BEFORE THE BOARD OF NURSING

DEPARTMENT OF LABOR AND INDUSTRY

                                                                           STATE OF MONTANA

 

In the matter of the amendment of ARM 24.159.301 definitions, 24.159.1405, 24.159.1412 through 24.159.1414, 24.159.1418, 24.159.1427, 24.159.1428, 24.159.1461, 24.159.1463, 24.159.1464, 24.159.1467, 24.159.1468, 24.159.1470, 24.159.1475, 24.159.1480, and 24.159.1485 advanced practice registered nurses, 24.159.2102 biennial continuing education credits, the adoption of NEW RULES I and II APRN practice and competence development, and the repeal of 24.159.1404, 24.159.1411, 24.159.1424, 24.159.1462, 24.159.1466, and 24.159.1490 standards related to APRNs

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NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT, ADOPTION, AND REPEAL

 

TO:  All Concerned Persons

 

            1.  On May 6, 2013, at 1.00 p.m., a public hearing will be held in room 439, 301 South Park Avenue, Helena, Montana, to consider the proposed amendment, adoption, and repeal of the above-stated rules.

 

            2.  The Department of Labor and Industry (department) will make reasonable accommodations for persons with disabilities who wish to participate in this public hearing or need an alternative accessible format of this notice.  If you require an accommodation, contact the Board of Nursing (board) no later than 5:00 p.m., on April 30, 2013, to advise us of the nature of the accommodation that you need.  Please contact Cynthia Gustafson, Board of Nursing, 301 South Park Avenue, P.O. Box 200513, Helena, Montana 59620-0513; telephone (406) 841-2380; Montana Relay 1 (800) 253-4091; TDD (406) 444-2978; facsimile (406) 841-2305; e-mail [email protected].

 

            3.  GENERAL STATEMENT OF REASONABLE NECESSITY:  At its April 7, 2011 meeting, the board formed a committee comprised of board members and a number of licensed APRNs familiar with current national standards and regulatory trends, to review the board's APRN rules and propose appropriate rule amendments.  The committee held approximately 14 public meetings over the 15 months following the committee's formation.  A primary goal of the committee's work was the incorporation of the National Council of State Boards of Nursing's (NCSBN's) APRN Consensus Model into the board's rules.

            Following the work and recommendations of this APRN rules committee, the board determined it is reasonably necessary to generally revise the board rules relating to advanced practice registered nurses (APRN), to update, clarify, harmonize, eliminate redundancies, create consistency, and to more closely conform to current national standards expressed in the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education (APRN Consensus Model).  For example, the board is amending these rules to introduce the term "population focus" as the term is used in the APRN Consensus Model, as the board concluded it is an important, limiting element to guide an APRN's scope of practice in relation to the type of patients APRNs treat.

            The board is updating the continuing education (CE) requirements that are relative to APRN endorsement and prescriptive authority to reflect current APRN certification and competence development requirements.  The term "competence development" is a method to clarify and define the APRN's process in maintaining and improving knowledge, skills, and abilities necessary for practice, which also provides accountability to the public.  It includes continuing education, quality assurance, and the maintenance of certification, along with appropriate documentation of each of these elements.  These changes are proposed through the amendment or repeal of numerous rules and the adoption of New Rule II (APRN Competency Development).

            The board is further amending the CE rules to acknowledge that APRNs need to obtain CE to maintain their certification, often in excess of the number required in board rules.  The actual CE required and associated timeframe varies depending upon the APRN certification.  The board is reducing the amount of CE the board requires of APRNs to be consistent with the CE required of LPNs and RNs.  The board notes that this does not necessarily decrease the total amount of CE the APRN will need to obtain, as APRNs will still need to satisfy certification requirements to maintain licensure and prescriptive authority.  These amendments may decrease the burden placed on the APRN to satisfy requirements from different authorities with various timeframes, without actually reducing the total amount of CE the APRN will need to obtain.

            Additional amendments are technical in nature, such as renumbering or amending punctuation within certain rules following amendment and to comply with ARM formatting requirements.  Accordingly, the board has determined that reasonable necessity exists to generally amend the APRN rules at this time.  Where additional specific bases for a proposed action exist, the board will identify those reasons immediately following that rule.

 

            4.  The rules proposed to be amended provide as follows, stricken matter interlined, new matter underlined:

 

            24.159.301  DEFINITIONS  (1)  "Accrediting organization" means a professional organization that establishes standards and criteria for continuing education programs in nursing, advanced practice nursing, medicine, and other health care specialties.

            (2)  "Advanced practice registered nurse Practice Registered Nurse" or "APRN" means a registered nurse licensed by the board to practice as an advanced practice registered nurse pursuant to 37-8-202, MCA, and ARM 24.159.1414.  Four types of APRNs APRN roles are recognized by Montana law:

            (a)  nurse practitioner Certified Nurse Practitioner (NP CNP);

            (b)  certified nurse midwife Certified Nurse Midwife (CNM);

            (c)  certified registered nurse anesthetist Certified Registered Nurse Anesthetist (CRNA); and

            (d)  clinical nurse specialist Clinical Nurse Specialist (CNS).

            (3) remains the same.

            (4)  "Certifying body" means a national certifying organization that has been approved by the board to use psychometrically sound and legally defensible examinations for certification of nursing specialties in APRN roles and population focus.

            (5)  "Charge nurse Nurse" means the nurse who is in charge of patient and/or resident care during a nursing shift.  An LPN may serve as a charge nurse in the absence of an RN in a long-term care facility, pursuant to 37-8-102, MCA.

            (6) through (10) remain the same.

            (11)  "Department" means the Montana Department of Labor and Industry as provided for in Title 2, chapter 15, part 17, MCA.

            (12) remains the same.

            (13)  "Direct supervision" means the supervisor is on the premises, and is quickly and easily available.

            (14) through (24) remain the same.

            (25)  "Ordering" means authorizing durable medical devices and equipment, nutrition, diagnostic, and supportive services, including, but not limited to, home healthcare, hospice, and physical and occupational therapy.

            (25) remains the same, but is renumbered (26).

            (26) (27)  "Peer-reviewer" for APRN practice means a licensed APRN or physician whose credentials and practice encompass the APRN's scope and type of practice setting.  The peer-reviewer may be a consultant working for a professional peer review organization.

            (28)  "Population focus" for APRN practice means the section of the population which the APRN is certified to practice within.  The categories of population focus are:  family/individual across the lifespan, adult-gerontology, neonatal, pediatrics, women's health/gender-related, or psychiatric/mental health.

     (27) (29)  "Practical nurse Nurse" means the same thing as "licensed practical nurse Licensed Practical Nurse," "PN," and "LPN," unless the context of the rule dictates otherwise.  The practice of practical nursing is defined at 37-8-102, MCA.

            (28) (30)  "Preceptorship" for APRN education means practical supervised training in the specialized role, population focus, or specialty area of APRN practice for which the applicant seeks licensure by the board.

            (31)  "Prescriber" as defined in 37-7-502, MCA, means a medical practitioner as defined in 37-2-101, MCA, licensed under the professional laws of the state to administer and prescribe medicine and drugs.

            (29)  remains the same, but is renumbered (32).

            (30) (33)  "Prescription drug " as defined in 37-7-101, MCA, means an order for a drug, as defined by 37-7-101, MCA, or any medicine, devices, or treatments any drug that is required by federal law or regulation to be dispensed only by a prescription subject to section 503(b) of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. 353.

            (31) remains the same, but is renumbered (34).

            (32) (35)  "Registered nurse Nurse" means the same thing as "RN" and "professional nurse Professional Nurse," unless the context of the rule dictates otherwise.  The practice of professional nursing is defined at 37-8-102, MCA.

            (33) through (35) remain the same, but are renumbered (36) through (38).

            (36) (39)  "Strategy of care" means the goal-oriented plan developed to assist individuals or groups to achieve optimum health potential.  This includes initiating and maintaining comfort measures, promoting and supporting human functions and responses, establishing an environment conducive to well-being, providing health counseling and teaching, and collaborating on certain aspects of the medical regimen, including, but not limited to, the administration of medications and treatments.

            (37) through (39) remain the same, but are renumbered (40) through (42).

 

            AUTH:  37-1-131, 37-8-202, MCA

            IMP:     37-1-131, 37-8-101, 37-8-102, 37-8-202, 37-8-422, MCA

 

REASON:  The board is adding the definition of "ordering" at (25), as it is within the APRN scope of practice as expressed in the APRN Consensus Model, but was not previously defined in board rule.  In conjunction with the amendment to "prescription," this new definition will provide guidance for APRN practice by differentiating between the acts of ordering and prescribing.

 

            24.159.1405  STANDARDS RELATED TO THE ADVANCED PRACTICE REGISTERED NURSE'S RESPONSIBILITIES AS A MEMBER OF THE NURSING PROFESSION NURSE  (1) remains the same.

            (a)  adhere to the standards for the RN in ARM 24.159.1205 Title 24, chapter 159, subchapter 12, Administrative Rules of Montana;

            (b)  abide by the current practice standards and guidelines established by a national professional organization for the APRN's specialty area of practice as identified by the APRN role and population focus;

            (c)  possess the knowledge, judgment, and skill to safely and competently perform an APRN function within the APRN's role and population focus; and

            (d)  submit documentation to the board of the APRN's quality assurance plan, as set forth by ARM 24.159.1466; and

            (e)  submit to the board verification of recertification by the national certifying body within 30 days of its expiration.

            (d)  adhere to the requirements for APRN competence development in ARM [New Rule II], APRN Competence Development.

            (2)  The APRN is accountable to patients, the nursing profession, and to the board for complying with the rules and statutes for the quality of advanced nursing care rendered, for recognizing limits of knowledge and experience, for planning for the management of situations beyond the APRN's expertise, and for consultation with or referring patients to other health care providers as appropriate.

 

            AUTH:  37-1-131, 37-8-202, MCA

            IMP:     37-1-131, 37-8-202, 37-8-409, MCA

 

REASON:  The board is replacing the reference to ARM 24.159.1205 with a broader reference to the entire RN rule subchapter to clarify RN licensure is a prerequisite for APRN endorsement.  New Rule II (APRN Competence Development) will replace the quality assurance plan currently required in ARM 24.159.1466.  With the repeal of the quality assurance rule, the board is deleting references to ARM 24.159.1466 from the APRN rules in subchapter 14.

 

            24.159.1412  APPLICATION FOR INITIAL APRN LICENSURE  (1) and (2) remain the same.

            (3)  The applicant shall request that an official transcript be sent to the board directly from the applicant's APRN program to verify the date of completion and degree conferred.

            (4) remains the same.

            (5)  The applicant shall submit a copy of current national certification in APRN specialty role and population focus, congruent with education preparation.

            (6) and (7) remain the same.

            (8)  Within one month of initiating APRN practice, the APRN must submit to the board a quality assurance plan, as outlined by ARM 24.159.1466.

            (8)  An additional application is needed for APRN prescriptive authority.

 

            AUTH:  37-1-131, 37-8-202, MCA

IMP:     37-1-131, 37-1-134, 37-8-202, 37-8-409, MCA

 

            24.159.1413  ADVANCED PRACTICE NURSING TITLE  (1)  Only a licensed RN holding a current Montana APRN license has the right to use the title of APRN, and the appropriate title of the specialties of nurse practitioner Certified Nurse Practitioner (NP CNP), certified nurse midwife Certified Nurse Midwife (CNM), certified registered nurse anesthetist Certified Registered Nurse Anesthetist (CRNA), or clinical nurse specialist Clinical Nurse Specialist (CNS).

            (2)  An APRN licensed in Montana may only practice in the specialized clinical area in which the APRN has current national certification.

            (2)  At a minimum, each CRNA and CNM shall use the designation of APRN and the certified role for purposes of identification and documentation:

            (a)  CRNA will use APRN-CRNA; and

            (b)  CNM will use APRN-CNM.

            (3)  At a minimum, each CNS and CNP shall use the designation of APRN followed by the certified role and population focus for purposes of identification and documentation.  For example:

            (a)  a Family Nurse Practitioner would be designated as APRN-FNP;

            (b)  a Women's Health Nurse Practitioner would be designated as APRN-WHNP; and

            (c)  an Adult Clinical Nurse Specialist would be designated as APRN-ACNS.

 

            AUTH:  37-1-131, 37-8-202, MCA

            IMP:     37-1-131, 37-8-202, MCA

 

REASON:  The board is amending this rule to update APRN titles to conform to national certification standards.  Additionally, Clinical Nurse Specialist (CNS) and Certified Nurse Practitioner (CNP) are further amended to specify the population served, thus providing more transparency to the public.

 

            24.159.1414  EDUCATIONAL REQUIREMENTS AND QUALIFICATIONS FOR APRN  (1)  Applicants seeking APRN licensure in the specialties of CNM, NP, CRNA, or CNS must possess the following educational and certification qualifications:

            (a)  for those licensed in 2008 or after, a master's degree or post-graduate certificate from an accredited APRN program that provided a minimum of 250 hours of didactic instruction and a minimum of 500 hours of preceptorship;

            (b)  for those licensed between 1995 and 2007, a master's degree from an accredited nursing education program, or a certificate from an accredited post master's program as defined in (1)(c), which prepares the RN for the APRN recognition sought; and, individual certification from a certifying body.  APRNs who completed an accredited APRN program and obtained national certification prior to June 30, 1995, may be recognized in Montana; or

            (c)  for those licensed prior to 1995, a degree from a post-basic professional nursing education program in an APRN specialty with the minimum length of one academic year consisting of at least 250 hours of didactic instruction and 400 hours under a preceptor; and, individual certification from a certifying body.

            (2)  Applicants seeking APRN licensure as a psychiatric CNS must possess a master's degree in nursing from an accredited nursing education program that integrates pharmacology and clinical practice.

            (3)  Applicants seeking APRN licensure must pass the examination of and be certified by a national certifying body in the congruent area of specialization.

            (4)  Contact information for national certifying bodies may be obtained from the board office.

            (1)  The APRN:

            (a)  must complete an accredited graduate-level education program which provides preparation in one of the four recognized APRN roles;

            (b)  must pass a national certification examination that measures APRN role and population focused competencies and maintain current certification;

            (c)  has acquired advanced clinical knowledge and skills preparing the APRN to provide direct care to patients, as well as a component of indirect care; however, the defining factor for all APRNs is that a significant component of the education and practice focuses on direct care of individuals;

            (d)  utilizes and builds upon the competency of RN practice by demonstrating a greater depth and breadth of knowledge, a greater synthesis of data, increased complexity of skills and interventions, and greater role autonomy;

            (e)  is educationally prepared to assume responsibility and accountability for health promotion and/or maintenance as well as the assessment, diagnosis, and management of patient health;

            (f)  must have acquired clinical experience of sufficient depth and breadth to reflect the intended role and population focus; and

            (g)  must have obtained licensure to practice as an APRN in one of the four APRN roles: Certified Registered Nurse Anesthetist (CRNA), Certified Nurse Midwife (CNM), Clinical Nurse Specialist (CNS), or Certified Nurse Practitioner (CNP).

 

            AUTH:  37-1-131, 37-8-202, MCA

            IMP:     37-1-131, 37-8-202, 37-8-409, MCA

 

            24.159.1418  LICENSURE BY ENDORSEMENT  (1) through (1)(c) remain the same.

            (d)  completed application for prescriptive authority, if applicable;

            (e)  verification of prescriptive authority from all jurisdictions for preceding two years, if applicable;

            (f)  proof of completion of a minimum of 10 contact hours of continuing education within the preceding two years that meets the requirements of ARM 24.159.1468;

            (d)  verification of current national certification in APRN role and population focus; and

            (g) (e)  the required fees for APRN licensure by endorsement and prescriptive authority, if applicable, as specified by ARM 24.159.401.

            (2)  The board may, on a case-by-case basis, issue a license to an applicant for APRN licensure by endorsement, whose license is under investigation or in disciplinary action of a board in another jurisdiction, or to an applicant who is under investigation for a felony criminal offense.

            (3) remains the same.

 

            AUTH:  37-1-131, 37-8-202, 37-8-409, MCA

            IMP:     37-1-131, 37-1-304, 37-8-409, MCA

 

REASON:  The board is amending this rule to remove prescriptive authority requirements from this endorsement rule and relocating them to ARM 24.159.1463, which specifically addresses application for prescriptive authority.

 

            24.159.1427  RENEWALS  (1) remains the same.

            (a)  all continuing education requirements have been met during the renewal period; and

            (b)  the quality assurance plan has been followed; and peer review has occurred on a quarterly basis during the renewal period.

            (c)  the national professional organization practice standards and guidelines for appropriate role and population focus have been followed.

            (2)  If the APRN renewal application is submitted on-line online or postmarked after the renewal deadline, the applicant is subject to the late penalty fee specified in ARM 24.101.403.

            (3) remains the same.

 

            AUTH:  37-1-131, 37-8-202, MCA

IMP:     37-1-131, 37-1-134, 37-1-141, 37-8-202, MCA

 

REASON:  In conjunction with the adoption of New Rule II and the repeal of ARM 24.159.1466, the board is amending this rule to remove the peer review requirement from APRN renewal.  Due to the independent practice of APRNs and the increased national emphasis on the APRN's role and population focus, APRNs will now be required to affirm their adherence to the applicable practice standards and guidelines.

 

            24.159.1428  INACTIVE APRN STATUS  (1)  A licensed APRN who wishes to retain a license, but who will not be practicing advanced practice nursing, may obtain an inactive status APRN license upon submission of an application to the board and payment of the appropriate fee.

            (2)  An APRN on inactive status may not practice advanced practice nursing during the period in which the licensee remains on inactive status.

            (3)  An APRN with an inactive license may not hold a prescriptive authority endorsement.

            (3) through (4)(a) remain the same, but are renumbered (4) through (5)(a).

            (b)  affirmation of 20 12 continuing education contact hours congruent with the APRN's specialty certification and obtained within 12 months prior to reactivation; and

            (c) remains the same.

            (5)  To reactivate prescriptive authority, an APRN must affirm completion of ten continuing education contact hours in pharmacology and/or pharmacotherapeutics obtained within 12 months prior to reactivation.

 

            AUTH:  37-1-131, 37-1-319, 37-8-202, MCA

            IMP:     37-1-131, 37-1-319, MCA

 

REASON:  The board determined it is reasonably necessary to add an express prohibition against prescriptive authority for inactive licensees in (3) to clarify that the act of prescribing is a part of the practice of advanced practice nursing.  The board is also amending the continuing education requirements in this rule to reflect the proposed changes to ARM 24.159.2102 and the adoption of New Rule II.

 

            24.159.1461  PRESCRIPTIVE AUTHORITY FOR ELIGIBLE APRNS  (1)  An Only an APRN granted prescriptive authority by the board may prescribe, procure, administer, and dispense drugs legend and controlled substances pursuant to applicable state and federal laws and within the APRN's role and population focus.  NPs, CRNAs, CNMs, and psychiatric CNSs with unencumbered licenses may hold prescriptive authority.

            (2)  Prescriptive authority permits the APRN to receive, sign for, record, and distribute pharmaceutical samples to patients in accordance with applicable state and federal Drug Enforcement Administration laws, regulations, and guidelines and to prescribe, dispense, and administer prescription drugs in the prevention of illness, the restoration of health, and/or the maintenance of health in accordance with 37-2-104, MCA.

            (3)  The board notifies the Board of Pharmacy in a timely manner when the status of an APRN's prescriptive authority changes All APRNs who hold an unencumbered license and meet the qualifications for prescriptive authority within ARM 24.159.1463 may hold prescriptive authority.

 

            AUTH:  37-1-131, 37-8-202, MCA

            IMP:     37-1-131, 37-8-202, MCA

 

REASON:  Although the APRN Consensus Model ties prescriptive authority to APRN licensure, the board requires a separate review of qualifications prior to granting prescriptive authority.  These amendments are necessary to bring the board's rules into line with the APRN Consensus Model, with the exception that prescriptive authority shall only be granted upon application and subject to qualifications as established by board rule.  These amendments correspond with changes proposed in ARM 24.159.1463.

 

            24.159.1463  INITIAL APPLICATION FOR PRESCRIPTIVE AUTHORITY

            (1)  The APRN shall submit a completed application for prescriptive authority and a nonrefundable fee as specified in ARM 24.159.401.  The application for all APRNs except practicing CRNAs must include:

            (a)  evidence of successful completion of a graduate level course that provides a minimum of the equivalent of three academic semester credit hours (equaling a minimum of 45 contact hours) from an accredited program in pharmacology, pharmacotherapeutics, and the clinical management of drug therapy related to the applicant's area of specialty.  The academic credits must be obtained within a three-year period immediately prior to the date the application is received at the board office and must meet the following requirements:

            (i)  no more than six of the 45 contact hours may concern the study of herbal or complementary therapies;

            (ii)  a minimum of 18 of the 45 contact hours must have been obtained within one year immediately prior to the date of application; and

            (iii)  a minimum of one-third of all contact hours must be face-to-face or interactive instruction.

            (b)  evidence of the course content and clinical preceptorship;

            (c)  a copy of the current certification from the APRN's national certifying body;

            (d)  a description of the proposed practice sites and typical caseload; and

            (e)  an updated quality assurance plan, if needed, as required by ARM 24.159.1466.

            (2)  Practicing CRNAs may qualify for prescriptive authority by meeting the continuing education requirements of ARM 24.159.1418.

            (1)  The APRN seeking prescriptive authority shall submit a completed application and the appropriate fee for prescriptive authority as specified in ARM 24.159.401.

            (2)  The APRN seeking prescriptive authority who has graduated from an accredited program in the last five years shall submit:

            (a)  evidence of successful completion of a graduate level course of three semester credits in advanced pharmacology that includes instruction in pharmacodynamics, pharmacokinetics, and pharmacotherapeutics of all broad categories of agents;

            (b)  evidence of successful completion of a graduate level course that includes differential diagnosis/disease management; and

            (c)  evidence of supervised clinical practice that integrates pharmacologic intervention with patient management.

            (3)  The APRN seeking prescriptive authority who has graduated more than five years ago from an accredited program must complete either a graduate level course of three semester credits or 45 contact hours of continuing education that includes instruction in pharmacodynamics, pharmacokinetics, and pharmacotherapeutics of all broad categories of agents.

            (4)  The APRN with prescriptive authority from another board jurisdiction shall submit a completed application and the appropriate fees for prescriptive authority as specified in ARM 24.159.401.  The application must include evidence of a current unencumbered APRN license with prescriptive authority in another board jurisdiction.

            (3) and (4) remain the same, but are renumbered (5) and (6).

 

            AUTH:  37-1-131, 37-8-202, MCA

            IMP:     37-1-131, 37-8-202, MCA

 

REASON:  Previously any CNP, CNM, or CRNA could apply for prescriptive authority, but only psychiatric/mental health CNSs were allowed to apply.  APRN education has evolved, and national standards are moving towards preparing all APRNs (including CNSs) to prescribe.  This amendment provides for any APRN who can demonstrate the appropriate qualifications to be granted prescriptive authority.  The board is amending this rule with the understanding that currently most APRNs are receiving the qualifications required by board rule.

 

            24.159.1464  PRESCRIBING PRACTICES  (1) through (2)(d) remain the same.

            (e) (g)  Drug Enforcement Administration (DEA) number of the prescriber on all scheduled drugs; and.

            (e)  number of refills;

            (f)  all requirements of state and federal regulations regarding prescriptions.

            (f)  signature of the prescriber on written prescriptions; and

            (3) remains the same.

            (4)  An APRN with prescriptive authority shall comply with federal DEA requirements for controlled substances and shall file DEA registrations and numbers with the board.

            (5) through (7) remain the same.

 

            AUTH:  37-1-131, 37-8-202, MCA

            IMP:     37-1-131, 37-8-202, MCA

 

REASON:  The board is deleting the requirement to file DEA registrations and numbers with the board because it is not the practice of the board to maintain records of that information.

 

            24.159.1467  SUSPENSION OR REVOCATION OF PRESCRIPTIVE AUTHORITY  (1)  The board may suspend or revoke an APRN's prescriptive authority when one or more of the following occur:

            (a)  the APRN has not met the requirements for renewal of prescriptive authority set by ARM 24.159.1461 through 24.159.1464 and 24.159.1466 through 24.159.1468;

            (b)  the APRN has not met requirements necessary to maintain APRN licensure;.

            (c)  the APRN has violated rules pertaining to prescriptive authority contained in this subchapter; or

            (d)  the APRN has violated state or federal law or regulations applicable to prescriptions.

            (2)  The APRN whose prescriptive authority has been suspended or revoked may not prescribe medications until the APRN has received written notice from the board that prescriptive authority has been reinstated.

 

            AUTH:  37-1-131, 37-1-136, 37-8-202, MCA

            IMP:     37-1-131, 37-1-136, 37-8-202, MCA

 

REASON:  The board determined it is reasonably necessary to amend this rule to allow the board to revoke or suspend an APRN's prescriptive authority for reasons other than those currently in rule.  This expanded rule takes into account the fact that prescriptive authority is a license that may be subjected to board discipline.

 

            24.159.1468  PRESCRIPTIVE AUTHORITY RENEWAL  (1) through (2)(a) remain the same.

            (b)  affirmation of a minimum of ten 12 contact hours of accredited education in pharmacology, pharmacotherapeutics, and/or clinical management of drug therapy completed during the two years immediately preceding the effective date of the prescriptive authority renewal period.  Contact hours for prescriptive authority renewal must:; and

            (i)  be provided by advanced academic education or educational programs approved by an accrediting organization;

            (ii)  include a minimum of four contact hours of face-to-face or interactive instruction; and

            (iii)  the majority of the contact hours must concern the study of pharmaceutical medications and not herbal or complementary therapies.

            (c)  these contact hours can be used to satisfy 12 of the required 24 contact hours to renew the APRN license.

            (3)  The prescriptive authority contact hours are in addition to contact hours required to renew the general APRN license.

            (4) (3)  When an APRN fails to renew prescriptive authority prior to the renewal date of that authority, the APRN's prescriptive authority will lapse and expire after 45 days.  The APRN whose prescriptive authority has expired may not prescribe until the board has reinstated the APRN's prescriptive authority and must reapply for prescriptive authority under the requirement in ARM 24.159.1463.

 

            AUTH:  37-1-131, 37-8-202, MCA

            IMP:     37-1-131, 37-8-202, MCA

 

REASON:  The board determined that it is reasonably necessary to amend this rule to address the unnecessarily restrictive limitations on acceptable continuing education for prescriptive authority renewal.  Travel for face-to-face instruction is difficult for licensees in rural Montana and many excellent distance-learning alternatives exist.  The board is aware of no evidence that face-to-face instruction is superior to the alternatives, and consistent with the independent practice of APRNs in Montana, the board concluded that APRNs can be trusted to obtain the type of learning experience that satisfies their learning style and professional needs.  The board is also amending this rule to align it with the APRN Consensus Model.

 

            24.159.1470  CERTIFIED NURSE PRACTITIONER PRACTICE  (1)  Nurse practitioner Certified Nurse Practitioner (NP CNP) practice means the independent and/or collaborative management of primary and/or acute health care of individuals, families, and communities including: across settings.  The CNP is certified in acute or primary care and in the population focus of adult/geriatric, pediatric, neonatal, family/individual health across the lifespan, women's/gender-related, and/or psychiatric/mental health.

            (a)  assessing the health status of individuals and families using methods appropriate to the client population and area of practice such as health history taking, physical examination, and assessing developmental health problems.

            (b)  instituting and facilitating continuity of health care to clients, including:

            (i)  ordering durable medical equipment, treatments and modalities, and diagnostic tests;

            (ii)  receiving and interpreting results of diagnostic procedures;

            (iii)  making medical and nursing diagnoses; and

            (iv)  working with clients to promote their understanding of and compliance with therapeutic regimens.

            (c)  promoting wellness and disease prevention programs;

            (d)  referring clients to a physician or other health care provider, when appropriate;

            (e)  providing instruction and counseling to individuals, families, and groups in the areas of health promotion and maintenance, including involving such persons in planning for their health care; and

            (f)  working in collaboration with other health care providers and agencies to provide and, where appropriate, coordinate services to individuals and families.

            (2)  Every licensed NP shall abide by the practice standards and guidelines established by a NP national professional organization as identified by the NP.

 

            AUTH:  37-1-131, 37-8-202, MCA

            IMP:     37-1-131, 37-8-202, 37-8-409, MCA

 

REASON:  The board is adopting New Rule I (APRN Practice) to update and clarify the definition of APRN practice, consistent with national standards.  In conjunction with the addition of New Rule I, the common elements found in this rule and ARM 24.159.1475, 24.159.1480, and 24.159.1485 are being deleted to eliminate redundancy.  In addition, the board is amending each of these rules to clarify the role and population focus for each APRN type, consistent with the APRN's certification, and to incorporate the central emphasis of role and population focus from the APRN Consensus Model.

 

            24.159.1475  CERTIFIED NURSE MIDWIFERY PRACTICE  (1)  Certified nurse midwifery Nurse Midwifery (CNM) practice means the independent and/or collaborative management of care of essentially normal newborns, providing perinatal and general women's healthcare within a health care system that provides for medical consultation, collaborative management, and referral women throughout the lifespan.  The CNM is certified in the population focus of women's/gender-related health and provides a full range of primary health care services to women throughout the lifespan, including gynecologic care, family planning services, preconception care, prenatal and postpartum care, childbirth, and the care of the newborn in diverse settings.  The practice includes treating the male partner of their female clients for sexually transmitted diseases and for reproductive health.

            (2)  All licensed CNMs shall be enrolled in either the certification maintenance program or the continuing competency assessment program through the American College of Nurse Midwives.

            (3)  Every licensed CNM shall abide by the practice standards and guidelines established by a CNM national professional organization as identified by the CNM.

 

            AUTH:  37-1-131, 37-8-202, MCA

            IMP:     37-1-131, 37-8-202, 37-8-409, MCA

 

            24.159.1480  CERTIFIED REGISTERED NURSE ANESTHETIST PRACTICE

            (1)  Certified registered nurse anesthetist Registered Nurse Anesthetist (CRNA) practice is the independent and/or collaborative performance of or the assistance in any act involving the determination, preparation, administration, or monitoring of any drug used in the administration of anesthesia or related services for surgical and other therapeutic procedures that require the presence of persons educated in the administration of anesthetics anesthesia care and anesthesia-related services, and the management of acute and chronic pain.  The CRNA is certified in the population of family/individual health across the lifespan whose health status may range from healthy through all recognized levels of acuity, including persons with immediate, severe, or life-threatening illnesses or injuries in diverse settings.

            (2)  Every licensed CRNA shall abide by the practice standards and guidelines established by a CRNA national professional organization as identified by the CRNA.

 

            AUTH:  37-1-131, 37-8-202, MCA

            IMP:     37-1-131, 37-8-202, 37-8-409, MCA

 

            24.159.1485  CLINICAL NURSE SPECIALIST PRACTICE  (1)  Clinical nurse specialist Nurse Specialist (CNS) practice means the independent and/or collaborative delivery and management of expert level nursing care to individuals, families, or groups, including the ability to: and communities.  CNS practice integrates nursing practice, which focuses on assisting patients in the prevention or resolution of illness, with medical diagnosis and treatment of disease, injury, and disability.  In addition to providing direct patient care, CNSs influence care outcomes by providing expert consultation for nursing staff and by implementing improvements in health care delivery systems.  CNS certification may include the population focus of adult/geriatric, pediatric, neo-natal, family/individual, and/or psychiatric/mental health.

            (a)  assess the health status of individuals and families using methods appropriate to the client population and area of practice;

            (b)  diagnose human responses to actual or potential health problems using the nursing process;

            (c)  plan for health promotion, disease prevention, and/or therapeutic intervention in collaboration with the client.  The goal is to enhance the problem-solving and self-care abilities of the client whenever and to whatever extent possible. The clinical nurse specialist works with other health care providers to maximize resources available to the client and family;

            (d)  implement therapeutic interventions based on the clinical nurse specialist's area(s) of expertise, including but not limited to:

            (i)  direct nursing care;

            (ii)  ordering durable medical equipment;

            (iii)  ordering nonpharmacological treatment;

            (iv)  providing medications or treatments according to protocol;

            (v)  receiving and monitoring diagnostic procedures according to protocols; and

            (vi)  counseling and/or teaching.

            (e)  refer for additional health care as necessary and appropriate;

            (f)  coordinate health care as necessary and appropriate;

            (g)  evaluate, with the client, the effectiveness of care;

            (h)  educate clients, families, other health care professionals, and the public;

            (i)  engage in research activities; and

            (j)  provide consultation to other health care providers.

            (2)  Every licensed CNS shall abide by the practice standards and guidelines established by a CNS national professional organization as identified by the CNS.

 

            AUTH:  37-1-131, 37-8-202, MCA

            IMP:     37-1-131, 37-8-202, 37-8-409, MCA

 

            24.159.2102  BIENNIAL CONTINUING EDUCATION REQUIREMENTS

            (1) through (1)(b) remain the same.

            (c)  APRNs must complete a minimum of 40 24 contact hours during the two-year renewal period that meet the requirements set forth in ARM 24.159.1425 [NEW RULE II], in addition to the ten with 12 contact hours of the continuing education required in pharmacotherapeutics, where no more than two pharmacology contact hours may concern the study of herbal or complementary therapies for maintaining prescriptive authority, if applicable, as set forth in ARM 24.159.1468.

            (2) through (6) remain the same.

 

            AUTH:  37-1-131, 37-1-319, 37-8-202, MCA

            IMP:     37-1-131, 37-1-306, 37-1-319, MCA

 

            5.  The proposed new rules provide as follows:

 

            NEW RULE I  APRN PRACTICE  (1)  The APRN licensed in Montana may only practice in the role and population focus in which the APRN has current national certification.  APRN practice is an independent and/or collaborative practice and may include:

            (a)  establishing medical and nursing diagnoses, treating, and managing patients with acute and chronic illnesses and diseases; and

            (b)  providing initial, ongoing, and comprehensive care, including:

            (i)  physical examinations, health assessments, and/or other screening activities;

            (ii)  prescribing legend and controlled substances when prescriptive authority is successfully applied for and obtained;

            (iii)  ordering durable medical equipment, diagnostic treatments and therapeutic modalities, laboratory imaging and diagnostic tests, and supportive services, including, but not limited to, home healthcare, hospice, and physical and occupational therapy;

            (iv)  receiving and interpreting results of laboratory, imaging, and/or diagnostic studies;

            (v)  working with clients to promote their understanding of and compliance with therapeutic regimens;

            (vi)  providing instruction and counseling to individuals, families, and groups in the areas of health promotion, disease prevention, and maintenance, including involving such persons in planning for their health care; and

            (vii)  working in collaboration with other health care providers and agencies to provide and, where appropriate, coordinate services to individuals and families.

 

            AUTH:  37-1-131, 37-8-202, MCA

            IMP:     37-1-131, 37-8-202, 37-8-409, MCA

 

            NEW RULE II  APRN COMPETENCE DEVELOPMENT  (1)  The APRN is expected to engage in ongoing competence development.  Competence development is the method by which an APRN gains, maintains, or refines practice, knowledge, skills, and abilities.  This development can occur through formal education programs, continuing education, or clinical practice and is expected to continue throughout the APRN's career.  Documentation of competence development activities should be retained by the APRN for a minimum of five years and must be made available to the board upon request.  The APRN must:

            (a)  submit verification of national recertification to the board within 30 days of issuance; and

            (b)  complete 24 contact hours of continuing education during each two-year license renewal period as stated in ARM Title 24, subchapter 21, Renewals and Continuing Education; and

            (i)  For the APRN who holds prescriptive authority, 12 of the 24 contact hours must be in pharmacotherapeutics, where no more than two of these contact hours may concern the study of herbal or complementary therapies.

            (ii)  At renewal, APRN licensees licensed by examination less than one full year are not required to complete the 24 contact hours.  APRN licensees licensed by examination at least one year, but less than two full years, shall complete one-half of the credit required for renewal.

            (c)  maintain an individualized quality assurance plan that:

            (i)  is relevant to the APRN's role and population focus, practice setting, and level of experience;

            (ii)  may include peer review, institutional review, and/or self-assessment;

            (iii)  includes methods for maintaining continued competence in providing patient care and evaluating patient outcomes; and

            (iv)  meets the standards set by the APRN's national professional organization.

 

            AUTH:  37-1-131, 37-1-319, 37-8-202, MCA

            IMP:     37-1-131, 37-8-202, 37-8-409, MCA

 

            6.  The rules proposed to be repealed are as follows:

 

            24.159.1404  STANDARDS RELATED TO THE ADVANCED PRACTICE REGISTERED NURSE'S RESPONSIBILITY TO APPLY THE NURSING PROCESS found at ARM page 24-16655.

 

            AUTH:  37-1-131, 37-8-202, MCA

            IMP:     37-1-131, 37-8-202, MCA

 

REASON:  This board is repealing this rule because updated language and current practice standards are proposed in New Rule I (APRN Practice) in this notice.

 

            24.159.1411  TEMPORARY PERMITS FOR GRADUATE APRNS found at ARM page 24-16661.

 

            AUTH:  37-8-202, 37-8-409, MCA

            IMP:     37-8-202, 37-8-409, MCA

 

REASON:  The board is repealing this rule as obsolete, since national certifying bodies for APRN certification provide examinations and results in a timely manner, whereas historically there was a significant delay that justified the need for this rule.  This rule is also being repealed because the board is concerned that an APRN graduate should not be allowed to perform advanced practice nursing before becoming certified.

 

            24.159.1424  CONTINUING EDUCATION REQUIREMENTS found at ARM page 24-16665.

 

            AUTH:  37-1-131, 37-1-319, 37-8-202, MCA

IMP:     37-1-131, 37-1-141, 37-8-202, MCA

 

REASON:  This rule is being repealed in conjunction with the adoption of New Rule II (APRN Competence Development).

 

            24.159.1462  ADVANCED PRACTICE NURSING COMMITTEE found at ARM page 24-16685.

 

            AUTH:  37-1-131, 37-8-202, MCA

            IMP:     37-1-131, 37-8-202, MCA

 

REASON:  The board is repealing this rule as unnecessary, since there no longer exists a desire or need for a standing committee for the purposes identified in this rule.  Moreover, the existing APRN committee has not been used for the stated purposes for a number of years, as department staff typically fulfills these roles.

 

            24.159.1466  QUALITY ASSURANCE OF APRN PRACTICE found at ARM page 24-16688.

 

            AUTH:  37-1-131, 37-8-202, MCA

            IMP:     37-1-131, 37-8-202, 37-8-409, MCA

 

REASON:  This rule is being repealed in conjunction with the adoption of New Rule II (APRN Competence Development).

 

            24.159.1490  PSYCHIATRIC-MENTAL HEALTH PRACTITIONER PRACTICE found at ARM page 24-16702.

 

            AUTH:  37-1-131, 37-8-202, MCA

            IMP:     37-1-131, 37-8-202, 37-8-409, MCA

 

REASON:  Consistent with the APRN Consensus Model, this rule is unnecessary since psychiatric CNSs and psychiatric CNPs are no longer distinguishable as independent APRN types.

 

            7.  Concerned persons may present their data, views, or arguments either orally or in writing at the hearing.  Written data, views, or arguments may also be submitted to the Board of Nursing, 301 South Park Avenue, P.O. Box 200513, Helena, Montana 59620-0513, by facsimile to (406) 841-2305, or by e-mail to [email protected], and must be received no later than 5:00 p.m., May 14, 2013.

 

            8.  An electronic copy of this Notice of Public Hearing is available through the department and board's web site at www.nurse.mt.gov.  The department strives to make the electronic copy of this notice conform to the official version of the notice, as printed in the Montana Administrative Register, but advises all concerned persons that in the event of a discrepancy between the official printed text of the notice and the electronic version of the notice, only the official printed text will be considered.  In addition, although the department strives to keep its web site accessible at all times, concerned persons should be aware that the web site may be unavailable during some periods, due to system maintenance or technical problems, and that technical difficulties in accessing or posting to the e-mail address do not excuse late submission of comments.

 

            9.  The board maintains a list of interested persons who wish to receive notices of rulemaking actions proposed by this board.  Persons who wish to have their name added to the list shall make a written request that includes the name, e-mail, and mailing address of the person to receive notices and specifies the person wishes to receive notices regarding all board administrative rulemaking proceedings or other administrative proceedings.  The request must indicate whether e-mail or standard mail is preferred.  Such written request may be sent or delivered to the Board of Nursing, 301 South Park Avenue, P.O. Box 200513, Helena, Montana 59620-0513; faxed to the office at (406) 841-2305; e-mailed to [email protected]; or made by completing a request form at any rules hearing held by the agency.

 

            10.  The bill sponsor contact requirements of 2-4-302, MCA, do not apply.

 

            11.  Tyler Moss, attorney, has been designated to preside over and conduct this hearing.

 

 

                                                                     BOARD OF NURSING

                                                                     HEATHER O'HARA, RN, PRESIDENT

 

 

/s/ DARCEE L. MOE                                 /s/ PAM BUCY

Darcee L. Moe                                           Pam Bucy, Commissioner

Rule Reviewer                                            DEPARTMENT OF LABOR AND INDUSTRY

 

 

            Certified to the Secretary of State April 1, 2013