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Can Florida Psychiatric Nurse Practitioners Register their Autonomous Practice for Primary Care Services?

Recently, the Board of Nursing voted to approve the following revised language for adoption by rule as the definition of “primary care practice”:

“Includes physical and mental health promotion, assessment, evaluation, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses, inclusive of behavioral and mental health conditions”.

This definition would be read in conjunction with Section 464.0123(3), Florida Statutes.

The Board also voted to accept the recommendation, also for adoption by rule, from the Council on APRN Autonomous Practice for “standards of practice” as:

“Advanced practice registered nurses who are registered pursuant to Section 464.0123, F.S., shall engage in autonomous practice only in a manner that meets the General Standard of Practice. The General Standard of Practice shall be that standard of practice, care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similarly situated health care providers.”

 They don’t mention psychiatric nurse practitioners by name but the revised definition’s inclusion of words like “Mental health promotion, assessment, evaluation” and “treatment of….behavioral and mental health conditions” implies that this is inclusive of the services that a psychiatric NP would provide in a primary care setting.

We are awaiting further comment form the Board of Nursing with additional direction for the scope of services that psychiatric nurse practitioners can provide under this revised definition. I would argue that if the Board of Nursing approves your autonomous practice registration based on your description of providing psychiatric services that the BON is in turn permitting your to engage in autonomous practice for the provision of psychiatric nursing services in a primary care setting.

UPDATE (October 17, 2022): During an October 2022 Board Hearing, the Board of Nursing considered whether it is within the scope of practice for an autonomous practice APRN who is a psychiatric and mental health nurse practitioner to provide psychiatric and mental health treatment, including psychotherapy, to patients with psychiatric and mental health conditions. They also discussed whether it is within the scope of practice for an autonomous practice APRN to prescribe controlled substances under Section 893.03(2), F.S. for greater than a seven-day supply, for treatment for psychiatric and mental health conditions. Also, whether a supervising physician is needed to provide treatment, including psychotherapy, for psychiatric or mental health conditions. (Susan Patricia Lynch, APRN, R.N. – File#1711/304094 was the involved party)

The Florida Board of Nursing, after thoughtful deliberation and consideration of the law, answered “No”. The practice of an APRN, certified as a PMHNP, is not considered to be solely within the definition of primary care and as such, the PMHNP must still maintain a collaborative agreement. 

The BON asked for a continuance regarding the seven day supply of controlled substance class II medications to treat psychiatric mental health issues as the BON attorney wanted to research this subject further. This had not been considered formally by the BON since the passage of HB 607 authorizing a pathway for autonomous practice.

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It should be noted that I am not your lawyer (unless you have presently retained my services through a retainer agreement). This post is not intended as legal advice, it is purely educational and informational, and no attorney-client relationship shall result after reading it. Please consult your own attorney for legal advice. If you do not have one and would like to retain my legal services, please contact me using the contact information listed above.

 

All information and references made to laws, rules, regulations, and advisory opinions were accurate based on the law as it existed at this time, but laws are constantly evolving. Please contact me to be sure that the law which will govern your business is current. Thank you.

 

Understanding the Intervention Project for Nurses Monitoring Contract

If you are a nurse (i.e. LPN, RN, APRN, etc) and have decided to participate in the Intervention Project for Nurses (“IPN”) you will first have to undergo an evaluation, which will include an interview with an IPN approved doctor and a toxicology test. After this evaluation has been completed, IPN may suggest no monitoring or require that you enter into a monitoring contract.

Typically, you have roughly two weeks to sign the monitoring contract. Prior to signing the contract, you should thoroughly review the IPN Participant Manual so that you understand the requirements for participation. The last thing you want is to comply with the monitoring contract only to have your contract extended or have your case referred to the Board of Nursing because you failed to adhere to the Participant Manual’s requirements.

You will also receive a contract packet, which will include: (1) Progress Evaluation for Therapy Form; (2) Work Performance Evaluation Form; (3) Notice of Address/Employer Change; (4) IPN Medication Management Evaluation Form and (5) Medication Report. Depending on your situation you many not be required to complete all of these forms.

Requirements

Contract lengths typically vary from 2 – 5 years and you are required to keep your contact information updated throughout the term of the contract. IPN will review your participation after one year of active monitoring. If you comply with the terms of the contract they will grant you early completion and suspend your contract. For example, if you are have a 2 year contract term and you pass all of your toxicology testing and other requirements under the contract IPN may suspend the second year of your contract so that you can return to practice without any further obligations under the contract.

During the contract period you will be required to undergo random toxicology testing. This is an abstinence contract which means that you are prohibited from using mood altering, controlled or addictive substances including alcohol or alcohol-based products or THC/cannabis products (i.e. CBD, Hemp, etc.). This is true even if you are not participating in the IPN program for any of these specific products.

Periodically, you will need to check in with the Affinity eHealth/Spectrum Compliance App for your toxicology testing notification Monday through Friday. Again, to ensure the accuracy of your testing, you must adhere to the recommendations in the Random Toxicology Testing section of your Participation Manual.

You are required to complete and submit a quarterly self-report online via the Spectrum Compliance App. Quarterly reports are due in January, April, July and October. The App will have a complete list of reports due each quarter some of which can be downloaded from the available reports page by clicking on the PDF link.

Employment Expectations

Prior to accepting a position (paid or volunteer) and/or beginning nursing school clinicals, you are required to inform your immediate supervisor you are an IPN participant. Your position must include direct supervision by another licensed healthcare professional who is: (1) aware of your IPN participation; (2) working on the premises or same unit with periodic observation; (3) readily available to provide assistance and intervention; (4) willing to complete required employer report each quarter.

RNs must be supervised by another RN or APRN and LPNs must be supervised by RNs. LPNs may only be supervised by LPNs in nursing home facilities. You must immediately notify and/or obtain approval from IPN prior to starting or making any changes in any health care related position (i.e. resignation/termination, new employment, supervisor change, etc.) You are also required to work in nursing a minimum of twelve (12), eight (8) hour shifts per quarter while employed, to meet completion criteria.

Unless you have special approval from IPN you may not: (1) be self-employed or work for multiple employers; (2) work for more than 40 hours per week and/or more than 84 hours bi-weekly, if not working 12-hour shifts; (3) work for an agency, home hospice, home health, or float outside the areas supervised by your manager.

Current Status

Your Contract will also state your employment status. Depending on the severity of your condition you may be approved for employment in a supervised nursing position. You are required to provide your immediate supervisor with a copy of the Monitoring Contract and provide your supervisor’s email address to IPN for completion of your quarterly reports. You also need to provide IPN with the contact information for your current place of employment as well as the name of your immediate supervisor. If you fail to relay this information to IPN you may face immediate termination from the IPN program.

Review for Early Completing

As stated above, you may have your contract reviewed for early completion. However, it is contingent upon: (1) compliance with all terms of the Monitoring Contract; (2) negative toxicology tests; (3) minimum of six (6) consecutive months of negative toxicology tests preceding the contract completion date; (4) satisfactory work performance in a clinical nursing position for a minimum of one year; (5) if applicable, recommendation for completion form your Support Group Facilitator, employment supervisor, and treatment provider; and (6) if applicable, work successfully for six (6) months in a clinical nursing capacity subsequent to controlled substance restriction being lifted. For Board of Nursing participants, a readiness-to-complete evaluation is mandatory.

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It should be noted that I am not your lawyer (unless you have presently retained my services through a retainer agreement). This post is not intended as legal advice, it is purely educational and informational, and no attorney-client relationship shall result after reading it. Please consult your own attorney for legal advice. If you do not have one and would like to retain my legal services, please contact me using the contact information listed above.

 

All information and references made to laws, rules, regulations, and advisory opinions were accurate based on the law as it existed at this time, but laws are constantly evolving. Please contact me to be sure that the law which will govern your business is current. Thank you.

Registration form for Autonomous Advanced Practice Registered Nurse is Now Available

Registration form for Autonomous Advanced Practice Registered Nurse is Now Available

Great news for Florida licensed Advanced Practice Nurse Practitioners. The registration application for Autonomous practice is now available. There is no fee associated with submitting the registration application.

Eligibility for registration as an autonomous APRN includes the following:

1. At least 3,000 clinical practice hours under the supervision of an allopathic or osteopathic physician within the past 5 year. These hours may include clinical instructional hours. [See Section 464.0123(1)(c) F.S. for complete requirements];

2. Three graduate-level semester hours, or the equivalent, in differential diagnosis and 3 graduate-level semester hours, or the equivalent, in pharmacology completed within the past 5 years (documentation required); and 

3. Not been subject to disciplinary action as specified in Section 456.072 F.S. or Section 464.018 F.S., or any similar disciplinary action in any state or jurisdiction within the past 5 years.

The Board is also working towards adopting a definition of “primary care practice”. It was the subject of a rules workshop on October 9, 2020.

 

Frequently Asked Questions are at this link – https://floridasnursing.gov/nursing-faqs/advanced-practice-registered-nurse-aprn/

 
 

Appointments Made to Autonomous APRN Council

Registration form for Autonomous Advanced Practice Registered Nurse is Now Available

The Boards of Medicine, Nursing, and Osteopathic Medicine have made appointments to the Council on Advanced Practice Registered Nurse (APRN) Autonomous Practice. Legislation creating the Council went into effect on July 1, 2020. The Council will recommend standards of practice for APRNs who register with the Board of Nursing for autonomous practice.

Appointees

Board of Medicine

Shailesh Gupta, MD (3 year term)

Hector Vila, MD (4 year term)

 

Board of Nursing

Charrita Ernewein, DNP, APRN, FNP (2 year term)

Vicky Stone-Gale, DNP, APRN, FNP (4 year term)

Sandra Williamson, APRN, CNM (3 year term)

Kathleen Wilson, PhD, APRN, FNP (2 year term)

 

Board of Osteopathic Medicine

Michelle Mendez, DO (4 year term)

Joel Rose, DO (2 year term)

Cassandra G. Pasley, BSN, JD, Director of the Division of Medical Quality Assurance, will serve as Chair of the Council as the State Surgeon General’s designee.

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The Board of Nursing voted to initiate rulemaking on various aspects of HB 607 during its meetings on June 5, 2020.

The registration application for autonomous APRNs will be available after it has been adopted by rule, which is anticipated to take approximately 90 days.  The Board voted to approve the application and move forward with rulemaking at its June 5th meeting.  The Board also voted to define “primary care practice” to include “health promotion, disease prevention, health maintenance, counseling, patient education, and diagnosis and treatment of acute and chronic illnesses in a variety of healthcare settings”.  This definition will also move through the rulemaking adoption process prior to becoming effective.

The Board determined that an equivalency to the required graduate level coursework required for registration would be 45 CE hours in each of the required subject areas.  These hours must be offered by a Board-approved provider or a national organization empowered to accredit nursing CE.  The courses must have been taken within the 5 years preceding the registration application.  Submitted courses must have documentation of differential diagnosis and pharmacology in the course description and objectives.

How Does a Nurse Practitioner Establish an Independent Practice in Florida?

Effective July 1, 2020, Advanced Practice Registered Nurses (“APRN”) will be able to register their own autonomous practice throughout Florida with the passage of House Bill 607. No longer will the APRN have to provide patient care within the framework of an established protocol with a supervising physician if they are properly registered. If the APRN is not registered then an established protocol will still be required. The term Health Care Provider has been re-defined to mean a physician, osteopathic physician, podiatric physician or an APRN registered under Florida Statute §464.0123.

 

Registering your Autonomous Practice

Autonomous Practice is defined as an advanced nursing practice by an advanced practice registered nurse who is registered under Florida Statute §464.0123 and who is not subject to supervision by a physician or a supervisory protocol. In order to be registered by the Board of Nursing as an autonomous practice the APRN has to demonstrate the following:

  1. Hold an active and unencumbered license to practice advanced nursing.
  2. Not be subject to any disciplinary action in Florida or any other state or territory within the 5 years immediately preceding the registration filing.
  3. Completed in any state, territory or jurisdiction of the United States, at least 3,000 clinical practice hours within the 5 years immediately preceding the registration request while practicing as an APRN under the supervision of an M.D. or D.O.
  4. Completed within the past 5 years 3 graduate-level semester hours, or the equivalent, in differential diagnosis and 3 graduate-level semester hours or the equivalent, in pharmacology.
  5. And any other additional registration requirements issued by the Board of Nursing.

 

After obtaining your registration certificate, an APRN must biennially renew the registration, which must coincide with the APRNs biennial renewal period for licensure. To renew the registration, an APRN must complete at least 10 hours of continuing education, in addition to completing 30 hours of usual continuing education requirements.

 

Financial Responsibility

An APRN registered to maintain an autonomous practice must demonstrate that they are financially responsible to pay claims and costs that may arise out of their rendering of care, treatment or services. An APRN can demonstrate this in one of two ways:

  1. Obtain and maintain professional liability coverage in an amount not less than $100,000 per claim, with a minimum annual aggregate of not less than $300,000.
  1. Obtain and maintain an unexpired, irrevocable letter of credit in an amount of not less than $100,000 per claim, with a minimum aggregate availability of credit of not less than $300,000, payable to the APRN.

 

These financial responsibility requirements do not apply to: (1) registered APRNs who practice exclusively for the Federal Government or the state; (2) APRNs who are inactive; (3) APRNs practicing only in teaching environments at an accredited school or teaching hospital; and (4) an APRN who is registered but is not engaged in autonomous practice.

 

Registered APRN Permitted Activities

A registered APRN may only establish an autonomous practice in primary care, including family medicine, general pediatrics, and general internal medicine. APRNs certified as nurse midwives may engage in the practice of midwifery in accordance with Florida Statute §464.012(4)(c). APRNs engaging in autonomous practice must provide information in writing to a new patient about his or her qualifications and the nature of the autonomous practice before or during the initial patient encounter.

A registered APRN may also (1) admit a patient to a health care facility; (2) manage the care that the patient receives at the facility: and (3) discharge the patient from the facility, unless prohibited by federal law. The ARPN may provide a signature, certification, stamp, etc., that is otherwise required by law to be provided by a physician so long as the APRN is not issuing a physician certification.

 

Adverse Incidents and Disciplinary Actions

Registered APRNs must report adverse incidents to the Department of Health in writing within 15 days after the occurrence of the adverse incident if the adverse incident occurred when the patient was in the direct care of the APRN. If not in the direct care of the APRN, the report must be postmarked within 15 days after the APRN discovered or reasonably should have discovered the occurrence of the adverse incident. An adverse incident occurs when a patient: (a) is transferred from the APRN practice location to a hospital; (b) suffers permanent physical injury; and/or (c) dies.

A registered APRN may be subject to disciplinary action if he or she:

  1. Pays or receives a kickback or any type of split-fee arrangement for referring patients to providers for healthcare goods or services.
  2. Uses their influence to engage a patient in sexual activity.
  3. Makes deceptive, untrue or fraudulent representations.
  4. Solicits patients by use of fraud, intimidation or undue influence.
  5. Fails to maintain legible medical records
  6. Uses their influence to exploit the patient for financial gain.
  7. Performs unauthorized professional services.
  8. Performs experimental therapies or procedures without first obtaining fill informed consent.
  9. Delegates professional responsibilities to a person that is not qualified by training to perform those activities.
  10. Acts in a manner that coerces or intimidates another APRN from advertising his or her services.
  11. Advertises that they have a certification that he or she has not received.
  12. Fails to inform patients about their rights and how to file a complaint.
  13. Provides deceptive or fraudulent expert witness testimony.

 

Conclusion

There are many other requirements that an APRN has to comply with in order to legally establish and operate their autonomous practice in Florida. As more APRNs register I’m confident that additional laws and/or rules will be created to further regulate the practice area. It is important to hire a health law attorney who has the requisite experience, knowledge and training required to help you navigate the laws.

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It should be noted that I am not your lawyer (unless you have presently retained my services through a retainer agreement). This post is not intended as legal advice, it is purely educational and informational, and no attorney-client relationship shall result after reading it. Please consult your own attorney for legal advice. If you do not have one and would like to retain my legal services, please contact me using the contact information listed above.

 

All information and references made to laws, rules, regulations, and advisory opinions were accurate based on the law as it existed at this time, but laws are constantly evolving. Please contact me to be sure that the law which will govern your business is current. Thank you.

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