Titles of Regulations: 18VAC90-30. Regulations Governing the Licensure of Nurse Practitioners (amending 18VAC90-30-80, 18VAC90-30-105).

18VAC90-40. Regulations for Prescriptive Authority for Nurse Practitioners (amending 18VAC90-40-40).

Statutory Authority: § 54.1-2400 of the Code of Virginia.

Public Hearing Information: No public hearing is currently scheduled.

Public Comment Deadline: February 16, 2022.

Effective Date: April 1, 2022.

Agency Contact: Jay P. Douglas, R.N., Executive Director, Board of Nursing, 9960 Mayland Drive, Suite 300, Richmond, VA 23233-1463, telephone (804) 367-4520, FAX (804) 527-4455, or email jay.douglas@dhp.virginia.gov.

Basis: Regulations are promulgated under the general authority of § 54.1-2400 of the Code of Virginia, which provides the Boards of Nursing and Medicine the authority to promulgate regulations to administer the regulatory system. Section 54.1-2957 of the Code of Virginia authorizes the boards to regulate licensure and practice of nurse practitioners.

Purpose: The purpose of the regulatory change is to use language consistent with the education and practice of clinical nurse specialists that will allow them to be licensed and to renew licensure to continue providing care to patients to protect public health and safety.

Rationale for Using Fast-Track Rulemaking Process: The amendments are not expected to be controversial because they are consistent with the current terminology and intended to allow for renewal of all clinical nurse specialists who were previously registered by the Board of Nursing but are now licensed by the joint boards.

Substance: 18VAC90-30-80 and 18VAC90-40-40 are amended to include the term "advanced practice registered nurse" to include clinical nurse specialists and all categories of nurse practitioners to ensure the graduate programs for clinical nurse specialists qualify them for licensure. 18VAC90-30-105 is amended to allow clinical nurse specialists who were registered with a retired certification by the Board of Nursing to renew their nurse practitioner license by completion of hours of continuing education rather than holding current specialty certification.

Issues: There are no advantages or disadvantages to the public apart from clarification of terminology and the ability of some clinical nurse specialists to renew licensure and continue to practice. There are no particular advantages or disadvantages to the agency.

Department of Planning and Budget's Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation. Pursuant to Chapter 157 of the 2021 Acts of Assembly, the Boards of Nursing and Medicine seek to amend 18VAC90-30, Regulations Governing the Licensure of Nurse Practitioners and 18VAC90-40, Regulations Governing Prescriptive Authority for Nurse Practitioners.¹ The proposed amendments to 18VAC90-30 would align language regarding the qualifications for initial licensure and for continuing competency with the new legislation, and the proposed amendments to 18VAC90-40 would allow advanced practice registered nurses to apply for prescriptive authority.

Background. Chapter 157 of the 2021 Acts of Assembly repealed sections of Chapter 30 of Title 54.1 relating to the registration of clinical nurse specialists (CNS) under the Board of Nursing and enacted changes to Chapter 29 of Title 54.1 authorizing licensure of CNS as nurse practitioners under the Joint Boards of Nursing and Medicine. The Department of Health Professions (DHP) reports that this legislation was introduced at the request of the CNS' organization in Virginia in an effort to recognize CNS as one category of Advanced Practice Registered Nurses (APRNs) and to be granted prescriptive authority.² Thus, the proposed amendments would not make any substantive change to the registration requirements or the responsibilities of CNS. DHP reports that the Board of Nursing would continue to handle applications for all four types of APRNs, whereas disciplinary actions matters would be addressed by a committee of the joint boards.

In order to conform the regulations to statute, the Board of Nursing has adopted an exempt action to remove sections of 18VAC90-19, Regulations Governing the Practice of Nursing that refer to the registration of CNS.³ Concurrently, the Boards of Nursing and Medicine adopted another exempt action to amend 18VAC90-30 to add a definition of CNS and grant prescriptive authority to CNS who enter into a practice agreement with a physician.⁴ Thus, the proposed amendments in this action seek to conform those sections of 18VAC90-30 and 18VAC90-40, that were not directly impacted by the legislation, with the changes made in the two exempt actions. Specifically, section 80 would be amended to replace "nurse practitioners" with APRN, which includes NP and CNS. Similarly, the proposed amendments to 18VAC90-40 would add APRNs in section 40 pertaining to prescriptive authority in keeping with other changes to that chapter.

The only proposed amendment that is clearly discretionary would be to amend 18VAC90-30-105, which lays out continuing competency requirements, so that CNS who were registered by the Board of Nursing with a retired certification could renew their nurse practitioner licenses by meeting the same requirements currently in place for those who registered prior to May 8, 2002. Currently, CNS are able to renew their registration with a retired certification provided it had been maintained; however, this provision would be repealed by the exempt actions described above.⁵ The proposed amendment would require CNS with retired certifications to complete 40 hours of approved continuing education in order to renew their license.

Estimated Benefits and Costs. Because the proposed amendments do not change the requirements to register as CNS, the benefits of the proposed amendments are mainly to conform the regulation to the Code of Virginia. However, CNS with retired certifications (including those whose certifications may be retired in the future) would only be allowed to renew their license if they have 40 hours of approved continuing education. This change would create new costs for any CNS with a retired certification. On the whole, the proposed amendments would grant CNS prescriptive authority, which would allow them to engage in more autonomous practice and could benefit the CNS as well as their patients.

Businesses and Other Entities Affected. The proposed amendments primarily affect current and future registered CNS. DHP reports that there were 408 registered CNS as of October 1, 2021. Their registrations were automatically changed to licensure under the Boards of Nursing and Medicine once the changes to statute made by Chapter 157 became effective on July 1, 2021. The number of CNS with a retired certification is unknown.

Small Businesses⁶ Affected. Some CNS may operate as a small business; however, DHP reports that the majority of CNS are likely employed by large health systems. Except for CNS with retired certifications who operate as small businesses, the proposed amendments would not adversely affect small businesses.

Localities⁷ Affected.⁸ The proposed amendments do not introduce new costs for local governments and are unlikely to affect any locality in particular.

Projected Impact on Employment. The proposed amendments are unlikely to impact the number of CNS in the workforce or the employment rates of CNS.

Effects on the Use and Value of Private Property. The proposed amendments would not affect the use or value of private property. Real estate development costs are not affected.

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¹See https://lis.virginia.gov/cgi-bin/legp604.exe?212+ful+CHAP0157.

²There are four categories of APRNs: certified nurse midwives, certified nurse anesthetists, nurse practitioners (NP) and CNS. See https://www.ncsbn.org/aprn.htm for details.

³See https://townhall.virginia.gov/l/ViewStage.cfm?stageid=9352; changes become effective November 10, 2021.

⁴See https://townhall.virginia.gov/l/ViewStage.cfm?stageid=9369; changes become effective November 10, 2021.

⁵See https://townhall.virginia.gov/l/ViewAction.cfm?actionid=5306 for details.

⁶Pursuant to § 2.2-4007.04 of the Code of Virginia, small business is defined as "a business entity, including its affiliates, that (i) is independently owned and operated and (ii) employs fewer than 500 full-time employees or has gross annual sales of less than $6 million."

⁷"Locality" can refer to either local governments or the locations in the Commonwealth where the activities relevant to the regulatory change are most likely to occur.

⁸§ 2.2-4007.04 defines "particularly affected" as bearing disproportionate material impact.

Agency's Response to Economic Impact Analysis: The Board of Nursing concurs with the economic impact analysis of the Department of Planning and Budget.

Summary:

The amendments conform these sections to the education and licensure requirements of clinical nurse specialists who were previously registered under the Board of Nursing and pursuant to Chapter 157 of the 2021 Acts of Assembly, Special Session I, became licensed as nurse practitioners under the joint Boards of Nursing and Medicine.

18VAC90-30-80. Qualifications for initial licensure.

A. An applicant for initial licensure as a nurse practitioner shall:

1. Hold a current, active license as a registered nurse in Virginia or hold a current multistate licensure privilege as a registered nurse;

2. Submit evidence of a graduate degree in nursing or in the appropriate nurse practitioner specialty from an educational program designed to prepare nurse practitioners advanced practice registered nurses that is an approved program as defined in 18VAC90-30-10. Evidence shall include a transcript that shows that the applicant has successfully completed core coursework that prepares the applicant for licensure in the appropriate specialty;

3. Submit evidence of professional certification that is consistent with the specialty area of the applicant's educational preparation issued by an agency accepted by the boards as identified in 18VAC90-30-90;

4. File the required application; and

5. Pay the application fee prescribed in 18VAC90-30-50.

B. Provisional licensure may be granted to an applicant who satisfies all requirements of this section with the exception of subdivision A 3 of this section, provided the board has received evidence of the applicant's eligibility to sit for the certifying examination directly from the national certifying body. An applicant may practice with a provisional license for either six months from the date of issuance or until issuance of a permanent license or until he receives notice that he has failed the certifying examination, whichever occurs first.

18VAC90-30-105. Continuing competency requirements.

A. In order to renew a license biennially, a nurse practitioner initially licensed on or after May 8, 2002, shall hold current professional certification in the area of specialty practice from one of the certifying agencies designated in 18VAC90-30-90, except for those renewing their licenses in accordance with subsection B of this section.

B. In order to renew a license biennially, nurse practitioners licensed prior to May 8, 2002, or clinical nurse specialists who were registered by the Board of Nursing with a retired certification, shall meet one of the following requirements:

1. Hold current professional certification in the area of specialty practice from one of the certifying agencies designated in 18VAC90-30-90; or

2. Complete at least 40 hours of continuing education in the area of specialty practice approved by one of the certifying agencies designated in 18VAC90-30-90 or approved by Accreditation Council for Continuing Medical Education (ACCME) of the American Medical Association as a Category I Continuing Medical Education (CME) course.

C. The nurse practitioner shall retain evidence of compliance and all supporting documentation for a period of four years following the renewal period for which the records apply.

D. The boards shall periodically conduct a random audit of their licensees to determine compliance. The nurse practitioners selected for the audit shall provide the evidence of compliance and supporting documentation within 30 days of receiving notification of the audit.

E. The boards may delegate the authority to grant an extension or exemption for all or part of the requirements for circumstances beyond the control of the licensee, such as temporary disability, mandatory military service, or officially declared disasters.

18VAC90-40-40. Qualifications for initial approval of prescriptive authority.

An applicant for prescriptive authority shall meet the following requirements:

1. Hold a current, unrestricted license as a nurse practitioner in the Commonwealth of Virginia;

2. Provide evidence of one of the following:

a. Continued professional certification as required for initial licensure as a nurse practitioner;

b. Satisfactory completion of a graduate level course in pharmacology or pharmacotherapeutics obtained as part of the nurse practitioner or advanced practice registered nurse education program within the five years prior to submission of the application;

c. Practice as a nurse practitioner for no less than 1000 hours and 15 continuing education units related to the area of practice for each of the two years immediately prior to submission of the application; or

d. Thirty contact hours of education in pharmacology or pharmacotherapeutics acceptable to the boards taken within five years prior to submission of the application. The 30 contact hours may be obtained in a formal academic setting as a discrete offering or as noncredit continuing education offerings and shall include the following course content:

(1) Applicable federal and state laws;

(2) Prescription writing;

(3) Drug selection, dosage, and route;

(4) Drug interactions;

(5) Information resources; and

(6) Clinical application of pharmacology related to specific scope of practice.;

3. Develop a practice agreement between the nurse practitioner and the patient care team physician as required in 18VAC90-40-90; and

4. File a completed application and pay the fees as required in 18VAC90-40-70.