Titles of Regulations: 18VAC90-30. Regulations Governing the Licensure of Nurse Practitioners (amending 18VAC90-30-10, 18VAC90-30-20, 18VAC90-30-30, 18VAC90-30-80, 18VAC90-30-85, 18VAC90-30-100, 18VAC90-30-105, 18VAC90-30-110, 18VAC90-30-120, 18VAC90-30-121, 18VAC90-30-220, 18VAC90-30-230).

18VAC90-40. Regulations for Prescriptive Authority for Nurse Practitioners (amending 18VAC90-40-10, 18VAC90-40-20, 18VAC90-40-40, 18VAC90-40-50, 18VAC90-40-55, 18VAC90-40-60, 18VAC90-40-90, 18VAC90-40-100, 18VAC90-40-130, 18VAC90-40-140; adding 18VAC90-40-121).

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

Public Hearing Information: No public hearings are scheduled.

Public Comments: Public comments may be submitted until 5 p.m. on December 10, 2008.

Effective Date: December 25, 2008.

Agency Contact: Jay P. Douglas, R.N., Executive Director, Board of Nursing, 9960 Mayland Drive, Suite 300, Richmond, VA 23233-1463, telephone (804) 367-4515, FAX (804) 527-4455, or email jay.douglas@dhp.virginia.gov.

Basis: Section 54.1-2400 of the Code of Virginia establishes the general powers and duties of health regulatory boards including the responsibility to promulgate regulations. Section 54.1-2957.01 of the Code of Virginia authorizes the Boards of Nursing and Medicine to jointly prescribe regulations governing the prescriptive authority of nurse practitioners.

Purpose: The purpose of the action is to clarify and update requirements pursuant to a periodic review of regulations and to reflect the collaborative nature of the practice arrangement between licensed nurse practitioners (LNP) and supervising physicians. Amendments to more clearly specify the evidence of educational qualification in a specialty category, to accept continuing medical education and to allow continuing education hours as evidence of competency to resume practice after the license has lapsed are all intended to ensure that a nurse practitioner has the appropriate knowledge and skills to practice safely. The amendments also make the requirements for maintaining a written protocol setting out the scope of the LNP’s practice and for submitting a current practice agreement whenever there are significant changes in prescriptive authority. Such changes are intended to encourage compliance with law and regulation to make nurse practitioners more competent and safer in their practice.

Rationale for Using Fast-Track Process: The boards have determined that a fast-track process is appropriate because the action is primarily clarifying rather than substantive. Amendments have been drafted by a committee of nurse practitioners and physicians, approved by the Committee of the Joint Boards, the Board of Nursing and the Board of Medicine and are not expected to be controversial.

Substance: The changes to 18VAC90-30 (i) clarify certain provisions and requirements; (ii) specify the evidence of coursework leading to specialty licensure that must be submitted with an initial application; (iii) include category 1 continuing medical education in the approved courses for continuing competency requirements; (iv) allow submission of continuing education as evidence of competency for reinstatement; and (v) clarify that a copy of the written protocol must be maintained.

The changes to 18VAC90-40 (i) provide a definition of a "nonprofit health care clinic" and modify the definition of "supervision" to reflect that both the LNP and the supervising physician are responsible for the patient and for collaboration on his course of treatment; (ii) allow for "regular" rather than "monthly" chart reviews; and (iii) clarify rules for prescribing for self and family.

Issues: There is an advantage to the public of clarifying the requirements for initial licensure, renewal and reinstatement to ensure competency to practice in a specialty category of licensure. Rules that reinforce the need to maintain a written protocol and a current practice agreement for prescriptive authority also ensure collaboration with supervising physicians on patient care. There are no disadvantages to the public.

The primary advantage to the agency and the Commonwealth is greater clarity of the regulations and consistency with the Code to reduce the confusion and misinterpretation.

The only pertinent matter of interest to the regulated community is the desire to eliminate or modify the supervisory relationship of nurse practitioners and physicians to allow nurse practitioners to practice more independently. The committee that reviewed the regulations considered that issue and modified the regulation within the context of the statute. The regulated community understands that any significant changes necessitate amendments to the Code of Virginia.

The Department of Planning and Budget's Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation. As a part of the periodic review process, the Joint Boards of Nursing and Medicine (Joint Boards) propose to amend their Regulations Governing Licensure of Nurse Practitioners and Regulations Governing Prescriptive Authority for Nurse Practitioners to make several clarifying and substantive changes. The Joint Boards propose to:

1. clarify and update regulations with current terminology and other DHP board practices,¹

2. specify the evidence of coursework leading to specialty licensure that must be submitted with an initial application,

3. clarify that a copy of the written protocol agreement between nurse practitioners and the doctors that supervise them must be maintained, ²

4. modify the definition of supervision to clarify that both the licensed nurse practitioner and the supervising physician are responsible for the patient and for collaboration on the patient’s course of treatment,

5. provide a definition of a "nonprofit health care clinic",

6. add rules for prescribing for self and family by nurse practitioners with prescriptive authority,

7. require that one member of the Joint Boards of Nursing and Medicine (one representative from the Board of Nursing) be a nurse practitioner,

8. allow category 1 continuing medical education to be used to meet continuing competency requirements for nurse practitioners,

9. allow submission of continuing education as evidence of competency for reinstatement and

10. allow for "regular" rather than "monthly" chart reviews.

Result of Analysis. The benefits likely exceed the costs for all proposed changes.

Estimated Economic Impact. Several of the changes that the Joint Boards propose to make as a part of the periodic review process (specifically, those encompassed by bullet points one through five on the list above) aim to bring greater clarity to these regulations. These changes are either standing Board policy being moved to regulation or other clarifications; for example, the Joint Boards propose to add language that explicitly states that licensees may not practice with a lapsed (or otherwise invalid) license, as required by the Code of Virginia, rather than assuming that this rule is understood and does not need to be in the text of the regulations. These changes ought not represent a change in practice for regulated entities of the Joint Boards and, so, regulated entities will likely not incur any costs on account of these changes. Having these rules more clearly spelled out ought to, however, provide a benefit for individuals who are either affected by these regulations or are interested in knowing the rules under which nurse practitioners must operate.

Current regulations do not have explicit rules that nurse practitioners must follow when prescribing medication for themselves or for family members. Doctors who supervise nurse practitioners, however, do have explicit rules for such prescriptions. Currently, doctors may not prescribe any drugs, other than schedule VI drugs, unless 1) the prescribing occurs in an emergency situation or in isolated settings where there is no other qualified practitioner available to the patient, or 2) it is for a single episode of an acute illness through one prescribed course of medication. Whether prescribing schedule VI drug or prescribing other drugs in exceptional circumstances, doctors must maintain statutorily required patient records. The Joint Boards propose to amend current regulations so that rules identical to those that apply to doctors when prescribing for themselves or family members are also explicitly laid out for nurse practitioners. Current prescribing practice of nurse practitioners should already be consistent with that of supervising doctors. The Department of Health Professions (DHP) reports that, to the extent that practices between nurse practitioners and doctors now diverge, nurse practitioners may not be prescribing for themselves or family members even to the extent allowed because they erroneously believe that it is against the rules to write such prescriptions at all. To the extent that nurse practitioners are ignorant of current (Board of Medicine) rules for prescribing for self and family, this regulatory change will provide the benefit of clarity.

Current regulations direct the president of the Board of Nursing and the president of the Board of Medicine to each appoint three members to the Joint Boards of Nursing and Medicine which administers regulations for nurse practitioners. Current regulations are silent on the professional licensure of those appointed. During the last legislative session, the General Assembly mandated that at least one member of the Board of Nursing be a nurse practitioner. The Boards propose to amend these regulations to also require that one of the Board of Nursing’s representatives to the Joint Boards be a nurse practitioner. This proposed change will not require a change to the current composition of the Joint Boards as two members are already nurse practitioners. There is likely a benefit in having at least one nurse practitioner on the Joint Boards as this individual (these individuals) will likely be better able to speak to how any new rulemaking activity will impact the practice of other nurse practitioners.

Current regulations require nurse practitioners to complete 40 hours of continuing education biennially and have a list of allowable sources for that continuing education. The Joint Boards propose to add American Medical Association (AMA) approved Category 1 continuing medical education to the list of approved continuing education options from which nurse practitioners may choose. No regulated entity is likely to incur any costs on account of this regulatory change. Nurse practitioners will likely benefit from this change as it will allow them a wider array of educational opportunities to choose from. This may also allow licensees to obtain required continuing education at reduced cost if additional continuing education options include some that cost less than those that are currently approved.

Current regulations require nurse practitioners who are seeking license reinstatement to submit, among other things, "evidence of current certification" (acceptable for Virginia licensure) or licensure or certification from another jurisdiction. The Joint Boards propose to add the option of providing proof of "continuing education hours taken during the period in which the license was lapsed, equal to the number required for licensure renewal during that period, not to exceed 120 hours". This proposed change will benefit nurse practitioners as it will allow greater flexibility in choosing the least costly and/or most convenient path to reinstatement should their licenses lapse.

Current regulations require that supervising physicians conduct monthly, random reviews of patient charts on which nurse practitioners (that they supervise) have entered prescriptions for approved drugs or devices. DHP notes that doctors and nurse practitioners likely engage in "on-going collaboration and consultation on patient care" that is likely as frequent as it needs to be for individual patients (at each visit for patient they see frequently or every couple of months for patients who are on maintenance medication and only see their doctors quarterly). Under those circumstances, requiring monthly records reviews likely add unnecessarily to doctors’ workload and record keeping burden. The Joint Boards propose to only require random patient record review on a regular, rather than monthly, basis. This change will benefit doctors and nurse practitioners by allowing them greater freedom to agree on a schedule of random record checks that takes into account their specific patients’ needs.

Businesses and Entities Affected. The Department of Health Professions (DHP) reports that the Joint Boards currently license 5,504 nurse practitioners; 3,184 of these licensees also have prescriptive authority.

Localities Particularly Affected. No locality will be particularly affected by this proposed regulatory action.

Projected Impact on Employment. To the extent that changes to the requirements for reinstatement of licensure encourages more nurse practitioners to hold current Virginia licenses, this regulatory action may slightly increase the number of licensed nurse practitioners in the Commonwealth. Since nurse practitioners can not practice independently, this regulatory action will likely only increase employment in this field if there are currently doctors who want to have nurse practitioners in their practices but do not currently because none are available for hire.

Effects on the Use and Value of Private Property. This regulatory action will likely have no effect on the use or value of private property in the Commonwealth.

Small Businesses: Costs and Other Effects. Small businesses in the Commonwealth are unlikely to incur any costs on account of this regulatory action.

Small Businesses: Alternative Method that Minimizes Adverse Impact. Small businesses in the Commonwealth are unlikely to incur any costs on account of this regulatory action.

Real Estate Development Costs. This regulatory action will likely have no effect on real estate development costs in the Commonwealth.

Legal Mandate. The Department of Planning and Budget (DPB) has analyzed the economic impact of this proposed regulation in accordance with § 2.2-4007.04 of the Administrative Process Act and Executive Order Number 36 (06). Section 2.2-4007.04 requires that such economic impact analyses include, but need not be limited to, the projected number of businesses or other entities to whom the regulation would apply, the identity of any localities and types of businesses or other entities particularly affected, the projected number of persons and employment positions to be affected, the projected costs to affected businesses or entities to implement or comply with the regulation, and the impact on the use and value of private property. Further, if the proposed regulation has adverse effect on small businesses, § 2.2-4007.04 requires that such economic impact analyses include (i) an identification and estimate of the number of small businesses subject to the regulation; (ii) the projected reporting, recordkeeping, and other administrative costs required for small businesses to comply with the regulation, including the type of professional skills necessary for preparing required reports and other documents; (iii) a statement of the probable effect of the regulation on affected small businesses; and (iv) a description of any less intrusive or less costly alternative methods of achieving the purpose of the regulation. The analysis presented above represents DPB’s best estimate of these economic impacts.

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¹ For example, this includes such changes as allowing hearings to be conducted by agency subordinates, and eliminating extensions "for good cause shown" due to the inherent difficulty of enforcing such language.

² This provision is being inserted due to a 2007 audit in which the board found that some nurse practitioners were unaware that they were required to maintain a protocol with a supervising physician.

Agency's Response to the Department of Planning and Budget's Economic Impact Analysis: The Boards of Nursing and Medicine concur with the analysis of the Department of Planning and Budget for the proposed amendments to 18VAC90-30, Regulations Governing the Practice of Nurse Practitioners and 18VAC90-40, Regulations Governing Prescriptive Authority for Nurse Practitioners.

Summary:

The proposed amendments (i) clarify and update regulations with current terminology and other Department of Health Professions board practices, (ii) specify the evidence of coursework leading to specialty licensure that must be submitted with an initial application, (iii) clarify that a copy of the written protocol agreement between nurse practitioners and the doctors that supervise them must be maintained, (iv) modify the definition of supervision to clarify that both the licensed nurse practitioner and the supervising physician are responsible for the patient and for collaboration on the patient’s course of treatment, (v) define "nonprofit health care clinics," (vi) establish provisions for prescribing for self and family by nurse practitioners with prescriptive authority, (vii) require that one member of the Joint Boards of Nursing and Medicine (one representative from the Board of Nursing) be a nurse practitioner, (viii) allow Category 1 continuing medical education to be used to meet continuing competency requirements for nurse practitioners, (ix) allow submission of continuing education as evidence of competency for reinstatement, and (x) allow for "regular" rather than "monthly" chart reviews.

Part I
General Provisions

18VAC90-30-10. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Approved program" means a nurse practitioner education program that is accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs/Schools, American College of Nurse Midwives, Commission on Collegiate Nursing Education or the National League for Nursing Accrediting Commission or is offered by a school of nursing or jointly offered by a school of medicine and a school of nursing which grant a graduate degree in nursing and which hold a national accreditation acceptable to the boards.

"Boards" means the Virginia Board of Nursing and the Virginia Board of Medicine.

"Committee" means the Committee of the Joint Boards of Nursing and Medicine.

"Controlling institution" means the college or university offering a nurse practitioner education program.

"Licensed nurse practitioner" means a registered nurse who has met the requirements for licensure as stated in Part II (18VAC90-30-60 et seq.) of this chapter.

"Licensed physician" means a person licensed by the Board of Medicine to practice medicine or osteopathy osteopathic medicine.

"National certifying body" means a national organization that is accredited by an accrediting agency recognized by the U. S. Department of Education or deemed acceptable by the National Council of State Boards of Nursing and has as one of its purposes the certification of nurse anesthetists, nurse midwives or nurse practitioners, referred to in this chapter as professional certification, and whose certification of such persons by examination is accepted by the committee.

"Preceptor" means a physician or a licensed nurse practitioner who supervises and evaluates the nurse practitioner student.

"Protocol" means a written statement, jointly developed by the collaborating physician(s) and the licensed nurse practitioner(s), that directs and describes the procedures to be followed and the delegated medical acts appropriate to the specialty practice area to be performed by the licensed nurse practitioner(s) in the care and management of patients.

18VAC90-30-20. Delegation of authority.

A. The boards hereby delegate to the executive director of the Virginia Board of Nursing the authority to issue the initial licensure and the biennial renewal of such licensure to those persons who meet the requirements set forth in this chapter and to grant extensions or exemptions for compliance with continuing competency requirements as set forth in subsection E of 18VAC90-30-105. Questions of eligibility shall be referred to the Committee of the Joint Boards of Nursing and Medicine.

B. All records and files related to the licensure of nurse practitioners shall be maintained in the office of the Virginia Board of Nursing.

18VAC90-30-30. Committee of the Joint Boards of Nursing and Medicine.

A. The presidents of the Boards of Nursing and Medicine respectively shall each appoint three members from their boards to the Committee of the Joint Boards of Nursing and Medicine; at least one of the appointees from the Board of Nursing shall be a licensed nurse practitioner. The purpose of this committee shall be to administer the Regulations Governing the Licensure of Nurse Practitioners, 18VAC90-30-10 et seq.

B. The committee, in its discretion, may appoint an advisory committee. Such an advisory committee shall be comprised of four licensed physicians and four licensed nurse practitioners, of whom one shall be a certified nurse midwife, one shall be a certified registered nurse anesthetist and two shall be nurse practitioners from other categories. Appointment to the advisory committee shall be for four years; members may be appointed for one additional four-year period.

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 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.

18VAC90-30-85. Qualifications for licensure by endorsement.

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

1. Provide verification of licensure as a nurse practitioner or advanced practice nurse in another U.S. jurisdiction with a license in good standing, or, if lapsed, eligible for reinstatement;

2. 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; and

3. Submit the required application and fee as prescribed in 18VAC90-30-50.

B. An applicant shall provide evidence that includes a transcript that shows successful completion of core coursework that prepares the applicant for licensure in the appropriate specialty.

18VAC90-30-100. Renewal of licensure.

A. Licensure of a nurse practitioner shall be renewed:

1. Biennially at the same time the license to practice as a registered nurse in Virginia is renewed; or

2. If licensed as a nurse practitioner with a multistate licensure privilege to practice in Virginia as a registered nurse, a licensee born in even-numbered years shall renew his license by the last day of the birth month in even-numbered years and a licensee born in odd-numbered years shall renew his license by the last day of the birth month in odd-numbered years.

B. The application for renewal notice of the license shall be mailed by the committee to the last known address of each nurse practitioner. Failure to receive the renewal notice shall not relieve the licensee of the responsibility for renewing the license by the expiration date.

C. The licensed nurse practitioner shall complete the application and return it with his signature attesting attest to compliance with continuing competency requirements of current professional certification or continuing education as prescribed in 18VAC90-30-105 and the license renewal fee prescribed in 18VAC90-30-50.

D. The license shall automatically lapse if the licensee fails to renew by the expiration date. Any person practicing as a nurse practitioner during the time a license has lapsed shall be subject to disciplinary actions by the boards.

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.

B. In order to renew a license biennially on or after January 1, 2004, nurse practitioners licensed prior to May 8, 2002, 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 at least 1.0% of its 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 grant an extension of the deadline for continuing competency requirements for up to one year for good cause shown upon a written request from the licensee prior to the renewal date.

F. E. The boards may delegate to the committee 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.

18VAC90-30-110. Reinstatement of license.

A. A licensed nurse practitioner whose license has lapsed may be reinstated within one renewal period by payment of the current renewal fee and the late renewal fee.

B. An applicant for reinstatement of license lapsed for more than one renewal period shall:

1. File the required application and reinstatement fee;

2. Be currently licensed as a registered nurse in Virginia or hold a current multistate licensure privilege as a registered nurse; and

3. Provide evidence of current professional competency consisting of:

a. Current professional certification by the appropriate certifying agency identified in 18VAC90-30-90;

b. Continuing education hours taken during the period in which the license was lapsed, equal to the number required for licensure renewal during that period, not to exceed 120 hours; or, if

c. If applicable, current, unrestricted licensure or certification in another jurisdiction.

C. An applicant for reinstatement of license following suspension or revocation shall:

1. Petition for a reinstatement and pay the reinstatement fee;

2. Present evidence that he is currently licensed as a Registered Nurse registered nurse in Virginia or hold a current multistate licensure privilege as a registered nurse; and

3. Present evidence that he is competent to resume practice as a licensed nurse practitioner in Virginia. to include:

a. Current professional certification by the appropriate certifying agency identified in 18VAC90-30-90; or

b. Continuing education hours taken during the period in which the license was suspended or revoked, equal to the number required for licensure renewal during that period, not to exceed 120 hours.

The committee shall act on the petition pursuant to the Administrative Process Act, § 2.2-4000 et seq. of the Code of Virginia.

Part III
Practice of Licensed Nurse Practitioners

18VAC90-30-120. Practice of licensed nurse practitioners other than certified nurse midwives.

A. A nurse practitioner licensed in a category other than certified nurse midwife shall be authorized to engage in practices constituting the practice of medicine in collaboration with and under the medical direction and supervision of a licensed physician.

B. The practice of licensed nurse practitioners shall be based on specialty education preparation as a nurse practitioner in accordance with standards of the applicable certifying organization and written protocols as defined in 18VAC90-30-10.

C. The licensed nurse practitioner shall maintain a copy of the written protocol and shall make it available to the boards upon request. The written protocol shall include the nurse practitioner's authority for signatures, certifications, stamps, verifications, affidavits, referral to physical therapy, and endorsements provided it is:

1. In accordance with the specialty license of the nurse practitioner and with the scope of practice of the supervising physician;

2. Permitted by § 54.1-2957.02 or applicable sections of the Code of Virginia; and

3. Not in conflict with federal law or regulation.

D. A certified registered nurse anesthetist shall practice in accordance with the functions and standards defined by the American Association of Nurse Anesthetists (Scope and Standards for Nurse Anesthesia Practice, Revised 2005) and under the medical direction and supervision of a doctor of medicine or a doctor of osteopathy osteopathic medicine or the medical direction and supervision of a dentist in accordance with rules and regulations promulgated by the Board of Dentistry.

E. For purposes of this section, the following definitions shall apply:

"Collaboration" means the process by which a nurse practitioner, in association with a physician, delivers health care services within the scope of practice of the nurse practitioner's professional education and experience and with medical direction and supervision, consistent with this chapter.

"Medical direction and supervision" means participation in the development of a written protocol including provision for periodic review and revision; development of guidelines for availability and ongoing communications that provide for and define consultation among the collaborating parties and the patient; and periodic joint evaluation of services provided, e.g., chart review, and review of patient care outcomes. Guidelines for availability shall address at a minimum the availability of the collaborating physician proportionate to such factors as practice setting, acuity, and geography.

18VAC90-30-121. Practice of nurse practitioners licensed as certified nurse midwives.

A. A nurse practitioner licensed as a certified nurse midwife shall be authorized to engage in practices constituting the practice of medicine in collaboration and consultation with a licensed physician.

B. The practice of certified nurse midwives shall be based on specialty education preparation as a nurse practitioner and in accordance with standards of the applicable certifying organization and written protocols as defined in 18VAC90-30-10.

C. The licensed nurse practitioner shall maintain a copy of the written protocol and shall make it available to the boards upon request. The written protocol shall include the nurse practitioner's authority for signatures, certifications, stamps, verifications, affidavits, referral to physical therapy, and endorsements provided it is:

1. In accordance with the specialty license of the nurse practitioner and within the scope of practice of the supervising physician;

2. Permitted by § 54.1-2957.02 of the Code of Virginia or applicable sections of the Code of Virginia; and

3. Not in conflict with federal law or regulation.

D. A certified nurse midwife, in collaboration and consultation with a duly licensed physician, shall practice in accordance with the Standards for the Practice of Nurse-Midwifery (Revised 2003) defined by the American College of Nurse-Midwives.

E. For purposes of this section, the following definition shall apply:

"Collaboration and consultation" means practice in accordance with the Standards for the Practice of Midwifery (Revised 2003) defined by the American College of Nurse-Midwives to include participation in the development of a written protocol including provision for periodic review and revision; development of guidelines for availability and ongoing communications that provide for and define consultation among the collaborating parties and the patient; periodic joint evaluation of services provided; and review of patient care outcomes. Guidelines for availability shall address at a minimum the availability of the collaborating physician proportionate to such factors as practice setting, acuity, and geography.

Part IV
Disciplinary Provisions

18VAC90-30-220. Grounds for disciplinary action against the license of a licensed nurse practitioner.

The boards may deny licensure or relicensure, revoke or suspend the license, or place on probation, censure or reprimand a nurse practitioner take other disciplinary action upon proof that the nurse practitioner:

1. Has had his a license or multistate privilege to practice nursing in this Commonwealth or in another jurisdiction revoked or suspended or otherwise disciplined;

2. Has directly or indirectly held himself out or represented himself to the public that he the nurse practitioner is a physician, or is able to, or will practice independently of a physician;

3. Has exceeded his the authority as a licensed nurse practitioner;

4. Has violated or cooperated in the violation of the laws or regulations governing the practice of medicine, nursing or nurse practitioners;

5. Has become unable to practice with reasonable skill and safety to patients as the result of a physical or mental illness or the excessive use of alcohol, drugs, narcotics, chemicals or any other type of material;

6. Has violated or cooperated with others in violating or attempting to violate any law or regulation, state or federal, relating to the possession, use, dispensing, administration or distribution of drugs; or

7. Has failed to comply with continuing competency requirements as set forth in 18VAC90-30-105.

18VAC90-30-230. Hearings Administrative proceedings.

A. The provisions of the Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia) shall govern proceedings on questions of violation of 18VAC90-30-220.

B. The Except as provided in 18VAC90-30-240, the Committee of the Joint Boards of Nursing and Medicine shall conduct all proceedings prescribed herein and shall take action on behalf of the boards.

C. When a person's license to practice nursing has been suspended or revoked by the Board of Nursing, the nurse practitioner license shall be suspended pending a hearing simultaneously with the institution of proceedings for a hearing.

D. Sanctions or other terms and conditions imposed by consent orders entered by the Board of Nursing on the license to practice nursing may apply to the nurse practitioner license, provided the consent order has been accepted by the Committee of the Joint Boards of Nursing and Medicine.

Part I
General Provisions

18VAC90-40-10. Definitions.

The following words and terms when used in this chapter shall have the following meanings, unless the context clearly indicates otherwise:

"Boards" means the Virginia Board of Medicine and the Virginia Board of Nursing.

"Committee" means the Committee of the Joint Boards of Nursing and Medicine.

"Nonprofit health care clinics or programs" means a clinic organized in whole or in part for the delivery of health care services without charge or when a reasonable minimum fee is charged only to cover administrative costs.

"Nurse practitioner" means a registered nurse who has met the additional requirements of education and examination for licensure as a nurse practitioner in the Commonwealth for licensure as a nurse practitioner as stated in 18VAC90-30.

"Practice agreement" means a written agreement jointly developed by the supervising physician and the nurse practitioner that describes and directs the prescriptive authority of the nurse practitioner.

"Supervision" means that the physician documents being readily available for medical consultation by with the licensed nurse practitioner or the patient, with the physician maintaining ultimate responsibility collaborating with the nurse practitioner for the agreed-upon course of treatment and medications prescribed.

18VAC90-40-20. Authority and administration of regulations.

A. The statutory authority for this chapter is found in §§ 54.1-2957.01, 54.1-3303, 54.1-3401, and 54.1-3408 of the Code of Virginia.

B. Joint boards of nursing and medicine.

1. The Committee of the Joint Boards of Nursing and Medicine shall be appointed to administer this chapter governing prescriptive authority.

2. The boards hereby delegate to the Executive Director of the Virginia Board of Nursing the authority to issue the initial authorization and biennial renewal to those persons who meet the requirements set forth in this chapter and to grant extensions or exemptions for compliance with continuing competency requirements as set forth in subsection E of 18VAC90-40-55. Questions of eligibility shall be referred to the committee.

3. All records and files related to prescriptive authority for nurse practitioners shall be maintained in the office of the Board of Nursing.

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; and

2. Provide evidence of one of the following:

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

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

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. Submit a practice agreement between the nurse practitioner and the supervising physician as required in 18VAC90-40-90 of this chapter. The practice agreement must be approved by the boards prior to issuance of prescriptive authority; and

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

18VAC90-40-50. Renewal of prescriptive authority.

An applicant for renewal of prescriptive authority shall:

1. Renew biennially at the same time as the renewal of licensure to practice as a nurse practitioner in Virginia.

2. Submit a completed renewal application along with his signature form attesting to compliance with continuing competency requirements set forth in 18VAC90-40-55 and the renewal fee as prescribed in 18VAC90-40-70.

3. Submit a new practice agreement which meets the requirements of 18VAC90-40-90 with the renewal application if there has been a change since the last practice agreement was filed.

18VAC90-40-55. Continuing competency requirements.

A. In order to renew prescriptive authority, a licensee shall meet continuing competency requirements for biennial renewal as a licensed nurse practitioner. Such requirements shall address issues such as ethical practice, an appropriate standard of care, patient safety, and appropriate communication with patients.

B. In addition to the minimal requirements for compliance with subsection B of 18VAC90-30-105, a A nurse practitioner with prescriptive authority shall obtain a total of eight hours of continuing education in pharmacology or pharmacotherapeutics for each biennium in addition to the minimal requirements for compliance with subsection B of 18VAC90-30-105.

C. The nurse practitioner with prescriptive authority 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 at least 1.0% of its 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 grant an extension of the deadline for continuing competency requirements for up to one year for good cause shown upon a written request from the licensee prior to the renewal date.

F. E. The boards may delegate to the committee the authority to grant an extension or an 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.

18VAC90-40-60. Reinstatement of prescriptive authority.

A. A nurse practitioner whose prescriptive authority has lapsed may reinstate within one renewal period by payment of the current renewal fee and the late renewal fee.

B. A nurse practitioner who is applying for reinstatement of lapsed prescriptive authority after one renewal period shall:

1. File the required application and a new practice agreement as required for renewal in 18VAC90-40-50;

2. Provide evidence of a current, unrestricted license to practice as a nurse practitioner in Virginia;

3. Pay the fee required for reinstatement of a lapsed authorization as prescribed in 18VAC90-40-70; and

4. If the authorization has lapsed for a period of two or more years, the applicant shall provide proof of:

a. Continued practice as a licensed nurse practitioner with prescriptive authority in another state; or

b. Continuing education, in addition to the minimal requirements for current professional certification, consisting of four contact hours in pharmacology or pharmacotherapeutics for each year in which the prescriptive authority has been lapsed in the Commonwealth, not to exceed a total of 16 hours.

C. An applicant for reinstatement of suspended or revoked authorization shall:

1. Request a hearing pursuant to the provisions of the Virginia Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia) to be held before the committee Petition for reinstatement and pay the fee for reinstatement of a suspended or revoked authorization as prescribed in 18VAC90-40-70;

2. Present evidence of competence to resume practice as a nurse practitioner with prescriptive authority; and

3. Pay the fee for reinstatement of a suspended or revoked authorization as prescribed in 18VAC90-40-70; and

4. 3. Meet the qualifications and resubmit the application required for initial authorization in 18VAC90-40-40.

Part III
Practice Requirements

18VAC90-40-90. Practice agreement.

A. A nurse practitioner with prescriptive authority may prescribe only within the scope of a written practice agreement with a supervising physician to be submitted with the initial application for prescriptive authority.

B. A new practice agreement shall be submitted: 1. With the initial application for prescriptive authority; or 2. With the application for each biennial renewal, if At any time there have been any are changes in supervision the primary supervising physician, authorization to prescribe, or scope of practice; or 3. At any time a change in the primary supervising physician shall occur, the nurse practitioner shall submit a revised practice agreement to the board.

C. The practice agreement shall contain the following:

1. A description of the prescriptive authority of the nurse practitioner within the scope allowed by law and the practice of the nurse practitioner.

2. An authorization for categories of drugs and devices within the requirements of § 54.1-2957.01 of the Code of Virginia.

3. The signatures of the primary supervising physician and any secondary physician who may be regularly called upon in the event of the absence of the primary physician.

18VAC90-40-100. Supervision and site visits.

A. In accordance with § 54.1-2957.01 of the Code of Virginia, physicians who enter into a practice agreement with a nurse practitioner for prescriptive authority shall supervise and direct, at any one time, no more than four nurse practitioners with prescriptive authority.

B. Except as provided in subsection C of this section, physicians shall regularly practice in any location in which the licensed nurse practitioner exercises prescriptive authority.

1. A separate practice setting may not be established for the nurse practitioner.

2. A supervising physician shall conduct a monthly regular, random review of patient charts on which the nurse practitioner has entered a prescription for an approved drug or device.

C. Physicians who practice with a certified nurse midwife or with a nurse practitioner employed by or under contract with local health departments, federally funded comprehensive primary care clinics, or nonprofit health care clinics or programs shall:

1. Either regularly practice at the same location with the nurse practitioner or provide supervisory services to such separate practices by making regular site visits for consultation and direction for appropriate patient management. The site visits shall occur in accordance with the protocol, but no less frequently than once a quarter.

2. Conduct a monthly regular, random review of patient charts on which the nurse practitioner has entered a prescription for an approved drug or device.

18VAC90-40-121. Prescribing for self or family.

A. Treating or prescribing shall be based on a bona fide practitioner-patient relationship, and prescribing shall meet the criteria set forth in § 54.1-3303 of the Code of Virginia.

B. A nurse practitioner shall not prescribe a controlled substance to himself or a family member, other than Schedule VI as defined in § 54.1-3455 of the Code of Virginia, unless the prescribing occurs in an emergency situation or in isolated settings where there is no other qualified practitioner available to the patient, or it is for a single episode of an acute illness through one prescribed course of medication.

C. When treating or prescribing for self or family, the nurse practitioner shall maintain a patient record documenting compliance with statutory criteria for a bona fide practitioner-patient relationship.

Part IV
Discipline

18VAC90-40-130. Grounds for disciplinary action.

The boards may deny approval of prescriptive authority, revoke or suspend authorization, or take other disciplinary actions against a nurse practitioner who:

1. Exceeds his authority to prescribe or prescribes outside of the written practice agreement with the supervising physician;

2. Has had his license as a nurse practitioner suspended, revoked or otherwise disciplined by the boards pursuant to 18VAC90-30-220 and 18VAC85-70-220;

3. Fails to comply with requirements for continuing competency as set forth in 18VAC90-40-55.

18VAC90-40-140. Hearings Administrative proceedings.

A. The Except as provided for delegation of proceedings to an agency subordinate in 18VAC90-30-240, the Committee of the Joint Boards of Nursing and Medicine shall conduct all hearings prescribed herein and shall take action on behalf of the boards.

B. The provisions of the Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia) shall govern proceedings on questions of violation of 18VAC90-40-130 nurse practitioner with prescriptive authority shall be subjective to the grounds for disciplinary action set forth in 18VAC90-30-220.

C. When the license of a nurse practitioner has been suspended or revoked by the joint boards, prescriptive authority shall be suspended pending a hearing simultaneously with the institution of proceedings for a hearing.

D. Any violation of law or of this chapter may result in disciplinary action including the revocation or suspension of prescriptive authority and may also result in additional sanctions imposed on the license of the nurse practitioner by the joint boards or upon the license of the registered nurse by the Board of Nursing.