EMERGENCY RULES An agency may adopt a new or amended section or repeal an existing section on an emergency basis if it determines that such action is necessary for the public health, safety, or welfare of this state. The section may become effective immediately upon filing with the Texas Register, or on a stated date less than 20 days after filing and remaining in effect no more than 120 days. The emergency action is renewable once for no more than 60 additional days. Symbology in amended emergency sections. New language added to an existing section is indicated by the use of bold text. [Brackets] indicate deletion of existing material within a section. TITLE 22. EXAMINING BOARDS Part XI. Board of Nurse Examiners Chapter 222. Advanced Nurse Practitioners Carrying Out Prescription Drug Orders 22 TAC sec.sec.222.1-222.4 (Editor's note: The text of the following sections adopted on an emergency basis for repeal will not be published. The sections may be examined in the offices of the Board of Nurse Examiners or in the Texas Register office, Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.) The Board of Nurse Examiners adopts, on an emergency basis, the repeal of sec.sec.222.1-222.4, concerning Advanced Nurse Practitioners Carrying out Prescription Drug Orders. During the 74th Legislative Session, Senate Bill 673 was passed which expanded limited prescriptive authority for Advanced Practice Nurses. Amendments to the Nursing Practice Act require the board to adopt rules. Senate Bill 673 became effective upon signature of the Governor and in order for the Board of Nurse Examiners to have rules in place to begin approving applicants for prescriptive authority in the new eligible sites, the emergency repeal is necessary to allow for new rules. The emergency repeals are adopted under the Nursing Practice Act (Texas Civil Statutes), Article 4514, sec.1, which provides the Board of Nurse Examiners with the authority and power to make and enforce all rules and regulations necessary for the performance of its duties and conducting of proceedings before it and Government Code, sec.2001.34, which provides for the adoption of administrative rules on an emergency basis. sec.222.1. Definitions. sec.222.2. Application for Approval. sec.222.3. Functions. sec.222.4. Enforcement. Issued in Austin, Texas, on September 20, 1995. TRD-9512068 Kathy Thomas, MN, RN, CPNP Interim Executive Director Board of Nurse Examiners Effective date: September 20, 1995 Expiration date: January 18, 1996 For further information, please call: (512) 835-8675 Chapter 222. Advanced Practice Nurses with Limited Prescriptive Authority 22 TAC sec.sec.222.1-222.7 The Board of Nurse Examiners adopts, on an emergency basis, new sec.sec.222. 1-222.7, concerning Advanced Practice Nurses with Limited Prescriptive Authority. During the 74th Legislative Session, Senate Bill 673 was passed which expanded limited prescriptive authority for Advanced Practice Nurses. Amendments to the Nursing Practice Act require the board to adopt rules. Senate Bill 673 became effective upon signature of the Governor and in order for the Board of Nurse Examiners to have rules in place to begin approving applicants for prescriptive authority in the new eligible sites, these rules are being adopted on an emergency basis. The emergency rules are adopted under the Nursing Practice Act (Texas Civil Statutes), Article 4514, sec.1, which provide the Board of Nurse Examiners with the authority and power to make and enforce all rules and regulations necessary for the performance of its duties and conducting of proceedings before it and Government Code, sec.2001.34, which provides for the adoption of administrative rules on an emergency basis. sec.222.1. Definitions. The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise. Advanced practice nurse (APN) formerly known as Advanced Nurse Practitioner (ANP)-A registered professional nurse, currently licensed in the State of Texas, who is prepared for advanced nursing practice by virtue of knowledge and skills obtained through a post-basic or advanced educational program of study acceptable to the board. The advanced practice nurse is prepared to practice in an expanded role to provide health care to individuals, families, and/or groups in a variety of settings including but not limited to homes, hospitals, institutions, offices, industry, schools, community agencies, public and private clinics, and private practice. The advanced practice nurse acts independently and/or in collabo ration with other health care professionals in the delivery of health care services. APNs include Nurse Practitioners, Nurse Midwives, Nurse Anesthetists and Clinical Nurse Specialists. Board-The Board of Nurse Examiners for the State of Texas. Carrying out or signing a prescription drug order-Completion of a prescrip tion drug order presigned by the delegating physician, or the signing of a prescrip tion by an APN after the APN has been designated with the Board of Medical Examiners by the delegating physician(s) as a person delegated to sign prescriptions. Dangerous drug -A device or a drug that is unsafe for self medication and that is not included in schedules I-V or penalty groups I-IV of Chapter 481 Texas Health and Safety Code (Texas Controlled Substances Act). The term includes a device or a drug that bears or is required to bear the legend: "Caution: federal law prohibits dispensing without prescription." Eligible sites -Sites serving medically underserved populations; a physician's primary practice site; or facility based practices at a licensed long term care facility or hospital. Facility-based practice -An APN's practice which is based at a licensed hospital or licensed long term care facility. Health Professional Shortage Area (HPSA)-An area, population group, or facility designated by the United States Department of Health and Human Services (USDHHS) as having a shortage of primary care physicians. Medically Underserved Area (MUA)-An area or population group desig nated by the USDHHS as having a shortage of personal health services; or an area defined by rule adopted by TDH that is based on demographics specific to this State, geographic factors that affect access to health care, and environmental health factors. Pharmacotherapeutics-A course that offers content in pharmacokinetics and pharmacodynamics, pharmacology of current/commonly used medications, and the application of drug therapy to the treatment of disease and/or the promotion of health. Physician's primary practice site-Any one of the following: (A) the practice location where the physician spends the majority of his/her time; (B) a licensed hospital, a licensed long-term care facility or a licensed adult care center where both the physician and the APN are authorized to practice, or an established patient residence; or (C) where the physician is physically present with the APN. Protocols/or other orders-Written authorization to initiate medical aspects of patient care which are agreed upon and signed by the APN and the physician, reviewed and signed at least annually, and maintained in the practice setting of the APN. Protocols/or other orders shall be defined to promote the exercise of profes sional judgement by the APN commensurate with his/her education and experience. Such protocols/or other orders need not describe the exact steps that the APN must take with respect to each specific condition, disease, or symptom and may state types or categories of drugs which may be prescribed rather than list specific drugs. Rural health clinic-A clinic designated as a rural health clinic under the Rural Health Clinic Services Act of 1977 (Public Law No. 95-210); the designation is made by the Health Care Financing Administration (HCFA) of the USDHHS. Shall and must -Mandatory requirements. Should-A recommendation. Sites serving medically underserved populations -A medically underserved area, a health professional shortage area, a rural health clinic, a public health clinic or family planning clinic under contract with the Texas Department of Health (TDH) or Texas Department of Human Services (TDHS) or other site approved by the TDH. sec.222.2. Application for Approval. (a) To be approved by the board to carry out prescription drug orders and issued a prescription authorization number, a Registered Nurse (RN) shall satis- factorily complete the following requirements: (1) the RN shall be approved by the board as an APN; and (2) the APN shall submit to the board the application for Limited Prescrip tive Authority and the appropriate documentation of the necessary education, training, and current skills, to include pharmacotherapeutics, as determined by the board to carry out or sign prescription drug orders. (b) The APN shall renew the privilege to carry out or sign prescription drug orders in conjunction with the RN license renewal application. sec.222.3. Renewal of Limited Prescriptive Authority. (a) The APN seeking to maintain prescriptive authority shall attest, on forms provided by the board, to completing at least five contact hours of continuing education in pharmacotherapeutics within the preceding biennium. (b) The continuing education requirement in subsection (a) of this section, shall be in addition to continuing education required under rule sec.217.15 of this title (relating to Continuing Education). sec.222.4. Functions. (a) The APN with a valid prescription authorization number may carry out or sign prescription drug orders under the following conditions: (1) The APN carries out or signs prescription drug orders in an eligible site. (2) The prescription drug order is carried out or signed in accordance with protocols, standing delegation orders, standing medical orders, practice guidelines or other physician orders for medical aspects of patient care including prescription drug orders. (3) The APN carries out or signs prescription drug orders under physician supervision which is consistent with rules adopted by the Board of Medical Examin ers (BME) and which consists of at least the following: (A) at a site serving medically underserved populations, the physician visits the site at least once a week; the physician receives daily reports from the APN regarding complications encountered; and the physician is available for consultation by direct telecommunications; (B) at a physician's primary practice site, the physician is limited to delegation to three full time equivalent APNs; the physician may delegate the carrying out or signing of a prescription drug order for patients with whom the physician has established or will establish a physician-patient relationship but no time period to establish this relationship is required; (C) at a facility-based practice, where the delegating physician is the medical director, chief of staff, credentialing committee chair, department chair or physician who consents to a request by the medical director or chief of staff; protocols or other orders must be developed in accordance with policies approved by the medical staff; the APN writing prescriptions for patients of physicians, other than the delegating physician, must have the approval of the patient's physician; delegation in long term care facilities is limited to three full time equivalent APNs; and the physician must have the approval of the BME to delegate at more than one licensed hospital or more than two long term care facilities. (4) The APN maintains appropriate documentation of physician supervi sion, patient records, and protocols which should comply with rules adopted by the BME. (b) The APN with a valid prescription authorization number may carry out or sign prescription drug orders by providing the following information on the prescription: (1) the patient's name and address; (2) the drug to be dispensed; (3) directions to the patient in regard to the taking and the dosage; (4) the intended use of the drug, if appropriate; (5) the name, address, and telephone number of the physician; (6) the name, address, telephone, and identification number of the APN completing or signing the prescription drug order; (7) the date; and (8) the number of refills permitted. (c) The format and essential elements of the prescription shall comply with the requirements of the rules of the Board of Pharmacy. (d) The medications which can be carried out or signed by the APN through prescription drug orders shall be those drugs classified as dangerous drugs and shall be limited to those categories of drugs identified in protocol or other order. (e) The APN with a valid prescription authorization number may request, receive, possess and distribute prescription drug samples provided: (1) protocols or other physician orders authorize the APN to sign the prescription drug orders; (2) the samples are dangerous drugs only; and (3) a record of the sample is maintained and samples are labeled as specified in the Dangerous Drug Act (Health and Safety Code, Chapter 483). sec.222.5. Nurse Midwives Administering or Providing Controlled Substances. A nurse midwife recognized by the board may administer or provide one or more unit doses of a controlled substance during intra-partum or immediate post-partum care subject to the following conditions: (1) physician delegation must be made through protocols or other physi cian orders; (2) delegation is limited to three full-time equivalent nurse midwives at the designated facility where the nurse midwife practices; and (3) providing is limited to the immediate needs of the patient not to exceed 48 hours. sec.222.6. Nurse Anesthetist Authorization to Select, Obtain, Order, Administer and/or Utilize Drugs, Devices and Anesthesia Techniques in the Provision of Anesthesia and Anesthesia-Related Services. (a) In a licensed hospital or ambulatory surgical center, consistent with facility policy or medical staff bylaws, a nurse anesthetist may select, obtain and administer drugs, including determination of appropriate dosages, techniques and medical devices for their administration and in maintaining the patient in sound physiologic status pursuant to a physician's order for anesthesia or an anesthesia- related service. This order need not be drug-specific, dosage specific, or administration-technique specific. (b) Pursuant to a physician's order for anesthesia or an anesthesia-related service, the nurse anesthetist may order anesthesia-related medications during perianesthesia periods in the preparation for or recovery from anesthesia. Another RN may carry out these orders. (c) In providing anesthesia or anesthesia-related service, the nurse anesthe tist shall select, order, obtain and administer drugs which fall within categories of drugs generally utilized for anesthesia or anesthesia-related services and provide the concomitant care required to maintain the patient in sound physiologic status during those experiences. sec.222.7. Enforcement. (a) Any nurse who violates these rules shall be subject to removal of the authority to prescribe under this rule and disciplinary action by the board under Article 4525, Texas Civil Statutes. (b) The practice of the APN approved by the board to carry out or sign prescription drug orders is subject to monitoring by the board on a periodic basis. Issued in Austin, Texas, on September 20, 1995. TRD-9512069 Kathy Thomas, MN, RN, CPNP Interim Executive Director Board of Nurse Examiners Effective date: September 20, 1995 Expiration date: January 18, 1996 For further information, please call: (512) 835-8675 TITLE 37. PUBLIC SAFETY AND CORRECTIONS Part I. Texas Department of Public Safety Chapter 23. Vehicle Inspection Parameter Vehicle Emission Inspection and Maintenance Program 37 TAC sec.23.91, sec.23.92 The Texas Department of Public Safety is renewing the effectiveness of the emergency adoption of new sec.23.91 and sec.23.92, for a 60-day period effective October 4, 1995. The text of new sec.23.91 and sec.23.92 was originally published in the June 13, 1995, issue of the Texas Register (20 TexReg 4319). Issued in Austin, Texas, on September 14, 1995. TRD-9512041 James R. Wilson Director Texas Department of Public Safety Effective date: October 4, 1995 Expiration date: December 3, 1995 For further information, please call: (512) 465-2890