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Nurse Licensure and NP Approval to Practice in North Carolina

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Nurse Licensure and NP Approval to Practice in North Carolina Eileen C. Kugler RN MSN MPH FNP MANAGER - PRACTICE May 15, 2009 Workshop Objectives Compare scopes of ... – PowerPoint PPT presentation

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Title: Nurse Licensure and NP Approval to Practice in North Carolina


1
Nurse Licensure and NP Approval to Practice in
North Carolina
  • Eileen C. Kugler RN MSN MPH FNP
  • MANAGER - PRACTICE

May 15, 2009
2
Workshop Objectives
  • Compare scopes of nursing practice for RN, LPN,
    NP
  • Discuss NP scope of practice
  • Describe the application and approval process for
    NPs in North Carolina
  • Identify documentation required at the practice
    site

3
Regulatory Authority
  • Purpose of Regulation PROTECTION OF THE PUBLIC
  • Occupational regulation based upon states rights
    to protect citizens and hold providers
    accountable
  • Mandate to Regulate Nursing and Medical Practice
    authority derived from legislative action
  • Rules and Regulations promulgated through NC
    Administrative Code

4
(No Transcript)
5
(No Transcript)
6
Compact States as of Feb. 2009
  •   
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Arizona 
  • Arkansas 
  • Colorado
  • Delaware 
  • Idaho  
  • Iowa 
  • Kentucky
  • Maine
  • Maryland  
  • Mississippi 
  • Nebraska
  • New Hampshire 
  • New Mexico
  • North Carolina  
  • North Dakota
  • Rhode Island  
  • South Carolina
  • Virginia  
  • Wisconsin 

7
What defines scope of practice?
  • Nursing Practice Act - Law
  • NC Administrative Code - Rules
  • Level of Licensure
  • Board Position/Advisory Statements and Opinions
  • Agency Policy/Procedure-can restrict, but not
    expand scope

8
WHAT DEFINES SCOPE OF PRACTICE?
  • Nursing Practice Act - NC G.S. 90-171
  • Level of License Components of practice defined
    under
    G.S.90-171.20 (7) (8)
  • NC Administrative Code - Rules for Occupational
    Licensing Boards
  • 21 NCAC 36.0224 Components of Nursing Practice
    for the Registered Nurse
  • 21 NCAC 36.0800 Approval and Practice Parameters
    for Nurse Practitioners
  • 21 NCAC 36.0226 Nurse Anesthesia Practice

9
Comparison of Scopes
  • Advanced Practice Nurse
  • Registered Nurse
  • Licensed Practical Nurse

10
Components of RN and LPN Scopes of Practice
11
NPA STATUTE G.S. 90-171.20
  • In North Carolina, the RN has an INDEPENDENT role
  • In North Carolina, the LPN has a DEPENDENT role.

12
Scopes of Practice for RN and LPN
  • GS. 90-171.20 (7)
  • Ten components of practice by the RN
  • Does not require the RN to have nursing
  • activities assigned to them nor be supervised by
    anyone.
  • GS. 90-171.20 (8)
  • Seven components of practice by the LPN
  • Requires the LPN to have assignment and
    supervision by the RN or physician or other duly
    authorized person.

13
Registered Nurse
  • full scope of nursing, comprehensive care for all
    clients in all settings
  • teaching theory and practice of nursing, managing
    nursing personnel, and administering nursing
    services

14
Licensed Practical Nurse
  • directed scope of nursing, under supervision of
    RN, APRN, MD or other authorized provider
  • collect focused data
  • contribute to and participate in the
    comprehensive care of clients

15
Advanced Practice Registered Nurses
  • expanded scope of nursing practice
  • graduate degree with advanced knowledge of
    theory, assessment, interventions, and management
    of health care
  • CRNA, NP, CNM, CNS

16
Nursing Practice Act Administrative Rule 21
NCAC 36 .0226
  • The CRNA may perform nurse anesthesia
    activities in collaboration with a physician,
    dentist, podiatrist, or other qualified health
    care provider, but may not prescribe a medical
    treatment regimen or make a medical diagnosis
    except under the supervision of a licensed
    physician.

17
Supervision vs Collaboration Is it lawful for
CRNAs in NC to practice without Physician
Supervision? The NCBON explicitly distinguishes
nurse anesthesia activities that are performed
in collaboration with from prescribing a
medical treatment regimen or making a medical
diagnosis, which are performed under the
supervision of a licensed physician
18
CRNA RECOGNITION PROCESS
  • On 7/01/03, the North Carolina Board of Nursing
    initiated the process for verifying that nurse
    anesthetists meet the requirements to practice in
    NC.

19
RECOGNITION PROCESS
  • CRNAs Practicing in North Carolina
  • Nurse Anesthetists Endorsing into North Carolina

20
Nurse Anesthetist NC School Information
  • Nurse anesthetist students
  • graduating from anesthesia school (not yet
    certified)
  • NC schools provide BON with list of
    names/addresses (including SSN and/or RN cert
    for database purposes) of new grads successfully
    completing program
  • Program Directors work with new grads on
    completion of online verification form to
    practice as Graduate Nurse Anesthetists
  • Out-of-State Grads need to provide transcript or
    letter from program director

21
GRNA Status and Issuance of Initial CRNA
Recognition
  • GRNA Status
  • Recognition certificate will be issued to
    Graduate Nurse Anesthetists indicating that they
    have 18 mos. from time of graduation to pass
    credentialing exam.
  • Issuance of Initial CRNA Recognition
  • Once certified, Recognition certificate sent from
    BON as acknowledgement for practice as a
    Certified Registered Nurse Anesthetist (CRNA).

22
Renewing NC CRNA Recognition
  • Renewal of national certification biennially in
    July.
  • Board sends recognition renewal notice 60 days
    prior to expiration of the national certification
    with instructions on how to update NCBON
    recognition.
  •  
  • A non-refundable administrative charge of 25.00

23
NURSE PRACTITIONER ADMINISTRATIVE CODE/RULES
  • Effective August 1, 2004 New NP Rules
  • NC Board of Nursing Rule 21 NCAC 36.0800
    Approval and Practice Parameters for Nurse
    Practitioners
  • NC Medical Board Rule 21 NCAC 32M.0101
    Approval of Nurse Practitioners

24
NP Scope of Practice
  • 21 NCAC 36 .0801(4)
  • Definition of Nurse Practitioner
  • Current NC RN license
  • Approved to perform medical acts
  • Consistent with NP academic prep and national
    certification
  • Collaborative Practice Agreement with licensed
    physician

25
Scope of NP Practice
  • Definition of NP, continued
  • Medical acts are in addition to nursing acts
    performed by virtue of RN license
  • NP held accountable under RN license for nursing
    acts performed

26
Scope of NP Practice
  • 21 NCAC 36 .0802
  • Scope of Practice
  • Continuous and comprehensive management of broad
    range of personal health services
  • Educationally prepared and competency maintained
  • Collaborative Practice Agreement

27
Scope of NP Practice
  • 21 NCAC 36 .0802, continued
  • Services include but not restricted to
  • Promotion and maintenance of health
  • Prevention of illness and disability
  • Diagnosing, treating and managing acute and
    chronic illnesses
  • Guidance and counseling individuals and families

28
Scope of NP Practice
  • 21 NCAC 36 .0802, continued
  • Services include but not restricted to
  • Prescribing, administering and dispensing
    therapeutic measures, tests, procedures and drugs
  • Planning for situations beyond NPs expertise,
    consulting with and referring to other providers
  • Evaluating health outcomes

29
NP Approval to Practice
  • 21 NCAC 36 .0801(6) Definition
  • Approval to practice means
  • Authorization by Medical Board and Board of
    Nursing for RN to perform medical acts
  • Within area of educational prep and certification
  • Under Collaborative Practice Agreement

30
NP Approval to Practice Requirements
  • REGISTRATION
  • Authorization by the Medical Board and Board of
    Nursing to use the title of Nurse Practitioner
    in accordance with the Rule without having an
    approval to practice with a supervising
    physician.
  • All NPs who desire to use the title NP are
    required to complete the Application for
    Registration as a Nurse Practitioner.
  • 25.00 administrative charge.

31
NP Approval to Practice Requirements
  • REQUIREMENTS FOR REGISTRATION AS A NURSE
    PRACTITIONER
  • 21 NCAC 36.0803 (a)
  • (1) An unrestricted license to practice as a RN
    in NC and when applicable unrestricted approval,
    registration or license as a NP in another state,
    territory, or possession of the US.
  • (2) Has successfully completed a NP education
    program as outlined in Rule 21 NCAC 36.0805

32
NP Approval to Practice Requirements
  • REQUIREMENTS FOR REGISTRATION AS A NP
  • (3) Has supplied information necessary to
    evaluate the application.
  • (b) Effective January 1, 2005 new graduates
    seeking first-time nurse practitioner
    registration in NC shall 21 NCAC 36.0803 NURSE
    PRACTITIONER REGISTRATION (b)(1)-(3)

33
NP Approval to Practice Requirements
  • REQUIREMENTS FOR REGISTRATION AS A NP
  • (1) Hold a Masters Degree in Nursing or related
    field with primary focus on Nursing
  • (2) Have successfully completed a graduate level
    NP education program accredited by a national
    credentialing body, and in addition met the
    criteria as outlined in Rule .0805 (a) and (c)
    under Education and Certification for
    Registration as a NP.
  • (3) Provide documentation of certification by a
    national credentialing body

34
NP Approval to Practice Requirements
  • 1. NOTORIZED letter of verification from the
    Director of the Nurse Practitioner Program that
    all the components of the core curriculum and the
    clinical management of common health problems
    found in Rule 21 NCAC 36.0805 or 21 NCAC 32M.0105
    are met, and the date of completion and type of
    NP program.

35
NP Approval to Practice Requirements
  • 2. Registration allows the individual to use
    the title Nurse Practitioner, but does not allow
    the individual to practice as a NP.
  • 3. An application for approval to practice must
    be completed and approved by the Boards before
    the NP may practice.

36
NP Approval to Practice Requirements
  • APPROVAL TO PRACTICE
  • A separate application for the NP who desires to
    practice (registration and approval applications
    may be done online at the same time).
  • A separate application must be completed for each
    Primary Supervising Physician
  • The NP can have more than one primary supervising
    physician.
  • With each Primary Supervising Physician there
    shall be a Collaborative Practice Agreement
    (CPA).

37
INTERIM STATUS FOR NURSE PRACTITIONER APPLICANT
  • Shall be granted to
  • Any registered nurse seeking first-time approval
    to practice as a NP in NC who
  • meets the NP education and registration
    requirements, if applicable
  • Interim status allows the NP to practice until
    the application is approved by the Boards

38
INTERIM STATUS CONTINUED
  • The following limitations apply 21 NCAC
    36.0804(g)(1)(2)(3)(4)
  • 1. No prescribing privileges
  • 2. Primary or back-up physicians shall be
    continuously available
  • 3. Countersigning by MD of notations of medical
    acts in all patient charts within two working
    days of NP applicant-patient contact

39
INTERIM STATUS CONTINUED
  • 4. Face to face consultation meetings with the
    primary supervising physician on a weekly basis
    with documentation of consultation consistent
    with Rule .0810(e)(3) (Quality Assurance
    Standards for a Collaborative Practice
    Agreement).
  • A. Identify clinical issues discussed and action
    taken,
  • B. Be signed and dated by those who attended
    and,
  • C. Be available for review by members or agents
    of either Board for the previous 5 calendar years
    and be retained by both the NP and primary
    supervising physician.
  • 5. Shall not exceed period of six months.

40
Continuing Education Requirements
  • 50 contact hours each year
  • Beginning with the first renewal after initial
    approval to practice granted

41
Continuing Education Requiements
  • Continuing Education are those hours for which
    approval has been granted by the
  • 1. American Nurses Credentialing Center (ANCC)
  • 2. Accreditation Council on Continuing Medical
    Education (ACCME)
  • 3. Other National Credentialing Body
  • 4. Practice relevant Courses in an Institution
    of Higher Learning (New Category)
  • 5. Documentation shall be maintained by the NP
    made available upon request to either Board.

42
COLLABORATIVE PRACTICE AGREEMENT
  • Definition Collaborative Practice Agreement
    means the arrangement for nurse
    practitioner-physician continuous availability to
    each other for on-going supervision,
    consultation, collaboration, referral and
    evaluation of care provided by the nurse
    practitioner.

43
COLLABORATIVE PRACTICE AGREEMENT
  • Written Protocols are not mandatory as in the
    previous NP rules, but the NP may use them AS
    PART of the COLLABORATIVE PRACTICE AGREEMENT.

44
COLLABORATIVE PRACTICE AGREEMENT
  • Discussed in Rules
  • 21 NCAC 36.080 Definitions (9)
  • 21 NCAC 36 .0804 Process for Approval to Practice
    (a)(4)
  • 21 NCAC 36 .0809 Prescribing Authority
    (b)(1)((2)(A)(B)(C)(3)(A)(B)
  • 21 NCAC 36 .0810 QA Standards for a CPA

45
COLLABORATIVE PRACTICE AGREEMENT
  • Quality Improvement Process
  • Written Plan for evaluating the quality of care
    provided for one or more frequently encountered
    clinical problems
  • The CPA can be more restrictive than Nursing Law
    just not less.

46
COLLABORATIVE PRACTICE AGREEMENT
  • Required Elements in the CPA
  • CPA must include
  • How NP and MD are continuously available to each
    other
  • A pre-determined plan for emergency services
  • Drugs, devices, tests, procedures
  • No specific format required.

47
COLLABORATIVE PRACTICE AGREEMENT
  • What elements to include???
  • Some examples
  • 1. Practices differ even if same specialty.
  • 2. What is the Patient Population?
  • 3. Most Common Diagnoses
  • 4. Complexity of care Client Population
  • 5. Availability of Emergency Services,
    Diagnostic Centers Specialists
  • 6. Address components of CPA discussed in the
    rules mentioned above.

48
COLLABORATIVE PRACTICE AGREEMENT
  • 7. New graduate, seasoned NP, or seasoned NP
    new Primary Supervising Physician
  • 8. When NP primary supervising physician
    address how they practice together, completed
    document will be the nurse practitioners
    collaborative practice agreement.

49
COLLABORATIVE PRACTICE AGREEMENT
  • 9. YOU WILL FIND THE COLLABORATIVE PRACTICE
    AGREEMENT A GUIDE FOR IMPLEMENTATION on
  • www.ncbon.com, then Practice, APRN, NP,
    Collaborative Practice Agreement Guidelines

50
INFORMATION REQUIRED
  • Required to be at each NP practice site
  • Signed Collaborative Practice Agreement (CPA)
    (according to NP Rules 21 NCAC 36 .0810(b)(1)
  • Registration as NP, if applicable
  • Current NP approval
  • Current RN license
  • DEA number, if applicable

51
INFORMATION REQUIRED
  • Required to be at each NP practice site
  • Documentation of QI Process Meetings
  • Copy of Notification of Original Approval to
    Practice
  • Documentation of Continuing Education
  • 21 NCAC 36.0807 - Documentation shall be
    maintained by the NP made available upon
    request to either Board

52
NP Refresher Course
  • 21 NCAC 36.0808 Inactive Status
  • Refresher Course Required if inactive NP status
    greater than 5 years.
  • NP seeking 1st time approval to practice in NC
    who has not provided direct patient care as an NP
    in more than 5 years

53
NP Refresher Course
  • An unrestricted RN license is required for the NP
    Refresher Course
  • NP Refresher Course is NCBON approved consists
    of common conditions their management directly
    related to the NPs area of education
    certification

54
Purpose of Compliance Reviews
  • To provide the opportunity for NP to review rules
    and regulations
  • To ensure NP and MD meet requirements

55
Compliance Review Process
  • Guiding Principles
  • Accountability for requirements in NP Rules
  • Review limited to current approval
  • If gt1 approval, only one will be reviewed
  • Acceptable documentation
  • QI framework

56
Compliance Review Process
  • Methods
  • Selection Process
  • Site Visits
  • Mail-In Self Assessments

57
NP Laws and Rules
  • Laws
  • 90-18.2 and 90-18.3
  • Rules
  • 21 NCAC 36.0801 - .0814
  • 21 NCAC 32M.0101 - .0116

58
2008 Compliance Review Results
Total reviews 29
Site visits 14
Mail-ins 15
Reviews in compliance 14 48
Reviews with discrepancies 15 52
59
Primary Discrepancies
Back up MD form 4
Continuing education 5
CPA 6
QI meetings 6
Additional documentation required 12
60
Questions/Discussion
  • Website www.ncbon.com
  • E-Mail ekugler_at_ncbon.com
  • (919) 782-3211, ext. 255
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