An Overview of The Kentucky Board of Nursing

An Overview of The Kentucky Board of Nursing and APRN Statutes and Regulations Pamela C. Hagan, MSN, RN APRN Education & Nursing Practice Consultant Kentucky Board of Nursing October 12, 2017

Mission Statement The Kentucky Board of Nursing protects the well-being of the public by development and enforcement of state law governing the safe practice of nursing, nursing education and credentialing.

Role of the Professional Organization Vs. Regulatory Agency Society PROFESSIONAL Defines nature and scope of nursing practice REGULATORY Statutory definition of nursing practice Standards of Practice Laws and Regulations Quality Assurance Licensure Public Protection

Standards of Care KRS 314. 011(6)(e) …which are consistent either with American Nurses’ Association Standards of Practice or with Standards of Practice established by nationally accepted organizations of registered nurses.

Who is “The Board”? State government agency 16 members appointed by the Governor Members serve four (4) year terms, may be reappt. ’d Ten (10) Registered Nurse Members One (1) APRN Member Three (3) Licensed Practical Nurse members Two (2) Citizens-at-Large KRS 314. 121

Nominating Organizations � Kentucky Nurses Association � Kentucky License Practical Nurses Organization � Kentucky Organization of Nurse Leaders � Kentucky Association of Health Care Facilities � Kentucky Association of Homes and Services for the Aging, Inc. , (Leading. Age) � KRS 314. 121 (3)

OPEN MEETINGS All meetings of the Board and its committees and advisory councils are open to the public.

KBN Committees � Education Committee � Practice Committee � APRN Council � Controlled Substances Formulary Development Committee � Collaborative Prescribing Agreement Joint Advisory Committee (CAPA-COM) � Consumer Protection Committee � Governance Committee � Dialysis Tech Council

Kentucky Board of Nursing Activities � Promulgate Kentucky Nursing Law through the creation of regulations � Issue Advisory Opinions about safe practice � Approve Prelicensure PN, RN, APRN/MSN, APRN/DNP Programs of Nursing � Issue RN, LPN and APRN licenses � Issue DT and SANE Credentials

Kentucky Board of Nursing Activities (Cont’d) � Approve � Renew Continuing Education Providers licenses � Administer special programs as directed by � Investigate Complaints/take Disciplinary legislature Action � Administer the Nursing Incentive Scholarship Fund (NISF) � Maintain the SRNA registry

Advisory Opinion Statements � Issued by the Board � Provide � Reflect � Do guidelines for safe patient care statutes & administrative regulations not have force and effect of law � Evidence-based practice

Nurse Licensure Compact (NLC) � KY in current NLC since 2007 � Proven � Cost to be safe and efficient effective � Responsive to modern healthcare delivery model, e. g. mobility, telehealth

ENLC Passed 2017 � Signed by KY Governor, March 21, 2017 � Currently 26 states have passed (AZ, AR, DE, FL, GA, ID, IA, KY, ME, MD, MS, MO, MT, NE, NC, NH, ND, OK, SC, SD, TN, TX, UT, VA, WV and WY ) 6/15/17 � Implemented when 26 states (July 24, 2017) have enacted or Dec. 31, 2018 � Implementation transition period � More information to come

Questions?

APRN Consensus Model & APRN Practice in Kentucky

APRN Consensus Model Framework that allows for a consistent definition of advanced nursing practice for quality and safety across jurisdictions, employers, and settings…. . towards uniformity

Consensus Model for APRN Regulation � 1993 NCSBN Position Paper on APRN Licensure � 1995 NCSBN worked to ensure certification exams legally defensible and psychometrically sound for regulatory purposes � 1997 -2004 Simultaneous Groups working on topic � 2004 -2007 Joint Dialogue Group (national nursing groups and NCSBN) � 2006 NCSBN APRN Vision Paper � 2008 Consensus Document Published

Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education July 7, 2008 FINAL APRN Consensus Document

KBN Implementation of Consensus Model � 2009 NCSBN developed Model Legislative Language � 2010 KBN Adopted Model � 2011 KY Law – KRS Chapter 314 [KRS 314. 011 (8)]

Regulatory Components �Licensure �Accreditation �Certification �Education LACE

KBN Implementation of Consensus Model � 2009 NCSBN developed Model Legislative Language � 2010 KBN Adopted Model � 2011 KY Law – KRS Chapter 314 [KRS 314. 011 (8)]

Elements of APRN Regulation in Consensus Model � Title -- APRN � Roles -- CNP, CNS, CRNA, CNM � Licensure -- RN + APRN � Education -- Graduate Degree � Certification – Advanced Certification

APRN Roles � CNP – certified nurse practitioner � CRNA –certified registered nurse anesthetist � CNM – certified nurse midwife � CNS – clinical nurse specialist (certified)

Elements of APRN Regulation in Consensus Model � Independent Practice –without MD oversight or written collaborative agreement � Full Prescriptive Authority –without MD oversight or written collaborative agreement

APRN Educational Preparation � Clinical and didactic coursework must be comprehensive and sufficient to prepare the graduate to obtain certification for licensure and to practice in the APRN role and population focus.

Population Foci for APRN In addition to the role, each APRN is educated in one of 6 population foci. Foci are: � Family/individual across the lifespan � Adult-gerontology � Neonatal � Pediatrics � Women’s health/gender related � Psychiatric/Mental Health

Population Foci for APRN � Family/individual across the lifespan � Adult-Gerontology v. Acute v. Primary � Neonatal � Pediatrics v. Acute v. Primary � Women’s Health/gender related � Psychiatric/Mental Health

Specialty Education and Practice � Specialty focus is on practice beyond role and population focus & linked to healthcare needs � Preparation in a specialty area of practice is optional in the graduate program, but if included, must build on the APRN role/population-focus competencies. � Example: palliative care, oncology, diabetes, new AANP ENP

Core Educational Goals � Ensure 3 P’s – advanced Physical/health assessment, advanced Pathophysiology, advanced Pharmacology –separate, unique courses � Ensure APRN role and population focused competencies attained � Integrate adult and older adult � Psychiatric-mental health across the lifespan

Relationship Between Education, Competencies, Licensure and Certification Competencies Measures of Competencies Identified by Professional Organizations (e. g. oncology, palliative care, CV) Specialty Certification* Specialty CNP, CRNA, CNM, CNS in Population context Population Foci Role APRN Core Courses: Pathophysiology, Pharmacology, Physical/health assess. APRN Licensure: Based on Education and Certification**

APRN Regulatory Model APRN Specialties Focus of Practice beyond role and population focus Linked to health care needs Licensure at levels of role and population foci Examples include but are not limited to: Oncology, Diabetes, Orthopedics, Nephrology, Palliative care POPULATION FOCI Family/Individual Across Lifespan Neonatal Women’s Health/ Adult-++ Gender Gerontology* Related Pediatrics ++ Psych/Mental Health** APRN ROLES Nurse Anesthetist Nurse Midwife Clinical Nurse Specialist+ Nurse Practitioner ++ Primary care Acute care

Principle of Population Focus � � * Adult-gerontology, encompasses the young adult to the older adult, including the frail elderly. APRNs educated and certified in the adultgerontology population are educated and certified across both areas of practice and are titled Adult-Gerontology CNP or CNS. All APRNs in any of the four roles providing care to the adult population, e. g. , family or gender specific, must be prepared to meet the growing needs of the older adult population. Therefore, the education program should include didactic and clinical education experiences necessary to prepare APRNs with these enhanced skills and knowledge. **Psychiatric/mental health, encompasses education and practice across the lifespan. + Clinical Nurse Specialist (CNS) is educated and assessed through national certification processes across the continuum from wellness through acute care.

Acute vs. Primary � ++The certified nurse practitioner (CNP) is prepared with the acute care CNP competencies and/or the primary care CNP competencies. � As of 2008 Consensus Document, the acute care and primary care CNP delineation applies only to the pediatric and adult-gerontology CNP population foci. � Programs may prepare individuals across both the primary care and acute care CNP competencies, but will need to write two exams.

Acute vs. Primary � If programs prepare graduates across both primary and acute care roles, the graduate must be prepared with the consensus-based competencies for both roles and must successfully obtain certification in both the acute and the primary care CNP roles. � CNP certification in the acute care or primary care roles must match the educational preparation for CNPs in these roles. � Scope of practice of the primary care or acute care CNP is not setting specific but is based on patient care needs.

KY APRN Scope of Practice � Performance of additional acts by registered nurses who have gained advanced clinical knowledge and skills through an accredited education program that prepares the registered nurse for one (1) of the four (4) APRN roles [designations] � Limited to certified population foci, and as described in applicable national scope and standards of practice… KRS 314. 011(8)

Kentucky’s Scorecard on Meeting Elements of Consensus

LACE Network Lace Network Site

Kentucky Nurse Practice Act Kentucky Nursing Laws

Kentucky Revised Statutes Kentucky Nursing Laws Chapter 314 Kentucky Administrative Regulations Nursing Regulations 201 KAR Chapter 20

Kentucky Nursing Laws & Regulations for APRN Nursing Education

KRS 314. 011(8) "Advanced practice registered nursing" means Ø the performance of additional acts by registered nurses Ø who have gained advanced clinical knowledge and skills through an accredited education program that prepares the registered nurse for one (1) of the four (4) APRN roles. Ø who are certified by the American Nurses' Association or other nationally established organizations or agencies recognized by the board to certify registered nurses for advanced practice registered nursing as a certified nurse practitioner, certified nurse anesthetist, certified nurse midwife, or clinical nurse specialist; and Ø who certified in at least one (1) population focus.

KRS 314. 111 Nursing school approval -- Standards -Administrative hearing. (1) An institution desiring to conduct a school of nursing shall apply to the board and submit evidence that it is prepared to carry out the minimum approved basic curriculum in nursing and that it is prepared to fulfill other requirements of standards which are established by KRS 314. 011 to 314. 161 and KRS 314. 991 and the administrative regulations promulgated by the board. No person shall operate a nursing education program or school of nursing without complying with the provisions of this section. …. (3) The board shall, by administrative regulations promulgated pursuant to KRS Chapter 13 A, set standards for the establishment and outcomes of nursing education programs that prepare advanced practice registered nurses, including clinical learning experiences, and shall approve such programs that meet the standards.

Authority of the Board to Approve Programs of Nursing KRS 314. 131 Board meetings -- Officers -- Quorum -- Duties -Executive director -- Compensation of members -- Liability insurance -- Expunging of disciplinary action records. …(2) The board shall approve programs of nursing and shall monitor compliance with standards for nurse competency under this chapter. It shall examine, license, and renew the license of duly-qualified applicants; … issue advisory opinions or declaratory rulings dealing with the practice of nursing; register and designate those persons qualified to engage in advanced nursing practice; and it shall conduct administrative hearings in accordance with KRS Chapter 13 B upon charges calling for discipline of a licensee and cause the prosecution of all persons violating any provisions of this chapter. It shall keep a record of all its proceedings and make an annual report to the Governor. �

201 KAR 20: 260 Organization and administration standards for prelicensure programs of nursing. …Section 2. Organization or Administration Standards for Prelicensure Registered Nurse and Practical Nurse Programs. To be eligible for approval by the board, a program shall have: (1) A governing institution. (a) The governing institution that establishes and conducts the program of nursing shall hold accreditation as a postsecondary institution, college, or university by an accrediting body recognized by the U. S. Department of Education. (b) The governing institution shall assume full legal responsibility for the overall conduct of the program of nursing. The program of nursing shall have comparable status with the other programs in the governing institution and the relationship shall be clearly delineated….

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. � Section 1. Definitions (1) APRN program of nursing … (2) APRN program coordinator … (3) Designated chief nursing academic officer … (4) National nursing accrediting body …

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. … Section 2. Establishing a New APRN Program of Nursing (1). . . may receive consultation from the Board (2). . . shall be accredited per 201 KAR 20: 260 (3). . . submit letter of intent to establish…and fee (4) …begin accreditation process (5) …submit proposal no less than 12 months prior to first intended admission of students

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. � …Section 2. Establishing a New APRN Program of Nursing (cont’d) (6) Under the direction of chief nursing academic officer or APRN coordinator (7)(a) Shall include information: 1. Mission 2. Ownership 3. Accreditation 4. Enrollment 5. Area served 6. Resources sufficient

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. 6. (b)… description and rationale for proposed APRN program… (c) approval from governing body (d) …needs assessment, including potential students and employment opportunities (e) …evidence of community support/interest

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. (f) …physical/virtual resources for faculty and students (g) …evidence of sound financial base, fiscal stability

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. (8) If the information in the form of a letter of intent is approved by the board, the governing institution shall be notified in writing that it may move to the proposal phase. The proposal shall be submitted within one (1) year of the date of the approval of the information or it shall expire

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. (9)(a)…completed program proposal shall be submitted at least one year prior to the anticipated opening date (b) …Program proposal shall include: 1. … organizational chart and written plan describing the organization of the program of nursing and its relationship to the governing institution. 2. …current or desired national nursing accrediting body… 3. …copy of CV of APRN Program Coordinator

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. 4. …timeline for admission of students, projected graduation of first class, and projected plans for expansion 5. …philosophy of program and program outcomes 6. …curriculum design for each track to include: a. proposed course sequence b. description of courses c. credit hours delineating theory and practice d. total number of clinical hours designated each track population foci

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. 7. … 5 year plan for securing clinical sites and preceptors sufficient to accommodate students 8. … 5 year plan for recruiting and retaining qualified nurse faculty 9. …recruitment plan and 5 year projection for student enrollment, policies and procedures for student selection and progression

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. (10) Program shall not be announced or advertised, nor students admitted until proposal has been approved and developmental status has been granted by the Board (11) Developmental status shall be granted, if met requirements of : 062 for no more than 2 years pending review and accreditation by national nursing accrediting body.

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. (12) When developmental status granted, program may proceed with implementation including admission of students. Chief nursing academic office notify board of admission and graduation of first class (13) Developmental status expires if class not admitted within 2 years of receiving developmental status (14) All formal communication between APRN program and accrediting body shall be forwarded to board within 30 days of receipt. (15) APRN program coordinator shall notify board within 30 days of change in status in accreditation (16) …notify board of pending site visits and provide copies of documentation submitted within 30 days

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. …provide copy of accreditation report within 30 days of receipt from accrediting body. (17) Full approval by board based on: (a) achievement and continued approval by accrediting body (b) report of site visit by Board representative evaluating compliance with administrative regulations (18) … approval may be granted, not to exceed approval period of accrediting body

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. � Section 3 Compliance with National Nursing Accrediting Body Standards. APRN program shall comply with standards of national nursing accrediting body and provide board with copies of communication necessary to maintain compliance.

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. � Section 4 Preceptor Standards In addition to the standards of the national nursing accrediting body the APRN program shall comply with preceptor standards established in this section

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. (1) The APRN program shall secure all necessary preceptors to students enrolled in the program. A student shall not be required to obtain their own preceptor, but may have input into the process.

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. (2) During the student’s enrollment in the program, the student shall have some clinical experience with a preceptor who is an APRN with the same role and population focus for which the student is preparing. (3) The preceptor who is an APRN shall have at least 1 year of clinical experience in the role and population focus for which the student is preparing.

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. (4)(a) A physician or a physician assistant (PA) may serve as a preceptor. (b) The physician or PA who serves as a preceptor shall have at least 1 year of clinical experience and shall practice in the same or similar population focus for which the student is preparing.

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. (5) a preceptor shall not precept more than 2 students at a time (6) The APRN program shall have a written plan for orienting and evaluating a preceptor. (7) This section shall become effective on January 1, 2016.

NTF Evaluation of NP Programs

Criterion : Organization & Administration � Organization and Administration IA. Director/coordinator of NP program is nationally certified as an NP and has the overall leadership for the NP program IB. The faculty member who provides direct oversight for the NP educational component or track is nationally certified in the same population-focused area of practice.

Criteria II: Students � Admission criteria � Progression and completion criteria � Reflect NP faculty input

Criterion III: Curriculum � A. Development, evaluation, and revision of NP curriculum, Reflect NP faculty input � B. Congruent with national standards for graduate level APRN education & � Consistent with nationally recognized core role and population-focused standards and competencies � C 1. Graduates eligible to sit for national certification corresponding with role/population

Criterion III: Curriculum � C 2. Official documentation (transcript, etc. ) reflects role/population foci � D. Curriculum reflects course sequencing � E. Minimum of 500 supervised, clinical hours overall to support competency representing population needs � F. Post-graduate students complete didactic and clinical requirements, master same outcome criteria, complete minimum of 500 clinical hours

Criteria IV: Resources, Facilities, and Services A. Institutional resources/facilities/services support development, management, and evaluation of program � B: Clinical resources support NP educational experiences � B 1: Sufficient faculty � B 2: Clinical settings diverse and sufficient � B 3: NP faculty share clinical teaching with qualified preceptors, � B 3 a: licensed in population foci/specialty, � B 3 b: at least one year experience � B 3 c: Preceptors oriented to program/track requirements and expectations for oversight and evaluation �

Criterion V: Faculty � A 1: Programs/tracks have sufficient faculty with preparation and current expertise � A 2: NP faculty teaching clinical components maintain current licensure and certification � A 3: NP faculty demonstrate competence � B: Non NP faculty have expertise in area teaching

Criterion VI: Evaluation � A: There is an evaluation plan for program/track � A: Courses are evaluated at regularly scheduled intervals � A 2: NP faculty competence evaluated at regularly scheduled intervals � A 3: Student progress evaluated through didactic/clinical components of program/track each semester/quarter/term

Criterion VI: Evaluation � A. 4: Student attainment of competencies evaluated throughout the program � A. 5: Students are evaluated cumulatively based on clinical observation of student competence and performance by NP faculty and/or preceptor � A. 6: Clinical sites are evaluated at regularly scheduled intervals � A. 7: Preceptors are evaluated at regularly scheduled intervals

Criterion VI: Evaluation � B: Formal evaluation of curriculum occurs every 5 years or sooner � C: There is an evaluation plan to measure outcomes of graduate.

NONPF National Task Force - Criteria for Evaluation of NP Programs � Commission on Collegiate Nursing Education (CCNE) has adopted the evaluation criteria into their accreditation standards � The National League For Nursing (ACEN) has endorsed the evaluation criteria and recognizes this document as the national standard for nurse practitioner educational programs. � Commission on Nursing Education Accreditation (CNEA) -nursing faculty may elect to integrate into their program curricula.

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. Section 8. Ongoing approval. (1)(a) The nursing academic officer shall notify the board within 30 days of any change in the APRN program coordinator (b) Approved APRN programs of nursing accredited by national nursing accrediting body may be subject to a site visit at intervals associated with their national nursing accreditation. (2) Board requires continuous accreditation

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. (3) The board may perform a site visit of a program on an announced or unannounced basis.

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. (4) Factors that may indicate the need for a site visit and that jeopardize program approval status shall include: (a) Reported deficiencies in compliance with this regulation. (b) Noncompliance with the governing institution or PON’s philosophy, mission, program design, objectives, outcomes, policies (c) Ongoing failure to submit records or reports to the board within the designated timeframe.

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. (d) Failure to provide sufficient clinical learning opportunities including securing preceptors for students to achieve stated outcomes. (e) Failure to comply with requirements of the board or to respond to recommendations of the board within the specified time. (f) Failure to submit communication from the accrediting agencies within the time frames identified (g) Withdrawal of accreditation of either the PON, college or university by a national or regional accrediting body, or if accredited for less than the maximum accreditation period.

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. (h) Failure to obtain approval of a change that requires board approval prior to implementation (i) Providing false or misleading information to students or the public concerning the PON (j) A change in ownership or organizational restructuring of the governing institution

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. (5) If the APRN program achieves reaccreditation, it shall submit documentation from the national nursing accreditation body to the Board for action. If the Board finds that all requirements have been met, the program shall continue to be eligible for approval.

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. (6) Action following a site visit: (a) …evaluate in terms of compliance (b) …draft site visit report shall be made available to the chief academic nursing officer and the APRN program coordinator for review and correction of fact (c) APRN program coordinator or designee shall be available during discussion of the report at the board committee (d) Following board’s review and decision, letter sent to the chief nursing academic officer and the APRN program coordinator and head of governing institution regarding any requirements to be met and timelines.

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. Section 6. Withdrawal of Approval of an APRN Program. (1) Approval of an APRN program may be withdrawn if: (a) It loses its national nursing accreditation. (b) It is unable to or does not meet the requirements of this regulation. (2) The board shall send notice to the chief nursing academic officer , the APRN program coordinator, and the head of the governing institution of its intent to withdraw approval.

201 KAR 20: 062 Standards for advanced practice registered nurse (APRN) programs of nursing. (3) Within 30 days of receipt of this notice the chief nursing academic officer may request an administrative hearing pursuant to KRS Chapter 13 B. If an administrative hearing is not requested, approval shall be withdrawn and the program shall be closed. A closed programs shall comply with 201 KAR 20: 360, Section 4 (5). (4) (a) If a program requests an administrative hearing, that hearing shall be held within 60 days of the request. (b) The hearing shall be held before a hearing officer or before the full board, at the discretion of the board.

KRS 314. 101 Excepted activities and practices -- Work permits -Withdrawal of temporary work permits. � (1) This chapter does not prohibit the following: … � …(b) The practice of nursing which is incidental to the program of study by individuals enrolled in nursing education programs and refresher courses approved by the board or in graduate programs in nursing;

Approval of Doctor of Nursing Practice (DNP) degree programs. � KBN no longer approves post-masters’ APRN or DNP only programs of nursing. � KBN approves programs of nursing that prepare for licensure as an APRN

KRS 164. 298 Advanced practice doctoral program in nursing -Degree – Portrayal of credentials � (1) The governing board as defined in KRS 164. 001 of each eligible postsecondary education institution and college as defined in KRS 164. 945 shall collaborate with the Kentucky Board of Nursing to ensure that each university offering an advanced practice doctoral degree in nursing complies with the accreditation standards of the National League for Nursing Accrediting Commission or the Commission on Collegiate Nursing Education and with minimal education and licensure standards for admission to and graduation from an advanced practice doctoral program in nursing.

KRS 164. 298 Advanced practice doctoral program in nursing -Degree – Portrayal of credentials (2) Each university offering an advanced nursing practice doctoral program shall refer to the degree as the "doctor of nursing practice, " with the degree being abbreviated as "DNP. " Any advertisement about the advanced nursing practice doctoral program shall not refer to graduates using the term "doctor. “ Graduates of the program shall accurately portray their academic credentials as well as their registered nurse and advanced practice registered nurse credentials, if applicable, subject to sanction under KRS 311. 375(4).

LICENSURE AS APRN � Presentation by: Ruby King/Curt Lowther Credentials Branch

PREPARING YOUR STUDENTS FOR APRN PRACTICE “AFTER GRADUATION”

Official Credentials Examples � APRN - Legal Credential � MSN, APRN � DNP, APRN � MSN, APRN, WHNP � APRN, CRNA � MSN, APRN, PMHCNS � APRN, CNM

314. 042 License to practice as an advanced practice registered nurse -Application -- Renewal -- Reinstatement -- Use of "APRN" -- Prescriptive authority under CAPA-NS and CAPA-CS -- Exemption from CAPA-NS requirement. (8) (a) Except as authorized by KRS 314. 196 and subsection (9) of this section, before an advanced practice registered nurse engages in the prescribing or dispensing of nonscheduled legend drugs as authorized by KRS 314. 011(8), the advanced practice registered nurse shall enter into a written "Collaborative Agreement for the Advanced Practice Registered Nurse's Prescriptive Authority for Nonscheduled Legend Drugs" (CAPA-NS) with a physician licensed in Kentucky that defines the scope of the prescriptive authority for nonscheduled legend drugs. (b) The advanced practice registered nurse shall notify the Kentucky Board of Nursing of the existence of the CAPA-NS and the name of the collaborating physician and shall, upon request, furnish to the board or its staff a copy of the completed CAPA-NS. The Kentucky Board of Nursing shall notify the Kentucky Board of Medical Licensure that a CAPA-NS exists and furnish the collaborating physician's name.

Common CAPA-NS Form � Adopted by both KBN and KBML 6/2015 Common CAPA- NS Form

KBN Notification of CAPA-NS Notification of a Collaborative Agreement for the Advanced Practice Registered Nurse’s Prescriptive Authority for Nonscheduled Legend Drugs (CAPA– NS) � APRN � Date signature

314. 042 License to practice as an advanced practice registered nurse -Application -- Renewal -- Reinstatement -- Use of "APRN" – Prescriptive authority under CAPA-NS and CAPA-CS -- Exemption from CAPA-NS requirement. (8)… (c) The CAPA-NS shall be in writing and signed by both the advanced practice registered nurse and the collaborating physician. A copy of the completed collaborative agreement shall be available at each site where the advanced practice registered nurse is providing patient care. (d) The CAPA-NS shall describe the arrangement for collaboration and communication between the advanced practice registered nurse and the collaborating physician regarding the prescribing of nonscheduled legend drugs by the advanced practice registered nurse. (e) The advanced practice registered nurse who is prescribing nonscheduled legend drugs and the collaborating physician shall be qualified in the same or a similar specialty.

Defining Same or Similar “Specialty” for Prescribing Purposes � KBN ◦ ◦ ◦ Guideline: APRN’s population foci certification MD determines MD’s population Population foci must overlap minimally Guided by facts of each particular situation (: 057) Scope of the APRN’s and the physician’s actual practice (201 KAR 20: 057)

314. 042 License to practice as an advanced practice registered nurse -Application -- Renewal -- Reinstatement -- Use of "APRN" – Prescriptive authority under CAPA-NS and CAPA-CS -- Exemption from CAPA-NS requirement. (f) The CAPA-NS is not intended to be a substitute for the exercise of professional judgment by the advanced practice registered nurse or by the collaborating physician.

Responsibility and Accountability � KY Nursing Law, holds each nurse [APRN] individually responsible and accountable for making decisions based on educational preparation and experience, and require each nurse [APRN] to practice with reasonable skill and safety. KRS 314. 021(2) � KBN Legal Opinion “The APRN as an Independent Practitioner

314. 042 License to practice as an advanced practice registered nurse -Application -- Renewal -- Reinstatement -- Use of "APRN" – Prescriptive authority under CAPA-NS and CAPA-CS -- Exemption from CAPA-NS requirement. (g) The CAPA-NS shall be reviewed and signed by both the advanced practice registered nurse and the collaborating physician and may be rescinded by either party upon written notice via registered mail to the other party, the Kentucky Board of Nursing, and the Kentucky Board of Medical Licensure.

314. 042 License to practice as an advanced practice registered nurse -Application -- Renewal -- Reinstatement -- Use of "APRN" -- Prescriptive authority under CAPA-NS and CAPA-CS -- Exemption from CAPA-NS requirement. (9) (a) Before an advanced practice registered nurse may discontinue or be exempt from a CAPA-NS required under subsection (8) of this section, the advanced practice registered nurse shall have completed four (4) years of prescribing* as a nurse practitioner, clinical nurse specialist, nurse midwife, or as a nurse anesthetist. For nurse practitioners and clinical nurse specialists, the four (4) years of prescribing shall be in a population focus of adult-gerontology, pediatrics, neonatology, family, women's health, acute care, or psychiatric-mental health. *[4 years from date of licensure]

314. 042 License to practice as an advanced practice registered nurse -Application -- Renewal -- Reinstatement -- Use of "APRN" -- Prescriptive authority under CAPA-NS and CAPA-CS -- Exemption from CAPA-NS requirement. (c) An advanced practice registered nurse wishing to practice in Kentucky through licensure by endorsement is exempt from the CAPA-NS requirement if the advanced practice registered nurse: 1. Has met the prescribing requirements in a state that grants independent prescribing to advanced practice registered nurses; and 2. Has been prescribing for at least four (4) years. (d) An advanced practice registered nurse wishing to practice in Kentucky through licensure by endorsement who had a collaborative prescribing agreement with a physician in another state for at least four (4) years is exempt from the CAPA-NS requirement.

314. 042 License to practice as an advanced practice registered nurse -Application -- Renewal -- Reinstatement -- Use of "APRN" -- Prescriptive authority under CAPA-NS and CAPA-CS -- Exemption from CAPA-NS requirement. (e) After July 15, 2014: 1. An advanced practice registered nurse whose license is in good standing at that time with the Kentucky Board of Nursing and who will be prescribing nonscheduled legend drugs without a CAPA-NS shall notify that board that the four (4) year requirement has been met and that he or she will be prescribing nonscheduled legend drugs without a CAPA-NS;

Notify KBN of Discontinuation of CAPA-NS Notification to Discontinue the CAPA-NS After Four Years � Signed � Date by APRN

314. 042 License to practice as an advanced practice registered nurse -Application -- Renewal -- Reinstatement -- Use of "APRN" – Prescriptive authority under CAPA-NS and CAPA-CS -- Exemption from CAPA-NS requirement. 2. An advanced practice registered nurse who has maintained a CAPA-NS for four (4) years or more will no longer be required to maintain a CAPA-NS and shall not be compelled to maintain a CAPA-NS as a condition to prescribe after the four (4) years have expired, but an advanced practice registered nurse may choose to maintain a CAPA-NS indefinitely after the four (4) years have expired; and

314. 042 License to practice as an advanced practice registered nurse -Application -- Renewal -- Reinstatement -- Use of "APRN" – Prescriptive authority under CAPA-NS and CAPA-CS -- Exemption from CAPA-NS requirement. 3. An advanced practice registered nurse who has maintained a CAPA-NS for less than four (4) years shall be required to continue to maintain a CAPA -NS until the four (4) year period is completed, after which the CAPA-NS will no longer be required.

314. 042 License to practice as an advanced practice registered nurse -Application -- Renewal -- Reinstatement -- Use of "APRN" -- Prescriptive authority under CAPA-NS and CAPA-CS -- Exemption from CAPA-NS requirement. (10) (a) Before an advanced practice registered nurse engages in the prescribing of Schedules II through V controlled substances as authorized by KRS 314. 011(8), the advanced practice registered nurse shall enter into a written "Collaborative Agreement for the Advanced Practice Registered Nurse's Prescriptive Authority for Controlled Substances" (CAPA-CS) with a physician licensed in Kentucky that defines the scope of the prescriptive authority for controlled substances.

314. 042 License to practice as an advanced practice registered nurse -Application -- Renewal -- Reinstatement -- Use of "APRN" -- Prescriptive authority under CAPA-NS and CAPA-CS -- Exemption from CAPA-NS requirement. (b) The advanced practice registered nurse shall notify the Kentucky Board of Nursing of the existence of the CAPA-CS and the name of the collaborating physician and shall, upon request, furnish to the board or its staff a copy of the completed CAPA-CS. The Kentucky Board of Nursing shall notify the Kentucky Board of Medical Licensure that a CAPA-CS exists and furnish the collaborating physician's name.

CAPA-CS Form � CAPA-CS Form from KCNPNM website

Notify KBN of CAPA-CS Notification of a Collaborative Agreement for the Advanced Practice Registered Nurse Prescriptive Authority for Controlled Substances (CAPA –CS)

314. 042 License to practice as an advanced practice registered nurse -Application -- Renewal -- Reinstatement -- Use of "APRN" – Prescriptive authority under CAPA-NS and CAPA-CS -- Exemption from CAPA-NS requirement. (c) The CAPA-CS shall be in writing and signed by both the advanced practice registered nurse and the collaborating physician. A copy of the completed collaborative agreement shall be available at each site where the advanced practice registered nurse is providing patient care. (d) The CAPA-CS shall describe the arrangement for collaboration and communication between the advanced practice registered nurse and the collaborating physician regarding the prescribing of controlled substances by the advanced practice registered nurse.

314. 042 License to practice as an advanced practice registered nurse -Application -- Renewal -- Reinstatement -- Use of "APRN" – Prescriptive authority under CAPA-NS and CAPA-CS -- Exemption from CAPA-NS requirement. (e) The advanced practice registered nurse who is prescribing controlled substances and the collaborating physician shall be qualified in the same or a similar specialty. (f) The CAPA-CS is not intended to be a substitute for the exercise of professional judgment by the advanced practice registered nurse or by the collaborating physician.

314. 042 License to practice as an advanced practice registered nurse -Application -- Renewal -- Reinstatement -- Use of "APRN" – Prescriptive authority under CAPA-NS and CAPA-CS -- Exemption from CAPA-NS requirement. (g) Before engaging in the prescribing of controlled substances, the advanced practice registered nurse shall: 1. Have been licensed to practice as an advanced practice registered nurse for one (1) year with the Kentucky Board of Nursing; or 2. Be nationally certified as an advanced practice registered nurse and be registered, certified, or licensed in good standing as an advanced practice registered nurse in another state for one (1) year prior to applying for licensure by endorsement in Kentucky. (h) Prior to prescribing controlled substances, the advanced practice registered nurse shall obtain a Controlled Substance Registration Certificate through the U. S. Drug Enforcement Agency.

314. 042 License to practice as an advanced practice registered nurse -Application -- Renewal -- Reinstatement -- Use of "APRN" – Prescriptive authority under CAPA-NS and CAPA-CS -- Exemption from CAPA-NS requirement. (i) The CAPA-CS shall be reviewed and signed by both the advanced practice registered nurse and the collaborating physician and may be rescinded by either party upon written notice via registered mail to the other party, the Kentucky Board of Nursing, and the Kentucky Board of Medical Licensure.

Notify KBN Rescinding CAPA-CS RESCISSION of a Collaborative Agreement for the Prescriptive Authority for Controlled Substances (CAPA –CS)

314. 042 License to practice as an advanced practice registered nurse -Application -- Renewal -- Reinstatement -- Use of "APRN" – Prescriptive authority under CAPA-NS and CAPA-CS -- Exemption from CAPA-NS requirement. (j) The CAPA-CS shall state the limits [if any]on controlled substances which may be prescribed by the advanced practice registered nurse, as agreed to by the advanced practice registered nurse and the collaborating physician. The limits so imposed may be more stringent than either the schedule limits on controlled substances established in KRS 314. 011(8) or the limits imposed in regulations promulgated by the Kentucky Board of Nursing thereunder.

314. 042 License to practice as an advanced practice registered nurse -Application -- Renewal -- Reinstatement -- Use of "APRN" – Prescriptive authority under CAPA-NS and CAPA-CS -- Exemption from CAPA-NS requirement. (11) Nothing in this chapter shall be construed as requiring an advanced practice registered nurse designated by the board as a certified registered nurse anesthetist to enter into a collaborative agreement with a physician, pursuant to this chapter or any other provision of law, in order to deliver anesthesia care.

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. Section 1. Definitions. (1) "Collaboration" means the relationship between the advanced practice registered nurse and a physician in the provision of prescription medication, including both autonomous and cooperative decision-making, with the advanced practice registered nurse and the physician contributing their respective expertise. (2) "Collaborative Agreement for the Advanced Practice Registered Nurse's Prescriptive Authority for Controlled Substances" or “CAPA-CS” means the written document pursuant to KRS 314. 042(9). (3) "Collaborative Agreement for the Advanced Practice Registered Nurse's Prescriptive Authority for Nonscheduled Legend Drugs" or “CAPA-NS” means the written document pursuant to KRS 314. 042(8).

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. Section 3. In the performance of advanced practice registered nursing, the advanced practice registered nurse shall seek consultation or referral in those situations outside the advanced practice registered nurse's scope of practice. Section 4. Advanced practice registered nursing shall include prescribing medications and ordering treatments, devices, and diagnostic tests which are consistent with the scope and standard of practice of the advanced practice registered nurse. Section 5. Advanced practice registered nursing shall not preclude the practice by the advanced practice registered nurse of registered nursing practice as defined in KRS 314. 011(5).

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. Section 6. (1) A CAPA-NS and a CAPA-CS shall include the name, address, phone number, and license number of both the advanced practice registered nurse and each physician who is a party to the agreement. It shall also include the specialty area of practice of the advanced practice registered nurse. (b) Pursuant to KRS 314. 196(2), an advanced practice registered nurse shall use the Common CAPA-NS Form. (2)(a) To notify the board of the existence of a CAPA-NS pursuant to KRS 314. 042(8)(b), the APRN shall file with the board the Notification of a Collaborative Agreement for the Advanced Practice Registered Nurse’s Prescriptive Authority for Nonscheduled Legend Drugs (CAPA-NS). (b) To notify the board that the requirements of KRS 314. 042(9) have been met and that the APRN will be prescribing nonscheduled legend drugs without a CAPA-NS, the APRN shall file the Notification to Discontinue the CAPA-NS After Four Years. (c) To notify the board of the existence of a CAPA-CS pursuant to KRS 314. 042(10)(a), the APRN shall file with the board the Notification of a Collaborative Agreement for the Advanced Practice Registered Nurse's Prescriptive Authority for Controlled Substances (CAPA-CS).

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. (3) For purposes of the CAPA-NS and the CAPA-CS, in determining whether the APRN and the collaborating physician are qualified in the same or a similar specialty, the board shall be guided by the facts of each particular situation and the scope of the APRN's and the physician's actual practice. (4)(a) An APRN with a CAPA-CS shall report all of his or her United States Drug Enforcement Agency (DEA) Controlled Substance Registration Certificate numbers to the board when issued to the APRN by mailing a copy of each registration certificate to the board within thirty (30) days of issuance. (b) Any change in the status of a DEA Controlled Substance Registration Certificate number shall be reported in writing to the board within thirty (30) days.

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. Section 7. Prescribing medications without a CAPA-NS or a CAPA-CS shall constitute a violation of KRS 314. 091(1), except when a CAPA-NS has been discontinued pursuant to KRS 314. 042(9) or the provisions of KRS 314. 196(4)(b) apply. Section 8. The board may make an unannounced monitoring visit to an advanced practice registered nurse to determine if the advanced practice registered nurse's practice is consistent with the requirements established by 201 KAR Chapter 20, and patient and prescribing records shall be made available for immediate inspection.

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. Section 9. Prescribing Standards for Controlled Substances. (1)(a) This section shall apply to an APRN if prescribing a controlled substance. It also applies to the utilization of KASPER. (b) The APRN shall practice according to the applicable scope and standards of practice for the APRN’s role and population focus. This section does not alter the prescribing limits set out in KRS 314. 011(8).

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. (2) Prior to the initial prescribing of a controlled substance to a patient, the APRN shall: (a) Obtain the patient’s medical history and conduct an examination of the patient and document the information in the patient’s medical record. An APRN certified in psychiatric/mental health shall obtain a medical and psychiatric history, perform a mental health assessment, and document the information in the patient’s medical record; (b) Query KASPER for all available data on the patient and maintain all KASPER report identification numbers and the date of issuance of each KASPER report in the patient’s record; (c) Make a written treatment plan stating the objectives of the treatment and further diagnostic examinations required; (d) Discuss with the patient, the patient’s parent if the patient is an unemancipated minor child, or the patient’s legal guardian or health care surrogate: 1. The risks and benefits of the use of controlled substances, including the risk of tolerance and drug dependence; 2. That the controlled substance shall be discontinued when the condition requiring its use has resolved; and 3. Document that the discussion occurred and obtain written consent for the treatment.

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. (3) The treatment plan shall include an exit strategy, if appropriate, including potential discontinuation of the use of controlled substances. (4) For subsequent or continuing long-term prescriptions of a controlled substance for the same medical complaint, the APRN shall: (a) Update the patient’s medical history and document the information in the patient’s medical record; (b) Modify the treatment plan as clinically appropriate; and (c) Discuss the risks and benefits of any new controlled substances prescribed with the patient, the patient’s parent if the patient is an unemancipated minor child, or the patient’s legal guardian or health care surrogate, including the risk of tolerance and drug dependence. (5) During the course of treatment, the APRN shall query KASPER no less than once every three (3) months for all available data on the patient before issuing a new prescription or a refill for a controlled substance. The APRN shall maintain all KASPER report identification numbers and the date of issuance of each KASPER report in the patient’s record.

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. (6) These requirements may be satisfied by other licensed practitioners in a single group practice if: (a) Each licensed practitioner involved has lawful access to the patient’s medical record; (b) Each licensed practitioner performing an action to meet these requirements is acting within the scope of practice of his or her profession; and (c) There is adequate documentation in the patient’s medical record reflecting the actions of each practitioner.

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. (6) During the course of treatment, the APRN shall query KASPER no less than once every three (3) months for all available data on the patient before issuing a new prescription or a refill for a controlled substance. (7) These requirements may be satisfied by other licensed practitioners in a single group practice if: (a) Each licensed practitioner involved has lawful access to the patient’s medical record; (b) Each licensed practitioner performing an action to meet these requirements is acting within the scope of practice of his or her profession; and (c) There is adequate documentation in the patient’s medical record reflecting the actions of each practitioner

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. (7) If prescribing a controlled substance for the treatment of chronic, noncancer pain, the APRN, in addition to the requirements of this section, shall obtain a baseline drug screen or further random drug screens if the APRN: (a) Finds a drug screen to be clinically appropriate; or (b) Believes that it is appropriate to determine whether or not the controlled substance is being taken by the patient. (8) If prescribing a controlled substance for the treatment of a mental health condition, the APRN shall meet the requirements of this section.

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. (8) If prescribing a controlled substance for the treatment of chronic, noncancer pain, the APRN, in addition to the requirements of this section, shall obtain a baseline drug screen or further random drug screens if the APRN: (a) Finds a drug screen to be clinically appropriate; or (b) Believes that it is appropriate to determine whether or not the controlled substance is being taken by the patient. (9) If prescribing a controlled substance for the treatment of a mental health condition, the APRN shall meet the requirements of this section.

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. (9) Prior to prescribing a controlled substance for a patient in the emergency department of a hospital that is not an emergency situation, the APRN shall: (a) Obtain the patient’s medical history, conduct an examination of the patient and document the information in the patient’s medical record. An APRN certified in psychiatric/mental health shall obtain a medical and psychiatric history, perform a mental health assessment, and document the information in the patient’s medical record; (b) Query KASPER for all available data on the patient; (c) Make a written treatment plan stating the objectives of the treatment and further diagnostic examinations required; (d) Discuss the risks and benefits of the use of controlled substances with the patient, the patient’s parent if the patient is an unemancipated minor child, or the patient’s legal guardian or health care surrogate, including the risk of tolerance and drug dependence, and document that the discussion occurred and that the patient consented to the treatment.

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. � (10) For each patient for whom an APRN prescribes a controlled substance, the APRN shall keep accurate, readily accessible, and complete medical records, which include: � (a) Medical history and physical or mental health examination; � (b) Diagnostic, therapeutic, and laboratory results; � (c) Evaluations and consultations; � (d) Treatment objectives; � (e) Discussion of risk, benefits, and limitations of treatments; � (f) Treatments; � (g) Medications, including date, type, dosage, and quantity prescribed; � (h) Instructions and agreements; � (i) Periodic reviews of the patient's file; and � (j) All KASPER report identification numbers and the date of issuance of each KASPER report.

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. � � � (11) The requirement to query KASPER shall not apply to: (a) An APRN prescribing or administering a controlled substance immediately prior to, during, or within the fourteen (14) days following an operative or invasive procedure or a delivery if the prescribing or administering is medically related to the operative or invasive procedure or the delivery and the medication usage does not extend beyond the fourteen (14) days; (b) An APRN prescribing or administering a controlled substance necessary to treat a patient in an emergency situation; or

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. (11) The requirement to query KASPER shall not apply to: (con’t) (c) An APRN prescribing a controlled substance: 1. For administration in a hospital or long-term-care facility with an institutional account, or an APRN in a hospital or facility without an institutional account, if the hospital, long-term-care facility, or licensee queries KASPER for all available data on the patient or resident for the twelve (12) month period immediately preceding the query within twelve (12) hours of the patient's or resident's admission and places a copy of the query in the patient's or resident's medical records during the duration of the patient's stay at the facility; 2. As part of the patient's hospice or end-of-life treatment; 3. For the treatment of pain associated with cancer or with the treatment of cancer; 4. To assist a patient when submitting to a diagnostic test or procedure;

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. � � (11) The requirement to query KASPER shall not apply to: (cont’d) 5. Within seven (7) days of an initial prescription pursuant to subsection (1) of this section if the prescribing: � a. Is done as a substitute for the initial prescribing; � b. Cancels any refills for the initial prescription; and � � c. Requires the patient to dispose of any remaining unconsumed medication; 6. Within ninety (90) days of an initial prescription pursuant to subsection (1) of this section if the prescribing is done by another licensee in the same practice or in an existing coverage arrangement, if done for the same patient for the same condition;

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. � � (2) This section shall not apply to: [KASPER REQUIREMENTS] (cont’d) 7. To a research subject enrolled in a research protocol approved by an institutional review board that has an active federal-wide assurance number from the United States Department of Health and Human Services, Office for Human Research Protections if the research involves single, double, or triple blind drug administration or is additionally covered by a certificate of confidentiality from the National Institutes of Health; 8. During the effective period of any disaster or situation with mass casualties that have a direct impact on the APRN’s practice; 9. As part of the administering or ordering of controlled substances to prisoners in a state, county, or municipal correctional facility;

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. (2) This section shall not apply to: [KASPER REQUIREMENTS] (cont’d) 10. That is a Schedule IV controlled substance for no longer than three (3) days for an established patient to assist the patient in responding to the anxiety of a nonrecurring event; or 11. That is classified as a Schedule V controlled substance. (12) Federal regulation 21 C. F. R. 1306. 12(b) concerning the issuance of multiple prescriptions for Schedule II controlled substances shall not be utilized by APRNs in this state. (13) An APRN may order a reverse KASPER report to review the APRN's prescribing practices and to verify the information contained in KASPER is correct.

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. Section 11. Incorporation by Reference. (1) The following material is incorporated by reference: (a) "AACN Scope and Standards for Acute Care Nurse Practitioner Practice", 2012 Edition, American Association of Critical-Care Nurses; (b) "AACN Scope and Standards for Acute and Critical Care Clinical Nurse Specialist Practice", 2014 Edition, American Association of Critical-Care Nurses; (c) "Neonatal Nursing: Scope and Standards of Practice", 2013 Edition, American Nurses Association/National Association of Neonatal Nurses; (d) "Nursing: Scope and Standards of Practice", 2015 Edition, American Nurses Association; (e) "Pediatric Nursing: Scope and Standards of Practice", 2015 Edition, American Nurses Association/Society of Pediatric Nursing/National Association of Pediatric Nurse Practitioners; (f) "Psychiatric-Mental Health Nursing Practice: Scope and Standards of Practice", 2014 Edition, American Nurses Association/American Psychiatric Nursing Association; (g) "Scope of Practice for Nurse Practitioners", 2013 Edition, American Association of Nurse Practitioners; (h) "Standards of Practice for Nurse Practitioners", 2013 Edition, American Association of Nurse Practitioners; (i) "Scope of Nurse Anesthesia Practice", 2013 Edition, American Association of Nurse Anesthetists; (j) "Standards for Nurse Anesthesia Practice", 2013 Edition, American Association of Nurse Anesthetists; (k) "Standards for Office Based Anesthesia Practice", 2015 Edition, American Association of Nurse Anesthetists; (l) "Standards for the Practice of Midwifery"; 2011 Edition, American College of Nurse-Midwives;

201 KAR 20: 057. Scope and standards of practice of advanced practice registered nurses. (m) "Statement on the Scope and Standards of Oncology Nursing Practice: Generalist and Advanced Practice", 2013 Edition, Oncology Nursing Society; (n) "The Women's Health Nurse Practitioner: Guidelines for Practice and Education", 2014 Edition, Association of Women’s Health, Obstetric and Neonatal Nurses/Nurse Practitioners in Women’s Health (o) "Notification of a Collaborative Agreement for the Advanced Practice Registered Nurse's Prescriptive Authority for Controlled Substances (CAPA-CS)", 12/2014, Kentucky Board of Nursing; (p) "Notification of a Collaborative Agreement for the Advanced Practice Registered Nurse’s Prescriptive Authority for Nonscheduled Legend Drugs (CAPA-NS)", 12/2014, Kentucky Board of Nursing; and (q) "Notification to Discontinue the CAPA-NS After Four Years", 8/2015, Kentucky Board of Nursing. (2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Kentucky Board of Nursing, 312 Whittington Parkway, Suite 300, Louisville, Kentucky 40222, Monday through Friday, 8 a. m. to 4: 30 p. m.

201 KAR 20: 059. Advanced practice registered nurse controlled substances prescriptions. Section 1. Specific Controlled Substances. The following controlled substances have been identified as having the greatest potential for abuse or diversion: (1) (2) (3) (4) (5) Diazepam (Valium), a Schedule IV medication; Clonazepam (Klonopin), a Schedule IV medication; Lorazepam (Ativan), a Schedule IV medication; Alprazolam (Xanax), a Schedule IV medication; and Carisoprodol (Soma), a Schedule IV medication. Section 2. Limitations. Prescriptions for the medications listed in Section 1 of this administrative regulation shall be limited to a thirty (30) day supply without any refills.

201 KAR 20: 063. Restrictions on use of amphetamine -like anorectic controlled substances. � � � Section 1. Definitions. Section 2. Prior to prescribing, ordering, or administering a Schedule III or IV amphetamine-like controlled substance, an advanced practice registered nurse (APRN) shall… Section 3. Treatment of Obesity with a Schedule III or IV Amphetaminelike Controlled Substance Section 4. Waiver. (1) For a legitimate medical purpose, such as a change in the Federal Food and Drug Administration’s (FDA’s) approval or an off -label use … Section 5. Failure to comply with the requirements of this administrative regulation and the scope and standards of practice in 201 KAR 20: 057 shall constitute actions inconsistent with the practice of nursing pursuant to KRS 314. 091(1).

Opioid Epidemic � Centers for Disease Control and Prevention’s Guideline for Prescribing Opioids for Chronic Pain � HB 1 Disciplinary Cases � Medication Assisted Treatment

Gabapentin � New regulation effective July 1, 2017 � KY classifies as Schedule V � First state to implement � Pharmacies report to KASPER � KRS 314. 011(8)(b)…. Prescriptions issued by advanced registered nurses for Schedules IV and V controlled substances classified under KRS 218 A. 100 and 218 A. 120 shall be limited to the original prescription and refills not to exceed a six (6) month supply.

HB 333 � Effective June 29, 2017 � Amends 218 A. 205(7) � CDC Guidelines � Acute medical condition vs. Chronic � Hydrocodone II (APRN prescribed as CIII) � Treat Pain as Acute Medical Condition – 72 hour prescription � Exceptions:

WITH THE FOLLOWING EXCEPTIONS: � � 1. The practitioner, in his or her professional judgment believes that more than a three (3) day supply of a Schedule II controlled substance is medically necessary to treat the patient's pain as an acute medical condition and the practitioner adequately documents the acute medical condition and lack of alternative treatment options which justifies deviation from the three (3) day supply limit established in this subsection in the patient's medical records; 2. The prescription for a Schedule II controlled substance is prescribed to treat chronic pain; 3. The prescription for a Schedule II controlled substance is prescribed to treat pain associated with a valid cancer diagnosis; 4. The prescription for a Schedule II controlled substance is prescribed to treat pain while the patient is receiving hospice or end-of-life treatment;

Additional exceptions � � 5. The prescription for a Schedule II controlled substance is prescribed as part of a narcotic treatment program licensed by the Cabinet for Health and Family Services; 6. The prescription for a Schedule II controlled substance is prescribed to treat pain following a major surgery or the treatment of significant trauma, as defined by the state licensing board in consultation with the Kentucky Office of Drug Control Policy; 7. The Schedule II controlled substance is dispensed or administered directly to an ultimate user in an inpatient setting; or 8. Any additional treatment scenario deemed medically necessary by the state licensing board in consultation with the Kentucky Office of Drug Control Policy.

201 KAR 20: 057 � � (14) An APRN shall not issue a prescription for hydrocodone combination products[, Schedule II controlled substances, ] for more than a three (3) day supply if the prescription is intended to treat pain as an acute medical condition, with the following exceptions: (a) The APRN, in his or her professional judgment, believes that more than a three (3) day supply of hydrocodone combination products[the Schedule II controlled substance] is medically necessary to treat the patient’s pain as an acute medical condition and the APRN adequately documents the acute medical condition and lack of alternative treatment options which justifies deviation from the three (3) day supply limit on the patient’s medical records; (b) The prescription for hydrocodone combination products [the Schedule II controlled substance] is prescribed to treat chronic pain; (c) The prescription for hydrocodone combination products [the Schedule II controlled substance] is prescribed to treat pain associated with a valid cancer diagnosis; …

201 KAR 20: 057 (d) The prescription for hydrocodone combination products [the Schedule II controlled substance] is prescribed to treat pain while the patient is receiving hospice or end-of-life treatment; � (e) The prescription for hydrocodone combinationproducts [the Schedule II controlled substance] is prescribed as part of a narcotic treatment program licensed by the Cabinet for Health and Family Services; � (f) The prescription for hydrocodone combination products [the Schedule II controlled substance] is prescribed to treat pain following a major surgery, which is any operative or invasive procedure or a delivery, or the treatment of significant trauma; or � (g) Hydrocodone combination products[The Schedule II controlled substance] is administered directly to an ultimate user in an inpatient setting. (15) Prescriptions written for hydrocodone combination products pursuant to subsection (14)(a) through (g) of this section shall not � exceed thirty (30) days without any refill.

Medication Assisted Treatment � Buprenorphine (Suboxone®) � CARA Act (Public Law 114 -198) � Nurse Practitioners only � Complete 24 hours SAMHSA approved education � CAPA-CS with MD who has also completed same education � Obtain DEAx � Submit copy(ies) of DEAx � Submit notification of (new) CAPA-CS � Regulation being DRAFTED

201 KAR 20: 056. Advanced practice registered nurse licensure and certification requirements. Section 1. An applicant for licensure as an advanced practice registered nurse in Kentucky shall: (1)(a) Complete an Application for Licensure as an Advanced Practice Registered Nurse as required by 201 KAR 20: 370, Section 1(1); (b) Provide a copy of a current active Registered Nurse license or validation of Registered Nurse licensure if the state of licensure does not issue licensure cards; (c) Submit the fee required by 201 KAR 20: 240, Section 1(2)(k); and (d) Comply with the requirements established in KRS 314. 042 and this administrative regulation.

201 KAR 20: 056. Advanced practice registered nurse licensure and certification requirements. (2) If the applicant is applying only for a license as an advanced practice registered nurse, the applicant shall also provide: (a) A completed Federal Bureau of Investigation (FBI) Applicant Fingerprint Card and the fee required by the FBI that is within six (6) months of the date of the application; (b) A report from the Kentucky Administrative Office of the Courts, Courtnet Disposition System that is within six (6) months of the date of the application; (c) A certified copy of the court record of any misdemeanor or felony conviction as required by 201 KAR 20: 370, Section 1(3); and (d) A letter of explanation that addresses each conviction, if applicable.

201 KAR 20: 056. Advanced practice registered nurse licensure and certification requirements. (3) An applicant shall not be licensed until: (a) A report is received from the FBI pursuant to the request submitted under subsection (2)(a) of this section and any conviction is addressed by the board; and (b) A query is completed to the board’s reporting agent to the National Practitioner Data Bank of the United States Department of Health and Human Services pursuant to KRS 218 A. 205(3)(g) and any relevant data on the applicant is received

201 KAR 20: 056. Advanced practice registered nurse licensure and certification requirements. Section 2. Postbasic Program of Study and Clinical Experience. (1) An applicant for licensure as an advanced practice registered nurse shall complete an organized postbasic program of study and clinical experience. This program shall conform to 201 KAR 20: 062 or its substantial equivalence if from an out of state program. (2)(a) If the applicant for licensure as an advanced practice registered nurse completed a postbasic program of study after January 1, 2005, the applicant shall hold a master’s degree, doctorate, or postmaster’s certificate awarding academic credit by a college or university related to the advanced practice registered nurse designation. (b) If the applicant for licensure as an advanced practice registered nurse completed a postbasic program of study before January 1, 2005, the program shall be evaluated by the board on an individual basis to find if the program sufficiently prepares a student for advanced practice registered nursing by complying with the requirements of 201 KAR 20: 062.

201 KAR 20: 056. Advanced practice registered nurse licensure and certification requirements. Section 3. National Certifying Organizations. (1) A nationally established organization or agency which certifies registered nurses for advanced practice registered nursing shall be recognized by the board if it meets the following criteria: (a) The certifying body is an established national nursing organization or a subdivision of this type of organization; (b) Eligibility requirements for certification are delineated; (c) Certification is offered in a role as defined by KRS 314. 042(2)(a) and in a population focus as defined by KRS 314. 011 and with primary or acute care competencies; (d) Scope and standards of practice statements are promulgated; (e) Mechanism for determining continuing competency is established; and (f) The certifying body is accredited by the American Board of Nursing Specialties or the National Commission for Certifying Agencies.

201 KAR 20: 056. Advanced practice registered nurse licensure and certification requirements. (2) The board recognizes the following national certifying organizations: (a) American Nurses Credentialing Center; (b) American Midwifery Certification Board; (c) National Board on Certification and Recertification of Nurse Anesthetists; (d) Pediatric Nursing Certification Board; (e) National Certification Corporation; (f) American Association of Nurse Practitioners; and (g) American Association of Critical-Care Nurses Certification Corporation. (3) The board recognizes the Oncology Nursing Certification Corporation only for an individual who has received certification prior to December 15, 2010 and who has continually renewed his or her Kentucky advanced practice registered nurse license since that date.

201 KAR 20: 056. Advanced practice registered nurse licensure and certification requirements. THIS DOES NOT APPLY TO NEWLY GRADUATED APRN APPLICANTS Section 4. Practice Pending Licensure. (1) A registered nurse who meets all the requirements for practice as an advanced practice registered nurse, and who holds a registered nurse temporary work permit issued pursuant to 201 KAR 20: 110 pending licensure by endorsement or a privilege to practice as a registered nurse, shall be authorized to practice as an advanced practice registered nurse for a period of time not to exceed the expiration date of the temporary work permit. (2) Authorization to practice pursuant to this section shall be in the form of a letter from the board acknowledging that the applicant has met all the requirements of this section. An applicant shall not practice until the authorization letter has been issued. (3) An individual authorized to practice pursuant to subsection (1) of this section may use the title "APRN Applicant“ or "APRN App. ". (endorsement only)

201 KAR 20: 056. Advanced practice registered nurse licensure and certification requirements. Section 5. License Renewal. (1) The advanced practice registered nurse license shall expire or lapse when the registered nurse license or privilege expires or lapses. (2) To be eligible for renewal of the license as an advanced practice registered nurse, the applicant shall: (a) Renew the registered nurse license or privilege on an active status; (b) Submit a completed Annual Licensure Renewal Application: RN and APRN or a completed Annual Licensure Renewal Application: APRN with RN Compact License (not Kentucky) form, as applicable, and as required by 201 KAR 20: 370, Section 1(1); (c) Submit the current renewal application fee, as established in 201 KAR 20: 240, Section 1(2)(l); and (d) Maintain current certification by a recognized national certifying organization.

201 KAR 20: 056. Advanced practice registered nurse licensure and certification requirements. (3) An advanced practice registered nurse who fails to renew the registered nurse license or privilege or is otherwise unable to legally practice as a registered nurse shall not practice as or use the title of advanced practice registered nurse until: (a) A current active license has been issued by the board or a privilege is recognized by the board; and (b) The advanced practice registered nurse license has been reinstated. (4) An advanced practice registered nurse shall provide evidence of current certification by a recognized national certifying organization upon recertification and at the request of the board.

201 KAR 20: 056. Advanced practice registered nurse licensure and certification requirements. Section 6. License Reinstatement. (1) If a nurse fails to renew the advanced practice registered nurse license as prescribed by KRS 314. 042 and this administrative regulation, the license shall lapse on the last day of the licensure period. (2) To be eligible for reinstatement of the advanced practice registered nurse license, the applicant shall: (a) Submit a completed Application for Licensure as an Advanced Practice Registered Nurse form as required by 201 KAR 20: 370, Section 1(1); (b) Submit the current reinstatement application fee, as established in 201 KAR 20: 240, Section 1(2)(m); and (c) Maintain current certification by a recognized national certifying organization.

201 KAR 20: 056. Advanced practice registered nurse licensure and certification requirements. (3) If the applicant is applying for reinstatement of a license as an advanced practice registered nurse, the applicant shall also provide a: (a) Completed Federal Bureau of Investigation (FBI) Applicant Fingerprint Card and the fee required by the FBI that is within six (6) months of the date of the application; (b) Report from the Kentucky Administrative Office of the Courts, Courtnet Disposition System that is within six (6) months of the date of the application; (c) Certified copy of the court record of any misdemeanor or felony conviction as required by 201 KAR 20: 370, Section 1(3); and (d) Letter of explanation that addresses each conviction, if applicable. (4) The license shall not be issued until a report is received from the FBI and any conviction is addressed by the board.

201 KAR 20: 056. Advanced practice registered nurse licensure and certification requirements. Section 7. Certification or Recertification. (1)(a) An advanced practice registered nurse shall maintain current certification or recertification from one (1) of the national organizations recognized in Section 3 of this administrative regulation throughout the licensure period. (b) The board shall conduct an audit to verify that an advanced practice registered nurse has met the requirements of subsection (1)(a) of this section. (2)(a) A nurse who fails to attain current, active certification or recertification from one (1) of the national organizations recognized in Section 3 of this administrative regulation shall not practice or use the title of advanced practice registered nurse (APRN) until current certification or recertification is obtained. (b)1. An APRN whose certification or recertification lapses prior to the expiration of the APRN license and who does not provide evidence of current certification or recertification prior to its expiration date after a request by the board shall have the APRN license voided. This action shall not be considered to be a disciplinary action.

201 KAR 20: 056. Advanced practice registered nurse licensure and certification requirements. 2. The APRN may request a hearing on this action by submitting the request in writing. If the action is upheld or not challenged, the APRN may seek reinstatement of the license in accordance with Section 6 of this administrative regulation, except as provided in subparagraph 3 of this paragraph. 3. If, after the APRN license has been voided, the APRN provides evidence that the certification had not lapsed, then the APRN shall meet the requirements of Section 6 of this administrative regulation except for Section 6(4) of this administrative regulation. A license may be issued prior to receipt of the FBI report. (3) An advanced practice registered nurse who is decertified by the appropriate national organization shall: (a) Notify the board of that fact; and (b) Not practice as or use the title of advanced practice registered nurse during the period of decertification.

201 KAR 20: 056. Advanced practice registered nurse licensure and certification requirements. Section 8. (1) An application shall be valid for a period of one (1) year from the date of submission to the board. (2) After one (1) year from the date of application, the applicant shall be required to reapply.

201 KAR 20: 056. Advanced practice registered nurse licensure and certification requirements. Section 9. The requirements of this administrative regulation shall not prohibit the supervised practice of a nurse enrolled in: (1) A postbasic educational program for preparation for advanced practice registered nursing; or (2) An advanced practice registered nurse refresher course.

201 KAR 20: 056. Advanced practice registered nurse licensure and certification requirements. Section 10. A registered nurse who holds himself or herself out as a clinical nurse specialist or is known as a clinical nurse specialist shall be required to be licensed as an advanced practice registered nurse if his or her practice includes the performance of advanced practice registered nursing procedures.

201 KAR 20: 056. Advanced practice registered nurse licensure and certification requirements. Section 11. A nurse practicing as an advanced practice registered nurse who is not licensed as an advanced practice registered nurse by the board, an advanced practice registered nurse whose practice is inconsistent with the specialty to which he or she has been designated, or an advanced practice registered nurse who does not recertify and continues to practice as an advanced practice registered nurse shall be subject to the disciplinary procedures established in KRS 314. 091.

201 KAR 20: 056. Advanced practice registered nurse licensure and certification requirements. Section 12. Dual designations. (1) An advanced practice registered nurse who wishes to practice in more than one (1) designation shall complete an accredited educational program of study and clinical experience for each desired designation in compliance with the educational requirements established in KRS Chapter 314 and 201 KAR 20: 062 and meet all the requirements for licensure for each designation. (2) To apply for licensure for more than one (1) designation, the applicant shall submit a separate application and fee for each desired designation. (3) To renew each designation, the APRN shall pay a separate licensure fee as set forth in 201 KAR 20: 240, Section 1(2)(k).

201 KAR 20: 056. Advanced practice registered nurse licensure and certification requirements. (4) For the purposes of Section 7(2)(b) of this administrative regulation, if the APRN does not provide evidence of current recertification in a designation, then that designation shall be voided. The license shall not be voided if the other designation is maintained. All other provisions of Section 7(2)(b) of this administrative regulation shall apply to the voided designation. (5) Designations shall be the Nurse Anesthetist, Nurse Midwife, Nurse Practitioner, and Clinical Nurse Specialist pursuant to KRS 314. 042.

APRN Inquiries � Collaborating Physician � Applying for CAPA-CS privileges � Same or Similar specialty � Scope of Practice � KASPER � Serial prescribing

Scope of Practice Determination Guidelines � Decision-Making ◦ ◦ ◦ Model KY Nursing Laws? Advanced education –population foci? Scope of practice support? Personal knowledge, competence and skill? Reasonable/Prudent? Accountability assumed?

APRN Scope of Practice Determination Decision-Making Model http: //kbn. ky. gov/practice/Pages/aprn_pract ice. aspx

Licensure Requirements � Submit notification of any CAPA-NS � Submit notification of any CAPA-CS � Submit copy of any DEA/any changes � Register with KASPER � Submit copy of DEAx � Submit evidence of certification/renewal to include name/certification #/expiration

QUESTIONS?

Contact Information Pamela C. Hagan, MSN, RN APRN Education & Nursing Practice Consultant E-mail: Pamela. C. Hagan@KY. gov Phone: 502 -429 -7181