Part 9.
TEXAS STATE BOARD OF MEDICAL EXAMINERS
Chapter 184.
SURGICAL ASSISTANTS
22 TAC §§184.1 - 184.16
The Texas State Board of Medical Examiners proposes new §§184.1-184.16,
concerning Surgical Assistants. The new chapter is proposed as a result of
HB 1183 of the 77th Legislature requiring the board to license and regulate
surgical assistants.
Michele Shackelford, General Counsel, Texas State Board of Medical Examiners,
has determined that for the first five-year period the sections are in effect
there will be fiscal implications to state or local government as a result
of enforcing the rules as proposed. The Fiscal impact to those individuals
required to comply is as follows: $300 for processing licensure application
and $200 for annual renewal. Revenue to state: FY02 estimated at 500 applications
x $300 = $150,000; FY03 estimated at 500 renewals x $200 = $100,000 + new
applications which we are unable to estimate at this time.
Ms. Shackelford also has determined that for each year of the first five
years the sections as proposed are in effect the public benefit anticipated
as a result of enforcing the sections will be the licensing and regulation
of surgical assistants. There will be no effect on small businesses. There
will be no effect to individuals required to comply with the sections as proposed.
Comments on the proposal may be submitted to Pat Wood, P.O. Box 2018, MC-901,
Austin, Texas 78768-2018. A public hearing will be held at a later date.
The new sections are proposed under the authority of the Occupations
Code Annotated, §153.001, which provides the Texas State Board of Medical
Examiners to adopt rules and bylaws as necessary to: govern its own proceedings;
perform its duties; regulate the practice of medicine in this state; and enforce
this subtitle.
The following are affected by the proposed new rules: Title 3, Subtitle
C, Tex. Occ. Code Ann. Chapter 206.
§184.1.Purpose.
The purpose of these rules is to create a system of licensing and regulating
surgical assistants as a means to ensure the competency of surgical assistants
without a financial burden to the people of Texas. Furthermore, the purpose
of these rules and regulations is to also encourage the more effective utilization
of the skills of physicians by enabling them to delegate health care tasks
to qualified surgical assistants. These sections are not intended to, and
shall not be construed to, restrict the physician from delegating technical
and clinical tasks to technicians, other assistants, or employees who perform
delegated tasks in a surgical setting and who are not rendering services as
a surgical assistant or identifying themselves as a surgical assistant. Nothing
in these rules and regulations shall be construed to relieve the supervising
physician of the professional or legal responsibility for the care and treatment
of his or her patients.
§184.2.Definitions.
The following words and terms, when used in this chapter, shall have
the following meanings, unless the context clearly indicates otherwise.
(1)
Act - Title 3, Subtitle C, Tex. Occ. Code Ann. Ch. 206.
(2)
Address of record - The mailing address of each licensee
or applicant as provided to the agency pursuant to the Act.
(3)
Advisory committee - An informal advisory committee to
the board whose purpose is to advise the board regarding rules relating to
the licensure, enforcement, and discipline of surgical assistants.
(4)
APA - Administrative Procedure Act, Texas Government Code,
Chapter 2001 as amended.
(5)
Applicant - A person seeking a surgical assistant license
from the board.
(6)
Board - The Texas State Board of Medical Examiners.
(7)
Delegating physician - A physician licensed by the board
who delegates, to a licensed surgical assistant, surgical assisting and oversees
and accepts responsibility for that surgical assisting.
(8)
Direct supervision - supervision by a delegating physician
who is physically present and personally directs delegated acts, and remains
immediately available in the operating room to respond to any emergency until
the patient is released from the operating room or care and has been transferred
to another physician.
(9)
Submit - The term used to indicate that a completed item
has been actually received and date-stamped by the board along with all required
documentation and fees, if any.
(10)
Surgical assistant - A person licensed as a surgical assistant
by the Texas State Board of Medical Examiners.
(11)
Surgical or first assisting - providing aid under direct
supervision in exposure, hemostasis, and other intraoperative technical functions
that assist a physician in performing a safe operation with optimal results
for the patient, including the delegated authority to provide local infiltration
or the topical application of a local anesthetic at the operation site.
§184.3.Meetings.
(a)
The advisory committee shall meet as requested by the board
to carry out the mandates of the Act.
(b)
A meeting may be held by telephone conference call.
(c)
Special meetings may be called by the president of the
board, by resolution of the board, or upon written request to the presiding
officer of the board signed by at least three members of the board.
(d)
Advisory committee meetings shall, to the extent possible,
be conducted pursuant to the provisions of Robert's Rules of Order Newly Revised
unless, by rule, the board adopts a different procedure.
(e)
All issues requiring a vote of the committee shall be decided
by a simple majority of the members present.
§184.4.Qualifications for Licensure.
(a)
Except as otherwise provided in this section, an individual
applying for licensure must:
(1)
submit an application on forms approved by the board;
(2)
pay the appropriate application fee;
(3)
certify that the applicant is mentally and physically able
to function safely as a surgical assistant;
(4)
not have a license, certification, or registration in this
state or from any other licensing authority or certifying professional organization
that is currently revoked, suspended, or subject to probation or other disciplinary
action for cause;
(5)
have no proceedings that have been instituted against the
applicant for the restriction, cancellation, suspension, or revocation of
certificate, license, or authority to practice surgical assisting in the state,
Canadian province, or uniformed service of the United States in which it was
issued;
(6)
have no prosecution pending against the applicant in any
state, federal, or Canadian court for any offense that under the laws of this
state is a felony;
(7)
be of good moral character;
(8)
not have been convicted of a felony or a crime involving
moral turpitude;
(9)
not use drugs or alcohol to an extent that affects the
applicant's professional competency;
(10)
not have engaged in fraud or deceit in applying for a
license;
(11)
pass an independently evaluated surgical assistant examination
approved by the board;
(12)
have been awarded at least an associate's degree other
than in a surgical assistant training program at a two or four year institution
of higher education;
(13)
have successfully completed an educational program in
surgical assisting or a substantially equivalent educational program.
(A)
A surgical assistant program or a substantially equivalent
program is limited to the following:
(i)
a surgical assistant program accredited by the Commission
on Accreditation of Allied Health Education Programs (CAAHEP);
(ii)
a medical school whereby the applicant can verify completion
of basic and clinical sciences coursework;
(iii)
an accredited registered nurse first assistant program;
and
(iv)
an accredited surgical physician assistant program.
(B)
The curriculum of a surgical assisting educational program
must include at a minimum the following courses:
(i)
anatomy;
(ii)
physiology;
(iii)
basic pharmacology;
(iv)
aseptic techniques;
(v)
operative procedures;
(vi)
chemistry;
(vii)
microbiology;
(viii)
pathophysiology; and
(ix)
clinical service rotations, that either:
(I)
are each 80 hours in length, in the following areas:
(-a-)
cardiovascular surgery;
(-b-)
emergency medicine;
(-c-)
general surgery;
(-d-)
obstetrics and gynecology;
(-e-)
orthopedics;
(-f-)
outpatient medicine; and
(-g-)
pediatrics; or
(II)
meet the CAAHEP's supervised clinical preceptorship guidelines.
(14)
demonstrate to the satisfaction of the board the completion
of full-time work experience performed in the United States under the direct
supervision of a physician licensed in the United States consisting of at
least 2,000 hours of performance as an assistant in surgical procedures for
the three years preceding the date of the application. Applicants must demonstrate
completion of at least 20 cases in the following areas:
(A)
general surgery;
(B)
orthopedic surgery;
(C)
peripheral vascular surgery;
(D)
endoscopic procedures;
(15)
be currently certified by a national certifying board
approved by the board; and
(16)
submit to the board any other information the board considers
necessary to evaluate the applicant's qualifications.
(b)
An applicant who submits an application before September
1, 2002 must provide documentation that the applicant has passed an examination
required for certification by one of the following certifying boards:
(1)
American Board of Surgical Assistants;
(2)
Association of Surgical Technologists; or
(3)
National Surgical Assistant Association.
(c)
An applicant who submits an application before September
1, 2002 and is unable to meet the educational requirements set out in subsection
(a)(12) (13) of this section must provide documentation that the applicant:
(1)
will complete before the third anniversary of the date
the license is issued under this chapter the following academic courses approved
by the board:
(A)
anatomy;
(B)
physiology;
(C)
basic pharmacology;
(D)
aseptic techniques;
(E)
operative procedures;
(F)
chemistry; and
(G)
microbiology; or
(2)
since September 30, 1995, has practiced full-time as a
surgical assistant in the United States under the direct supervision of a
physician licensed in the United States and has continuously been certified
as a surgical assistant by one of the following national certifying boards:
(A)
American Board of Surgical Assistants;
(B)
Association of Surgical Technologists; or
(C)
National Surgical Assistant Association.
§184.5.Procedural Rules for Licensure Applicants.
(a)
An applicant for licensure:
(1)
whose documentation indicates any name other than the name
under which the applicant has applied must furnish proof of the name change;
(2)
whose application has been on file with the board in excess
of one year from the date of receipt, shall be considered inactive. Any fees
previously submitted with that application shall be forfeited. Any further
application procedure for licensure will require submission of a new application
and inclusion of the current licensure fee;
(3)
who in any way falsifies the application may be required
to appear before the board. It will be at the discretion of the board whether
or not the applicant will be issued a license;
(4)
on whom adverse information is received by the board may
be required to appear before the board. It will be at the discretion of the
board whether or not the applicant will be issued a license;
(5)
shall be required to comply with the board's rules and
regulations which are in effect at the time the completed application form
and fee are received by the board;
(6)
must have the application for licensure complete in every
detail at least 20 days prior to the board meeting at which the applicant
is considered for licensure. An applicant may qualify for a temporary license
prior to being considered by the board for licensure, as required by §184.7
of this title (relating to Temporary Licensure); and
(7)
must complete an oath swearing that the applicant has submitted
an accurate and complete application.
(b)
An applicant for licensure who applies before September
1, 2002 must submit a preliminary application along with appropriate application
fees in order to qualify for the special eligibility provisions under §206.205
of the Act and §§184.4 (b) and (c) of this title (relating to Qualifications
for Licensure).
(c)
The executive director shall review each application for
licensure and shall recommend to the board all applicants eligible for licensure.
The executive director also shall report to the board the names of all applicants
determined to be ineligible for licensure, together with the reasons for each
recommendation. An applicant deemed ineligible for licensure by the executive
director may request review of such recommendation by the board's licensure
committee within 20 days of receipt of such notice, and the executive director
may refer any application to the licensure committee for a recommendation
concerning eligibility. If the committee finds the applicant ineligible for
licensure, such recommendation, together with the reasons, shall be submitted
to the board unless the applicant requests a hearing not later than the 20th
day after the date the applicant receives notice of the determination. The
hearing shall be before an administrative law judge of the State Office of
Administrative Hearings and shall comply with the Administrative Procedure
Act and its subsequent amendments and the rules of the State Office of Administrative
Hearings and the board. The board shall, after receiving the administrative
law judge's proposed findings of fact and conclusions of law, determine the
eligibility of the applicant for licensure. A surgical assistant whose application
for licensure is denied by the board shall receive a written statement containing
the reasons for the board's action. All reports received or gathered by the
board on each applicant are confidential and are not subject to disclosure
under the Public Information Act, Tex. Gov't Code, Ch.552. The board may disclose
such reports to appropriate licensing authorities in other states.
§184.6.Licensure Documentation.
(a)
Original documents may include, but are not limited to,
those listed in subsections (b) and (c) of this section.
(b)
Documentation required of all applicants for licensure.
(1)
Birth Certificate/Proof of Age. Each applicant for licensure
must provide a copy of a birth certificate and translation if necessary to
prove that the applicant is at least 21 years of age. In instances where a
birth certificate is not available the applicant must provide copies of a
passport or other suitable alternate documentation.
(2)
Name change. Any applicant who submits documentation showing
a name other than the name under which the applicant has applied must present
copies of marriage licenses, divorce decrees, or court orders stating the
name change. In cases where the applicant's name has been changed by naturalization,
the applicant should send the original naturalization certificate by certified
mail to the board office for inspection.
(3)
Examination scores. Each applicant for licensure must have
a certified transcript of grades submitted directly from the appropriate testing
service to the board for all examinations used in Texas or another state for
licensure.
(4)
Certification. All applicants must submit:
(A)
a valid and current certificate from a board approved national
certifying organization; and
(B)
a certificate of successful completion of an educational
program whose curriculum includes surgical assisting submitted directly from
the program on a form provided the board.
(5)
Evaluations. All applicants must provide evaluations, on
forms provided by the board, of their professional affiliations for the past
five years or since graduation from an educational program, in compliance
with §184.4(a)(13) of this title (relating to Qualifications for Licensure),
whichever is the shorter period.
(6)
Temporary license affidavit. Each applicant must submit
a completed form, furnished by the board, titled "Temporary License Affidavit"
prior to the issuance of a temporary license.
(7)
License verifications. Each applicant for licensure who
is licensed, registered, or certified in another state must have that state
submit directly to the board, on a form provided by the board, that the applicant's
license, registration, or certification is current and in full force and that
the license, registration, or certification has not been restricted, suspended,
revoked or otherwise subject to disciplinary action. The other state shall
also include a description of any sanctions imposed by or disciplinary matters
pending in the state.
(c)
Applicants may be required to submit other documentation,
which may include the following:
(1)
Translations. Any document that is in a language other
than the English language will need to have a certified translation prepared
and a copy of the translation submitted with the translated document.
(A)
An official translation from the school or appropriate
agency attached to the foreign language transcript or other document is acceptable.
(B)
If a foreign document is received without a translation,
the board will send the applicant a copy of the document to be translated
and returned to the board.
(C)
Documents must be translated by a translation agency who
is a member of the American Translation Association or a United States college
or university official.
(D)
The translation must be on the translator's letterhead,
and the translator must verify that it is a "true word for word translation"
to the best of his/her knowledge, and that he/she is fluent in the language
translated, and is qualified to translate the document.
(E)
The translation must be signed in the presence of a notary
public and then notarized. The translator's name must be printed below his/her
signature. The notary public must use the phrase: "Subscribed and Sworn this
_______ day of ________, 20___." The notary must then sign and date the translation,
and affix his/her notary seal to the document.
(2)
Arrest records. If an applicant has ever been arrested
the applicant must request that the arresting authority submit to the board
copies of the arrest and arrest disposition.
(3)
Inpatient treatment for alcohol/substance abuse or mental
illness. Each applicant that has been admitted to an inpatient facility within
the last five years for treatment of alcohol/substance abuse or mental illness
must submit the following:
(A)
applicant's statement explaining the circumstances of the
hospitalization;
(B)
all records, submitted directly from the inpatient facility;
(C)
a statement from the applicant's treating physician/psychotherapist
as to diagnosis, prognosis, medications prescribed, and follow-up treatment
recommended; and
(D)
a copy of any contracts signed with any licensing authority,
professional society or impaired practitioner committee.
(4)
Outpatient treatment for alcohol/substance abuse or mental
illness. Each applicant that has been treated on an outpatient basis within
the past five years for alcohol/substance abuse must submit the following:
(A)
applicant's statement explaining the circumstances of the
outpatient treatment;
(B)
a statement from the applicant's treating physician/psychotherapist
as to diagnosis, prognosis, medications prescribed, and follow-up treatment
recommended; and
(C)
a copy of any contracts signed with any licensing authority,
professional society or impaired practitioners committee.
(5)
Malpractice. If an applicant has ever been named in a malpractice
claim filed with any liability carrier or if an applicant has ever been named
in a malpractice suit, the applicant must:
(A)
have each liability carrier complete a form furnished by
this board regarding each claim filed against the applicant's insurance;
(B)
for each claim that becomes a malpractice suit, have the
attorney representing the applicant in each suit submit a letter to the board
explaining the allegation, relevant dates of the allegation, and current status
of the suit. If the suit has been closed, the attorney must state the disposition
of the suit, and if any money was paid, the amount of the settlement. If such
letter is not available, the applicant will be required to furnish a notarized
affidavit explaining why this letter cannot be provided; and
(C)
provide a statement composed by the applicant, explaining
the circumstances pertaining to patient care in defense of the allegations.
(6)
Additional documentation. Additional documentation may
be required as is deemed necessary to facilitate the investigation of any
application for surgical assistant licensure.
§184.7.Temporary Licensure.
(a)
The executive director of the board may issue a temporary
license to an applicant:
(1)
whose completed application has been filed, processed,
and found to be in order; and
(2)
who has met all other requirements for licensure under
the Act but is waiting for the next scheduled meeting of the board for the
license to be issued.
(b)
A temporary license is valid for 100 days from the date
issued and may be extended for not more than an additional 30 days after the
expiration date of the initial temporary license.
§184.8.License Renewal.
(a)
Surgical assistants licensed by the board shall register
annually and pay a fee. A surgical assistant may, on notification from the
board, renew an unexpired license by submitting a required form and paying
the required renewal fee to the board on or before the expiration date of
the license. The fee shall accompany a written application that sets forth
the licensee's name, mailing address, residence, the address of each of the
licensee's offices, and other necessary information prescribed by the board.
(b)
The board shall provide written notice to each practitioner
at the practitioner's address of record at least 30 days prior to the expiration
date of the license.
(c)
Within 30 days of a surgical assistant's change of mailing,
residence or office address from the address on file with the board, a surgical
assistant shall notify the board in writing of such change.
(d)
Falsification of an affidavit or submission of false information
to obtain renewal of a license shall subject a surgical assistant to denial
of the renewal and/or to discipline pursuant to §206.301 of the Act.
(e)
Practicing as a surgical assistant without an annual registration
permit for the current year as provided for in the board's rules has the same
force and effect as and is subject to all penalties of practicing as a surgical
assistant without a license.
§184.9.Relicensure.
If a surgical assistant's license has been expired for one year or
longer, the person may not renew the license. The surgical assistant may obtain
a new license by complying with the requirements and procedures for obtaining
an original license.
§184.10.Fees Related to the Renewal of Expired Licenses.
(a)
If the renewal fee and completed application form are not
received on or before the expiration date of the license, the following penalties
will be imposed:
(1)
one to 90 days late - one and one-half times the required
annual registration fee;
(2)
91 days to one year late - two times the required annual
registration fee;
(3)
over one year late - licensee may not renew the license.
(b)
The board shall not waive fees or penalties.
§184.11.Schedule of Fees.
(a)
The board shall charge the following non-refundable, nontransferable
fees:
(1)
Processing licensure application - $300;
(2)
Temporary license - $50;
(3)
Annual registration fee - $200;
(4)
Duplicate license - $45.
(b)
All licensure fees or penalties must be submitted in the
form of a check, money order or cashier's check payable on or through a United
States bank. Fees and penalties are not refundable.
§184.12.Surgical Assistant Scope of Practice.
The practice of surgical assisting is limited to surgical assisting
performed under the direct supervision of a physician who delegates the acts.
A surgical assistant may practice in any place authorized by a delegating
licensed physician, including, but not limited to a clinic, hospital, ambulatory
surgical center, or other institutional setting.
§184.13.Physician Supervision.
(a)
Supervision shall be continuous, and shall require that
the delegating physician be physically present and immediately available in
the operating room to personally respond to any emergency until the patient
is released from the operating room or care has been transferred to another
physician. Telecommunication is insufficient for supervision purposes.
(b)
It is the obligation of each team of physician(s) and surgical
assistant(s) to ensure that:
(1)
the surgical assistant's scope of practice is identified;
(2)
delegation of medical tasks is appropriate to the surgical
assistant's level of competence;
(3)
the relationship between the members of the team is defined;
(4)
that the relationship of, and access to, the supervising
physician is defined;
(5)
a process for evaluation of the surgical assistant's performance
is established; and
(6)
the surgical assistant's license is not expired.
§184.14.Supervising Physician.
To be authorized to supervise a surgical assistant, a physician must
be currently licensed as a physician in this state by the medical board. The
license must be unrestricted and active, and not under an order of the board.
§184.15.Grounds for Denial of Licensure and for Disciplinary Action.
The board may refuse to issue a license to any person and may, following
notice of hearing as provided for in the APA, take disciplinary action against
any surgical assistant that:
(1)
fraudulently or deceptively obtains or attempts to obtain
a license;
(2)
fraudulently or deceptively uses a license;
(3)
falsely represents that the person is a physician;
(4)
violates the Act, or any rules relating to the practice
of surgical assisting;
(5)
is convicted of a felony, or has imposition of deferred
adjudication or pre-trial diversion;
(6)
habitually uses drugs or alcohol to the extent that, in
the opinion of the board, the person cannot safely perform as a surgical assistant;
(7)
has been adjudicated as mentally incompetent or has a mental
or physical condition that renders the person unable to safely perform as
a surgical assistant;
(8)
has committed an act of moral turpitude. An act involving
moral turpitude shall be defined as an act involving baseness, vileness, or
depravity in the private and social duties one owes to others or to society
in general, or an act committed with knowing disregard for justice, honesty,
principles, or good morals;
(9)
has acted in an unprofessional or dishonorable manner that
is likely to deceive, defraud, or injure any member of the public;
(10)
has failed to practice as a surgical assistant in an acceptable
manner consistent with public health and welfare;
(11)
has committed any act that is in violation of the laws
of this state if the act is connected with practice as a surgical assistant;
a complaint, indictment, or conviction of a law violation is not necessary
for the enforcement of this provision. Proof of the commission of the act
while in practice as a surgical assistant or under the guise of practice as
a surgical assistant is sufficient for action by the board under this section;
(12)
has had the person's license or other authorization to
practice as a surgical assistant suspended, revoked, or restricted or who
has had other disciplinary action taken by another state regarding practice
as a surgical assistant or had disciplinary action taken by the uniformed
services of the United States. A certified copy of the record of the state
or uniformed services of the United States taking the action is conclusive
evidence of it;
(13)
unlawfully advertises in a false, misleading, or deceptive
manner as defined by §101.201 of the Tex. Occ. Code;
(14)
alters, with fraudulent intent, any surgical assistant
license, certificate, or diploma;
(15)
uses any surgical assistant license, certificate, or diploma
that has been fraudulently purchased, issued, or counterfeited or that has
been materially altered;
(16)
directly or indirectly aids or abets the practice as a
surgical assistant by any person not duly licensed by the board to practice
as a surgical assistant;
(17)
is removed or suspended or has disciplinary action taken
by his peers in any professional association or society, whether the association
or society is local, regional, state, or national in scope, or is being disciplined
by a licensed hospital or medical staff of a hospital, including removal,
suspension, limitation of privileges, or other disciplinary action, if that
action, in the opinion of the board, was based on unprofessional conduct or
professional incompetence that was likely to harm the public. This action
does not constitute state action on the part of the association, society,
or hospital medical staff;
(18)
has repeated or recurring meritorious health care liability
claims that in the opinion of the board evidence professional incompetence
likely to harm the public; or
(19)
sexually abuses or exploits another person during the
licensee's practice as a surgical assistant.
§184.16.Discipline of Surgical Assistants.
(a)
The board, upon finding a surgical assistant has committed
any of the acts set forth in (184.15 of this title (relating to Grounds for
Denial of Licensure and for Disciplinary Action), shall enter an order imposing
one or more of the following:
(1)
deny the person's application for a license or other authorization
to practice as a surgical assistant;
(2)
administer a public reprimand;
(3)
order revocation, suspension, limitation, or restriction
of a surgical assistant's license, or other authorization to practice as a
surgical assistant, including limiting the practice of the person to, or excluding
from the practice, one or more specified activities of the practice as a surgical
assistant or stipulating periodic board review;
(4)
require a surgical assistant to submit to care, counseling,
or treatment by a health care practitioner designated by the board;
(5)
order the surgical assistant to perform public service;
(6)
require the surgical assistant to complete additional training;
(7)
require the surgical assistant to participate in continuing
education programs; or
(8)
assess an administrative penalty against the surgical assistant.
(b)
The board may stay enforcement of any order and place the
surgical assistant on probation. The board shall retain the right to vacate
the probationary stay and enforce the original order for noncompliance with
the terms of probation or to impose any other remedial measures or sanctions
authorized by subsection (a) of this section in addition to or instead of
enforcing the original order.
(c)
A private nondisciplinary rehabilitation order may impose
one or more of the above board actions or such other actions as agreed to
by the board and the person subject to the order.
(d)
The time period of an order shall be extended for any period
of time in which the person subject to an order subsequently resides or practices
outside this state or for any period during which the person's license is
subsequently cancelled for nonpayment of licensure fees.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State on February 15, 2002.
TRD-200200969
Donald W. Patrick, MD, JD
Executive Director
Texas State Board of Medical Examiners
Earliest possible date of adoption: March 31, 2002
For further information, please call: (512) 305-7016
22 TAC §185.16
The Texas State Board of Medical Examiners proposes an amendment
to §185.16, concerning Supervising Physician. The amendment is necessary
to prohibit a physician assistant from being supervised by a physician under
a board order.
Michele Shackelford, General Counsel, Texas State Board of Medical Examiners,
has determined that for the first five-year period the section is in effect
there will be no fiscal implications to state or local government as a result
of enforcing the rule as proposed.
Ms. Shackelford also has determined that for each year of the first five
years the section as proposed is in effect the public benefit anticipated
as a result of enforcing the section will be to prohibit a physician assistant
from being supervised by a physician under a board order. There will be no
effect on small businesses. There will be no effect to individuals required
to comply with the section as proposed.
Comments on the proposal may be submitted to Pat Wood, P.O. Box 2018, MC-901,
Austin, Texas 78768-2018. A public hearing will be held at a later date.
The amendment is proposed under the authority of the Occupations
Code Annotated, §153.001, which provides the Texas State Board of Medical
Examiners to adopt rules and bylaws as necessary to: govern its own proceedings;
perform its duties; regulate the practice of medicine in this state; and enforce
this subtitle.
The following are affected by the proposed amendment: Tex. Occ. Code Ann., §§204.204,
204.205.
§185.16.Supervising Physician.
(a)
To be authorized to supervise a physician assistant, a
physician must:
(1)
be currently licensed as a physician in this state by the
medical board. The license must be unrestricted and active [
(2)
notify the board of the physician's intent to supervise
a physician assistant; and
(3)
submit a statement to the board that the physician will:
(A)
supervise the physician assistant according to rules adopted
by the board; and
(B)
retain professional and legal responsibility for the care
rendered by the physician assistant.
[
(b)
A physician assistant may be supervised by an alternate
supervising physician in the absence of the supervising physician consistent
with this chapter,
the
Texas Medical Practice Act, Physician Assistant
Licensing Act, board rules, medical board rules, and any standing orders or
protocols established in accordance with these statutes and rules.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State on February 15, 2002.
TRD-200200970
Donald W. Patrick, MD, JD
Executive Director
Texas State Board of Medical Examiners
Earliest possible date of adoption: March 31, 2002
For further information, please call: (512) 305-7016
22 TAC §§189.1 - 189.14
The Texas State Board of Medical Examiners proposes new §§189.1-189.14,
concerning Compliance Program. The new chapter contains requirements and responsibilities
for probationers and the system for monitoring a probationer's compliance.
Michele Shackelford, General Counsel, Texas State Board of Medical Examiners,
has determined that for the first five-year period the sections are in effect
there may be fiscal implications as a result of enforcing the rules as proposed.
There is a cost to persons who must comply that is outlined in the terms of
each individual order. There is no additional cost incurred by state government
as a result of this rule.
Ms. Shackelford also has determined that for each year of the first five
years the sections as proposed are in effect the public benefit anticipated
as a result of enforcing the sections will be requirements and responsibilities
for probationers and the system for monitoring a probationer's compliance.
There will be no effect on small businesses. There will be no effect to individuals
required to comply with the sections as proposed.
Comments on the proposal may be submitted to Pat Wood, P.O. Box 2018, MC-901,
Austin, Texas 78768-2018. A public hearing will be held at a later date.
The new sections are proposed under the authority of the Occupations
Code Annotated, §153.001, which provides the Texas State Board of Medical
Examiners to adopt rules and bylaws as necessary to: govern its own proceedings;
perform its duties; regulate the practice of medicine in this state; and enforce
this subtitle.
The following are affected by the proposed new sections: Tex. Occ. Code
Ann., §164.010.
§189.1.Purpose and Scope.
(a)
Purpose. The purposes of this chapter are:
(1)
to establish requirements and responsibilities for a probationer
who is under an order of the board; and
(2)
to establish a system of monitoring a probationer's compliance
with the terms and conditions of an order of the board.
(b)
Scope.
(1)
This chapter shall govern the enforcement of all orders
of the board.
(2)
This chapter shall not be construed so as to enlarge, diminish,
modify, or otherwise alter the jurisdiction, powers, or authority of the board,
board staff, or the substantive rights of any person.
§189.2.Definitions.
(a)
Act - Title 3, Subtitle B, Chapter 151-165, Tex Occ. Code
Ann. for physicians; Title 3, Subtitle C, Chapter. 204, Tex Occ. Code Ann.
for physician assistants; Title 3 Subtitle C, Chapter 206, Tex Occ. Code Ann.
for surgical assistants; and Title 3, Subtitle C, Chapter 205, Tex Occ. Code
Ann. for acupuncturists.
(b)
Address of record - The mailing address of each probationer
as provided to the board pursuant to the Act.
(c)
Agency - The divisions, departments, and employees of the
Texas State Board of Medical Examiners, the Texas State Board of Physician
Assistant Examiners, and the Texas State Board of Acupuncture Examiners.
(d)
Agency representative - A compliance officer, other agency
staff, board member, or agent of the agency.
(e)
APA - The Administrative Procedures Act, Tex. Govt. Code,
Chapter 2001 as amended.
(f)
Authorized representative - An attorney of record or any
other person who has been designated in writing by a party to represent the
party at a board proceeding
(g)
Board - the appointed members of the Board of Medical Examiners
for physicians and surgical assistants, the Board of Physician Assistants
for physicians assistants, and the Board of Acupuncture for acupuncturists.
(h)
Board representative - a board member or district review
committee member who sits on a panel at a proceeding to determine compliance
with an order.
(i)
Chief of compliance - The agency staff person who supervises
the agency compliance program.
(j)
Compliance officer - An employee of the agency assigned
to each probationer to investigate a probationer's compliance with the terms
and conditions of an order.
(k)
Group practice - Any business entity including a partnership,
professional association, professional limited liability company, or other
entity allowed by state law and established for the purpose of practicing
medicine in which two or more physicians licensed in Texas are members of
the practice.
(l)
Institutional setting - A medical facility established
by a governmental entity, non-profit organization, or educational institution
that has a permanent staff, including full-time physician employees, by-laws,
and an internal governing structure for the operation of the facility for
the purpose of practicing medicine.
(m)
Licensee - A person to whom the board has issued a license,
permit, certificate, approved registration, or similar form of permission
authorized by law.
(n)
Modification/termination hearing - a hearing before board
representatives conducted upon the written request of a probationer for the
modification of one or more terms and conditions of an order, the termination
of an order prior to the prescribed termination of an order, or the reinstatement
of a license following a suspension.
(o)
Monitoring physician - A licensed Texas physician who meets
the requirements as set out in §189.11 of this title (relating to Process
for Approval of Physicians, Other Professionals, Group Practices and Institutional
Settings) and who conducts onsite reviews of a probationer's practice site
on a periodic basis for the purpose of monitoring and educating a probationer,
and periodically reports in writing to the board on the probationer's medical
practice and practice of medicine as stipulated by an order.
(p)
Order - An agreed order, final order of the board, rehabilitation
order, or other order approved by the board that requires an agency representative
to monitor a probationer's compliance with the order's terms and conditions.
(q)
Probation appearance - An appearance by a probationer at
an informal board proceeding before board representatives to discuss a probationer's
compliance with an order.
(r)
Probationer - A licensee who is under an order.
(s)
Proctor - A licensed Texas physician who meets the requirements
as set out in §189.11 of this title (relating to Process for Approval
of Physicians, Other Professionals, Group Practices and Institutional Settings)
and who physically and actually works with and oversees a probationer's practice
of medicine on a daily basis and periodically reports in writing to the board
on the probationer's medical practice and practice of medicine as stipulated
by an order.
(t)
SOAH - The State Office of Administrative Hearings
(u)
Supervising physician - A licensed Texas physician who
meets the requirements as set out in §189.11 of this title (relating
to Process for Approval of Physicians, Other Professionals, Group Practices
and Institutional Settings) and who is physically present at a probationer's
practice on a daily basis in order to evaluate, educate, and provide guidance
regarding the probationer's practice of medicine; and periodically reports
in writing to the board on probationer's medical practice and practice of
medicine as stipulated by an order.
§189.3.Responsibilities of Probationers.
(a)
Comply with Terms and Conditions of Order. A probationer
must comply with all terms and conditions of his or her order. If a probationer
fails to comply with the terms and conditions of an order, the probationer
shall be subject to agency review and action for non-compliance as set out
in §189.8 of the title (relating to Procedures Concerning Non-Compliance).
(b)
Document Continuing Medical Education (CME).
(1)
A probationer is solely responsible for providing acceptable
documentation to demonstrate compliance with CME or other educational requirements
under an order.
(2)
The following documentation will be acceptable to demonstrate
compliance with CME requirements under an order:
(A)
a certificate of completion from any formal CME course
taken as defined under §166.2(a)(1) of this title (relating to Continuing
Medical Education);
(B)
a letter from the presenter(s) on letterhead sent directly
from the author of the letter to the agency; or
(C)
a report of CME activities provided directly to the agency
by a third party testing entity accredited by Accreditation Council for Continuing
Medical Education and approved by the American Medical Association or American
Osteopathic Association.
(3)
The following documentation is not acceptable to demonstrate
compliance with a CME or other educational requirement:
(A)
a copy of attendance form;
(B)
answers from tests taken;
(C)
a letter sent by a probationer from an individual stating
that the probationer was at a class; or
(D)
a listing of CME/ethics courses taken.
(c)
Ensure Submission of Third Party Reports.
(1)
A probationer is solely responsible for ensuring that all
reports are timely submitted to the agency by third parties.
(2)
In order to avoid a finding of non-compliance, a probationer
must present evidence that the probationer made good faith efforts to ensure
the timely submission of reports to the agency from third parties. Evidence
may include, but is not limited to:
(A)
copies of certified letter(s) with proof of mail receipt,
air-bill or shipping document receipt attached, which were sent directly to
the third party requesting the report or document;
(B)
a copy of a receipt of payments for services rendered by
third parties; or
(C)
objective evidence that the probationer has attempted to
have a report submitted to the agency.
(3)
If the agency does not receive reports after a probationer
has made good faith efforts to ensure such documentation is submitted by an
approved third party, the Executive Director of the agency has the authority
to revoke approval of that third party.
§189.4.Limitations on Physician Probationer's Practice.
(a)
A probationer is not authorized to supervise a physician
assistant, advanced practice nurse, or surgical assistant unless expressly
permitted under the probationer's order.
(b)
A probationer may not delegate prescriptive authority to
a physician assistant or advanced practice nurse unless expressly permitted
under the probationer's order.
(c)
A finding that a probationer has violated or attempted
to violate subsections (a) and (b) of this section shall be considered unprofessional
and dishonorable conduct likely to deceive, defraud or injure the public and
is a violation of the Act.
§189.5.Compliance Visits and Communications.
(a)
Agency representatives shall make random and unannounced
visits with a probationer at a probationer's practice location, residence,
or other location to investigate compliance with an order.
(b)
Agency representatives shall determine the time, date,
and location of all visits. A probationer must submit to random unannounced
visits. A probationer or a probationer's authorized representative may not
request to meet at specific times, dates, or locations.
(c)
While agency representatives will focus on assuring the
confidentiality of rehabilitation orders, agency representatives investigating
a probationer's compliance with a rehabilitation order may communicate with
third parties. Agency representatives shall not discuss the existence of an
order, findings of fact, conclusions of law, or the terms and conditions of
the order with persons to whom the order does not authorize disclosure. This
does not preclude agency representatives from communicating that they are
employees of the board.
§189.6.Probation Appearances.
(a)
Written notice directing a probationer to appear for a
probation appearance shall be mailed no less than 10 days before the scheduled
probation appearance to the probationer's address of record.
(b)
A probationer shall be required to make probation appearances
as stipulated in an order unless waived by the board.
(c)
Upon recommendation of the executive director, the board
may, with just cause, waive probation appearances required under the terms
and conditions of an order. Just cause includes, but is not limited to, a
probationer being in full compliance with the terms and conditions set forth
in an order since the last anniversary date of the order.
§189.7.Modification/Termination Hearings.
(a)
A request for a modification/termination hearing or reinstatement
hearing must be submitted in writing by the probationer. The writing must
specifically detail the requested desired action.
(b)
If a probationer is determined to be eligible for a hearing
according to the order, §187.43 of this title (relating to Proceedings
for the Modification/Termination of Agreed Orders and Disciplinary Orders),
and Chapter 167 of this title (relating to Reinstatement and Reissuance),
a date and time for the hearing shall be set and the probationer shall be
notified in writing.
(c)
If the probationer desires to submit evidence for consideration
by the board's representatives, the probationer must provide at least three
copies of all evidence no less than ten calendar days prior to the hearing.
The board's representatives may refuse to consider evidence not timely submitted.
(d)
When considering a modification, termination, or reinstatement
request, the board's representatives shall make a determination if the probationer
is eligible for the request pursuant to §187.43(d) of this title (relating
to Proceedings for the Modification/Termination of Agreed Orders and Disciplinary
Orders) and/or Chapter 167 of this title (relating to Reinstatement and Reissuance).
(e)
When considering a modification, termination, or reinstatement
request, the board's representatives may also consider:
(1)
evidence presented by probationer;
(2)
the existence of pending investigations;
(3)
past compliance with the order;
(4)
the existence of prior orders; and
(5)
any information or evidence the board's representatives
deem necessary to make an informed decision.
(f)
If a probationer is requesting a reinstatement hearing,
the probationer must submit evidence of completion of any required stipulations
prior to the hearing being set.
(g)
In addition to requirements, set forth in §167.2 of
this title (relating to Informal Disposition of Requests for Reinstatement)
a probationer requesting reinstatement of a license must prove that the probationer
is mentally, physically, clinically, and otherwise competent to return to
the practice of medicine.
(h)
The decision to modify or terminate all or any part of
an order is at the sole discretion of the board unless otherwise specified
in the order.
§189.8.Procedures Concerning Non-compliance.
(a)
A finding that a probationer is in non-compliance with
the terms and conditions of the probationer's order may be made by the board's
representatives at the conclusion of a probation appearance or by the executive
director.
(b)
A finding of non-compliance shall be considered unprofessional
or dishonorable conduct likely to deceive, defraud, or injure the public and
is a violation of the Act.
(c)
Non-compliance includes, but is not limited to:
(1)
Failure to comply with a term or condition in an order;
(2)
Failure to cooperate with agency representatives;
(3)
Failure to promptly respond to communications by agency
representatives;
(4)
Failure to comply with deadlines set forth in an order
or established by agency representatives for the purpose of enforcement of
an order;
(5)
Failure to timely submit documents required as a term or
condition of an order;
(6)
Failure to release documents as requested by agency representatives;
(7)
Failure and/or refusal to meet with and discuss compliance
matters with agency representatives during any compliance visit;
(8)
Interference by probationer or agents of probationer that
compromises and/or prevents agency representatives from fulfilling duties
and responsibilities as set by an order, rule, or statute during a compliance
visit; and
(9)
Any expression by word or deed, either directly or indirectly,
to agency representatives that a reasonable person would find as harassing,
insulting, disrespectful, or rude.
(d)
Upon a finding of non-compliance, due process will be extended
to a probationer in accordance with the Act and the probationer shall be invited
to attend a probationer show compliance proceeding as set forth in §187.44
of this title (relating to Probationer Show Compliance Proceedings).
(e)
In lieu of a probationary show compliance proceeding and
in order to resolve violations of an order, a probationer may waive his or
her rights to a hearing as provided under the Act, §187.44 of this title
(relating to Probationer Show Compliance Proceedings), and the APA, and accept
a settlement agreement proposed by the chief of compliance with the approval
of the executive director.
§189.9.Grounds for Temporary Suspension or Automatic Suspension of Probationers.
Certain violations of an order by a probationer are of such a nature
that the continuation in practice by the probationer shall be considered a
continuing threat to the public welfare. Such violation is grounds for a temporary
suspension hearing as provided under §187.41 of this title (relating
to Temporary Suspensions) or for automatic suspension pursuant to terms and
conditions of the probationer's order. Such violations include, but are not
limited to:
(1)
failure to pass the Special Purpose Examination within
the required number of attempts;
(2)
failure to pass the Medical Jurisprudence Examination within
the required number of attempts;
(3)
testing positive for a prohibited substance;
(4)
failure to timely submit to a drug and/or alcohol screen;
(5)
refusal to submit to a drug and/or alcohol screen; and
(6)
any attempt to circumvent or tamper with the accuracy of
a drug and/or alcohol screen.
§189.10.Drug Screens.
(a)
If the terms and conditions of an order provide for the
screening of a prohibited substance, the probationer shall be screened by
urine, blood, hair, breath, or other scientifically acceptable means to test
for prohibited substances within a prescribed time period.
(b)
Random testing is mandated. Agency representatives shall
not make appointments or schedule times to collect screens.
(c)
The probationer must submit to the screen within the prescribed
time period.
(d)
Probationers may not prospectively request copies of screens.
The agency does not accept a standing request for copies of all drug screens.
Upon receipt of written request, a copy of a screen may be forwarded only
to a probationer or a probationer's authorized representative.
(e)
The selection of any drug screening panel or screening
method is at the sole discretion of the board and may be changed without prior
notice to the probationer.
(f)
The probationer is responsible for all costs related to
drug screens.
§189.11.Process for Approval of Physicians, Other Professionals, Group Practices and Institutional Settings.
(a)
Any approval of a physician or other professional to serve
as a proctor, monitor, or supervisor or the approval of a group practice or
institutional setting required by an order shall be given by the executive
director or his or her designee.
(b)
Approval of a physician or other professional required
by an order must meet all of the following criteria:
(1)
board certification by a board certifying organization
that meets the requirements of §164.4 of this title (relating to Board
Certification);
(2)
no economic relationship with probationer;
(3)
no direct personal relationship with probationer;
(4)
no more than three medical malpractice suits filed and/or
pending against the physician or other professional within a five year period;
(5)
no more than three resolved investigations by the board
against the physician or other professional within a five year period; and
(6)
no disciplinary history, pending investigations, or formal
SOAH complaints with the board.
(c)
The criteria for approval of a group practice or institutional
setting required by an order may include a review of the physicians connected
with the group practice or institutional setting utilizing the criteria set
forth in subsection (b) of this section.
(d)
The executive director or his or her designee may consider
other factors in addition to those listed in subsection (b) of this section.
§189.12.Suspended licenses.
A probationer whose license has been suspended by the board remains
under the jurisdiction of the board and must comply with Chapter 166 of this
title (relating to Physician Registration). Failure to do so may lead to cancellation
of probationer's license for non-payment.
§189.13.Investigative Reports.
All reports created by agency representatives while investigating a
probationer's compliance with an order are investigative reports as defined
by the Act.
§189.14.Receipt of Probationer's Address of Record and Contact Information.
(a)
A probationer must maintain an address of record with the
agency.
(b)
In addition to the requirements set out in subsection (a)
of this section, a probationer must provide current up to date contact information
to the agency. Such contact information shall include, all the following information
applicable to the probationer:
(1)
Mailing address;
(2)
Home address;
(3)
Work address;
(4)
Home telephone number;
(5)
Work telephone number;
(6)
Mobile pager number;
(7)
Cellular telephone number; and
(8)
Electronic mail address.
(c)
Any change to the contact information listed under subsection
(b) of this section must be reported to the agency within ten calendar days
after the effective date of the change.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State on February 15, 2002.
TRD-200200971
Donald W. Patrick, MD, JD
Executive Director
Texas State Board of Medical Examiners
Earliest possible date of adoption: March 31, 2002
For further information, please call: (512) 305-7016
22 TAC §193.6
The Texas State Board of Medical Examiners proposes an amendment
to §193.6, concerning designation of prescriptive authority to alternative
practice sites. The amendment is necessary as a result of SB 1166.
Michele Shackelford, General Counsel, Texas State Board of Medical Examiners,
has determined that for the first five-year period the section is in effect
there will be no fiscal implications to state or local government as a result
of enforcing the rule as proposed.
Ms. Shackelford also has determined that for each year of the first five
years the section as proposed is in effect the public benefit anticipated
as a result of enforcing the section will be compliance with SB 1166. There
will be no effect on small businesses. There will be no effect to individuals
required to comply with the section as proposed.
Comments on the proposal may be submitted to Pat Wood, P.O. Box 2018, MC-901,
Austin, Texas 78768-2018. A public hearing will be held at a later date.
The amendment is proposed under the authority of the Occupations
Code Annotated, §153.001, which provides the Texas State Board of Medical
Examiners to adopt rules and bylaws as necessary to: govern its own proceedings;
perform its duties; regulate the practice of medicine in this state; and enforce
this subtitle.
The following are affected by the proposed amendment: Tex. Occ. Code Ann., §§157.051,
157.052, 157.053, 157.054, 157.055, 157.056, 157.057, 157.058, 157.059, 157.060.
§193.6.Delegation of the Carrying Out or Signing of Prescription Drug Orders to Physician Assistants and Advanced Practice Nurses.
(a)
Purpose. The purpose of this section is to provide guidelines
for implementation of the Medical Practice Act
("the Act"),
Texas
Occupations Code Annotated, §§157.051-157.060, which provide for
the use by physicians of standing delegation orders, standing medical orders,
physician's
orders
[
[
[
[
[
[
[
[
[
[
[
[
[
(b)
[
(1)
Acts that may be delegated. At a site serving
a medically underserved population, a physician authorized by the board may
delegate to a physician assistant or an advanced practice nurse the act or
acts of administering, providing, or carrying out or signing a prescription
drug order as authorized through physician's orders, standing medical orders,
standing delegation orders, or other orders or protocols as defined by the
board. Providing and carrying out or signing a prescription drug order under
this subdivision is limited to dangerous drugs and shall comply with other
applicable laws.
[
(2)
Physician supervision at site
serving medically underserved populations. Physician supervision of a physician
assistant or an advanced practice nurse at a site serving a medically underserved
population will be adequate if a delegating physician:
(A)
receives a daily status report to be conveyed
in person, by telephone, or by radio from the advanced practice nurse or physician
assistant on any complications or problems encountered that are not covered
by a protocol;
(B)
visits the clinic in person at least once every
ten business days during regular business hours during which the advanced
practice nurse or physician assistant is on site providing care, in order
to observe and provide medical direction and consultation to include, but
not be limited to:
(i)
reviewing with the physician assistant or advanced
practice nurse the case histories of patients with problems or complications
encountered;
(ii)
personally diagnosing or treating patients
requiring physician follow-up; and
(iii)
verifying that patient care is provided by
the clinic in accordance with a written quality assurance plan on file at
the clinic, which includes a random review and countersignature of at least
10% of the patient charts by the physician;
(C)
is available by telephone or direct telecommunication
for consultation, assistance with medical emergencies, or patient referrals;
and
(D)
is responsible for the formulation or approval
of such physician's orders, standing medical orders, standing delegation orders,
or other orders or protocols and periodically reviews such orders and the
services provided to patients under such orders.
(3)
Supervision of clinics. A physician
may not supervise more than three clinics serving medically underserved populations
without approval of the board. A physician may not supervise any number of
clinics with combined regular business hours exceeding 150 concurrent hours
per week without approval of the board.
[
(c)
[
(1)
"Primary practice site" means:
(A)
the practice location where the physician spends
the majority of the physician's time;
(B)
a licensed hospital, long-term care facility,
or adult care center where both the physician and the physician assistant
or advanced practice nurse are authorized to practice;
(C)
a clinic operated by or for the benefit of a
public school district for the purpose of providing care to the students of
that district and the siblings of those students, if consent to treatment
at that clinic is obtained in a manner that complies with the Family Code,
Chapter 32;
(D)
an established patient's residence; or
(E)
where the physician is physically present with
the physician assistant or advanced practice nurse.
(2)
Acts that may be delegated.
At a
physician's primary practice site [
(3)
Physician supervision.
Physician
supervision of the carrying out and signing of prescription drug orders shall
conform to what a reasonable, prudent physician would find consistent with
sound medical judgment but may vary with the education and experience of the
advanced practice nurse or physician assistant. A physician shall provide
continuous supervision, but the constant physical presence of the physician
is not required.
(4)
[
(A)
three physician assistants or advanced practice nurses
or their full-time equivalents practicing at the physician's primary
or alternate
practice site; and
(B)
the patients with whom the physician has established or
will establish a physician-patient relationship, but this shall not be construed
as requiring the physician to see the patient within a specific period of
time.
[
[
[
[
(d)
Delegation of prescriptive
authority at a physician's alternate practice site.
(1)
"Alternate practice site" means a site:
(A)
where services similar to the services provided
at the delegating physician's primary practice site are provided; and
(B)
located within 60 miles of the delegating physician's
primary practice site.
(2)
Acts that may be delegated. At a physician's
alternate practice site, a licensed physician authorized by the board may
delegate to a physician assistant or an advanced practice nurse acting under
adequate physician supervision the act or acts of administering, providing,
carrying out or signing a prescription drug order as authorized through physician's
orders, standing medical orders, standing delegation orders, or other orders
or protocols as defined by the board. Providing, carrying out or signing a
prescription drug order under this subsection is limited to dangerous drugs
and shall comply with other applicable laws.
(3)
Physician supervision is adequate for the purposes
of this subsection if the delegating physician:
(A)
is on-site with the advance practice nurse or
physician assistant at least 20 percent of the time;
(B)
randomly reviews at least 10 percent of the
medical charts of patients seen by a physician assistant or advanced practice
nurse at the site; and
(C)
is available through direct telecommunication
for consultation, patient referral, or assistance with a medical emergency.
(4)
A physician may not delegate to a combined number
of more than three physician assistants or advanced practice nurses or their
full-time equivalents at the physician's primary and alternate practice sites.
(e)
[
(1)
Acts that may be delegated.
A
licensed
physician
authorized
[
(2)
Limitations on authority to delegate.
A physician's authority to delegate under this subsection is limited as follows
[
(A)
[
(B)
[
(C)
[
(D)
[
(E)
[
(3)
Physician supervision. Physician
supervision of the carrying out and signing of a prescription drug order shall
conform to what a reasonable, prudent physician would find consistent with
sound medical judgment but may vary with the education and experience of the
advanced practice nurse or physician assistant. A physician shall provide
continuous supervision, but the constant physical presence of the physician
is not required.
(f)
Documentation of supervision.
If the physician assistant or advanced practice nurse is located at a site
other than the site where the physician spends the majority of the physician's
time, physician supervision shall be documented. The documentation should
be through a log or other method appropriate to the practice. The documentation
will include the names or identification numbers of patients discussed during
the daily status reports, the times when the physician is on site, and a summary
of what the physician did while on site. Said summary shall include a description
of the quality assurance activities conducted and the names of any patients
seen or whose case histories were reviewed with the physician assistant or
advanced practice nurse. The supervising physician shall sign the documentation
at the conclusion of each site visit. Documentation is not required if the
physician assistant or advanced practice nurse is permanently located with
the physician at a site where the physician spends the majority of the physician's
time.
(g)
Alternate physicians. If a
delegating physician will be unavailable to supervise the physician assistant
or advanced practice nurse as required by this section, arrangements shall
be made for another physician to provide that supervision. The physician providing
that supervision shall affirm in writing that he or she is familiar with the
protocols or standing delegation orders in use at the site and is accountable
for adequately supervising care provided pursuant to those protocols or standing
delegation orders by fulfilling the requirements for registration as an alternate
supervising physician to include completing and submitting a board approved
form.
(h)
Prescription forms. Prescription
forms shall comply with applicable rules adopted by the Texas State Board
of Pharmacy. Prescriptions issued pursuant to this section may only be written
for dangerous drugs. No prescriptions for controlled substances may be authorized
or issued. A delegating physician is responsible for devising and enforcing
a system to account for and monitor the issuance of prescriptions under the
physician's supervision.
(i)
Waivers.
(1)
The board may waive or modify any of the site
or supervision requirements for a physician to delegate the carrying out or
signing of prescription drug orders to an advanced practice nurse or physician
assistant at facilities serving medically underserved populations, at physician
primary and alternate practice sites, and at facility-based practice sites.
(2)
The board may grant a waiver under subsection
(1) if the board determines that:
(A)
the practice site where the physician is seeking
to delegate prescriptive authority is unable to meet the requirements of Chapter
157 of the Act or this section, or compliance would cause an undue burden
without a corresponding benefit to patient care;
(B)
safeguards exist for patient care and for fostering
a collaborative practice between the physician and the advanced practice nurses
and physician assistants; and
(C)
if the requirement for which the waiver is sought
is the amount of time the physician is on-site, the frequency and duration
of time the physician is on-site when the advanced practice nurse is present
is sufficient for collaboration to occur, taking into consideration the other
ways the physician collaborates with the advanced practice nurse or physician
assistant at other sites.
(3)
The board may not waive the limitation on the
number of primary or alternate practice sites at which a physician may delegate
the carrying out or signing of prescription drug orders or the number of advanced
practice nurses or physician assistants to whom a physician may delegate the
carrying out or signing of prescription drug orders.
(4)
Procedure.
(A)
In accordance with this section and §157.0542
of the Act, the board shall appoint an advisory committee to meet as needed
to review and make recommendations on applications for waivers.
(B)
A physician may apply for a waiver by submitting
a written request to the licensure division of the board.
(C)
Applications must be submitted at least 20 days
prior to the next scheduled meeting of the advisory committee in order for
the committee to consider the application at that meeting.
(D)
The board must receive recommendations from
the advisory committee at least 20 days prior to the board meeting at which
they shall be considered.
(E)
An advisory committee recommendation of the
approval of a waiver, with or without modifications, requires a vote of at
least:
(i)
three advanced practice nurse committee members;
(ii)
three physician assistant committee members;
and
(iii)
three physician committee members.
(F)
The Standing Orders Committee of the board shall
review recommendations from the advisory committee and may recommend to the
full board that a waiver be granted, denied or modified.
(G)
The board may grant a waiver only if the advisory
committee recommends that the waiver be granted, unless the board determines
good cause exists to grant a waiver the committee does not recommend.
(H)
The advisory committee may recommend that the
board approve a waiver with modifications.
(I)
If the board denies a waiver, a written explanation
for the denial shall be given to the physician along with any recommended
modifications that would make the waiver application acceptable.
(J)
The board may revoke, suspend or modify a waiver
previously granted after providing the physician notice and opportunity for
a hearing as provided for by the Administrative Procedure Act and Chapter
187 of this title (relating to Procedure).
(j)
Violations. Violation of this
section by the delegating physician may result in a refusal to approve supervision
or the cancellation of the physician's authority to delegate to a physician
assistant or an advanced practice nurse under this section. Violation of this
section may also subject the physician to disciplinary action as provided
by the Act, §164.001, for violation of §164.051. If an advanced
practice nurse violates this section or the Act, §§157.051-157.060,
the board shall promptly notify the Texas Board of Nurse Examiners of the
alleged violation. If a physician assistant violates this section or the Act, §§157.051-157.060,
the board shall promptly notify the Texas State Board of Physician Assistant
Examiners.
(k)
Delegation to certified registered nurse anesthetists.
(1)
In a licensed hospital or ambulatory surgical center a
physician may delegate to a certified registered nurse anesthetist the ordering
of drugs and devices necessary for a certified registered nurse anesthetist
to administer an anesthetic or an anesthesia-related service ordered by the
physician. The physician's order for anesthesia or anesthesia-related services
does not have to be drug-specific, dose-specific, or administration-technique-specific.
Pursuant to the order and in accordance with facility policies or medical
staff bylaws, the nurse anesthetist may select, obtain, and administer those
drugs and apply the appropriate medical devices necessary to accomplish the
order and maintain the patient within a sound physiological status.
(2)
This paragraph shall be liberally construed to permit the
full use of safe and effective medication orders to utilize the skills and
services of certified registered nurse anesthetists.
(l)
Delegation related to obstetrical services.
(1)
A physician may delegate to a physician assistant offering
obstetrical services and certified by the board as specializing in obstetrics
or an advanced practice nurse recognized by the Texas State Board of Nurse
Examiners as a nurse midwife the act or acts of administering or providing
controlled substances to the nurse midwife's or physician assistant's clients
during intra-partum and immediate post-partum care. The physician shall not
delegate the use or issuance of a triplicate prescription form under the triplicate
prescription program, the Health and Safety Code, section 481.075.
(2)
The delegation of authority to administer or provide controlled
substances under this paragraph must be under a physician's order, medical
order, standing delegation order, or protocol which shall require adequate
and documented availability for access to medical care.
(3)
The physician's orders, medical orders, standing delegation
orders, or protocols shall provide for reporting or monitoring of client's
progress including complications of pregnancy and delivery and the administration
and provision of controlled substances by the nurse midwife or physician assistant
to the clients of the nurse midwife or physician assistant.
(4)
The authority of a physician to delegate under this paragraph
is limited to:
(A)
three nurse midwives or physician assistants or their full-time
equivalents; and
(B)
the designated facility at which the nurse midwife or physician
assistant provides care.
(5)
The administering or providing of controlled substances
under this paragraph shall comply with other applicable laws.
(6)
In this paragraph, "provide" means to supply one or more
unit doses of a controlled substance for the immediate needs of a patient
not to exceed 48 hours.
(7)
The controlled substance shall be supplied in a suitable
container that has been labeled in compliance with the applicable drug laws
and shall include the patient's name and address; the drug to be provided;
the name, address, and telephone number of the physician; the name, address,
and telephone number of the nurse midwife or physician assistant; and the
date.
(8)
This paragraph does not permit the physician or nurse midwife
or physician assistant to operate a retail pharmacy as defined under the Texas
Pharmacy Act (Article 4542a-1, Vernon's Texas Civil Statutes).
(9)
This paragraph shall be construed to provide a physician
the authority to delegate the act or acts of administering or providing controlled
substances to a nurse midwife or physician assistant but not as requiring
physician delegation of further acts to a nurse midwife or as requiring physician
delegation of the administration of medications to registered nurses or physician
assistants other than as provided in this paragraph.
(m)
Liability. A physician shall not be liable for the act
or acts of a physician assistant or advanced practice nurse solely on the
basis of having signed an order, a standing medical order, a standing delegation
order, or other order or protocols authorizing a physician assistant or advanced
practice nurse to perform the act or acts of administering, providing, carrying
out, or signing a prescription drug order unless the physician has reason
to believe the physician assistant or advanced practice nurse lacked the competency
to perform the act or acts.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State on February 15, 2002.
TRD-200200972
Donald W. Patrick, MD, JD
Executive Director
Texas State Board of Medical Examiners
Earliest possible date of adoption: March 31, 2002
For further information, please call: (512) 305-7016
Chapter 365.
LICENSING AND REGISTRATION
22 TAC §365.14
The Texas State Board of Plumbing Examiners proposes amendments
to §365.14 which provides criteria for Board approval of continuing professional
education programs. Section 365.14 also explains how the continuing professional
education (CPE) programs shall function.
The proposed amendments to §365.14 will revise the schedule of reporting
to the Board of Licensee evaluations of Course Materials, Course Providers
and Course Instructors. Currently, Course Material Providers are required
by §365.14(a)(12)(G) to have a method for quarterly reporting of Course
Provider, Instructors, and Licensee evaluations of Course Materials to the
Board. The method that Course Material Providers have used is to assign the
reporting to the Course Providers. The Course Providers include the Course
Material evaluations in their compilations of the Licensee evaluations of
Course Providers and Course Instructors that is required of the Course Providers
under §365.14(b)(15)(K). This method has worked well, since it is the
Course Provider that has the most direct contact with the Licensees. The Board
proposes to remove the reporting requirements from the Course Material Providers.
Additionally, the Board has determined that annual reporting is sufficient
for Course Providers that have met the Board's requirements and have been
providing CPE for at least one CPE course year. The Board proposes to maintain
the quarterly reporting requirements for new Course Providers during their
first year of providing CPE courses. The proposed amendments are specifically
found in §365.14(a)(12)(G) and §365.14(b)(15)(K).
Robert L. Maxwell, Administrator of the Texas State Board of Plumbing Examiners,
has determined that for the first five-year period the rule is in effect there
will be no fiscal impact on state and local government as well as small businesses
and persons required to comply with the rule amendments.
Mr. Maxwell also has determined that each year of the first five years
the rule is effect the public benefit anticipated as a result of enforcing
the rule will be a savings to the resources expended by the Course Material
Providers, Course Providers and the Board. The Licensee will continue to benefit
from the Board's review of CPE evaluations. The citizens health and safety
will continue to benefit by having qualified and continually educated plumbers
available to them.
Comments on the proposed rule changes may be submitted within 30 days of
publication of the proposed rule amendments in the
Texas Register
, to Robert L. Maxwell, Administrator, Texas State Board
of Plumbing Examiners, 929 East 41st Street, P.O. Box 4200, Austin, Texas
78765-4200.
The amendments to §365.14 are proposed under and affect
Texas Revised Civil Statutes Annotated Article 6243-101 ("Act"), §§5(a),
12B(a), 12B(b), 12B(c) and the rule it amends. Section 5(a) of the Act authorizes,
empowers and directs the Board to prescribe, amend and enforce all rules and
regulations necessary to carry out the Act. Section 12B(a) requires a plumbing
license holder to complete at least six hours of continuing professional education
each license year. Section 12B(b) directs that the Board, by rule, adopt criteria
for continuing professional education. Section 12B(c) specifies that in order
for persons to receive credit for participation in a continuing professional
education program or course, the program or course must have been provided
according to criteria adopted by the Board and by an individual, business,
or association approved by the Board.
No other statute, article or code is affected by this proposed amendment.
§365.14.Continuing Professional Education Programs.
(a)
Course Materials--Beginning in preparation for the 2000-2001
Continuing Professional Education year (begins on July 1, 2000), the Board
will annually approve Course Materials to be used for the Continuing Professional
Education (CPE) required for renewal of Journeyman Plumber, Master Plumber,
Tradesman Plumber-Limited Licensee and Plumbing Inspector Licenses. The Course
Materials are the printed materials that are the basis for a substantial portion
of a CPE course and which are provided to the Licensees. Board approval of
Course Materials will be subject to all of the terms and conditions of this
Section. The following minimum criteria will be used by the Board in considering
approval of Course Materials:
(1) - (11)
(No change.)
(12)
The Board shall annually approve only individuals, businesses
or associations to provide Course Materials. Any individual, business or association
who wishes to offer to provide Course Materials shall apply to the Board for
approval using application forms prepared by the Board. In order to be approved,
the application must satisfy the Board as to the ability of the individual,
business or association to provide quality Course Materials as required in
this Section and must include:
(A) - (F)
(No change.)
[(G)
method for quarterly reporting of Course
Provider, Instructors, and Licensee evaluations of Course Materials to the
Board,]
(13) - (19)
(No change.)
(b)
Course Providers--The Board will annually approve only
individuals, businesses or associations as Course Providers. Course Providers
will offer classroom and correspondence instruction in the Course Materials
used for the Continuing Professional Education (CPE) required for renewal
of all licenses issued under the Act. Board approval of Course Providers will
be subject to all of the terms and conditions of this Section. The following
minimum criteria will be used by the Board in considering approval of Course
Providers:
(1) - (14)
(No change.)
(15)
Any individual, business or association who wishes to
be a Course Provider shall apply to the Board for approval using application
forms prepared by the Board. In order to be approved, the application must
satisfy the Board as to the ability of the individual, business or association
to provide quality instruction in the Course Materials as required in this
Section and must include:
(A) - (J)
(No change.)
(K)
method for [
(i)
Course Providers shall provide quarterly
reports no later than December 15, March 15, June 15 and September 15, for
the first year in which the Course Provider provides CPE courses;
(ii)
Renewing Course Providers shall provide
only annual reports, no later than September 15 of each year, for the preceding
CPE course year.
(L) - (M)
(No change.)
(16) - (18)
(No change.)
(19)
Beginning with the 2000-2001 CPE year, the Board will
establish the deadline in which applications must be submitted after the effective
date of this rule. For the 2001-2002 and following CPE years, all Course Provider
applications must be submitted to the Board office no later than December
1, each year for approval at the Board's January meeting[
(20) - (21)
(No change.)
(c)
(No change.)
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State on February 14, 2002.
TRD-200200938
Robert L. Maxwell
Administrator
Texas State Board of Plumbing Examiners
Earliest possible date of adoption: March 31, 2002
For further information, please call: (512) 458-2145
Chapter 591.
GENERAL PROVISIONS
Chapter 185.
PHYSICIAN ASSISTANTS
;
]
and may not be under any order of the medical board.
(4)
submit the name, Texas license
number, and signature of any alternate supervising physician(s).]
Chapter 189.
COMPLIANCE PROGRAM
Chapter 193.
STANDING DELEGATION ORDERS
order
], or other orders or protocols
in delegating authority to physician assistants or advanced practice nurses
at
a site
[
sites
] serving medically underserved populations,
at a physician's primary practice
or alternate practice
site, or
at a
facility-based practice
site
.
[
described in
subsection (j) of this section. In accord with Texas Occupations Code Annotated, §§157.051-157.060,
]
This section establishes minimum standards for supervision by
physicians when delegating prescriptive authority to physician assistants
and advanced practice nurses at such sites.
[
this section establishes
minimum standards for supervision by physicians of physician assistants and
advanced practice nurses for provision of services at such sites.
] This
section also provides for the signing of a prescription by an advanced practice
nurse or a physician assistant after the person has been designated by the
delegating physician
as a person delegated to sign a prescription
[
and for the use of prescriptions pre-signed by the supervising physician
] which may be carried out by a physician assistant or advanced practice
nurse according to protocols. Such protocols may authorize diagnosis of the
patient's condition and treatment, including prescription of dangerous drugs.
Proper use of protocols allows integration of clinical data gathered by the
physician assistant or advanced practice nurse. Neither the [
Medical
Practice
] Act, [
Texas Occupations Code Annotated
], §157.051-157.060,
nor these rules authorize the exercise of independent medical judgment by
physician assistants or advanced practice nurses, and the
delegating
[
supervising
] physician remains responsible to the board
and to his or her patients for acts performed under the physician's delegated
authority. Advanced practice nurses and physician assistants remain professionally
responsible for acts performed under the scope and authority of their own
licenses.
(b)
Physician supervision at site
serving medically underserved populations. Physician supervision of a physician
assistant or advanced practice nurse at a site serving a medically underserved
population will be adequate if a delegating physician:]
(1)
receives a daily status report to be conveyed
in person, by telephone, or by radio from the advanced practice nurse or physician
assistant on any complications or problems encountered that are not covered
by a protocol;]
(2)
visits the clinic in person at least once every
ten business days during regular business hours during which the advanced
practice nurse or physician assistant is on site providing care, to observe
and to provide medical direction and consultation to include, but not be limited
to:]
(A)
reviewing with the physician assistant or advanced
practice nurse case histories of patients with problems or complications encountered;]
(B)
personally diagnosing or treating patients
requiring physician follow-up;]
(C)
verifying that patient care is provided by
the clinic in accordance with a written quality assurance plan on file at
the clinic, which includes a random review and countersignature of at least
10% of the patient charts by the supervising physician;]
(3)
is available by telephone or direct telecommunication
for consultation, assistance with medical emergencies, or patient referrals.]
(4)
is responsible for the formulation or approval
of such physician's orders, standing medical orders, standing delegation orders,
or other orders or protocols and periodically reviews such orders and the
services provided patients under such orders.]
(c)
Documentation of supervision.
If the physician assistant or advanced practice nurse is located at a site
other than the site where the physician spends the majority of the physician's
time, physician supervision shall be documented through a log kept at the
clinic where the physician assistant or advanced practice nurse is located.
The log will include the names or identification numbers of patients discussed
during the daily status reports, the times when the physician is on site,
and a summary of what the physician did while on site. Said summary shall
include a description of the quality assurance activities conducted and the
names of any patients seen or whose case histories were reviewed with the
physician assistant or advanced practice nurse. The supervising physician
shall sign each log at the conclusion of each site visit. A log is not required
if the physician assistant or advanced practice nurse is permanently located
with the physician at a site where the physician spends the majority of the
physician's time.]
(d)
Alternate physicians. If a
delegating physician will be unavailable to supervise the physician assistant
or advanced practice nurse as required by this section, arrangements shall
be made for another physician to provide that supervision. The physician providing
that supervision shall affirm in writing that he or she is familiar with the
protocols or standing delegation orders in use at the clinic and is accountable
for adequately supervising care provided pursuant to those protocols or standing
delegation orders by fulfilling the requirements for registration as an alternate
supervising physician as detailed in rules of the Texas State Board of Physician
Assistant Examiners, 22 Texas Administrative Code, Chapter 185.of this title
(relating to Physician Assistants).]
(e)
Supervision of clinics. A
physician may not supervise more than three clinics without approval of the
board. A physician may not supervise any number of clinics with combined regular
business hours exceeding 150 concurrent hours per week without approval of
the board.]
(f)
Exceptions to patient chart
review. Exceptions to the percentage of patient chart reviews required by
subsection (b)(2)(C) of this section and the provisions of subsection (e)
of this section relating to the number of clinics or clinic hours supervised
may be made by the board upon special request by a delegating physician. Such
a request shall state the special circumstances and needs prompting the exception,
the names and locations of the clinics and/or hours to be supervised, and
a plan of supervision. In granting an exception, the board shall state the
percentage of charts that must be reviewed and/or the number of clinics or
the combined clinic hours that can be supervised.]
(g)
] Delegation of prescriptive
authority at site serving underserved populations.
A physician may delegate to a physician assistant
or advanced practice nurse the act or acts of administering, providing, or
carrying out or signing a prescription drug order as authorized by the physician
through physician's orders, standing medical orders, standing delegation orders,
or other orders or protocols as defined by the board in treating patients
at a site serving a medically underserved population. The prescription forms
itself shall comply with applicable rules adopted by the Texas State Board
of Pharmacy. Prescriptions issued pursuant to this section may only be written
for dangerous drugs. No prescriptions for controlled substances may be authorized
or issued. An appropriate signature on one of the two signature lines on the
prescription shall convey instructions to a pharmacist regarding the pharmacist's
authority to dispense a generically equivalent drug, if available. If the
physician assistant or advanced practice nurse authorizes generic substitution,
the protocol shall provide direction to the physician assistant or advanced
practice nurse as to whether and under what circumstances product selection
will be permitted by a pharmacist. A delegating physician is responsible for
devising and enforcing a system to account for and monitor the issuance of
prescriptions under his supervision.
]
(h)
Violations. Violation of this
section by the supervising physician may result in a refusal to approve supervision
or cancellation of the physician's authority to supervise a physician assistant
or advanced practice nurse under this section. Violation of this section may
also subject the physician to disciplinary action as provided by the Medical
Practice Act, Texas Occupations Code Annotated, §164.001, for violation
of Texas Occupations Code Annotated, §164.051. If an advanced practice
nurse violates this section or the Medical Practice Act, Texas Occupations
Code Annotated, §§157.051-157.060, the board shall promptly notify
the Texas Board of Nurse Examiners of the alleged violation. If a physician
assistant violates this section or the Medical Practice Act, Texas Occupations
Code Annotated, §§157.051-157.060, the board shall promptly notify
the Texas State Board of Physician Assistant Examiners.]
(i)
] Delegation
of prescriptive
authority
at primary practice site.
or a location as described by subsection
(j) of this section
], a
licensed
physician
authorized
[
licensed
] by the board may delegate to a physician assistant
or an advanced practice nurse acting under adequate physician supervision
the act or acts of administering, providing, carrying out or signing a prescription
drug order as authorized through physician's orders, standing medical orders,
standing delegation orders, or other orders or protocols as defined by the
board. Providing and carrying out or signing a prescription drug order under
this subdivision is limited to dangerous drugs and shall comply with other
applicable laws.
(1)
]
Additional limitations.
A physician's authority to delegate the carrying out or signing of
a prescription drug order [
at his primary practice site
] under
this
subsection
[
section
] is limited to:
(2)
"Primary practice site" means:]
(A)
the practice location where the physician spends
the majority of the physician's time;]
(B)
a licensed hospital, a licensed long-term care
facility, and a licensed adult care center where both the physician and the
physician assistant or advanced practice nurse are authorized to practice,
a clinic operated by or for the benefit of a public school district for the
purpose of providing care to the students of that district and the siblings
of those students, if consent to treatment at that clinic is obtained in a
manner that complies with the Family Code, Chapter 32, or an established patient's
residence; or]
(C)
where the physician is physically present with
the physician assistant or advanced practice nurse.]
(j)
] Delegation
of prescriptive
authority
at
a
facility-based practice
site
.
licensed
] by the
board shall be authorized to delegate, to one or more physician assistants
or advanced practice nurses acting under adequate physician supervision whose
practice is facility based at a licensed hospital or licensed long-term care
facility, the carrying out or signing of prescription drug orders if the physician
is the medical director or chief of medical staff of the facility in which
the physician assistant or advanced practice nurse practices, the chair of
the facility's credentialing committee, a department chair of a facility department
in which the physician assistant or advanced practice nurse practices, or
a physician who consents to the request of the medical director or chief of
medical staff to delegate the carrying out or signing of prescription drug
orders at the facility in which the physician assistant or advanced practice
nurse practices.
Providing and carrying out or signing a prescription
drug order under this subdivision is limited to dangerous drugs and shall
comply with other applicable laws.
in paragraphs (1)-(5) of this subsection
]:
(1)
] the delegation is pursuant
to a physician's order, standing medical order, standing delegation order,
or other order or protocol developed in accordance with policies approved
by the facility's medical staff or a committee thereof as provided in facility
bylaws;
(2)
] the delegation occurs in the
facility in which the physician is the medical director, the chief of medical
staff, the chair of the credentialing committee, or a department chair;
(3)
] the delegation does not permit
the carrying out or signing of prescription drug orders for the care or treatment
of the patients of any other physician without the prior consent of that physician;
(4)
] delegation in a long-term care
facility must be by the medical director and the medical director is limited
to delegating the carrying out and signing of prescription drug orders to
no more than three advanced practice nurses or physician assistants or their
full-time equivalents; and
(5)
] under this section, a physician
may not delegate at more than one licensed hospital or more than two long-term
care facilities unless approved by the board.
Part 17.
TEXAS STATE BOARD OF PLUMBING EXAMINERS
quarterly
] reporting compilations
of Licensee evaluations of
Course Materials,
Course Provider and
Course Instructors to the Board
, in accordance with the following:
[
and
]
, unless an
extension is requested at or before the January Board meeting and granted
by the Board
].
Part 25.
STRUCTURAL PEST CONTROL BOARD