by the physician. APRNs are not allowed to prescribe controlled substances for any child who is less than 2 years of age without a consultation. The only non-facility based APRNs permitted to prescribe or order Schedule II drugs are those treating hospice patients. Another limitation is that if a prescription can only be written for a 90 day supply and if a medication is needed longer than a consultation must be had and noted and another 90 day supply may be written (Woolbert, n.d.).
In regards to the Harwin Case there were several things that were wrong within the practice. Controlled substances were being prescribed by APRN’s in the absence of a physician’s presence. The physician who was “overseeing” the clinic was not reachable and living in another state. I definitely think that both the MD and APRN’s involved need to be investigated and disciplined accordingly. Without knowing any more than the information from the video I would hope that the APRN’s were not fully aware of what rules they were breaking or that this clinic was not being run according to Texas law. However, on the other hand as an APRN we should all we aware of the rules and regulations to ensure that we are practicing to the law for the safety of our license and the patients.
Coalition for Nurses in Advanced Practice. (2014). Overview of APRN prescriptive privileges in Texas. Retrieved from http://www.cnaptexas.org/?page=15

KPRC News. (2006, February 8). Harwin clinic video clip. Retrieved from blackboard online website: http://twu.blackboard.com

Woolbert, L. (n.d.). APRN practice & professional advocacy in Texas. Retrieved from blackboard online website:http://twu.blackboard.com

* Purpose/content of QAI monthly meetings * share information about patient care & treatment, * changes in treatment plans and * issues relating to referrals * QAI monthly in-person meetings * Location, day and time determined jointly * Face-to-face 1 year for APRNs who prescribed for 5 of past 7 yrs * Face-to-face for 3 years for APRNs with less experience * Thereafter, meet quarterly in-person & monthly in between by electronic means. * Document implementation method & compliance

According to Texas law, facility-based practices transpire in two environments, hospitals and long-term care facilities. In hospitals, prescriptive authority may be assigned through the medical director or chief of medical staff, or a department chair. Prescriptive authority is delegated through protocols in facility-based practices as opposed to a prescriptive authority contract (Woolbert, n.d.). Texas law has several requirements for delegation of prescriptive authority. The physicians name, address, and contact number are necessary. The MD/APRN ratio of prescriptive authority depends on the site. In facility-based protocol, there are no restrictions. However, in other sites, the law entails one MD per seven APRNs. Furthermore, there are no restrictions to the amount of doctors who may allot prescriptive authority to an APRN ( FAQs for prescriptive authority, n.d.).
A prescriptive authority agreement is a contract between the doctor and advanced practice nurse in which the doctor entrusts to the APRN ordering a medication or piece of equipment. The contract is necessary in every practice setting excluding a facility based practice in which they function within facility’s set of rules (Woolbert, n.d.). There are certain specifications that must be included in the prescriptive authority contract including the name, address, and license numbers of both individuals apart of the contract. The type of the practice and the practice’s whereabouts must also be included, as well as the kind of medications and pieces of equipment that may be prescribed. Also, a strategy that is available for patient recommendations, patient crisis, a mode for corresponding regarding patient treatment plans, and an approach that incorporates evaluating patient records and formal meetings must be integrated in the contract (FAQs for Prescriptive Delegation, n.d.).
Physicians may give prescriptive authority to APRNs for controlled substances III-V with restrictions. If a refill is needed beyond the 90 day amount, the delegating physician must be notified. APRNs may order scheduled II medications under delegation in a hospital site for a patient, who is in the hospital for a lengthy time or is receiving end of life care (Woolbert, n.d.).
Regarding the Harwin case, I think the APRN and MD involved should have been disciplined, but I think they should have been able to keep their license. I want to give them the benefit of the doubt and hope that they were unaware and did not know that both parties were violating both the Texas nursing and medical boards.
References
FAQs for prescriptive authority. (n.d.). Retrieved from tmb.state.tx.us
Woolbert, L. (n.d.). APRN practice & professional advocacy in Texas. Retrieved from blackboard online website:http://twu.blackboard.com

According to Texas law, before an APRN is able to prescribe medications they must be delegated the authority to do so by a physician. This must be accomplished through a written document such as a Prescriptive Authority Agreement (PAA) or a Facility-based Protocol. The APRN must have a full and active license, valid prescriptive authorization number, and be in good standing. The physician must also have a full license issued by the Texas Medical Board. A PAA requires several elements including the names, addresses, and professional licenses of all involved parties, a description of the nature of the practice, the drugs and devices that the APRN is allowed to order, a consultation plan, a patient emergency plan, a process for information sharing, a plan for chart reviews and monthly meetings, and signatures of all participants (Coalition for Nurses in Advanced Practice, 2014). A PAA must be reviewed and revised as necessary on a yearly basis. If the APRN is working in a facility, including a hospital or long-term care facility, they may be able to prescribe medications through the use of a facility based protocol, which must include involved party signatures including that of a delegating physician stating that the APRN met requirements for the annual review and the limitations on the medications that the APRN is allowed to prescribe(Coalition for Nurses in Advanced Practice, 2014).

In order to prescribe schedule III-V controlled substances, APRNs must first register with the DEA and DPS (Stewart & DeNisco, 2015). They may prescribe for children over 2 years and adults with physician delegation as long as the duration of prescription does not exceed 90 days, otherwise a physician consultation is required and must be documented (Coalition for Nurses in Advanced Practice, 2014). Schedule II substances may only be prescribed by an APRN for inpatients in a facility based hospital and terminally ill patients under hospice care or if the APRN works in the ER of a facility based hospital (Coalition for Nurses in Advanced Practice, 2014).

Physicians are not allowed to delegate prescriptive authority to more than 7 APRNS and PAs or their full time equivalent, which is 50 hours per provider, unless it is for a medically underserved population or a facility-based practice (Coalition for Nurses in Advanced Practice, 2014). Physicians must register the delegation of authority with the Texas Medical Board within 30 days and also notify them as well as the DPS when terminating delegation (Coalition for Nurses in Advanced Practice, 2014).

In regards to the Harwin Case, I think that the MD and APRNs involved should have their licenses suspended. There seems to have been no physician supervision in this case, which is required by Texas law (KPRC News, 2006). The physician involved was almost impossible to contact which should have sent up a red flag to the APRNs that were employed there. Also the clinic was giving out a 2 month supply of prescription weight loss drugs over the counter, where normally they should be giving out a prescription to fill at a pharmacy. This is a serious patient safety concern, and I do not believe that the APRNs that were involved did not know that what they were doing was wrong.

Coalition for Nurses in Advanced Practice. (2014). Overview of APRN prescriptive privileges in Texas. Retrieved from http://www.cnaptexas.org/?page=15

KPRC News. (2006, February 8). Harwin clinic video clip. Retrieved from blackboard online website: http://twu.blackboard.com

Stewart, J. G. & DeNisco, S. M. (2015). Prescriptive Authority. In J.G. Stewart and S.M. DeNisco.Role development for the nurse practitioner (pp. 294-299). Burlington, MA: Jones & Bartlett.…...

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