Alert April 2017 Recognition of Advance Practice Registered Nurses by Michigan Statute By Patrick J. Haddad, JD, Kerr, Russell and Weber, PLC, MSMS Legal Counsel Public Act 499 of 2016, effective April 9, 2017, defines an advanced practice registered nurse ( APRN ) as a registered professional nurse who has been granted a specialty certification by the Michigan Board of Nursing in one of the following health professions specialty fields: nurse midwifery, nurse practitioner, or clinical nurse specialist. By this definition, nurse anesthetists do not qualify as APRNs. However, this does not alter the Board of Nursing s specialty certification for nurse anesthetists. Clinical nurse specialist is a new specialty certification recognized by Public Act 499. The Board of Nursing may grant such certification to registered professional nurses with advanced training beyond that required for initial licensure when specified criteria is satisfied. To date, the Michigan Department of Licensing and Regulatory Affairs ( LARA ), in consultation with the Board of Nursing, has neither proposed nor adopted administrative rules establishing the criteria for the Board to issue a clinical nurse specialist certification. However, recently enacted Public Act 22 of 2017 clarifies that an individual currently practicing as a clinical nurse specialist may continue to use the title clinical nurse specialist and related derivations and abbreviations until 12 months after such rules take effect. Thereafter, an individual may not use the title clinical nurse specialist and related derivations and abbreviations until the individual has been issued a clinical nurse specialist certification by the Board of Nursing. Other Public Health Code (the Code ) updates include: Allowing APRNs to make calls or go on rounds in private homes, public institutions, emergency vehicles, ambulatory care clinics, hospitals, intermediate or extended care facilities, health maintenance organizations, nursing homes, or other healthcare facilities without restrictions on the time or frequency of visits by a physician or the APRN and without physician delegation and supervision. Including APRNs in the definition of prescriber. Authorizing APRNs to prescribe nonscheduled prescription drugs, schedule 2-5 controlled substances as a delegated act of a supervising physician, and complimentary starter dose drugs. Permitting APRNs to refer patients to speech-language pathologists and physical therapists. Adding references to APRNs and/or clinical nurse specialists to provisions in the Code dealing with the rights and responsibilities of patients or residents of health facilities/agencies, granting eligibility for Michigan s Essential (CONTINUED) This publication is furnished for informational purposes only. It does not communicate legal advice by the Michigan State Medical Society or Kerr, Russell and Weber, PLC. Receipt of this publication does not establish an attorney/client relationship. 2017 Michigan State Medical Society and Kerr, Russell and Weber, PLC. msms.org
Health Provider Loan Repayment Program, and responsibilities of health professionals to notify and counsel marriage license applicants if one tests positive for HIV. Prescribing Authority of APRNs Under Public Act 499, an APRN is permitted, for Michigan health professional licensure purposes, to prescribe a nonscheduled prescription drug, a controlled substance included in schedules 2 to 5 as a delegated act of a supervising physician, and the ordering, receipt and dispensing of complementary starter does drugs under specified conditions. However, due to the present absence of administrative rules providing for the Board of Nursing to issue specialty certifications as clinical nurse specialists and guidance or other authority from LARA permitting such delegation to clinical nurse specialists, a clinical nurse specialist may not prescribe a nonscheduled prescription drug, and physicians may not delegate prescribing authority for controlled substances to clinical nurse specialists at this time. Until new administrative rules are promulgated, physicians may only delegate prescribing authority for controlled substances to qualified nurse practitioners and nurse midwives. The legislation does not require new or additional third-party reimbursement or mandate worker s compensation benefits for services rendered by an APRN who is authorized to prescribe nonscheduled prescription drugs and controlled substances included in schedules 2 to 5. Third party payers are free to determine the circumstances under which APRNs may enroll as providers and be reimbursed. Nonscheduled Prescription Drugs and Other Items and Services Public Act 499 permits an APRN to prescribe nonscheduled prescription drugs without physician delegation and supervision. This prescribing authority is limited to nonscheduled prescription drugs. This prescribing authority does not extend to the ordering of any diagnostic tests, medical devices, and other services and items which are exclusively within the licensed scope of practice of medicine, unless provided otherwise by Public Act 499 (see examples immediately below) or by law (see delegation and supervision in the next section below). Public Act 499 permits a physical therapist or physical therapist assistant to treat a patient if prescribed by an APRN. Public Act 499 also permits a speech-language pathologist to provide treatment or therapy to a patient if referred by an APRN. Public Act 499 further permits an APRN to authorize physical and chemical restraints for a patient for a specified and limited time or as necessitated by an emergency to protect the patient from injury to self or others. Controlled Substances Subject to the Code s existing delegation and supervision requirements, the Boards of Medicine and Osteopathic Medicine and Surgery rules, and, if applicable, implementation of clinical nurse specialist certification, Public Act 499 permits an APRN to prescribe a controlled substance included in schedules 2 to 5 as the delegated act of a supervising physician, provided that following requirements are satisfied: The Code s general delegation and supervision requirements must be satisfied: Delegation is an authorization granted by a physician to a licensed or unlicensed individual to perform selected acts, tasks, or functions that fall within the scope of practice of the delegator and that are not within the physician s licensed scope of practice and that, in the absence of the authorization, would constitute illegal practice of a licensed profession. These provisions permit a physician to delegate to a licensed or unlicensed individual who is otherwise qualified by education, training, or experience the performance of selected acts, tasks, or functions where the acts, tasks, or functions fall within the scope of practice of the licensee s profession and will be performed under the licensee s supervision. A physician shall not delegate an act, task, or function which, under standards of acceptable and prevailing practice, requires the level of education, skill, and judgment required of a physician. Supervision means the overseeing of or participation in the work of another individual by the supervising physician where at least all of the following conditions exist: (i) the continuous availability of direct communication in person or by radio, telephone, or telecommunication between the supervised individual and a licensed health professional; (ii) the availability of a licensed health professional on a regularly scheduled basis to review the practice of the supervised individual, to provide consultation to the supervised individual, to review records, and to further educate the supervised individual in the performance of the individual s functions; and msms.org (CONTINUED) This publication is furnished for informational purposes only. It does not communicate legal advice by the Michigan State Medical Society or Kerr, Russell and Weber, PLC. Receipt of this publication does not establish an attorney/client relationship. 2017 Michigan State Medical Society and Kerr, Russell and Weber, PLC.
(iii) the provision by the licensed supervising health professional of predetermined procedures and drug protocol. In addition, the Board of Medicine s rules for delegation of prescribing authority must be satisfied: The supervising physician must establish a written authorization containing all of the following information: (i) the name, license number and signature of the delegating physician; (ii) the name, license number and signature of the nurse practitioner or nurse midwife; (iii) the limitations or exceptions to the delegation; and (iv) the effective date of the delegation. In addition, the written authorization should confirm compliance with the standards for delegation and supervision described above. The supervising physician and APRN also should maintain documentation confirming compliance with such standards on an on-going basis. Attached is a sample which physicians and APRNs may use for guidance in developing their own written authorization. The supervising physician must provide a copy of the signed, written authorization to the nurse practitioner or nurse midwife. The supervising physician is required to maintain a written authorization at the supervising physician s primary place of practice. The supervising physician is no longer required to maintain the written authorization in each separate location of the physician s office where the delegation occurs. The supervising physician must review and update the written authorization on an annual basis from the original date or the date of an amendment and to note the review date on the written authorization. A supervising physician may not authorize a nurse practitioner or a nurse midwife to issue a prescription for schedule 2 controlled substances with a quantity greater than a 30-day supply. In addition, Public Act 499 requires that both the APRN s name and the physician s name, and both of their respective DEA registration numbers, shall be used, recorded, or otherwise indicated in connection with the prescription for the controlled substance. The new Board of Medicine rules no longer limit delegation of prescribing authority for schedule 2 controlled substances to prescriptions for patients located within certain health facilities where the delegating physician and nurse practitioner or nurse midwife are practicing. Complementary Starter Dose Drugs Public Act 499 permits an APRN to order, receive, and dispense a complimentary starter dose drug, other than controlled substances included in schedules 2 to 5, without delegation from a physician and without the need to obtain a Michigan drug control license. Only the name of the advanced practice registered nurse shall be used, recorded, or otherwise indicated in connection with an order, receipt, or dispensing of a complimentary starter dose drug under this subsection. An APRN may order, receive, and dispense complimentary starter doses of controlled substances included in schedules 2 to 5 as a delegated act of a supervising physician. If a delegated ordering, receipt, or dispensing of such complimentary starter dose drugs occurs, the APRN s name and the delegating physician s name, and each of their respective DEA registration numbers, shall be used, recorded, or otherwise indicated in connection with each order, receipt, or dispensing. In addition, the delegating/supervising physician and APRN must comply with the delegation and supervision standards described above. Complimentary starter dose means a prescription drug packaged, dispensed, and distributed in accordance with state and federal law that is provided to a dispensing prescriber free of charge by a manufacturer or distributor and dispensed free of charge by the dispensing prescriber to his or her patients. MCL 333.17745(14). The ordering, receipt, and dispensing of complimentary starter does drugs are subject to the storage, record keeping, dispensing and labeling requirements of MCL 333.17745 and the additional requirements of MCL 333.7303a for controlled substances included in schedules 2 to 5. (CONTINUED) This publication is furnished for informational purposes only. It does not communicate legal advice by the Michigan State Medical Society or Kerr, Russell and Weber, PLC. Receipt of this publication does not establish an attorney/client relationship. 2017 Michigan State Medical Society and Kerr, Russell and Weber, PLC. msms.org
What are the prescribing rights of APRNs? Profession General Prescribing Authority Controlled Substances APRN s Clinical Nurse Specialist Nurse Midwife Nurse Practitioner Non-scheduled prescription drugs can be prescribed without delegation. Also, can receive and dispense complimentary starter dose drugs without delegation from a physician. Permitted to write a prescription for a controlled substance, schedule 2-5 under the delegation of a physician. The prescription must have the names and DEA# of the APRN and the delegating doctor. If a complementary starter dose containing a controlled substance is involved, the APRN and delegating physician s name and DEA registration number must be linked to the prescription. Because they are writing CS s under delegation, they do not get their own CS license. Under the Board of Medicine rules, there must be a written delegation agreement between the APRN and the doctor when dealing with controlled substances. Source: MDLARA, Bureau of Professional Licensing, Nursing FAQs, http://www.michigan.gov/documents/lara/nursing_faqs_538224_7.pdf Follow-up Steps for Physicians and APRNs Physicians and APRNs should review their existing delegation or other collaboration agreements and make any necessary revisions to reflect the changes in prescribing authority and scope of practice for APRNs under Public Act 499 beginning April 9, 2017. This publication is furnished for informational purposes only. It does not communicate legal advice by the Michigan State Medical Society or Kerr, Russell and Weber, PLC. Receipt of this publication does not establish an attorney/client relationship. 2017 Michigan State Medical Society and Kerr, Russell and Weber, PLC. 120 West Saginaw St., East Lansing, MI 48823» P: 517 / 337.1351» E: msms@msms.org
INSTRUCTIONS FOR SAMPLE COLLABORATIVE AGREEMENT 1 Each medical practice is unique and will need to custom tailor a Collaborative Agreement to reflect the education, training and experience of the Advanced Practice Registered Nurse (APRN), the complexity of services provided by the practice, the APRN s longevity at the practice or working with the Supervising Physician, availability of the Supervising Physician (and alternate physician(s) when the Supervising Physician is not available for consultation), and overall needs of the medical practice and its patients. The attached Sample Collaborative Agreement is provided to assist in the final drafting of a Collaborative Agreement. The Collaborative Agreement should provide the framework by which the APRN s knowledge and skills will be utilized in the respective practice setting. Below are important considerations when entering into a Collaborative Agreement: 1. Carefully consider and complete the information as described in the Collaborative Agreement. Do not include any blank lines in the final official Collaborative Agreement to avoid confusion or unauthorized additions. Remove references to Sample or Instructions when personalizing and finalizing sample or template documents. 2. Spell out additional duties and responsibilities either by expanding the Collaborative Agreement or by including as an Addendum to the Collaborative Agreement (a sample Duties, Responsibilities and Practice Protocols addendum is attached). 3. If the APRN will be prescribing schedule 2-5 drugs, it must be done via delegation by the physician. 4. Each party should sign and retain a copy of the agreement on file. The Collaborative Agreement does not need to be filed with the State of Michigan, but it must be readily available for inspection. 5. The Collaborative Agreement must be updated and signed by all parties if the conditions of the agreement change. Definitions of Key Terms "Advanced Practice Registered Nurse " - means a registered professional nurse who has been granted a specialty certification under section 17210 in 1 of the following health profession specialty fields: (i) Nurse Midwifery. (ii) Nurse Practitioner (iii) Clinical Nurse Specialist. Clinical Nurse Specialist-Certified - means an individual who is licensed as a Registered Professional Nurse under Part 172 who has been granted a specialty certification as a clinical nurse specialist by the Michigan Board of Nursing under section 17210. (NOTE: The titles Clinical Nurse Specialist, Clinical Nurse Specialist-Certified, CNS, or CNS-C cannot be referenced in official documents until the Board of Nursing rules are amended to recognize and issue this specialty certificate.) Supervision" except as otherwise provided in Article 15 of the Public Health Code, means the overseeing of or participation in the work of another individual by a health professional licensed under this article in circumstances where at least all of the following conditions exist: a. The continuous availability of direct communication in person or by radio, telephone, or telecommunication between the supervised individual and a licensed health professional. b. The availability of a licensed health professional on a regularly scheduled basis to review the practice of the supervised individual, to provide consultation to the supervised individual, to review records, and to further educate the supervised individual in the performance of the individual's functions. c. The provision by the licensed supervising health professional of predetermined procedures and drug protocol. 1 These sample documents are furnished for informational purposes. They do not communicate legal advice by the Michigan State Medical Society or Kerr, Russell and Weber, PLC.
SAMPLE COLLABORATIVE AGREEMENT BETWEEN SUPERVISING PHYSICIAN AND ADVANCED PRACTICE REGISTERED NURSE PRACTICE/ORGANIZATION NAME: PRACTICE/ORGANIZATION ADDRESS: AGREEMENT EFFECTIVE DATE. This Collaborative Agreement shall take effect on COLLABORATIVE AGREEMENT DUTIES AND RESPONSIBILITIES. The Supervising Physician and Advanced Practice Registered Nurse (APRN) shall mutually develop, or approve as satisfactory, the Collaborative Agreement and any related protocols and/or addendums, which are intended to evidence compliance with the provisions of the Michigan Public Health Code, MCL 333.1001 et seq., including but not limited to MCL 333.16215, relative to the delegation of selected acts, tasks and functions by Supervising Physician to APRN. APRN shall provide care services within his or her licensed scope of practice including, but not limited to, health maintenance, management and treatment of acute medical conditions and chronic health conditions, prescription of nonscheduled prescription drugs, referrals to physical therapists or speech-language pathologists for treatment or therapy, and documentation of a patient s medical condition, proposed course of treatment, and prospects for recovery. These services are not subject to delegation and supervision by Supervising Physician unless agreed otherwise herein. Supervising Physician agrees to be continuously available in person or by direct telecommunication to ensure that appropriate physician consultation is available to APRN at all times that APRN is engaged in clinical activities. In the absence of Supervising Physician, APRN may consult an alternate physician designated by Supervising Physician. Supervising Physician and APRN agree to follow the practice protocols described on Addendum A. Supervising Physician and APRN each agree to periodically review the Collaborative Agreement and any related protocols and/or addendums and to document such review. PERMITTED ACTS, TASKS AND FUNCTIONS OUTSIDE OF APRN S LICENSED SCOPE OF PRACTICE. Subject to the conditions, limitations and requirements specified herein, Supervising Physician delegates the selected acts, tasks and functions specified herein, which are within Supervising Physician's licensed scope of practice and outside of APRN s licensed scope of practice, to APRN. APRN accepts such delegated authority, subject to supervision by Supervising Physician, and confirms that he or she is qualified by education, training and experience to perform such selected acts, tasks and functions delegated hereunder. The collaborating APRN is authorized to perform the following general acts, tasks and functions which he or she is qualified to furnish by education, training and experience: The collaborating APRN is authorized to perform the following specific acts, tasks and functions which he or she is qualified to furnish by education, training and experience: The collaborating APRN is authorized to prescribe, write and sign drug orders for controlled substances listed in Schedules 3 to 5, except for any restrictions designated below or on Addendum B: The collaborating APRN is authorized to prescribe, write and sign drug orders for controlled substances listed in Schedule 2 in a quantity that shall not be for more than a 30-day period, except for any other restrictions designated below or on Addendum B: See Addendum B for additional prescribing authorizations or restrictions. 1
DECLARATION BY SUPERVISING PHYSICIAN AND APRN. This Collaborative Agreement governs services provided only to the Practice s patients. This Collaborative Agreement may be terminated at any time by the Supervising Physician or APRN by providing written notice to the other party at least thirty (30) days before the date of termination. My signature below signifies that I fully understand the foregoing Collaborative Agreement and attached Addendum(s) having received a copy of such documents for my possession and guidance, and agree to comply with its terms without reservations. Michigan License No. DEA Registration No. APRN s Printed Name Michigan License No. DEA Registration No. Physician s Printed Name 2
SAMPLE ADDENDUM A Duties, Responsibilities, and Practice Protocol Communication and Availability. While on duty, Supervising Physician shall continuously be available for direct communication in person or by radio, telephone or telecommunication with APRN. Consultation Requirements. APRN is required to always and immediately to seek consultation from Supervising Physician for any conditions which APRN believes exceeds his or her ability to manage based upon education, training and experience and/or when specifically requested by the patient. Backup Procedures in Absence of Physician. In the event Supervising Physician is not available when needed, APRN shall immediately contact the designated alternate or backup physician who will provide such consultation functions during such time for purposes of this Collaborative Agreement. Medical Emergencies. APRN will follow the procedure described below for dealing with emergencies: Click here to enter text. (Note: Specify the emergency procedure; e.g., immediately call 911, notify Supervising Physician, contact emergency room at specified hospital, direct EMS to transport patient to specified hospital.) Reporting by APRN. Each time APRN provides care for a patient, he or she shall enter his or her name, signature, initials or computer code on the patient's record, chart or written order, the name of Supervising Physician if such care involves a delegated act, task or function, and all other information required to be documented by the Practice and/or prevailing standards of clinical practice. Delegated Prescribing. APRN's and Supervising Physician's names and DEA registrations shall be used, recorded or otherwise indicated in connection with each individual prescription or order so that the individual who dispenses or administers the prescription knows under whose delegated authority APRN is prescribing. Superseding and Other Directives of Physician. Notwithstanding anything in this Collaborative Agreement to the contrary, the conditions, limitations and requirements of this Collaborative Agreement are subject to modification on a case by case basis by Supervising Physician in his or her clinical judgment. At all times, APRN shall comply with the clinical instructions, orders, conditions, limitations and instructions furnished by Supervising Physician. Notwithstanding, nothing in this Collaborative Agreement shall be construed to mean that APRN is an employee or agent of Participating Physician for employment or other purposes. Review of APRN Practice. Supervising Physician may review medical records written by APRN, including but not limited to those cases which by diagnosis, problem, treatment or procedure represent, in his or her judgment, the most significant risk to the patient. On a periodic basis, Supervising Physician shall review with APRN his or findings of record reviews, shall further educate APRN in the performance of his or her functions, and shall maintain documentation of the same. (Note: Consider specifying the review parameters; e.g., same day, a sample every three months, a minimum percentage of patients seen by APRN which involved a delegated act, task, or function, etc.) No Delegation by APRN. APRN shall not delegate an act, task or function to another licensed or unlicensed person which has been delegated to APRN by Supervising Physician. Acts, Tasks and Functions Not Specified Herein. Without first obtaining Supervising Physician's authorization, APRN is not authorized to undertake acts, tasks or functions not specified herein which are within Supervising Physician's licensed scope of practice and which are not within APRN s licensed scope of practice. On a case by case basis or by amendment to this Practice Protocol, Supervising Physician may authorize APRN to undertake such additional acts, tasks and functions. 3
SAMPLE ADDENDUM B Authorized and/or Restricted Prescription Drug List Subject to Accompanying Collaborative Agreement Drug Quantity Limitation Additional Limitations or Exceptions, if any (insert or write "none") Acknowledged: APRN s Name/MI License No./DEA Registration No. _ Signature Continue on additional pages if necessary Physician's Name/MI License No./DEA Registration No. _ Signature 4
SAMPLE Confirmation of Periodic Review of Medical Records and Performance of Acts, Tasks and Functions by Advanced Practice Registered Nurse Supervising Physician and APRN have reviewed Supervising Physician s findings of medical record reviews and APRN s performance of acts, tasks and functions periodically on the following dates: of Review: Comments: of Review: Comments: of Review: Comments: Continue on additional pages if necessary 5
SAMPLE Confirmation of Annual Review of Collaborative Agreement Supervising Physician and APRN have reviewed the accompanying Collaborative Agreement (including Addendums, if applicable) together annually on the following dates, with any modifications to the Collaborative Agreement (including Addendums, if applicable) made in writing and signed by Supervising Physician and APRN: Continue on additional pages if necessary 6