TITLE 22.EXAMINING BOARDS

Part 5. STATE BOARD OF DENTAL EXAMINERS

Chapter 108. PROFESSIONAL CONDUCT

The State Board of Dental Examiners adopts new Chapter 108, Professional Conduct that includes Subchapter A, Professional Responsibility, §§108.1 through 108.11, Subchapter B, Sanitation and Infection Control, §§108.20 through 108.25, Subchapter C, Anesthesia and Anesthetic Agents, §§108.30 through 108.35, Subchapter D, Mobile Dental Facilities, §§108.40 through 108.43, Subchapter E, Business Promotion, §§108.50 through 108.61, and Subchapter F, Contractual Agreements, §§108.70 and 108.71. Section 108.8 of Subchapter A, Professional Responsibility and §§108.40, 108.41, 108.42 and 108.43 of Subchapter D, Mobile Dental Facilities were adopted with changes to the proposed text as published in the September 22, 2000, issue of the Texas Register (25TexReg9311). All other sections were adopted without changes.

Chapter 108, Professional Conduct, is adopted as a replacement for Chapter 109, Conduct which was repealed and a complete explanation of the disposition of each rule in Chapter 108 follows.

Subchapter A, Professional Responsibility covers Rules 108.1 through 108.11.

Section 108.1, Professional Responsibility. Language of this rule was formerly found in Rule 109.103, which fixed professional responsibility in the provision of dental services and enumerated a list of prohibited actions. The preamble was modified by adding an admonition for honesty, integrity and fair dealing. The Board elects to retain the language found in paragraphs (1) through (6), because that language continues to serve a useful purpose in the regulation of a dentist's conduct. Paragraph (7) is amended to conform with the intent of the language found in the preamble. The words "without first" are substituted for the words "only after" in Rule 109.103 (7). The words "but are not limited to" have been eliminated because the words "shall include" make them unnecessary. The review of repealed rule 109.103 confirms that the reasons for initially adopting the language and intent of that rule still exist.

No comments were received regarding adoption of the proposal.

Section 108.2, Fair Dealing, language was derived from former Rules 109.105, 109.122, 109.141 and 109.211. Those four rules dealt with the same subject matter and the Board decided it would be more efficient to combine them into one rule. The language of 108.2 (a) adds the words "...of the proposed treatment, and any reasonable alternatives, in a manner that allows the patient to become involved in treatment decisions" to the preamble, which was found in Rule 109.122. This is based on the American Dental Association's guidelines for ethical behavior. The language of 108.2 (b) derived from former Rule 109.122 and is repeated verbatim. The language of 108.2 (c) repeats that found in former Rule 109.141 (b). Subsection (d) of Rule 108.2 repeats the language of former Rule 109.141 (a), with the exception of the first sentence of that section. The language of 108.2 (e) derives from Section 101.203 of the Texas Occupations Code and Rule 109.211 (17), which defines "overcharging." Section 108.2 (f) repeats verbatim the language of former Rule 109.105 and states that a dentist cannot ask an auxiliary to perform a procedure that he or she cannot perform. The Board has determined that the language and intent of repealed rules 109.105, 109.122, 109.141 and 109.211 continues to exist and has been supplanted by new rule 108.2. The Board has determined that the reasons for initially adopting the language and the intent of the repealed rules 109.105, 109.122, 109.141 and 109.211 continue to exist and have been supplanted by new rule 108.2.

No comments were received regarding adoption of the proposal.

Section 108.3, Consumer Information, repeats almost verbatim the language found in repealed rule 109.10. The former paragraph (4) of Rule 109.10 has been eliminated because it is unnecessary verbiage and unnecessary. The former paragraph (5) is now paragraph (4) of Rule 108.3. The Board chooses to retain the language and intent of repealed rule 109.10 for the benefit of consumers.

No comments were received regarding adoption of the proposal.

Section 108.4, Names of Dentists, combines provisions of repealed rules 109.2, 109.6, 109.7, 109.201 and Sections 259.002 and 259.003 of the Texas Occupations Code. Section 259.002 requires that the names of, degrees received by and school attended by each dentist in a dental office shall be listed. This requirement is repeated in Subsection (a) of 108.4. Subsection (b) combines language of Section 259.003, Occupations Code and subsection (b) of former rule 109.2. Subsection (c) derives from former rule 109.6 (a) and requires that only the name(s) of a dentist(s) actually practicing at a particular location shall be displayed there. Subsection (d) derives from former rule 109.6 (a), second sentence. The third sentence of that rule is deleted, because it places an open-ended burden on dentists who have left that location. Subsection (e) derives from former rule 109.6 (b), with minor grammatical changes. Subsection (f) derives from former rule 109. 81, with a change in the language from "employing dentist" to "supervising dentist," to reflect a change in the practice requirements for dental hygienists. The review of the repealed rules, as well as the cited statutes, confirms that the reasons for the language and intent of the rules still exists.

No comments were received regarding adoption of the proposal.

Section 108.5, Termination of Relationship, is adopted as a replacement for Rule 109.121, which was repealed. The new rule clarifies that a dental patient's oral health should not be jeopardized by termination of the dentist-patient relationship. The Board found that it was called upon frequently to explain the requirements for termination and the new rule is intended to provide guidelines and prevent confusion. Rule 108.5 provides detailed instructions that a dentist can follow in terminating a dentist-patient relationship. Paragraph (1) directs a minimum 30-day notice period and the methods to deliver the notice. Paragraph (2) lists the elements of a proper written notice and paragraph (3) states that a dentist shall continue to render appropriate care for at least 30 days from the date the notice was mailed.

In response to publication for comment, the Board received written comments from a representative of the University of Texas Medical Branch, which provides dental services to the Texas Department of Criminal Justice and the Texas Youth Commission.

The written comments expressed concern that a dentist working in a correctional institution might be found to have improperly terminated dental services for a patient who was transferred to another institution. An inmate who is a dental patient may be transferred to a different facility, at any time. The transfer is outside the control of the treating dentist, who, it is feared, might be held accountable for terminating the dentist-patient relationship. The new rule only applies to a situation when a dentist terminates the relationship. Rule 108.8 provides that a dentist may transfer original records to another dentist "who will provide treatment. The Board is of the opinion that a transfer of an inmate who is a dental patient does not trigger the application of Rule 108.5.

On the other hand, the Board recognizes that there may be times when a treating dentist wishes to terminate the dentist-patient relationship with an inmate. The fact that the relationship occurred in an institutional setting does not seem to be an impediment to compliance with the rule. If a patient is transferred within the 30-day notice period, treatment can be assumed by a dentist at the new location, who will be informed of the termination by referral to the patient's dental records.

The Board is of the opinion that the language of Rule 108.5 is appropriate and should not be changed.

Section 108.6, Report of Patient Death or Injury Requiring Hospitalization, replaces repealed rule 109.177, which was difficult to interpret, because of ambiguous language. Rule 108.6 is an attempt to clarify the circumstances under which a dentist must report an adverse incident arising as a consequence of dental treatment. Under repealed rule 109.177, any time a dental patient died, a dentist who had rendered dental services to that person had to report the death, no matter how remote in time or circumstances from the dental treatment. Paragraph (1) makes it clear that the death of a dental patient must be reported if the death was a consequence of the receipt of dental services from the reporting dentist. Likewise, the conditions under which an injury to a dental patient must be reported have been clarified, in paragraph (2). Rule 108.6 as stated requires that an injury requiring admission to a hospital must be reported, if the injury was a consequence of receiving dental services from the reporting dentist. The new rule also eliminates a confusing, unclear definition of "morbidity." All reports of death or injury will be evaluated by the Enforcement Committee, to determine whether the circumstances should be investigated by the Board. The Board has determined that the intent of the repealed rule continues to be valid and has been supplanted by new rule 108.6.

No comments were received regarding adoption of the proposal.

Section 108.7, Minimum Standard of Care, General, repeats verbatim the language of the repealed rule 109.173. The intent of new rule 108.7 is to establish a minimum standard of care for all dentists practicing in Texas. Because of the location of repealed rule 109.173 in Subchapter L, Anesthesia and Anesthetic Agents, many dentists were unaware of the rule, because they do not hold anesthesia permits. Rule 108.7 in new Subchapter A, Professional Responsibility, makes it clearer that the standard applies to all dentists. The Board has determined that the intent of the language of repealed rule 109.173 is still valid and has been supplanted by new rule 108.7.

No comments were received regarding adoption of the proposal.

Section 108.8, Records of the Dentist is adopted as a replacement for Rule 109.144, which was repealed. The new rule expands the provisions of the former rule pertaining to dental records and recognizes the effect of new legislation, effective September 1, 1999, that provides dental patients with a privilege against disclosure of personal information found in those records. In response to publication for comment, the Board received written comments from a representative of the University of Texas Medical Branch (UTMB), which provides dental services to the Texas Department of Criminal Justice and Texas Youth Commission.

Section 108.8 clarifies the requirements for record keeping and provides guidelines about responsibility for the custody of patient records. Subsection (a) provides a definition of "adequate records." Subsection (b) provides a listing of documents and tangible objects that can be considered "dental records." Subsection (c) requires compliance with DEA and DPS prescription programs. Subsection (d) requires compliance with the Texas Controlled Substances Act. Subsection (e) clarifies that dental records belong to the dentist who provided treatment. The language also permits transfers of records under certain circumstances. Some minor grammatical changes are made for consistency. Subsection (f) explains what a dentist should do with records when he or she leaves a practice or location. It also clarifies the requirements for the possible transfer of records in an employment situation. Subsection (g) recognizes the new privilege against disclosure and provides that compliance with a request for records by Board investigators does not violate that privilege. Subsection (h) spells out the procedure for a patient to follow in order to obtain copies of dental records. It also clarifies that copies may not be withheld because of a past due account.

Written comments received in response to publication expressed concern about the possible impact of the rule on state agencies which employ dentists. UTMB commented about subsections (b) (e) and (h) of the rule. Requirements to retain bulky objects such as study models, casts, molds and impressions, found in the definition of "dental records" in subsection (b), would require additional expenditures to increase warehouse space. The agency archives paper records but has no guidelines to retain the other items. The commenter suggested that the Board adopt additional language permitting state agencies to establish rules for maintenance of health records.

The rule governs the conduct of individual dentists in the provision of dental services to patients. As such, the rule is intended to protect dental patients and dentists who treat them. The rule does not mandate how an organization that employs dentists should conduct its business.

The Board is not insensitive to the unique environment in which correctional institutions operate and the requirements placed upon them by federal and state law. However, in the event of a claim of unsatisfactory dental services, it is essential to have thorough documentation of procedures performed on dental patients. Dentists who practice in institutional settings are held to the same standard of care as sole practitioners in private practice. Regrettably, the impact of the requirement to keep study models, casts, molds and impressions increases significantly in magnitude for a large population, such as residents of correctional institutions. The Board, while sensitive to the additional burden placed on such organizations, is of the opinion that subsection (b) is appropriate and should not be changed.

UTMB also expressed concern about the application of subsection (e). This subsection states that dental records belong to the treating dentist. The records of offenders are maintained in a centralized depository. He suggested language that would permit a different interpretation of the responsibility for dental records. The Dental Practice Act at §255.051(a) provides that dental records belong to the dentist who performs a dental service and the Board by rule cannot change the effect of that provision.

Concerning subsection (h), the commenter pointed out that his agency does provide dental records to patients who request them, but that fees charged for copies should be established internally. The Board recognizes that dentists employed in correctional institutions work under different circumstances than private practitioners. They are paid by salary and do not personally incur costs for reproduction of records. Offenders are paid according to institutional standards. All costs and fees addressed in subsection (h) are paid, ultimately, from tax revenue. Fees to be paid will come from the same source.

The Board approves the suggested language and Rule 108.8 at subsection (h) is amended by adding the following language in new paragraph (4): "state agencies and institutions will provide copies of dental health records to patients who request them following applicable agency rules and directives."

Section 108.9, Dishonorable Conduct, provides that the listed conduct constitutes a violation of the law. It is derived from repealed rule 109.211, which, by contrast, merely defined the types of conduct that could be considered dishonorable. Paragraph (1) combines the language found in former paragraphs (2) and (3). Paragraph (2) modifies former paragraph (4) and states a clearly identifiable course of conduct related to the provision of dental services that constitutes a violation. Paragraph (3) derives from former paragraph (8) and provides that a dentist is prohibited from grossly over administering drugs as well as grossly over prescribing and dispensing. Paragraph (4) derives from former paragraph (9) but changes the former language from "...or not for a dental or maxillofacial surgery problem" to "...or not for a dental purpose." The words "dental purpose" encompass "maxillofacial surgery problem." Paragraph (5) repeats former paragraph (10), except that the new section uses the active voice. Paragraph (6) addresses conduct that might not be capable of precise classification by referring to the statutes or rules but is, nonetheless, accepted by the profession as dishonorable. An example might be inappropriate sexual contact with a dental patient. This language replaces paragraph (1) of repealed rule 109.211. Paragraph (1) of former rule 109.211 is unnecessary, in view of the language contained in new paragraph (5). Former paragraph (6) is addressed in Sections 251.003 and 256.001 of the Occupations Code and is repealed as unnecessary. Former paragraph (7) is repealed as unnecessary, because its subject matter is covered in Sections 102.001 through 102.011 and 259.008 of the Occupations Code. The intent of former paragraphs (11), (12) and (13) of former Rule 109.211 is addressed in new rule 108. 1 (1) and is repealed as unnecessary. Former paragraph (14) is addressed in Chapter 53 of the Occupations Code, as well as Sections 263.001, 263.002 and Rule 101.8. Former paragraph (15) is repealed as unnecessary because its intent is contained in Section 251.003 of the Occupations Code and new rule 108.70, formerly rule 109.500. Former paragraph (16) and (17) are repealed because their intent is found in the language of new rule 108.2 (e). The Board has determined that the reasons for initially adopting the language and the intent of repealed rule 109.211 still exist and are supplanted with modifications in new rule 108.9.

No comments were received regarding adoption of the proposal.

Section 108.10, Educational or Other Requirement, derives from repealed rule 109.181 and is repeated verbatim, except that the words "...and must not have been convicted of any felony offense during the term of retired status." have been deleted. This language is unnecessary because such a situation is addressed by Chapter 53 of the Occupations Code, as well as Sections 263.001, 263.002 and rule 101.8, pertaining to the effect of a felony conviction. The Board has determined that the reasons for initially adopting the language and intent of repealed rule 109.181 continue to exist and the language regarding felony convictions is contained in another rule and statutes.

No comments were received regarding adoption of the proposal.

Section 108.11, Display of Registration is adopted to comply with new legislation effective September 1, 1999 in Senate Bill 964, Section 6. The new legislation amended former article 4548d, now Section 256.103 of the Occupations Code, which required display of a license by a dentist. The legislation requires that dentists and dental hygienists display a current registration certificate in each office where they practice. It recognizes that dental hygienists as well as dentists must annually renew their registration with the Board. It was possible that a practitioner could have received a dental license at some time in the past, but might not be current with the Board. The requirement to display a current registration certificate expands application of the rule to dental hygienists and assures the public that they are receiving dental services from practitioners who are properly registered with the Board,. The new rule implements the recent legislation.

The Board received a written comment from the University of Texas Medical Branch, which provides dental services to the Texas Department of Criminal Justice and the Texas Youth Commission. Dentists and dental hygienists employed in correctional institutions may provide dental treatment at several facilities and the requirement to display duplicate registration certificates could place a financial burden on the agency, which would have to pay the fee for duplicate certificates.

The Board is sensitive to the unique circumstances that dentists and dental hygienists who work in an institutional setting face, but the Board is bound by the new enabling legislation. Such a change is within the province of the State Legislature. The Board suggests, in response, that dentists and dental hygienists could carry their registration certificates with them, to display in each location where they practice. The language of the rule will not be changed.

New Subchapter B, Sanitation and Infection Control covers new rules 108.20 through 108.25. The new Subchapter is made up of rules previously found in repealed Chapter 109, Conduct, Subchapters H and Q, which are discussed as follows.

Section 108.20, Purpose, is a repeat of repealed rule 109.220 with no changes except that a statutory reference has been changed to refer to the appropriate section of the Occupations Code that became effective September 1, 1999. The rule sets forth the purpose of the subchapter, to establish proper infection control procedures. That purpose has not changed and the need to state it continues.

No comments were received regarding adoption of the proposal.

Section 108.21, Requirement, is a repeat of repealed rule 109.131 with non-substantive language changes. The rule requires dentists to maintain clean and sanitary conditions in their offices. Superfluous language concerning filth, trash and debris was dropped from this rule. The intent of the rule remains valid and the Board proposes that it continues to exist.

No comments were received regarding adoption of the proposal.

Section 108.22, Access to Dental Office, repeats verbatim the language of the repealed rule 109.132, effective February 5, 1999, and which was repealed as part of the rule review process, to be supplanted by new rule 108.22. No comments were received when former rule 109.132 was published for comment. Written comments concerning rule 108.22 have been received from a representative of the University of Texas Medical Branch, which provides dental services to the Texas Department of Criminal Justice and the Texas Youth Commission. The purpose of the rule clarifies that an unsanitary dental office may present a threat to the public health and welfare. Accordingly, refusal to grant access to Board investigators acting pursuant to an allegation of unsanitary conditions is considered serious enough to call into play the provisions of the law that allow a temporary suspension of a dental license.

A dentist working in a correctional institution might be held accountable for refusing to grant access to an institutional dental facility which is subject to security regulations and restrictions to access of the institution. The Board recognizes the problems attendant to maintaining security in an institutional setting, and Board investigators are instructed to work with authorities when investigating complaints occurring on institutional premises. The rule is intended to regulate the conduct of individual dentists not other state agencies. A dentist who is willing to grant access to dental facilities but encounters difficulty in complying because of security considerations of the correctional institution need not fear reprisal from the Board. The Board is of the opinion that the language of the rule is reasonable and should not be changed.

Section 108.23, Definitions, is a repeat of repealed rule 109.221 with minor non-substantive language changes. The Board has determined that the reasons for initially adopting the language and intent of repealed rule 109.221 still exist and it is supplanted by new rule 108.23.

No comments were received regarding adoption of the proposal.

Section 108.24, Required Sterilization and Disinfection. The language of this rule is taken verbatim from repealed rule 109.222, Required Sterilization and Disinfection. The Board has determined that the language and intent should be continued unchanged in new rule 108.24.

No comments were received regarding adoption of the proposal.

Section 108.25, Dental Health Care Workers. Subsections (a) and (b) of this rule are taken verbatim from subsections (a) and (b) of repealed rule 109.223, Dental Health Care Workers. Subsections (c) (d) and (e) of Rule 109.223 are deleted on the basis of Attorney General Opinion DM-136 which held that adoption by the State Board of Dental Examiners of these sections was not authorized by the Health and Safety Code §85.204 et.seq., 1991. A new subsection (c) is added requiring a dental health care worker who knows he/she is HbeAg positive to report his/her status to an expert review panel pursuant to THSC §85.204, 1991. Further, repealed rule 109.223(f), now rule 108.25(d) is amended to require dental health care workers who are HbeAg positive to notify prospective patients of that status and to get patient consent before performing an exposure-prone procedure. The new language is a more clear statement of requirements.

No comments were received regarding adoption of the proposal.

New Subchapter C, Anesthesia and Anesthetic Agents which covers rules 108.30 through 108.34 replaces repealed rules 109.171 through 109.175. With the exception of Rule 108.32, Minimum Standard of Care, Anesthesia, discussed in detail below, the rules in this Subchapter are repeated verbatim from repealed rules 109.171 through 109.175. The agency adopted amendments to all the rules in September, 1999 after several public hearings and over two years of discussion. The Board has determined that the reasons for initially adopting the language and intent of these repealed rules continue to exist and is supplanted in the new rules 108.30 through 108.34.

Section 108.30, Effective Date, is a verbatim repeat of repealed rule 109.171, Effective Date.

No comments were received regarding adoption of the proposal.

Section 108.31, Definitions, is a verbatim repeat of repealed rule 109.172, Definitions.

No comments were received regarding adoption of the proposal.

Section 108.32, Minimum Standard of Care, Anesthesia, is changed from repealed rule 109.173, Minimum Standard of Care, by adding the word Anesthesia to the title and by changing the introductory paragraph to limit the reach of the rule to dentists who utilize anesthesia or anesthetic agents. The prior rule by its terms affected all dentists. The remainder of the rule is a verbatim repeat of repealed rule 109.173.

No comments were received regarding adoption of the proposal.

Section 108.33, Sedation/Anesthesia Permit, is a verbatim repeat of repealed rule 109.174.

No comments were received regarding adoption of the proposal.

Section 108.34, Permit Requirements and Clinical Provisions, is a verbatim repeat of repealed rule 109.175.

No comments were received regarding adoption of the proposal.

Section 108.35, Authority to Demonstrate Anesthesia, is a repeat of repealed rule 109.176 with minor language changes. The effect of the rule is unchanged in that clinical demonstrations of sedative/anesthetic techniques must be approved by the Board except those provided by a recognized school of dentistry. The Board has determined that the reasons for initially adopting the language and intent of repealed rule 109.176 continues to exist and it is supplanted by new rule 108.35.

No comments were received regarding adoption of the proposal.

Subchapter D, Mobile Dental Facilities contains all new rules. Repealed rules addressing Mobile or Moveable Offices, rules 109.151 through 109.155 affected operations provided on a "no fee" basis required prior approval in thirty day increments and required prior designation of all locations to be visited.

The new rules require registration for a permit for all mobile and portable dental operations unless an exception is provided in the rules. Since the current rules apply only to mobile operations where no fee is charged and since almost all dental operations are provided in exchange for a fee paid by Medicaid or other governmental programs, there are no rules affecting most mobile and portable operations. As a result most mobile and portable facilities providing dental services in Texas are doing so without having provided any information to the Board concerning operations. Thus, when the Board receives inquiries from legislators, local officials, other state agencies or the public regarding any mobile or portable dental operations it is not in a position to provide reliable information. Of great concern to the Board is whether the services are provided in a manner to meet standard of care requirements, whether arrangements have been made for follow-up care, especially in emergency situations, and whether records of treatment provided will be available to the patients. It is to meet theses concerns that the Board proposed new Subchapter D, which consists of four rules. They are:

Section 108.40, Permit Required, provides that mobile and portable dental operations must be permitted and provides five exception categories.

Section 108.41, Definitions, defines terms needed to make rules clear.

Section 108.42 Obtaining a Permit

Section 108.43, Operating Requirements for Permitted Mobile Dental Facilities or Portable Dental Units describes operating and reporting requirements.

Changes were made to rules as published for purposes of clarification, even though there were no comments on those points. Rule 108.40, Permit Requirement, at subsection (a) was amended to add an effective date of September 1, 2001 for the rules. Rule 108.42 (a) was also amended to replace a reference to board rules with a reference to the Dental Practice Act, which is a more appropriate reference. Also, the words "or educational" was added to the last sentence of subsection (a) to make it clear that one permit fee will be required of governmental and educational entities.

A number of written comments were received and a number of individuals requested a public hearing to present their comments. The Board conducted a public hearing on November 10, 2000. Comments made at the hearing will be addressed first.

Appearing at the public hearing were representatives of the Texas Dental Association, Texas Academy of General Dentistry, University of Texas Health Science Center, San Antonio, San Antonio Dental Society, Dentists Who Care, and National Heritage Insurance Corporation. Also, six persons appeared on their own behalf.

Three speakers addressed the Board and suggested that rule 108.40 should be amended to include an exception to allow a dentist to take equipment to another dentist's office and provide dental services without having to first obtain a permit under the rule. At that point staff circulated proposed changes that would address this issue. The speakers reviewed the language and agreed that it addressed their concerns. As a result only the representatives from the Texas Dental Association, Dentists Who Care, and University of Texas Health Science Center, San Antonio chose to speak as they had other concerns; all the remainder of those who appeared did not speak as their concerns had been addressed.

The Board agrees that the concerns expressed by the speakers and by those who made written comments on this point are well taken. Services provided in the office of a licensed dentist do not pose the risks that the Board is addressing by adoption of these rules. Accordingly, the rules as published are amended as follows:

Section 108.40 (5) the term "only" is deleted and the section now reads "anesthesia/sedation services are provided and the licensee is permitted to provide portable anesthesia service under the provisions of Rule 108.33 of this title (relating to Sedation/Anesthesia Permit); or,".

Paragraph (6) is added to read "the service is provided in an office of another licensed dentist."

Section 108.41 (2) is amended by deleting the phrase "other dentists' offices", to read "Portable Dental Unit - any non-facility in which dental equipment, utilized in the practice of dentistry, is transported to and utilized on a temporary basis at an out-of-office location including, but not limited to, patients' homes, schools, nursing homes, or other institutions."

Next a representative of Dentists Who Care spoke and raised two concerns. The first was that Dentists Who Care, which is a non-profit organization that provides dental care through a mobile van using area dentists who volunteer their time may not be an appropriate entity to seek a mobile permit. The rules contemplate that either licensed dentists or organizations by which dentists legally may be employed must obtain a permit. Dentists Who Care is not such an organization; it does not hire dentists, and as the rules are proposed there is no method for the organization to obtain a permit. Since the dentists who operate the van do so on a voluntary basis it would not be reasonable to require each of them to obtain permits. The Board in discussing the matter agreed that the rules should be amended to allow the Board to consider special situations such as that of Dentists Who Care and when appropriate to issue a permit. Accordingly the proposed rules are amended. Rule 108.41 (3) is amended by adding the phrase, "or an organization not otherwise included herein that demonstrates to the SBDE that it is an appropriate entity to provide mobile or portable dental services." Rule 108.42 is amended by including the phrase, "or other organizations as defined by Rule 108.41 (3) of this title (relating to Definitions ) and approved by the SBDE."

The Dentists Who Care representative also raised a concern about the amount of paper work these rules would require. He pointed out that under the rules, written approval from all government units such as counties and cities in which the mobile unit will provide services would be required. The rules require that applicants state in writing that they are in compliance with all applicable governmental requirements. Even though there is some burden imposed on permittees, it is not so heavy as to require permittees to appear before all government units in which they may operate to obtain permits especially to comply with these rules. For purposes of obtaining a permit the SBDE will accept the applicant's statement of compliance.

Next, a representative of the University of Texas Health Science Center, San Antonio spoke and repeated concerns raised in written comments. Those comments will be addressed below. Finally, a representative of the Texas Dental Association spoke and in general terms praised the rules and the efforts of the State Board of Dental Examiners.

Written comments were filed by four individuals who all requested that an exception be added to allow dentists to provide treatment in other dentists' offices. Those requests have been met as described above. One commenter also pointed out that reporting requirements for obtaining the permits are onerous. The proposed rules included a requirement for quarterly reporting by all permittees setting forth all locations served and the dates, the number of patients served and the types and quantity of services provided. The adopted rules require annual reporting rather than quarterly of all the matters set out above. Further, the Board is of the opinion that requirements for obtaining a permit for most applicants (see discussion below for governmental and educational entities) should be maintained. Permitting and reporting requirements are maintained in order for the Board to have some assurance that concerns set forth at the beginning of this justification are met. Because mobile and portable dental operations are transient in nature and there is only limited contact with patients there is no longstanding and continuing doctor-patient relationship and there is a strong possibility that a sense of accountability may be reduced or even non-existent in rare cases. The Board must provide some mechanism to maintain such accountability, permitting and reporting requirements are intended to fill that need.

Written comments were filed by San Antonio Metro Health District, University of Texas Health Science Center, San Antonio, Texas Department of Health, Texas Academy of General Dentistry, Dallas County Dental Society, University of Texas Health Science Center, Houston, and San Antonio District Dental facility urging an exemption for dentists practicing in other dentists' offices, objecting to quarterly reporting requirements and objecting to requirements for permitting, all of which have been addressed above. Further, the educational and governmental entities requested that they either be exempted from the rules or that requirements for them be adjusted concerning permitting fees, permitting requirements and reporting requirements. The Board is of the opinion that such organizations should not be exempt from permitting requirements. The rules already address the concern about the negative impact that permitting fees could have on organizations that operate multiple mobile and portable facilities. They provide that governmental and educational entities may obtain one permit for all their vans and facilities. Even though the amount of the permitting fee has not been set at this time, it will be in an amount intended to cover administrative costs and will be minimal. It, however, does agree that the accountability issues discussed above do not apply to them. Therefore rules 108.42 and 108.43 are amended to reduce permitting and operating requirements for governmental and educational entities. The substantive effect of the changes is to reduce permitting and reporting requirements. Now governmental and educational entities must meet very limited permitting and operating requirements while all other permittees must continue to meet such requirements set forth in the rules as proposed, except that as noted above annual rather than quarterly reports are required. To accomplish this a structural change was required. Rather than detailing the changes here the reader is referred to the rules themselves.

New Subchapter E, Business Promotion covers new rules 108.50 through 108.61 and deals with efforts to obtain business, including advertising, professional announcements and referral services. The former rules addressing these subject matters were found in several subchapters of the now repealed Chapter 109. New subchapter E represents an effort to reorganize and update the language previously found in these repealed rules and to reflect the realities of modern-day business practices.

Subsection (a) announces that purpose. Subsection (b) is based on the American Dental Association's guidelines for ethical behavior.

Section 108.50, Objective of Rules, serves as an introduction to the subchapter. Subsection (a) announces the purpose of the rules. Subsection (b) is based on the American Dental Association's Guidelines for Ethical Behavior.

No comments were received regarding adoption of the proposal.

Section 108.51, Advertisements, is a new rule that provides a definition of the term "Advertisements." The former rules contained only scanty references to the several media available to communicate a practitioner's qualifications to those members of the public who are searching for a qualified professional. The Board adopts this new rule as a necessary explanation of the term "Advertising".

No comments were received regarding adoption of the proposal.

Section 108.52, False or Misleading Communications derives from repealed rule 109.204 and the American Dental Association's guidelines for ethical behavior, and provides some examples of communications that could be considered to be false or misleading in a material respect. The intent of the language contained in paragraphs (1) through (6) and (8) of repealed rule 109.204 is found in paragraphs (1) through (5) of the new rule. The intent of the language of paragraph (7) of repealed rule 109.204 is contained in Section 101.201 (4) of the Occupations Code. The intent of the language of repealed rule 109.204, paragraph (9), is found in Section 259.005 (10) of the Occupations Code. The intent of the language of paragraph (10) of repealed rule 109.204 is contained in Sections 254.002 and 259.005 of the Occupations Code. The intent of the language of paragraph (11) of repealed rule 109.204 is found in new rules 108.54, 108.55 and 108.58. The Board has determined that the reason for initially adopting the language and intent of these repealed rules continues to exist and is now contained in new rule 108.52.

No comments were received regarding adoption of the proposal.

Section 108.53, Professional Announcements, derives from repealed rule 109.107, subsection (c) and provides that a dentist may announce the availability of any dental service as prescribed by the Texas Dental Practice Act, found in the Occupations Code. . The Board has determined that the reason for initially adopting the language and intent of the repealed rule continues to exist and is now contained in new rule 108.53.

No comments were received regarding adoption of the proposal.

Section 108.54, Announcement of Services, derives from repealed rule 109.107, subsection (e) and provides that general dentists may announce the services available in their practice so long as they do not express or imply specialization and so long as they announce that the services are provided by a general dentist. The Board has determined that the reason for initially adopting the language and intent of the repealed rule continues to exist and is now contained in new rule 108.54.

No comments were received regarding adoption of the proposal.

Section 108.55, Announcement of Credentials in Non-Specialty Areas, derives from repealed rule 109.109 and the American Dental Association's guidelines for ethical behavior and provides that a general dentist may announce the attainment of additional credentials in an area of practice not recognized as a specialty by the American Dental Association. The dentist must announce that the services are provided by a general dentist. The Board has determined that the reason for initially adopting the language and intent of the repealed rule continues to exist and is now contained in new rule 108.55.

No comments were received regarding adoption of the proposal.

Section 108.56, Specialty Announcement, derives from repealed rule 109.107, subsection (a) and American Dental Association guidelines for ethical behavior and provides that a dentist who is a specialist in a specialty recognized by the American Dental Association may announce that status. The Board has determined that the reason for initially adopting the language and intent of the repealed rule continues to exist and is now contained in new rule 108.56.

No comments were received regarding adoption of the proposal.

Section 108.57, Specialist Announcement of Credentials in Non-Specialty Areas, derives from repealed rule 109.109 and the American Dental Association's guidelines for ethical behavior and provides that a dentist who is a specialist in one of the specialties recognized by the American Dental Association and who also has obtained additional credentials in an area of practice not recognized as a specialty by the American Dental Association, may announce those credentials as long as specialization in the non-recognized area is not implied. The Board has determined that the reason for initially adopting the language and intent of the repealed rule continues to exist and is now contained in new rule 108.57.

No comments were received regarding adoption of the proposal.

Section 108.58, Degrees. Subsection (a) of this rule finds its origin in repealed rule 109.145. The words "A Texas dental licensee, in any professional communication..." are changed to read "A licensed Texas dentist, in any professional communication..." These changes make it clearer that the subsection applies to dentists and that the requirements apply to all professional communications, not just those that are written. Subsections (b) and (c) of this rule derive from repealed rule 109.191. The initials "D.O" are added as initials that can be used in addition to "D.D.S." and "M.D." Doctors of Osteopathy and Doctors of Medicine are both regulated by the same state agency and this change acknowledges Osteopathy as a recognized area of medical practice. The Board has determined that the reason for initially adopting the language and intent of the repealed rule continues to exist and is now contained in new rule 108.58.

No comments were received regarding adoption of the proposal.

Section 108.59, Testimonials, derives from the repealed rule 109.142, and is repeated, except for minor changes in the interest of grammatical consistency. The rule prohibits testimonials from Texas dentists except under certain prescribed conditions and the intent of the rule remains valid.

No comments were received regarding adoption of the proposal.

Section 108.60, False, Misleading or Deceptive Referral Schemes. The subject matter of this rule was formerly found in repealed rule 109.108. The new rule more closely tracks the provisions of Sections 102.001 through 102.011 and 259.008 (8) of the Occupations Code, prohibiting and defining false, misleading referral schemes. The Board has determined that the language and intent of the repealed rule remains valid and is now contained in new rule 108.60.

No comments were received regarding adoption of the proposal.

Section 108.61, Unlicensed Clinicians, replaces former Rule 109.161, which is repeated verbatim, providing guidelines for situations when an unlicensed clinician may teach and demonstrate procedures for the administration of anesthesia, provided that advance approval is obtained from the Board. The intent of the repealed rule remains valid.

No comments were received regarding adoption of the proposal.

New Subchapter F, Contractual Arrangements, covers Rules 108.70 and 108.71. Section 108.70, Improper Influence on Professional Judgment is a verbatim repeat of repealed rule 109.500. The Board adopted rule 109.500 in February, 2000. The rule was passed to ensure that a dentist's independent professional judgment regarding the diagnosis or treatment of any dental disease or disorder is not influenced by anyone other than a dentist. The Board has determined that the language and intent of the repealed rule remains valid and is now contained in new rule 108.70.

No comments were received regarding adoption of the proposal.

Section 108.71, Providing Copies of Certain Contracts, is a verbatim repeat of repealed rule 109.300 which was originally adopted by the Board in December 1997. The rule was passed so that contracts entered into between dentists and management professionals would be subject to review, to ensure that a dentist's independent professional judgment was not improperly influenced by non-dentists. The subject matter of the rule is also closely related to that of repealed rule 109.500. The Board has determined that the intent of repealed rules 109.300 and 109.500 remains valid and that language is now found in rules 108.70 and 108.71 of new Subchapter F.

No comments were received regarding adoption of the proposal.

Subchapter A. PROFESSIONAL RESPONSIBILITY

22 TAC §§108.1 - 108.11

The new rules are adopted under Texas Government Code §2001.021 et.seq., Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and promulgate rules consistent with the Dental Practice Act.

§108.8.Records of the Dentist.

(a)

A Texas dental licensee practicing dentistry in Texas shall make, maintain, and keep adequate records of the diagnoses made and the treatments performed for and upon each dental patient for reference, identification, and protection of the patient and the dentist. Adequate records are records from which diagnoses can be made and which clearly and accurately document all of the facts related to the treatment of a dental patient, including diagnoses, services, treatments and progress of care. Records shall be kept for a period of not less than five (5) years.

(b)

The term "dental records" includes, but is not limited to documentation of: identification of practitioner providing treatment; medical and dental history; limited physical examination; x-rays and radiographs; dental and periodontal charting; diagnoses made; treatment plans; informed consent statements or confirmations; study models, casts, molds, impressions; cephalometric diagrams; narcotic drugs, dangerous drugs, controlled substances dispensed, administered or prescribed; anesthesia records; pathology and medical laboratory reports; progress and completion notes; materials used; dental laboratory prescriptions; billing and payment records; appointment records; consultations and recommended referrals; and post treatment recommendations.

(c)

The dispensing, administering, or prescribing of narcotic drugs, dangerous drugs, or controlled substances to or for a dental patient shall be made a part of such patient's dental record. The entry in the patient's dental record shall be in addition to any record keeping requirements of the DPS or DEA prescription programs. All such drugs and substances which are kept in the dental office or under the control of the dentist are to be maintained by a centralized inventory which shall indicate dates acquired, description and quantity of drugs, date, method, quantity dispensed, and the patient to whom the drug is dispensed.

(d)

All records pertaining to Controlled Substances and Dangerous Drugs shall be maintained in accordance with the Texas Controlled Substances Act.

(e)

Dental records are the sole property of the dentist who performs the dental service. Such records shall be available for inspection by the patient after and upon appointment with a dentist. This shall not prohibit the transfer of a copy of records to the patient, or to an agreed designated consultant for ascertainment of facts, nor transfer of original records to another Texas dental licensee who will provide treatment to the patient. The transferring dentist shall retain a copy of the written record if such original transfer is made.

(f)

A dentist who leaves a location or practice, whether by retirement, sale, transfer, termination of employment or otherwise, shall either maintain all dental records belonging to him or her, make a written transfer of records to the succeeding dentist, or make a written agreement for the maintenance of records, and the State Board of Dental Examiners shall be notified within fifteen (15) days of any such event, giving full information concerning the dentists and location(s) involved. A maintenance of records agreement shall not transfer ownership of the dental records, but shall require: that the dental records be maintained in accordance with the laws of the State of Texas and the Rules of the State Board of Dental Examiners; and that the dentist(s) performing the service(s) recorded shall have access to and control of the records for purposes of inspection and copying. A transfer of records may be made by agreement at any time in an employment or other working relationship between a dentist and another entity. Such transfer of records may apply to all or any part of the dental records generated in the course of the relationship, including future dental records.

(g)

Dental records shall be made available for inspection and reproduction on demand by the officers, agents, or employees of the State Board of Dental Examiners. The patient's privilege against disclosure does not apply to the Board in a disciplinary investigation or proceeding under the Dental Practice Act.

(h)

A dentist shall furnish copies of dental records to a patient who requests his or her dental records. Requested copies including radiographs shall be furnished within thirty (30) days of the date of the request, provided however, that copies need not be released until payment of copying costs has been made. Records may not be withheld based on a past due account for dental care or treatment previously rendered to the patient.

(1)

A dentist providing copies of patient dental records is entitled to a reasonable fee for copying which shall be no more than $25 for the first 20 pages and $0.15 per page for every copy thereafter.

(2)

Fees for radiographs, which if copied by an x-ray duplicating service, may be equal to actual cost verified by invoice.

(3)

Reasonable costs for radiographs duplicated by means other than by an x-ray duplicating service shall not exceed the following charges:

(A)

a full mouth series: $15.00;

(B)

a panoramic x-ray: $15.00;

(C)

a lateral cephalogram: $15.00;

(D)

a single extra-oral x-ray: $5.00;

(E)

a single intra-oral x-ray: $5.00.

(4)

State agencies and institutions will provide copies of dental health records to patients who request them following applicable agency rules and directives.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100571

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter B. SANITATION AND INFECTION CONTROL

22 TAC §§108.20 - 108.25

The new rules are adopted under Texas Government Code §2001.021 et.seq., Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and promulgate rules consistent with the Dental Practice Act.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100573

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter C. ANESTHESIA AND ANESTHETIC AGENTS

22 TAC §§108.30 - 108.35

The new rules are adopted under Texas Government Code §2001.021 et.seq., Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and promulgate rules consistent with the Dental Practice Act.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100574

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter D. MOBILE DENTAL FACILITIES

22 TAC §§108.40 - 108.43

The new rules are adopted under Texas Government Code §2001.021 et.seq., Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and promulgate rules consistent with the Dental Practice Act.

§108.40.Permit Required.

(a)

Beginning September 1, 2001, every mobile dental facility, and, except as provided herein, every portable dental unit operated in Texas by any entity must have a permit as provided by this title (relating to Mobile Dental Facilities).

(b)

Licensees who do not have a permit for a portable dental unit or who are employed by a dental organization not having a portable dental unit permit may provide dental services through use of dental instruments and equipment taken out of a dental office without a permit if;

(1)

the service is provided as emergency treatment;

(2)

a patient of record of the licensee or organization is treated outside of the dental office;

(3)

treatment is provided to residents of nursing homes or convalescent facilities; or

(4)

treatment is provided without charge to patients or to any third party payer, so long as such treatment is not provided on a regular basis.

(5)

anesthesia/sedation services are provided and the licensee is permitted to provide portable anesthesia services under the provisions of Rule 108.33 of this title (relating to Sedation/Anesthesia Permit); or

(6)

the service is provided in an office of another licensed dentist.

§108.41.Definitions.

The following words and terms, when used in Subchapter D, Mobile Dental Facilities, shall have the following meanings, unless the context clearly indicates otherwise;

(1)

Mobile Dental Facility - any self-contained facility in which dentistry will be practiced which may be moved, towed, or transported from one location to another.

(2)

Portable Dental Unit - any non-facility in which dental equipment, utilized in the practice of dentistry, is transported to and utilized on a temporary basis at an out-of-office location including, but not limited to, patients' homes, schools, nursing homes, or other institutions.

(3)

Permit Holder - a licensed Texas dentist or an organization authorized by the Dental Practice Act to employ licensed Texas dentists to whom the permit is issued as provided by this title (relating to Mobile Dental Facilities and Portable Dental Units), or an organization not otherwise included herein that demonstrates to the SBDE that it is an appropriate entity to provide mobile or portable dental services.

(4)

Session - a period of time during which personnel associated with a permitted facility or unit are available to provide dental services at a location.

§108.42.Obtaining a Permit.

(a)

A licensed Texas dentist, an organization authorized by the Dental Practice Act or other organization as defined by rule 108.41 (3) of this title (relating to Definitions) and approved by the SBDE wishing to operate a mobile dental facility or a portable dental unit, shall apply to the State Board of Dental Examiners (SBDE) for a permit on a form provided by the Board and pay an application fee in an amount set by the Board. A governmental or educational entity may obtain a single permit, respectively, for all facilities; or all units listed on an application.

(b)

A completed application form submitted to the SBDE with all questions answered will be reviewed and if all the requirements listed in this section are met, a permit will be issued. All applications must include:

(1)

an address of record that is not a Post Office Box; and,

(2)

the name and address of the permit holder.

(c)

All applicants except governmental and higher educational entities must also include:

(1)

the name and address, and when applicable, the license number of each dentist, dental hygienist, laboratory technician, and dental assistant associated with the facility or unit for which a permit is sought;

(2)

a copy of a written agreement for the emergency follow-up care for patients treated in the mobile dental facility, or through a portable dental unit, and such agreement must include identification of and arrangements for treatment in a dental office which is permanently established within a reasonable geographic area;

(3)

a statement that the mobile dental facility or portable dental unit has access to communication facilities which will enable dental personnel to contact assistance as needed in the event of an emergency;

(4)

a statement that the mobile dental facility or portable dental unit conforms to all applicable federal, state, and local laws, regulations, and ordinances dealing with radiographic equipment, flammability, construction standards, including required or suitable access for disabled individuals, sanitation, and zoning;

(5)

a statement that the applicant posses all applicable county and city licenses or permits to operate the facility or unit;

(6)

either a statement that the unit will only be used in dental offices of the applicant or other licensed dentists, or a list of all equipment to be contained and used in the mobile dental facility or portable dental unit, which must include:

(A)

dental treatment chair;

(B)

a dental treatment light;

(C)

when radiographs are to be made by the mobile dental facility or portable dental unit, a stable portable radiographic unit that is properly monitored by the authorized agency;

(D)

when radiographs are to be made by the mobile dental facility or portable dental unit, a lead apron which includes a thyroid collar;

(E)

a portable delivery system, or an integrated system if used in a mobile dental facility

(F)

an evacuation unit suitable for dental surgical use; and

(G)

a list of appropriate and sufficient dental instruments including explorers and mouth mirrors, and infection control supplies, such as gloves, face masks, etc., that are on hand.

§108.43.Operating Requirements for Permitted Mobile Dental Facilities or Portable Dental Units.

(a)

A permit holder is required to operate a permitted Mobile Dental Facility or Portable Dental Unit in compliance with all state statutes and regulations. Further, all permit holders shall;

(1)

in writing, notify the SBDE of a change in any address required in Rule 108.42 (b) (1) of this title (relating to Obtaining a Permit) within 60 days of the change;

(2)

prominently display all dental and dental hygienist licenses and current registration certificates, Mobile Dental Facilities or Portable Dental Unit permits, or copies of permits if one permit is issued for multiple facilities or units, a consumer information sign as described in Rule 108.5 of this title (relating to Consumer Information) in compliance with the Dental Practice Act and/or the Rules and Regulations of the SBDE, provided, however, that a licensee may display a duplicate registration certification obtained from the SBDE;

(3)

maintain, in full compliance with all record-keeping requirements contained in these rules, all dental records and official records at the official address of record for the facility or unit.

(b)

All permit holders except, governmental and higher education entities, shall:

(1)

in writing, notify the SBDE of a change in personnel listed as required by Rule 108.42(b)(2) of this title (relating to Obtaining a Permit) within 30 days of any such change;

(2)

before beginning a session at any location, arrange for;

(A)

access to a properly functioning sterilization system;

(B)

ready access to an adequate supply of potable water; and

(C)

ready access to toilet facilities.

(3)

on the 10th work day of September of each year, file with the SBDE a written report for the preceding year ending August 31, detailing the location, including a street address, the dates of each session, and the number of patients served and the types of dental procedures and quantity of each service provided.

(4)

insure that all written or printed materials available from or issued by the Mobile Dental Facility or Portable Dental Unit contain the official address of record for the facility or unit;

(5)

operate a Mobile Dental Facility or Portable Dental Unit only when all requirements described in Rule 108.42 of this title (related to Obtaining a Permit) are being met.

(c)

A permit to operate a Mobile Dental Facility or Portable Dental Unit expires one (1) year after the issuance date, or on the date when the permit holder is no longer associated with the Mobile Dental Facility or Portable Dental Unit, which ever is first.

(d)

A permit holder may renew a permit by submitting an annual application which shall include a list of all locations served during the past year, and payment of required fee.

(e)

Upon cessation of operations by the Mobile Dental Facility or Portable Dental Unit, the permit holder shall notify the SBDE of the final disposition of patient records and charts.

(f)

A permit to operate a Mobile Dental Facility or Portable Dental Unit is not transferable.

(g)

The SBDE may cancel a permit if upon investigation and after opportunity for a hearing, a determination is made of non-compliance with the Dental Practice Act or the SBDE Rules and Regulations.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100575

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter E. BUSINESS PROMOTION

22 TAC §§108.50 - 108.61

The new rules are adopted under Texas Government Code §2001.021 et.seq., Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and promulgate rules consistent with the Dental Practice Act.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100576

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter F. CONTRACTUAL AGREEMENTS

22 TAC §108.70, §108.71

The new rules are adopted under Texas Government Code §2001.021 et.seq., Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and promulgate rules consistent with the Dental Practice Act.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100577

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Chapter 109. CONDUCT

The State Board of Dental Examiners adopts The repeal , Title 22, Texas Administrative Code, Part 5, Examining Board, including Subchapter A, Professional Signs, §§109.1, 109.2 and 109.6 - 109.10; Subchapter B, Telephone Directory Listings, §§109.43 and 109.44; Subchapter C, Listings of Auxiliary Personnel, §109.81; Subchapter D, Gifts and Premiums, §109.91; Subchapter E, Prohibitions, §§109.102 -109.105 and 109.107 - 109.109; Subchapter F, Suspended or Revoked Licenses, §109.111; Subchapter G, Termination of Relationship, §§109.121 and 109.122; Subchapter H, Sanitation, §§109.131 and 109.132; Subchapter I, Fair Dealing, §§109.141 - 109.145; Subchapter J, Mobile or Moveable Offices, §§109.151 - 109.155; Subchapter K, Visiting Clinicians - Courses Seminars, §109.161; Subchapter L, Anesthesia and Anesthetic Agents, §§109.171 - 109.177; Subchapter M, Retired Status, §109.181; Subchapter N, Double Degrees, §109.191; Subchapter O, Advertising, §§109.201, 109.203, 109.204; Subchapter P, Definitions, §109.211; Subchapter Q, Infection Control, §§109.220 - 109.224; Subchapter R, Providing Copies of Certain Contracts, §109.300 and Subchapter T, Agreements with Non-Dentists, §109.500 without changes to the proposed text published in the September 22, 2000 issue of the Texas Register (25 TexReg 9332). The repeal et. seq. is adopted without changes and therefore will not be republished.

Pursuant to the rule review process, the General Appropriations Act of 1997, Article IX, §167, Acts of the 75th Legislature Regular Session, 1997, the State Board of Dental Examiners determined that many of the rules found in Chapter 109, Conduct, were duplicative, obsolete and irrelevant. Many of the rules had not been visited for several years and were found to be inapplicable to agency policies and procedures and the realities of dental practice in the 21st century. Rules pertaining to particular subject matter, such as Advertising, were scattered throughout the chapter, creating confusion. The process of reorganizing, amending, repealing and readopting the rules found in Chapter 109 would have created an administrative and logistical nightmare. The Board determined that it is more efficient to propose The repeal , Conduct, in its entirety and replace it with the proposed new Chapter 108. The conceptual content of the rules governing conduct found in Chapter 109 will not cease to exist, but will be supplanted by the rules in new Chapter 108 adopted by the Board on January 26, 2001 and published in the Adopted Rules section of this issue of the Texas Register .

No comments were received regarding the proposal to repeal Chapter 109 et.seq.

Subchapter A. PROFESSIONAL SIGNS

22 TAC §§109.1, 109.2, 109.6 - 109.10

The repeal is adopted under Texas Government Code §2001.021 et. seq.; Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and enforce rules necessary for it to perform its duties, and to ensure compliance with laws relating to the practice of dentistry.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100578

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter B. TELEPHONE DIRECTORY LISTINGS

22 TAC §109.43, §109.44

The repeal is adopted under Texas Government Code §2001.021 et. seq.; Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and enforce rules necessary for it to perform its duties, and to ensure compliance with laws relating to the practice of dentistry.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100579

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter C. LISTINGS OF AUXILIARY PERSONNEL

22 TAC §109.81

The repeal is adopted under Texas Government Code §2001.021 et. seq.; Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and enforce rules necessary for it to perform its duties, and to ensure compliance with laws relating to the practice of dentistry.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100580

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter D. GIFTS AND PREMIUMS

22 TAC §109.91

The repeal is adopted under Texas Government Code §2001.021 et. seq.; Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and enforce rules necessary for it to perform its duties, and to ensure compliance with laws relating to the practice of dentistry.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100581

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter E. PROHIBITIONS

22 TAC §§109.102 - 109.105, 109.107 - 109.109

The repeal is adopted under Texas Government Code §2001.021 et. seq.; Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and enforce rules necessary for it to perform its duties, and to ensure compliance with laws relating to the practice of dentistry.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100582

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter F. SUSPENDED OR REVOKED LICENSES

22 TAC §109.111

The repeal is adopted under Texas Government Code §2001.021 et. seq.; Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and enforce rules necessary for it to perform its duties, and to ensure compliance with laws relating to the practice of dentistry.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100583

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter G. TERMINATION OF RELATIONSHIP

22 TAC §109.121, §109.122

The repeal is adopted under Texas Government Code §2001.021 et. seq.; Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and enforce rules necessary for it to perform its duties, and to ensure compliance with laws relating to the practice of dentistry.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100584

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter H. SANITATION

22 TAC §109.131, §109.132

The repeal is adopted under Texas Government Code §2001.021 et. seq.; Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and enforce rules necessary for it to perform its duties, and to ensure compliance with laws relating to the practice of dentistry.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100585

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter I. FAIR DEALING

22 TAC §§109.141 - 109.145

The repeal is adopted under Texas Government Code §2001.021 et. seq.; Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and enforce rules necessary for it to perform its duties, and to ensure compliance with laws relating to the practice of dentistry.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100586

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter J. MOBILE OR MOVEABLE OFFICES

22 TAC §§109.151 - 109.155

The repeal is adopted under Texas Government Code §2001.021 et. seq.; Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and enforce rules necessary for it to perform its duties, and to ensure compliance with laws relating to the practice of dentistry.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100587

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter K. VISITING CLINICIANS-COURSES: SEMINARS

22 TAC §109.161

The repeal is adopted under Texas Government Code §2001.021 et. seq.; Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and enforce rules necessary for it to perform its duties, and to ensure compliance with laws relating to the practice of dentistry.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100588

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter L. ANESTHESIA AND ANESTHETIC AGENTS

22 TAC §§109.171 - 109.177

The repeal is adopted under Texas Government Code §2001.021 et. seq.; Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and enforce rules necessary for it to perform its duties, and to ensure compliance with laws relating to the practice of dentistry.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100589

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter M. RETIRED STATUS

22 TAC §109.181

The repeal is adopted under Texas Government Code §2001.021 et. seq.; Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and enforce rules necessary for it to perform its duties, and to ensure compliance with laws relating to the practice of dentistry.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100590

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter N. DOUBLE DEGREES

22 TAC §109.191

The repeal is adopted under Texas Government Code §2001.021 et. seq.; Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and enforce rules necessary for it to perform its duties, and to ensure compliance with laws relating to the practice of dentistry.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100591

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter O. ADVERTISING

22 TAC §§109.201, 109.203, 109.204

The repeal is adopted under Texas Government Code §2001.021 et. seq.; Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and enforce rules necessary for it to perform its duties, and to ensure compliance with laws relating to the practice of dentistry.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100592

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter P. DEFINITIONS

22 TAC §109.211

The repeal is adopted under Texas Government Code §2001.021 et. seq.; Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and enforce rules necessary for it to perform its duties, and to ensure compliance with laws relating to the practice of dentistry.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100593

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter Q. INFECTION CONTROL

22 TAC §§109.220 - 109.224

The repeal is adopted under Texas Government Code §2001.021 et. seq.; Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and enforce rules necessary for it to perform its duties, and to ensure compliance with laws relating to the practice of dentistry.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100594

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter R. PROVIDING COPIES OF CERTAIN CONTRACTS

22 TAC §109.300

The repeal is adopted under Texas Government Code §2001.021 et. seq.; Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and enforce rules necessary for it to perform its duties, and to ensure compliance with laws relating to the practice of dentistry.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100595

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Subchapter T. AGREEMENTS WITH NON-DENTIST

22 TAC §109.500

The repeal is adopted under Texas Government Code §2001.021 et. seq.; Texas Civil Statutes, the Occupations Code §254.001 which provides the State Board of Dental Examiners with the authority to adopt and enforce rules necessary for it to perform its duties, and to ensure compliance with laws relating to the practice of dentistry.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on January 31, 2001.

TRD-200100596

Jeffry R. Hill

Executive Director

State Board of Dental Examiners

Effective date: February 20, 2001

Proposal publication date: September 22, 2000

For further information, please call: (512) 463-6400


Part 11. BOARD OF NURSE EXAMINERS

Chapter 221. ADVANCED PRACTICE NURSES

22 TAC §§221.1-221.15

The Board of Nurse Examiners for the State of Texas adopts the repeal of §§221.1-221.15, relating to Advance Practice Nurses without changes to the proposed repeal published in the December 1, 2000, issue of the Texas Register (25 TexReg 11821).

The rules are repealed due to the adoption of new rules §§221.1-221.17 made in response to the Board's effort to implement House Bill 1, §167, Article IX, passed by the 75th Legislative Session, which requires that each rule adopted by an agency be reviewed and revised, if necessary, within four years of the date of its adoption. The new rules are being adopted simultaneously with this notice.

No comments were received concerning the repeal, and therefore the repeal will be adopted without changes and will not be republished.

The repeal is authorized under the authority of the Texas Occupations Code, §301.151 and §301.152 which authorizes the Board of Nurse Examiners to adopt and enforce rules consistent with its legislative authority under the Nursing Practice Act including rules relating to registered nurses who are approved, or seeking approval, as advanced practice nurses.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on February 5, 2001.

TRD-200100706

Katherine A. Thomas, MN, RN

Executive Director

Board of Nurse Examiners

Effective date: February 25, 2001

Proposal publication date: December 1, 2000

For further information, please call: (512) 305-6811


22 TAC §§221.1-221.17

The Board of Nurse Examiners for the State of Texas adopts new §§221.1-221.17, relating to Advance Practice Nurses. Section 221.16 and §221.17 are adopted with changes to the proposed text as published in the December 1, 2000, issue of the Texas Register (25 TexReg 11821). Sections 221.1-221.15 are adopted without changes and will not be republished.

The new rules are adopted in response to the Board's effort to implement House Bill 1, §167, Article IX, passed by the 75th Legislative Session, which requires that each rule adopted by an agency be reviewed and revised, if necessary, within four years of the date of its adoption.

Section 221.16(a)(1) was slightly modified in response to a comment received. The Texas Association of Nurse Anesthetists (TANA) submitted a recommendation that proposed §221.16 (relating to the Provision of Anesthesia Services by Nurse Anesthetists in Outpatient Settings) include language requiring certified registered nurse anesthetists administering any inhaled anesthetic, including nitrous oxide, to register with the Board when doing so in outpatient settings. It is TANA's position that patient response to these anesthetic agents can vary significantly. As a result, the anesthesia provider must be prepared to handle complications or side effects by meeting the minimum standards as addressed in Proposed §221.16. Inclusion of the recommended language would further provide for the safety of patients in these settings.

The Board of Nurse Examiners agrees with the comment made by the Texas Association of Nurse Anesthetists and the rationale for the amendment to the rule as proposed. This amendment is consistent with the Board's intention to include registration of nurse anesthetists administering inhaled anesthetics in these settings. The adoption of this additional language will allow the Board to better promote and protect the welfare of the people of Texas and clarify the requirement as intended. Therefore, the Board, in adopting Chapter 221, has included the specific language requested by TANA's comment in §221.16(a)(1).

Section 221.16(a)(1) was slightly modified in response to a comment received and does not reflect a substantive variation from the proposed text, and therefore republication of the proposed amendment is not required.

The new §§221.1-221.17 are adopted under the authority of the Texas Occupations Code, §301.151 and §301.152 which authorizes the Board of Nurse Examiners to adopt and enforce rules consistent with its legislative authority under the Nursing Practice Act including rules relating to registered nurses who are approved, or seeking approval, as advanced practice nurses.

§221.16.Provision of Anesthesia Services by Nurse Anesthetists in Outpatient Settings.

(a)

Purpose. The purpose of these rules is to identify the roles, and responsibilities of certified registered nurse anesthetists authorized to provide anesthesia services in outpatient settings and to provide the minimum acceptable standards for the provision of anesthesia services in outpatient settings.

(1)

On or after August 31, 2000 certified registered nurse anesthetists shall comply with subsections (b)(2)-(e) of this section in order to be authorized to provide general anesthesia, regional anesthesia, or monitored anesthesia care in outpatient settings. This requirement shall include certified registered nurse anesthetists administering any inhaled anesthetic agents, including, but not limited to, nitrous oxide, due to the significant variability in patient response to such drugs.

(2)

Subsections (b)(2)-(e) of this section do not apply to the registered nurse anesthetist who practices in the following:

(A)

an outpatient setting in which only local anesthesia, peripheral nerve blocks, or both are used;

(B)

an outpatient setting in which only anxiolytics and analgesics are used and only in doses that do not have the probability of placing the patient at risk for loss of the patient's life-preserving protective reflexes;

(C)

a licensed hospital, including an outpatient facility of the hospital that is separately located apart from the hospital;

(D)

a licensed ambulatory surgical center;

(E)

a clinic located on land recognized as tribal land by the federal government and maintained or operated by a federally recognized Indian tribe or tribal organization as listed by the United States secretary of the interior under 25 U.S.C. Section 479-1 or as listed under a successor federal statute or regulation

(F)

a facility maintained or operated by a state or governmental entity;

(G)

a clinic directly maintained or operated by the United States or by any of its departments, officers, or agencies; and

(H)

an outpatient setting accredited by

(i)

the Joint Commission on Accreditation of Healthcare Organizations relating to ambulatory surgical centers;

(ii)

the American Association for the Accreditation of Ambulatory Surgery Facilities,

(iii)

the Accreditation Association for Ambulatory Health Care.

(b)

Roles and Responsibilities

(1)

Certified registered nurse anesthetists shall follow current, applicable standards and guidelines as put forth by the American Association of Nurse Anesthetists (AANA) and other relevant national standards regarding the practice of nurse anesthesia as adopted by the AANA or the Board.

(2)

Certified registered nurse anesthetists shall comply with all building, fire, and safety codes. A two-way communication source not dependent on electrical current shall be available. Each location should have sufficient electrical outlets to satisfy anesthesia machine and monitoring equipment requirements, including clearly labeled outlets connected to an emergency power supply. Sites shall also have a secondary power source as appropriate for equipment in use in case of power failure.

(3)

In an outpatient setting, where a physician has delegated to a certified registered nurse anesthetist the ordering of drugs and devices necessary for the nurse anesthetist to administer an anesthetic or an anesthesia-related service ordered by a physician, a certified registered nurse anesthetist may select, obtain and administer drugs, including determination of appropriate dosages, techniques and medical devices for their administration and in maintaining the patient in sound physiologic status. This order need not be drug-specific, dosage specific, or administration-technique specific. Pursuant to a physician's order for anesthesia or an anesthesia-related service, the certified registered nurse anesthetist may order anesthesia-related medications during perianesthesia periods in the preparation for or recovery from anesthesia. In providing anesthesia or an anesthesia-related service, the certified registered nurse anesthetist shall select, order, obtain and administer drugs which fall within categories of drugs generally utilized for anesthesia or anesthesia-related services and provide the concomitant care required to maintain the patient in sound physiologic status during those experiences.

(c)

Standards

(1)

The certified registered nurse anesthetist shall perform a pre-anesthetic assessment, counsel the patient, and prepare the patient for anesthesia per current AANA standards. Informed consent for the planned anesthetic intervention shall be obtained from the patient/legal guardian and maintained as part of the medical record. The consent must include explanation of the technique, expected results, and potential risks/complications. Appropriate pre-anesthesia diagnostic testing and consults shall be obtained per indications and assessment findings.

(2)

Physiologic monitoring of the patient shall be determined by the type of anesthesia and individual patient needs. Minimum monitoring shall include continuous monitoring of ventilation, oxygenation, and cardiovascular status. Monitors shall include, but not be limited to, pulse oximetry and EKG continuously and non-invasive blood pressure to be measured at least every five minutes. If general anesthesia is utilized, then an O 2 analyzer and end-tidal CO 2 analyzer must also be used. A means to measure temperature shall be readily available and utilized for continuous monitoring when indicated per current AANA standards. An audible signal alarm device capable of detecting disconnection of any component of the breathing system shall be utilized. The patient shall be monitored continuously throughout the duration of the procedure by the certified registered nurse anesthetist. Postoperatively, the patient shall be evaluated by continuous monitoring and clinical observation until stable by a licensed health care provider. Monitoring and observations shall be documented per current AANA standards. In the event of an electrical outage which disrupts the capability to continuously monitor all specified patient parameters, at a minimum, heart rate and breath sounds will be monitored on a continuous basis using a precordial stethoscope or similar device, and blood pressure measurements will be reestablished using a non-electrical blood pressure measuring device until electricity is restored.

(3)

All anesthesia-related equipment and monitors shall be maintained to current operating room standards. All devices shall have regular service/maintenance checks at least annually or per manufacturer recommendations. Service/maintenance checks shall be performed by appropriately qualified biomedical personnel. Prior to the administration of anesthesia, all equipment/monitors shall be checked using the current FDA recommendations as a guideline. Records of equipment checks shall be maintained in a separate, dedicated log which must be made available upon request. Documentation of any criteria deemed to be substandard shall include a clear description of the problem and the intervention. If equipment is utilized despite the problem, documentation must clearly indicate that patient safety is not in jeopardy. All documentation relating to equipment shall be maintained for a period of time as determined by board guidelines.

(4)

Each location must have emergency supplies immediately available. Supplies should include emergency drugs and equipment appropriate for the purpose of cardiopulmonary resuscitation. This must include a defibrillator, difficult airway equipment, and drugs and equipment necessary for the treatment of malignant hyperthermia if "triggering agents" associated with malignant hyperthermia are used or if the patient is at risk for malignant hyperthermia. Equipment shall be appropriately sized for the patient population being served. Resources for determining appropriate drug dosages shall be readily available. The emergency supplies shall be maintained and inspected by qualified personnel for presence and function of all appropriate equipment and drugs at intervals established by protocol to ensure that equipment is functional and present, drugs are not expired, and office personnel are familiar with equipment and supplies. Records of emergency supply checks shall be maintained in a separate, dedicated log and made available upon request. Records of emergency supply checks shall be maintained for a period of time as determined by board guidelines.

(5)

Certified registered nurse anesthetists shall maintain current competency in advanced cardiac life support and must demonstrate proof of continued competency upon re-registration with the Board. Competency in pediatric advanced life support shall be maintained for those certified registered nurse anesthetists whose practice includes pediatric patients. Certified registered nurse anesthetists shall verify that at least one person in the setting other than the person performing the operative procedure maintains current competency in basic life support (BLS) at a minimum.

(6)

Certified registered nurse anesthetists shall verify that the appropriate policies or procedures are in place. Policies, procedures, or protocols shall be evaluated and reviewed at least annually. Agreements with local emergency medical service (EMS) shall be in place for purposes of transfer of patients to the hospital in case of an emergency. EMS agreements shall be evaluated and re-signed at least annually. Policies, procedures, and transfer agreements shall be kept on file in the setting where procedures are performed and shall be made available upon request. Policies or procedures must include, but are not limited to:

(A)

Management of outpatient anesthesia-At a minimum, these must address:

(i)

Patient selection criteria

(ii)

Patients/providers with latex allergy

(iii)

Pediatric drug dosage calculations, where applicable

(iv)

ACLS algorithms

(v)

Infection control

(vi)

Documentation and tracking use of pharmaceuticals: including controlled substances, expired drugs and wasting of drugs

(vii)

Discharge criteria

(B)

Management of emergencies to include, but not be limited to:

(i)

Cardiopulmonary emergencies

(ii)

Fire

(iii)

Bomb threat

(iv)

Chemical spill

(v)

Natural disasters

(vi)

Power outage

(C)

EMS response and transport--Delineation of responsibilities of the certified registered nurse anesthetist and person performing the procedure upon arrival of EMS personnel. This policy should be developed jointly with EMS personnel to allow for greater accuracy.

(D)

Pursuant to §217.11(16) of this title (relating to Standards of Professional Nursing Practice), adverse reactions/events, including but not limited to those resulting in a patient's death intraoperatively or within the immediate postoperative period shall be reported in writing to the Board and other applicable agencies within 15 days. Immediate postoperative period shall be defined as 72 hours.

(d)

Registration.

(1)

Beginning April 1, 2000, each certified registered nurse anesthetist who intends to provide anesthesia services in an outpatient setting must register with the board and submit the required registration fee, which is non-refundable. The information provided on the registration form shall include, but not be limited to, the name and business address of each outpatient setting(s) and proof of current competency in advanced life support.

(2)

Registration as an outpatient anesthesia provider must be renewed and the registration renewal fee paid on a biennial basis, at the time of registered nurse licensure renewal.

(e)

Inspections and Advisory Opinions.

(1)

The Board may conduct on-site inspections of outpatient settings, including inspections of the equipment owned or leased by a certified registered nurse anesthetist and of documents that relate to provision of anesthesia in an outpatient setting, for the purpose of enforcing compliance with the minimum standards. Inspections may be conducted as an audit to determine compliance with the minimum standards or in response to a complaint. The Board may contract with another state agency or qualified person to conduct these inspections. Unless it would jeopardize an ongoing investigation, the board shall provide the certified registered nurse anesthetist at least five business days' notice before conducting an on-site inspection.

(2)

The Board may, at its discretion and on payment of a fee, conduct on-site inspections of outpatient settings in response to a request from a certified registered nurse anesthetist for an inspection and advisory opinion.

(A)

The Board may require a certified registered nurse anesthetist to submit and comply with a corrective action plan to remedy or address current or potential deficiencies with the nurse anesthetist's provision of anesthesia in an outpatient setting.

(B)

A certified registered nurse anesthetist who requests and relies on an advisory opinion of the board may use the opinion as mitigating evidence in an action or proceeding by the board to impose an administrative penalty or assess a monetary fine. The board shall take proof of reliance on an advisory opinion into consideration and mitigate the imposition of administrative penalties or the assessment of a monetary fine accordingly.

(C)

An advisory opinion issued by the board is not binding on the board and the board except as provided for in subsection (a) of this section, may take any action in relation to the situation addressed by the advisory opinion that the Board considers appropriate.

§221.17.Enforcement.

(a)

The board may conduct an audit to determine compliance with §221.4 of this chapter (relating to Requirements for Full Authorization to Practice), §221.8 of this chapter (relating to Maintaining Active Authorization as an Advanced Practice Nurse), and §221.16 of this chapter (relating to Provision of Anesthesia Services by Nurse Anesthetists in Outpatient Settings).

(b)

Any nurse who violates the rules set forth in this chapter shall be subject to disciplinary action and/or termination of the authorization by the board under Texas Occupations Code, §301.452.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on February 5, 2001.

TRD-200100707

Katherine A. Thomas, MN, RN

Executive Director

Board of Nurse Examiners

Effective date: February 25, 2001

Proposal publication date: December 1, 2000

For further information, please call: (512) 305-6811


Chapter 222. ADVANCED PRACTICE NURSES WITH LIMITED PRESCRIPTIVE AUTHORITY

22 TAC §§222.1-222.7

The Board of Nurse Examiners for the State of Texas adopts the repeal of §§222.1-222.7, relating to Advance Practice Nurses without changes to the proposed repeal published in the December 1, 2000, issue of the Texas Register (25 TexReg. 11829).

The rules are repealed due to the adoption of new rules §§222.1-222.9 made in response to the Board's effort to implement House Bill 1, §167, Article IX, passed by the 75th Legislative Session, which requires that each rule adopted by an agency be reviewed and revised, if necessary, within four years of the date of its adoption. The new rules are being adopted simultaneously with this notice.

No comments were received concerning the repeal, and therefore the repeal will be adopted without changes and will not be republished.

The repeal is authorized under the authority of the Texas Occupations Code, §301.151 and §301.152 which authorizes the Board of Nurse Examiners to adopt and enforce rules consistent with its legislative authority under the Nursing Practice Act including rules relating to registered nurses who are approved, or seeking approval, as advanced practice nurses.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on February 5, 2001.

TRD-200100708

Katherine A. Thomas, MN, RN

Executive Director

Board of Nurse Examiners

Effective date: February 25, 2001

Proposal publication date: December 1, 2000

For further information, please call: (512) 305-6811


Chapter 222. ADVANCED PRACTICE NURSES AND LIMITED PRESCRIPTIVE AUTHORITY

22 TAC §§222.1-222.9

The Board of Nurse Examiners for the State of Texas adopts the new §§222.1-222.9, relating to Advance Practice Nurses without changes to the proposed text published in the December 1, 2000, issue of the Texas Register (25 TexReg 11830).

The rules are adopted in response to the Board's effort to implement House Bill 1, §167, Article IX, passed by the 75th Legislative Session, which requires that each rule adopted by an agency be reviewed and revised, if necessary, within four years of the date of its adoption.

No comments were received and new sections will be adopted without changes and will not be republished.

The rules are adopted under the authority of the Texas Occupations Code, §301.151 and §301.152 which authorizes the Board of Nurse Examiners to adopt and enforce rules consistent with its legislative authority under the Nursing Practice Act including rules relating to registered nurses who are approved, or seeking approval, as advanced practice nurses.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on February 5, 2001.

TRD-200100709

Katherine A. Thomas, MN, RN

Executive Director

Board of Nurse Examiners

Effective date: February 25, 2001

Proposal publication date: December 1, 2000

For further information, please call: (512) 305-6811