Titles of Regulations: 18VAC90-20. Regulations Governing the Practice of Nursing (amending 18VAC90-20-35, 18VAC90-20-190, 18VAC90-20-200, 18VAC90-20-271, 18VAC90-20-280; adding 18VAC90-20-34, 18VAC90-20-37; repealing 18VAC90-20-240, 18VAC90-20-270, 18VAC90-20-370, 18VAC90-20-380, 18VAC90-20-390, 18VAC90-20-400, 18VAC90-20-410).

18VAC90-21. Medication Administration Training and Immunization Protocol (adding 18VAC90-21-10 through 18VAC90-21-50).

Statutory Authority: §§ 54.1-2400 and 54.1-3005 of the Code of Virginia.

Public Hearing Information: No public hearings are scheduled.

Public Comment Deadline: February 12, 2014.

Effective Date: February 27, 2014.

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 authorizes the health regulatory boards to promulgate regulations that are reasonable and necessary to administer the regulatory system. Section 54.1-3005 of the Code of Virginia authorizes the Board of Nursing to promulgate regulations for certification of nurse aides.

Purpose: The purpose of the amendments is to update language and simplify the process of applying for licensure. Elimination of unnecessary or outdated provisions and inclusion of language consistent with current practices will facilitate submission of documentation for licensure or registration as a volunteer nurse for a nonprofit organization. The goal is to enable qualified applicants to obtain licensure, which provides the public with some assurance of competency and accountability in the delivery of nursing services.

Rationale for Using Fast-Track Process: The amendments are less restrictive and not controversial. They are consistent with the intent and purpose of regulatory reform.

Substance: Regulations are amended to facilitate electronic submission of documents and forms, accept a certificate of naturalization as evidence of a name change, eliminate burdensome timelines and documentation for certain applicants, and clarify regulations. This action also relocates requirements for medication administration training and immunization protocols into a separate chapter (18VAC90-21).

Issues: The primary advantage to the public is facilitation of applications and renewals and elimination of confusing, outdated language. There are no disadvantages. The advantage to the Commonwealth is clarity in the regulations, which reduces queries to board staff.

Department of Planning and Budget's Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation. As part of the regulatory reform initiative, the Board of Nursing (Board) proposes to amend its Regulations Governing the Practice of Nursing to: 1) allow a certificate of naturalization as proof of legal name change, 2) allow applicants for licensure 12 months from the date that their application is filed with the Board, rather than the currently allowed 6 months, to take their licensure examination and also to establish eligibility, 3) allow applicants for registration for voluntary practice by out-of-state licensees to provide an electronic copy of current licensure and to provide attestations that the applicants are in compliance with the current controlling statute and 4) repeal sections of these regulations that govern medication aide administration training programs and replace them with a new concurrently promulgated regulatory chapter.

Result of Analysis. Benefits likely outweigh costs for these proposed regulations.

Estimated Economic Impact. Currently, licensees who are seeking to change their name with the Board must provide a copy of a marriage certificate or a court order for name change as proof that the requested name change is legal. The Board now proposes to allow a certificate of naturalization to also serve as proof. No entity is likely to incur costs on account of this change. Licensees who are changing their names will benefit as the proposed regulation will give them more flexibility.

Current regulations require that applicants for licensure prove eligibility for licensure and take their licensure examination within 6 months of application. The Board proposes to extend this time frame to 12 months. No entity is likely to incur additional costs on account of these changes. Applicants for licensure will benefit from the extra flexibility afforded by this change and may save money as they will not have to pay an additional application for licensure fee if they miss the 6 month window (the fee is $190 for registered nurses and $170 for licensed practical nurses).

Currently, an out-of-state licensee who is volunteering for nursing duties in the Commonwealth must provide a complete record of professional licensure in each state in which he has held a license and a copy of every current license and also must provide a notarized statement from a representative of the non-profit organization with which he is volunteering that the organization is in compliance with subdivision 11 of 54.1-3001 of the Code of Virginia. The Board now proposes to ease these requirements by allowing out-of-state licensees to submit electronic evidence of unrestricted licensure in a U.S. jurisdiction and by allowing non-profit organizations to attest to their compliance with the controlling law. These changes will make it slightly easier for nurses licensed out-of-state to volunteer in Virginia and may save non-profits the small amount of money (probably less than $5) that it may cost to get a statement notarized. No entity is likely to incur costs on account of these changes.

Current regulations include rules that govern medication aide training programs. The Board proposes to repeal these rules in this chapter and promulgate them in a separate chapter (18VAC90-21, Medication Administration Training and Immunization Protocols) so that they are easier to search for and find. While these rules are being moved, they are not being changed. Therefore, no entity is likely to incur costs on account of this Board action.

Businesses and Entities Affected. The Department of Health Professions (DHP) reports that there are 100,608 registered nurses, 31,276 licensed practical nurses, 426 clinical nurse specialists 5,250 registered medication aides and 201 approved medication aide training programs in the Commonwealth. All of these entities, as well as out-of-state licensees who are volunteering their skills and time in the state, will be affected by these regulatory changes.

Localities Particularly Affected. No localities will be particularly affected by these proposed regulations.

Projected Impact on Employment. These proposed regulatory changes are unlikely to have an appreciable impact on employment in the Commonwealth.

Effects on the Use and Value of Private Property. These proposed regulatory changes are unlikely to affect the use or value of private property in the Commonwealth.

Small Businesses: Costs and Other Effects. No small business is likely to incur and additional expense on account of these regulatory changes.

Small Businesses: Alternative Method that Minimizes Adverse Impact. No small business is likely to incur and additional expense on account of these regulatory changes.

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 14 (10). Section 2.2-4007.04 requires that such economic impact analyses include, but need not be limited to, a determination of the public benefit, 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 an 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.

Agency's Response to Economic Impact Analysis: The Board of Nursing concurs with the analysis of the Department of Planning and Budget on proposed amended regulations for 18VAC90-20, Regulations Governing the Practice of Nursing.

Summary:

The amendments (i) allow a certificate of naturalization as proof of legal name change, (ii) extend the time applicants for licensure may take their licensure examination and establish eligibility from six months to 12 months from the date that their application is filed with the board, (iii) allow applicants for registration for voluntary practice by out-of-state licensees to provide an electronic copy of current licensure and to provide attestations that the applicants are in compliance with the current controlling statute, and (iv) relocate provisions governing medication aide administration training programs to a new chapter numbered 18VAC90-21.

18VAC90-20-34. Duplicate license.

A duplicate license for the current renewal period shall be issued by the board upon receipt of the required information and fee.

18VAC90-20-35. Identification; accuracy of records.

A. Any person regulated by this chapter who provides direct patient care shall, while on duty, wear identification that is clearly visible and indicates the person's first and last name and the appropriate title for the license, certification, or registration issued to such person by the board under which he is practicing in that setting. Any person practicing in hospital emergency departments, psychiatric and mental health units and programs, or in health care facilities units offering treatment for patients in custody of state or local law-enforcement agencies may use identification badges of first name and first letter only of last name and appropriate title.

B. A licensee who has changed his name shall submit as legal proof to the board a copy of the marriage certificate, a certificate of naturalization, or court order evidencing the change. A duplicate license shall be issued by the board upon receipt of such evidence and the required fee.

C. Each licensee shall maintain an address of record with the board. Any change in the address of record or in the public address, if different from the address of record, shall be submitted by a licensee electronically or in writing to the board within 30 days of such change. All notices required by law and by this chapter to be mailed by the board to any licensee shall be validly given when mailed to the latest address of record on file with the board.

18VAC90-20-37. Supervision of licensed practical nurses.

Licensed practical nursing is performed under the direction or supervision of a licensed medical practitioner, a registered nurse, or a licensed dentist.

Part III
Licensure and Practice

18VAC90-20-190. Licensure by examination.

A. The board shall authorize the administration of examinations for registered nurse licensure and examinations for practical nurse licensure.

B. A candidate shall be eligible to take the NCLEX examination (i) upon receipt by the board of the completed application, fee and an official transcript from the nursing education program; and (ii) when a determination has been made that no grounds exist upon which the board may deny licensure pursuant to § 54.1-3007 of the Code of Virginia.

C. To establish eligibility for licensure by examination, an applicant for the licensing examination shall:

1. File the required application, any necessary documentation and fee.

2. Arrange for the board to receive an official transcript from the nursing education program which shows either:

a. That the degree or diploma has been awarded and the date of graduation or conferral; or

b. That all requirements for awarding the degree or diploma have been met and specifies the date of conferral.

3. File a new application and reapplication fee if:

a. The examination is not taken within six 12 months of the date that the board determines the applicant to be eligible; or

b. Eligibility is not established within six 12 months of the original filing date.

D. The minimum passing standard on the examination for registered nurse licensure and practical nurse licensure shall be determined by the board.

E. Any applicant suspected of giving or receiving unauthorized assistance during the examination may be noticed for a hearing pursuant to the provisions of the Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia) to determine eligibility for licensure or reexamination.

F. Practice of nursing pending receipt of examination results.

1. A graduate who has filed a completed application for licensure in Virginia and has received an authorization letter issued by the board may practice nursing in Virginia from the date of the authorization letter. The period of practice shall not exceed 90 days between the date of successful completion of the nursing education program, as documented on the applicant's transcript, and the publication of the results of the candidate's first licensing examination.

2. Candidates who practice nursing as provided in subdivision 1 of this subsection shall use the designation "R.N. Applicant" or "L.P.N. Applicant" on a nametag or when signing official records.

3. The designations "R.N. Applicant" and "L.P.N. Applicant" shall not be used by applicants who either do not take the examination within 90 days following receipt of the authorization letter from the board or who have failed the examination.

G. Applicants who fail the examination.

1. An applicant who fails the licensing examination shall not be licensed or be authorized to practice nursing in Virginia.

2. An applicant for licensure by reexamination shall file the required board application and reapplication fee no later than 60 days prior to the first day of the month in which the applicant expects to take the examination in order to establish eligibility for reexamination.

3. Applicants who have failed the examination for licensure in another U.S. jurisdiction but satisfy the qualifications for licensure in this jurisdiction may apply for licensure by examination in Virginia. Such applicants shall submit the required application and fee. Such applicants shall not, however, be permitted to practice nursing in Virginia until the requisite license has been issued.

18VAC90-20-200. Licensure by endorsement.

A. A graduate of an approved nursing education program who has been licensed by examination in another U.S. jurisdiction and whose license is in good standing, or is eligible for reinstatement, if lapsed, shall be eligible for licensure by endorsement in Virginia, provided the applicant satisfies the same requirements for registered nurse or practical nurse licensure as those seeking initial licensure in Virginia. Applicants who have graduated from approved nursing education programs that did not require a sufficient number of clinical hours, as specified in 18VAC90-20-120, may qualify for licensure if they can provide evidence of at least 960 hours of clinical practice with an active, unencumbered license in another U.S. jurisdiction.

1. A graduate of a nursing school in Canada where English was the primary language shall be eligible for licensure by endorsement provided the applicant has passed the Canadian Registered Nurses Examination (CRNE) and holds an unrestricted license in Canada.

2. An applicant for licensure by endorsement who has not passed a licensing examination other than NCLEX may only be issued a single state license to practice in Virginia.

B. An applicant for licensure by endorsement who has submitted the required application and fee and submitted the required form to the appropriate credentialing agency for verification of licensure may practice for 30 days upon receipt of an authorization letter from the board. If an applicant has not received a Virginia license within 30 days and wishes to continue practice, he shall seek an extension of authorization to practice by submitting a request and evidence that he has requested verification of licensure.

C. If the application is not completed within one year of the initial filing date, the applicant shall submit a new application and fee.

18VAC90-20-240. Duplicate license. (Repealed.)

A duplicate license for the current renewal period shall be issued by the board upon receipt of the required information and fee.

18VAC90-20-270. Supervision of licensed practical nurses. (Repealed.)

Licensed practical nursing is performed under the direction or supervision of a licensed medical practitioner, a registered nurse or a licensed dentist.

18VAC90-20-271. Registration for voluntary practice by out-of-state licensees.

Any licensed nurse who does not hold a license to practice in Virginia and who seeks registration to practice on a voluntary basis under the auspices of a publicly supported, all volunteer, nonprofit organization that sponsors the provision of health care to populations of underserved people shall:

1. File a complete application for registration on a form provided by the board at least five business days prior to engaging in such practice. An incomplete application will not be considered;

2. Provide a complete record of professional licensure in each state in which he has held a license and a copy of every current license evidence of current, unrestricted licensure in a U.S. jurisdiction;

3. Provide the name of the nonprofit organization, the dates and location of the voluntary provision of services;

4. Pay a registration fee of $10; and

5. Provide a notarized statement an attestation from a representative of the nonprofit organization attesting to its compliance with provisions of subdivision 11 of § 54.1-3001 of the Code of Virginia.

18VAC90-20-280. Clinical nurse specialist registration.

A. Initial registration. An applicant for initial registration as a clinical nurse specialist shall:

1. Be currently licensed 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 from an approved program as defined in 18VAC90-20-275;

3. Submit evidence of current specialty certification as a clinical nurse specialist from a national certifying organization acceptable to the board or has an exception available from March 1, 1990, to July 1, 1990; and

4. Submit the required application and fee.

B. Renewal of registration.

1. Registration as a clinical nurse specialist shall be renewed biennially at the same time the registered nurse license is renewed. If registered as a clinical nurse specialist 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.

2. The clinical nurse specialist shall complete the renewal form and submit it with the required fee and evidence. An attestation of current specialty certification is required unless registered in accordance with an exception.

3. Registration as a clinical nurse specialist shall lapse if the registered nurse license is not renewed or the multistate licensure privilege is lapsed and may be reinstated upon:

a. Reinstatement of R.N. license or multistate licensure privilege;

b. Payment of reinstatement and current renewal fees; and

c. Submission of evidence of continued specialty certification unless registered in accordance with an exception.

Part VI

Medication Administration Training Program (Repealed)

18VAC90-20-370. Establishing a medication administration training program. (Repealed.)

A. A program provider wishing to establish a medication administration training program pursuant to § 54.1-3408 of the Code of Virginia shall submit an application to the board at least 90 days in advance of the expected beginning date.

B. The application shall be considered at a meeting of the board. The board shall, after review and consideration, either grant or deny approval.

C. If approval is denied, the program provider may request a hearing before the board, and the provisions of the Administrative Process Act shall apply (§ 2.2-4000 et seq. of the Code of Virginia).

18VAC90-20-380. Qualifications of instructional personnel. (Repealed.)

Instructors shall be licensed health care professionals who, consistent with provisions of the Drug Control Act (§ 54.1-3400 et seq. of the Code of Virginia), are authorized to administer, prescribe or dispense drugs and who have completed a program designed to prepare the instructor to teach the course as it applies to the clients in the specific setting in which those completing the course will administer medications.

18VAC90-20-390. Content. (Repealed.)

The curriculum shall include a minimum of 32 hours of classroom instruction and practice in the following:

1. Preparing for safe administration of medications to clients in specific settings by:

a. Demonstrating an understanding of the client's rights regarding medications, treatment decisions and confidentiality.

b. Recognizing emergencies and other health-threatening conditions and responding accordingly.

c. Identifying medication terminology and abbreviations.

2. Maintaining aseptic conditions by:

a. Implementing universal precautions.

b. Insuring cleanliness and disinfection.

c. Disposing of infectious or hazardous waste.

3. Facilitating client self-administration or assisting with medication administration by:

a. Reviewing administration records and prescriber's orders.

b. Facilitating client's awareness of the purpose and effects of medication.

c. Assisting the client to interpret prescription labels.

d. Observing the five rights of medication administration and security requirements appropriate to the setting.

e. Following proper procedure for preparing medications.

f. Measuring and recording vital signs to assist the client in making medication administration decisions.

g. Assisting the client to administer oral medications.

h. Assisting the client with administration of prepared instillations and treatments of:

(1) Eye drops and ointments.

(2) Ear drops.

(3) Nasal drops and sprays.

(4) Topical preparations.

(5) Compresses and dressings.

(6) Vaginal and rectal products.

(7) Soaks and sitz baths.

(8) Inhalation therapy.

(9) Oral hygiene products.

i. Reporting and recording the client's refusal to take medication.

j. Documenting medication administration.

k. Documenting and reporting medication errors.

l. Maintaining client records according to facility policy.

m. Sharing information with other staff orally and by using documents.

n. Storing and securing medications.

o. Maintaining an inventory of medications.

p. Disposing of medications.

4. Facilitating client self-administration or assisting with the administration of insulin. Instruction and practice in the administration of insulin shall be included only in those settings where required by client needs and shall include:

a. Cause and treatment of diabetes.

b. The side effects of insulin.

c. Preparation and administration of insulin.

18VAC90-20-400. Post-course examination. (Repealed.)

The program provider shall require that each student shall pass a written and practical examination at the conclusion of the training which measures minimum competency in medication administration.

Part VII
Protocol for Adult Immunization (Repealed)

18VAC90-20-410. Requirements for protocol for administration of adult immunization. (Repealed.)

Pursuant to provisions of § 54.1-3408 of the Code of Virginia, a protocol shall be submitted to the board prior to the administration of an adult immunization program that includes the following:

1. Purpose and objectives of immunization program.

2. Target population.

3. Name and address of medical director.

4. A signed and dated medical directive.

5. Screening criteria for inclusion and exclusion.

6. Informed consent form.

7. Immunization procedures.

a. Dosage.

b. Single or multiple dose administration.

c. Injection site.

d. Vaccine storage.

e. Biohazardous waste disposal.

f. Standard precautions.

8. Post-immunization instructions.

9. Emergency guidelines, including a signed medical directive for emergency treatment.

10. Qualification of immunization providers.

a. Virginia licensure as a registered nurse, licensed practical nurse, or pharmacist.

b. Supervision of LPN provider.

c. Current cardiopulmonary resuscitation training.

11. Resource personnel and supervision.

12. Sample of patient record with date, vaccine, dose, site, expiration date, lot number, and administering person's signature.

CHAPTER 21
MEDICATION ADMINISTRATION TRAINING AND IMMUNIZATION PROTOCOL

18VAC90-21-10. Establishing a medication administration training program.

A. A program provider wishing to establish a medication administration training program pursuant to subsection L of § 54.1-3408 of the Code of Virginia shall submit an application to the board at least 90 days in advance of the expected beginning date.

B. The application shall be considered at a meeting of the board. The board shall, after review and consideration, either grant or deny approval.

C. If approval is denied, the program provider may request a hearing before the board, and the provisions of the Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia) shall apply.

18VAC90-21-20. Qualifications of instructional personnel.

Instructors shall be licensed health care professionals who, consistent with provisions of the Drug Control Act (§ 54.1-3400 et seq. of the Code of Virginia), are authorized to administer, prescribe, or dispense drugs and who have completed a program designed to prepare the instructor to teach the course as it applies to the clients in the specific setting in which those completing the course will administer medications.

18VAC90-21-30. Content of medication administration training.

The curriculum shall include a minimum of 32 hours of classroom instruction and practice in the following:

1. Preparing for safe administration of medications to clients in specific settings by:

a. Demonstrating an understanding of the client's rights regarding medications, treatment decisions, and confidentiality.

b. Recognizing emergencies and other health-threatening conditions and responding accordingly.

c. Identifying medication terminology and abbreviations.

2. Maintaining aseptic conditions by:

a. Implementing universal precautions.

b. Insuring cleanliness and disinfection.

c. Disposing of infectious or hazardous waste.

3. Facilitating client self-administration or assisting with medication administration by:

a. Reviewing administration records and prescriber's orders.

b. Facilitating client's awareness of the purpose and effects of medication.

c. Assisting the client to interpret prescription labels.

d. Observing the five rights of medication administration and security requirements appropriate to the setting.

e. Following proper procedure for preparing medications.

f. Measuring and recording vital signs to assist the client in making medication administration decisions.

g. Assisting the client to administer oral medications.

h. Assisting the client with administration of prepared instillations and treatments of:

(1) Eye drops and ointments.

(2) Ear drops.

(3) Nasal drops and sprays.

(4) Topical preparations.

(5) Compresses and dressings.

(6) Vaginal and rectal products.

(7) Soaks and sitz baths.

(8) Inhalation therapy.

(9) Oral hygiene products.

i. Reporting and recording the client's refusal to take medication.

j. Documenting medication administration.

k. Documenting and reporting medication errors.

l. Maintaining client records according to facility policy.

m. Sharing information with other staff orally and by using documents.

n. Storing and securing medications.

o. Maintaining an inventory of medications.

p. Disposing of medications.

4. Facilitating client self-administration or assisting with the administration of insulin. Instruction and practice in the administration of insulin shall be included only in those settings where required by client needs and shall include:

a. Cause and treatment of diabetes.

b. The side effects of insulin.

c. Preparation and administration of insulin.

18VAC90-21-40. Post-course examination.

The program provider shall require that each student shall pass a written and practical examination at the conclusion of the training that measures minimum competency in medication administration.

18VAC90-21-50. Requirements for protocols for administration of adult immunizations.

Pursuant to provisions of subsection I of § 54.1-3408 of the Code of Virginia, a protocol shall be submitted to and approved by the board prior to the administration of an adult immunization program that includes the following:

1. Purpose and objectives of immunization program.

2. Target population.

3. Name and address of medical director.

4. A signed and dated medical directive.

5. Screening criteria for inclusion and exclusion.

6. Informed consent form.

7. Immunization procedures.

a. Dosage.

b. Single or multiple dose administration.

c. Injection site.

d. Vaccine storage.

e. Biohazardous waste disposal.

f. Standard precautions.

8. Post-immunization instructions.

9. Emergency guidelines, including a signed medical directive for emergency treatment.

10. Qualification of immunization providers.

a. Virginia licensure as a registered nurse, licensed practical nurse, or pharmacist.

b. Supervision of a licensed practical nurse provider.

c. Current cardiopulmonary resuscitation training.

11. Resource personnel and supervision.

12. Sample of patient record with date, vaccine, dose, site, expiration date, lot number, and administering person's signature.