Title of Regulation: 18VAC90-30. Regulations Governing the Licensure of Nurse Practitioners (amending 18VAC90-30-10, 18VAC90-30-90, 18VAC90-30-100, 18VAC90-30-105, 18VAC90-30-120, 18VAC90-30-121; adding 18VAC90-30-122).

Statutory Authority: §§ 54.1-2400 and 54.1-2957 of the Code of Virginia.

Public Hearing Information:

October 8, 2014 - 9 a.m. - Department of Health Professions, Perimeter Center, 9960 Mayland Drive, Suite 201, Richmond, VA 23233

Public Comment Deadline: November 21, 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: Regulations are promulgated under the general authority of Chapter 24 of Title 54.1 of the Code of Virginia. Section 54.1-2400 of the Code of Virginia provides the Boards of Nursing and Medicine the authority to promulgate regulations to administer the regulatory system. The specific mandate to promulgate regulations for the practice of nurse practitioners is found in § 54.1-2957 of the Code of Virginia.

Purpose: A team care approach emphasizing collaboration and consultation will allow for more creative and fuller utilization of nurse practitioners while ensuring appropriate setting-specific physician input. The law and regulations also embrace technological and communication advances such as telemedicine not envisaged under the earlier statutes. Nurse practitioner mobility and geographic outreach into underserved areas can be facilitated by the revised practice paradigm. Collaboration and consultation on patient care within a patient care team protects public health and safety by utilizing the strengths and expertise of nurse practitioners and physicians.

Substance: The definitions of "collaboration" and "consultation" are added and are identical to the definitions specified in subsection F of § 54.1-2957. The term "licensed physician" is deleted and replaced by the term "patient care team physician," which is the term now used in the Code of Virginia and similarly defined in § 54.1-2900 of the Code of Virginia. Likewise, the requirement for a protocol has been replaced in the law with a practice agreement, as specified in subsection C of § 54.1-2957.

The requirement for supervision of the practice of a nurse practitioner is replaced with a requirement for collaboration and consultation with a patient care team physician as part of a patient care team. The certified registered nurse anesthetist is omitted from this section because the revisions to the Code of Virginia retained the supervisory requirement for that category of nurse practitioners.

The requirements for a practice agreement, which was described as the "protocol" for practice of a nurse practitioner, are established consistent with elements of a practice agreement are found in subsection C of § 54.1-2957.

Issues: The most significant benefit is to the patients and clients in Virginia who may benefit from an expansion of care by nurse practitioners since they are not required to practice in the same location as the patient care team physician and are able to deliver care in a collaborative approach in which each member of the team practices to the extent of his training. There are no disadvantages to the public.

There are no specific advantages to the agency or the Commonwealth except possibly better utilization of nurse practitioners throughout underserved parts of the state. There are no disadvantages.

Department of Planning and Budget's Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation. Pursuant to Chapter 213 of the 2012 Acts of the Assembly, the Boards of Nursing and Medicine (Boards) propose to amend these Regulations Governing the Practice of Nurse Practitioners so that they are consistent with the model of collaboration for patient care teams. Specifically, the Boards propose to:

1. Add definitions for collaboration and consultation identical to those added to the Code of Virginia (Code) by Chapter 213,

2. Replace references to "licensed physician" with "patient care team physician" to conform the language of these regulations to Code changed by Chapter 213,

3. Remove the requirement for a written protocol and, again to conform these regulations to Code, replace it with a requirement for a practice agreement between nurse practitioners and patient care team physicians,

4. Remove the requirement for supervision of the practice of nurse practitioners and replace it with a requirement for collaboration and consultation with a patient care team physician, and

5. Add language that specifically identifies the rules (which are not changing) that certified registered nurse anesthetists (CRNA) work under because revisions to the Code retained supervision requirements for CRNAs.

Result of Analysis. Benefits likely outweigh costs for this proposed regulatory change.

Estimated Economic Impact. In 2012, the Virginia General Assembly passed legislation (Chapter 213) that restructured how most nurse practitioners may work in collaboration with physicians. This restructuring revised terminology that is used to describe this collaboration and its participants. It also substituted a statutory requirement for a written practice agreement that includes all elements that were in the formerly required written protocols plus provision for periodic review of patients' charts and provision for patient care team physicians to have appropriate input for complex cases and patient emergencies. Chapter 213 also replaced requirements that nurse practitioners, except for CRNAs, be supervised with a structure of collaboration and consultation between physicians and the nurse practitioners with whom they work.

The Boards now propose to revise these regulations to bring them into conformance with Code of Virginia (Code) changes brought about by Chapter 213. Most of these changes are not substantive as they are just making regulatory terminology consistent with that used in Code or are separating rules that are not changing so that they are easily found. No such changes are likely to cause any extra costs of affected entities and all such changes provide the benefit of consistency between regulatory text and Code.

Regulatory changes that set out the content of practice agreements reflect Code changes; the things required in these agreements are more comprehensive than what was formerly required in Code for protocols between physicians and nurse practitioners. As practice agreements will likely be longer than protocols, licensees may incur more time costs in crafting them. These costs are likely outweighed by both the benefit to licensees in having greater definition for their roles in the agreement and by the benefit of having these regulations conform to Code text.

Businesses and Entities Affected. The Department of Health Professions (DHP) reports that there are 7,408 licensed nurse practitioners who will be affected by these proposed regulations.

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

Projected Impact on Employment. This regulatory action will likely have little impact on employment in the Commonwealth.

Effects on the Use and Value of Private Property. This regulatory action will likely have little effect on the use or value of private property in the Commonwealth.

Small Businesses: Costs and Other Effects. No affected small business is likely to incur any net costs on account of these proposed regulations.

Small Businesses: Alternative Method that Minimizes Adverse Impact. No affected small business is likely to incur any net costs on account of these proposed regulations.

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, 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.

Agency's Response to Economic Impact Analysis: The Boards of Nursing and Medicine concur with the analysis of the Department of Planning and Budget.

Summary:

The proposed amendments revise (i) requirements for the practice of nurse practitioners consistent with a model of collaboration and consultation with a patient care team physician working under a mutually agreed-upon practice agreement within a patient care team and (ii) terminology and criteria for practice consistent with changes to the Code of Virginia as enacted by Chapter 213 of the 2012 Acts of the Assembly.

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 that 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.

"Collaboration" means the communication and decision-making process among members of a patient care team related to the treatment and care of a patient and includes (i) communication of data and information about the treatment and care of a patient, including exchange of clinical observations and assessments, and (ii) development of an appropriate plan of care, including decisions regarding the health care provided, accessing and assessment of appropriate additional resources or expertise, and arrangement of appropriate referrals, testing, or studies.

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

"Consultation" means the communicating of data and information, exchanging of clinical observations and assessments, accessing and assessing of additional resources and expertise, problem solving, and arranging for referrals, testing, or studies.

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

"Licensed nurse practitioner" means a an advanced practice 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 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.

"Patient care team physician" means a person who holds an active, unrestricted license issued by the Virginia Board of Medicine to practice medicine or osteopathic medicine.

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

"Protocol" "Practice agreement" means a written or electronic statement, jointly developed by the collaborating patient care team 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. The practice agreement also describes the prescriptive authority of the nurse practitioner, if applicable.

18VAC90-30-90. Certifying agencies.

A. The boards shall accept the professional certification by examination of the following:

1. American College of Nurse Midwives Midwifery Certification Council Board;

2. American Nurses Credentialing Center;

3. Council on Certification of Nurse Anesthetists National Board of Certification and Recertification for Nurse Anesthetists;

4. Pediatric Nursing Certification Board;

5. National Certification Corporation for the Obstetric, Gynecologic and Neonatal Nursing Specialties; and

6. American Academy of Nurse Practitioners.

B. The boards may accept professional certification from other certifying agencies on recommendation of the Committee of the Joint Boards of Nursing and Medicine provided the agency meets the definition of a national certifying body set forth in 18VAC90-30-10 and that the professional certification is awarded on the basis of:

1. Completion of an approved educational program as defined in 18VAC90-30-10; and

2. Achievement of a passing score on an examination.

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 renewal notice of the license shall be mailed sent to the last known address of record 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 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 its 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.

Part III
Practice of Licensed Nurse Practitioners

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

A. A nurse practitioner licensed in a category other than certified registered nurse midwife anesthetist shall be authorized to engage in practices constituting the practice of medicine render care in collaboration and consultation with and under the medical direction and supervision of a licensed patient care team physician as part of a patient care team.

B. The practice of all licensed nurse practitioners shall be based on specialty education preparation as a nurse practitioner an advanced practice registered nurse in accordance with standards of the applicable certifying organization and written protocols as defined in 18VAC90-30-10, as identified in 18VAC90-30-90. A nurse practitioner licensed in the category of a certified nurse midwife shall practice in accordance with the Standards for the Practice of Midwifery (Revised 2011) defined by the American College of Nurse-Midwives.

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 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 registered nurse midwives anesthetists.

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.

A. A nurse practitioner licensed in a category of certified registered nurse anesthetist shall be authorized to render care under the supervision of a licensed doctor of medicine, osteopathy, podiatry, or dentistry.

B. The practice of a certified registered nurse anesthetist shall be based on specialty education preparation as an advanced practice registered nurse in accordance with standards of the applicable certifying organization and with the functions and standards defined by the American Association of Nurse Anesthetists (Standards for Nurse Anesthesia Practice, Revised 2013).

18VAC90-30-122. Practice agreements.

A. All nurse practitioners licensed in any category shall practice in accordance with a written or electronic practice agreement as defined in 18VAC90-30-10.

B. The written or electronic practice agreement shall include provisions for:

1. The periodic review of patient charts or electronic patient records by a patient care team physician and may include provisions for visits to the site where health care is delivered in the manner and at the frequency determined by the patient care team;

2. Appropriate physician input in complex clinical cases and patient emergencies and for referrals; and

3. The nurse practitioner's authority for signatures, certifications, stamps, verifications, affidavits, and endorsements provided it is:

a. In accordance with the specialty license of the nurse practitioner and within the scope of practice of the patient care team physician;

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

c. Not in conflict with federal law or regulation.

C. The practice agreement shall be maintained by the nurse practitioner and provided to the boards upon request. For nurse practitioners providing care to patients within a hospital or health care system, the practice agreement may be included as part of documents delineating the nurse practitioner's clinical privileges or the electronic or written delineation of duties and responsibilities; however, the nurse practitioner shall be responsible for providing a copy to the boards upon request.

DOCUMENTS INCORPORATED BY REFERENCE (18VAC90-30)

Scope and Standards for Nurse Anesthesia Practice, revised 2005, American Association of Nurse Anesthetists.

Standards for the Practice of Midwifery, revised 2003, American College of Nurse-Midwives.

Standards for Nurse Anesthesia Practice, revised 2013, American Association of Nurse Anesthetists

Standards for the Practice of Midwifery, revised 2011, American College of Nurse-Midwives