SECTION II
QUALIFICATIONS FOR
LICENSURE
Advanced practice registered nurse (APRN) licensure shall be
designated in one of the four roles below and at least one population focus:
Family/Individual Across the Lifespan, Adult-Gerontology, Neonatal, Pediatrics,
Women's Health/Gender-Related, or Psychiatric/Mental Health (effective 2015). A
current, unencumbered registered nurse license to practice in Arkansas is
required for all categories of advanced practice licensure. Effective January
1, 2003, all applicants for advanced practice licensure by examination shall
have completed a graduate or post-graduate level advanced practice registered
nursing education program. Applicants for advanced practice licensure by
endorsement shall have met the educational and certification requirements set
forth in Arkansas State Board of Nursing Rules at the time of
their initial licensure as an advanced practice registered nurse in another
jurisdiction. APRN roles and their respective qualifications are:
A.
CERTIFIED NURSE PRACTITIONER
(CNP)
1. Successful completion of a
nationally accredited graduate or post-graduate APRN education program that
prepares nurses for the advanced practice role of nurse practitioner;
and
2. Hold current certification
by a national certifying body recognized by the Board of Nursing in the APRN
role and population foci appropriate for educational preparation.
B.
CERTIFIED REGISTERED
NURSE ANESTHETIST (CRNA)
1. Successful
completion of a nationally accredited graduate or post-graduate APRN education
program that prepares nurses to perform as nurse anesthetists; and
2. Hold current certification by a national
certifying body recognized by the Board of Nursing in the APRN role and
population foci appropriate for educational preparation.
C.
CERTIFIED NURSE MIDWIFE (CNM)
1. Successful completion of a nationally
accredited graduate or post-graduate APRN education program that prepares
nurses for the advanced practice role of nurse midwife; and
2. Hold current certification by a national
certifying body recognized by the Board of Nursing in the APRN role and
population foci appropriate for educational preparation; and
3. Written agreement with a consulting
physician if providing intrapartum care.
D.
CLINICAL NURSE SPECIALIST
(CNS)
1. Successful completion of a
nationally accredited graduate or post-graduate APRN education program that
prepares nurses for the advanced practice role of clinical nurse specialist
which shall include supervised clinical practice and classroom instruction in a
nursing clinical practice specialty; and
2. Hold current certification by a national
certifying body recognized by the Board of Nursing in the APRN role and
population foci appropriate for educational preparation.
SECTION III
LICENSURE
A.
ELIGIBILITY
The applicant shall meet the licensure requirements of the
Board.
B.
APPLICATION
FOR LICENSURE BY EXAMINATION
In addition to a current registered nurse license to practice
in Arkansas, the information submitted to the Board shall include:
1. A completed Board application
form;
2. Verification of active
practice of nursing as a registered nurse for a minimum of two-thousand (2,000)
hours, effective July 1, 2019;
3.
An official transcript or document from a nursing education program accredited
by a nursing accrediting body that is recognized by the U.S. Secretary of
Education and/or Council for Higher Education Accreditation (CHEA), as
acceptable by the Board and meets the qualifications of Section II of this
Chapter in the category of advanced practice nursing for which the applicant is
seeking licensure. The transcript or document shall verify the date of
graduation, the degree or certificate conferred, clinical hours completed, and
the role and population focus of the education program;
4. Evidence of state and federal criminal
background checks conducted by the Arkansas State Police and the Federal Bureau
of Investigation completed no earlier than twelve (12) months prior to the
application for advanced practice licensure;
5. Verification of certification directly
from the Board-approved national certifying body evidencing current
certification in good standing; and
6. Payment of the nonrefundable
fee.
C.
APPLICATION FOR LICENSURE BY ENDORSEMENT
1. The Board may issue a license by
endorsement to an APRN licensed under the laws of another state if, in the
opinion of the Board, the applicant meets the qualifications for licensure in
this state.
2. In addition to the
requirements set forth in Section II and III. A. and B. of this Chapter, the
information submitted to the Board shall include documentation of current
unencumbered advanced practice licensure/authority to practice in another
jurisdiction.
3. An individual
applying for licensure by endorsement who has been out of practice for more
than two (2) years shall provide evidence of passing an APRN nursing refresher
course approved by the Board or an extensive orientation, which shall include a
minimum of 200 hours, in the appropriate advanced practice role and population
focus which includes a supervised clinical component by a qualified preceptor
who meets the following requirements:
a.
Holds an active unencumbered APRN or physician license,
b. Is in current practice in the advanced
role and population focus and
c.
Functions as a supervisor and teacher and evaluates the individual's
performance in the clinical setting.
D.
APPLICATION FOR AN INTERNATIONALLY
EDUCATED APRN (educated outside the United States) An internationally
educated applicant for licensure in this state as an APRN shall:
1. Graduate from a graduate level APRN
program equivalent to an APRN educational program in the United States accepted
by the Board.
2. Submit an official
transcript directly from the international nursing education program and
verified through a qualified credentials evaluation process for the license
being sought.
3. Meet all other
licensure criteria required of applicants educated in the United States,
including English proficiency.
E.
TEMPORARY PERMITS
1. Upon application and payment of the
required fee, the Board shall issue a nonrenewable temporary permit to practice
in an advanced practice nursing category to a qualified applicant who has no
violations as listed in ACA §
17-3-102
on the Arkansas State Police criminal background check and:
a. Meets the educational requirements set
forth in Section II of this Chapter and has been accepted by the appropriate
certification body to sit for the national certification exam he or she is
eligible to take; or
b. Has a
current advanced practice registered nurse license or the equivalent from
another jurisdiction and has current Board-approved certification in the
appropriate advanced practice nursing education category.
2. The temporary permit shall immediately
become invalid upon receipt of information obtained from the federal criminal
background check indicating any offense listed in ACA §
17-3-102
or upon notification to the applicant or ASBN of failure of the certification
examination.
3. The temporary
permit is not renewable and does not apply to prescriptive authority.
4. In no event shall the permit be valid in
excess of six (6) months.
F.
RENEWALS
1. The date for renewal of licensure to
practice as an advanced practice registered nurse shall coincide with renewal
of the applicant's registered nurse license.
2. An applicant for renewal of an advanced
practice registered nurse license shall submit to the Board:
a. A completed Board renewal application
form;
b. Documentation of current
national certification in the appropriate APRN specialty through a maintenance
program of a Board approved certifying body;
c. Documentation of current compact state RN
licensure if primary state of residence has enacted the Interstate Nurse
Licensure Compact; and
d. Payment
of the nonrefundable renewal fee.
3. Advanced practice registered nurses with
prescriptive authority shall submit evidence of a current collaborative
practice agreement as a prerequisite to license renewal.
4. If disciplinary proceedings have been
initiated against an individual with a lapsed, inactive, or retired license,
the license shall not be renewed until the proceedings have been
completed.
5. Continuing education
submitted to the certifying body to meet the qualifications for recertification
shall be accepted as meeting the statutory requirement for continuing
education.
6. Upon request, an APRN
shall submit documentation to the Board of continuing education.
7. APRNs with prescriptive authority shall
complete five (5) contact hours of pharmacotherapeutics continuing education in
the APRN's area of certification each biennium prior to license renewal.
Effective January 1, 2017, two (2) of the five (5) hours must contain
information related to maintaining professional boundaries and the prescribing
rules and laws that apply to APRNs in the State of Arkansas.
8. Pursuant to Act 204 of 2017, upon
notification of active duty status and submission of appropriate documentation,
the license renewal fee will be waived for members of the military.
G.
LAPSED APRN
LICENSE
The license is lapsed if not renewed or placed on inactive
status by the expiration date.
1. The
license is lapsed if the RN license or privilege to practice in Arkansas is not
current.
2. The license is lapsed
when the national certification upon which licensure was granted
expires.
3. Failure to receive the
renewal notice at the last address of record in the Board office shall not
relieve the licensee of the responsibility for renewing the license by the
expiration date.
4. Any licensee
whose license has lapsed shall submit to the Board:
a. A completed Board renewal application
form;
b. Documentation of current
national certification; and
c. The
renewal fee and the reinstatement fee/late penalty.
5. Fees submitted to the Board are
nonrefundable.
6. Any person
engaged in advanced practice nursing during the time his or her license has
lapsed shall be considered an illegal practitioner and shall be subject to the
penalties provided for violation of the Nurse Practice
Act.
H.
REINSTATEMENT OF APR
N LICENSE
1. An individual who applies for licensure
reinstatement who has been out of practice for more than two (2) years shall
provide evidence of passing an APRN refresher course approved by the Board or
an extensive orientation, which shall include a minimum of 200 hours, in the
appropriate advanced practice role and population focus which includes a
supervised clinical component by a qualified preceptor who meets the following
requirements:
a. Holds an active unencumbered
APRN or physician license
b. Is in
current practice in the advanced role and population focus; and
c. Functions as a supervisor and teacher and
evaluates the individual's performance in the clinical setting.
2. For those licensees applying
for licensure reinstatement following disciplinary action, compliance with all
Board licensure requirements as well as any specified requirements set forth in
the Board's discipline order is required.
I.
INACTIVE STATUS
1. Any licensee who desires to temporarily
inactivate their advanced practice registered nurse license in this state shall
submit a request to the Board.
2.
The APRN license may immediately be placed on inactive status when the
registered nurse license is placed on inactive status.
3. While the license is inactive, the
licensee shall not engage in advanced practice nursing nor be subject to the
payment of renewal fees.
4. If the
APRN desires to resume practice in this state, he or she shall submit a
reinstatement application and meet the continuing education
requirements.
J.
RETIRED ADVANCED PRACTICE REGISTERED NURSE
1. Any advanced practice registered nurse in
good standing, who desires to retire for any length of time from the practice
of nursing in this state shall submit a request and their APRN license shall be
placed on retired status.
2. While
retired, the APRN shall not practice advanced practice nursing; however, an
APRN with a retired license may use the title "Advanced Practice Registered
Nurse" or the abbreviation "APRN." Retired APRNs that maintain an active RN or
RNP license may practice in the role of a Registered Nurse or Registered Nurse
Practitioner.
3. When the licensee
desires to resume practice, he or she shall submit a reinstatement application
with a reinstatement fee and the active renewal fee. The licensee must also
meet those requirements outlined in Section III, F.
4. When disciplinary proceedings have been
initiated against a retired licensee, the license shall not be reinstated until
the proceedings have been completed.
K.
ADDITIONAL CERTIFICATIONS
1. An APRN who has completed post-masters
education for an additional nursing specialty shall:
a. Submit a request for permission to
practice in the new certification area;
b. Submit evidence of eligibility to sit for
the new certification exam from the Board-approved certifying body;
c. Immediately cease practicing in the
specialty upon notification of failure of the exam;
d. Submit results of the certification in the
additional specialty directly from the certifying body;
e. Submit an official transcript or document
from a nursing education program that meets the qualifications in Section II of
this Chapter verifying the date and degree or certificate conferred.
2. An APRN who has prescriptive
authority shall:
a. Prescribe only for
patients covered by the original specialty while waiting additional specialty
results.
b. Submit a collaborative
practice agreement which includes the additional certification.
SECTION VI
STANDARDS OF NURSING
PRACTICE
A.
PURPOSE
1. To establish standards
essential for safe practice by the advanced practice registered
nurse.
2. To serve as a guide for
evaluation of advanced nursing practice.
B.
STANDARDS FOR ALL CATEGORIES OF
ADVANCED PRACTICE REGISTERED NURSING
1.
The advanced practice registered nurse shall assess clients at an advanced
level, identify health status including abnormal conditions, establish a
diagnosis, develop and implement treatment plans and evaluate client
outcomes.
2. The advanced practice
registered nurse shall use advanced knowledge and skills in teaching and
guiding clients and other health team members.
3. The advanced practice registered nurse
shall use critical thinking and decision making at an advanced level,
commensurate with the autonomy, authority, and responsibility of his/her
practice category.
4. The advanced
practice registered nurse shall have knowledge of the statutes and rules
governing advanced nursing practice, and function within the legal boundaries
of the appropriate advanced practice registered nursing category.
5. The advanced practice registered nurse is
authorized to sign the following official documents:
a. Certification of disability for patients
to receive disabled parking permits or placards from the Office of Motor
Vehicle;
b. Sports physicals to
authorize student athletes to participate in athletic activities;
c. Physicals for bus drivers;
d. Forms relating to do-not-resuscitate
orders;
e. Forms excusing a
potential jury member due to an illness;
f. Death certificate;
g. Workers' compensation forms;
h. Forms relating to absenteeism for
employment or school purposes; and
i. Authorizations for durable medical
equipment.
6. The
advanced practice registered nurse shall recognize the APRN's limits of
knowledge and experience, planning for situations beyond expertise, and
collaborating with or referring clients to other health care providers as
appropriate.
7. The advanced
practice registered nurse shall retain professional accountability for advanced
practice nursing care when delegating interventions.
8. The advanced practice registered nurse
shall maintain current knowledge and skills in the advanced practice nursing
category.
9. Rules which apply to
registered nurses are hereby incorporated by reference.
10. The APRN shall comply with the standards
for registered nurses as specified in Chapter 1.
Standards for a specific role and population focus of APRN
supersede standards for registered nurses where conflict between the standards,
if any, exists.
C.
In addition to the standards, the advanced practice registered nurse shall
practice in accordance with the standards established by the national
certifying body from which the APRN holds his or her certification required for
licensure. These standards shall have been reviewed and accepted by the
Board.
D.
ADDITIONAL
STANDARDS FOR CRNAs
1. The CRNA, acting
in the normal course of his/her professional practice, may be authorized by a
hospital or institution to act as their agent or employee to order the
administration of controlled substances under the DEA registration of the
hospital or institution.
2. The
CRNA may order nurses to administer drugs preoperatively and/or postoperatively
in connection with an anesthetic and/or other operative or invasive procedure
that will be or has been provided.
3. The CRNA's order shall be directly related
to the administration of drugs preoperatively and/or postoperatively in
connection with an anesthetic and/or other operative or invasive procedure that
will be or has been provided.
4. A
CRNA who has not been granted authority by a DEA registrant as described in
Title
21 CFR
1301.22, or its successor to order the
administration of controlled substances shall give all orders as verbal orders
from the supervising physician, dentist, podiatrist, or other person lawfully
entitled to order anesthesia.
5.
The CRNA shall be responsible for complying with all applicable state and
federal laws and rules related to medications.
SECTION VII
PROFESSIONAL CERTIFICATION
PROGRAMS
A. A
national certification program which meets the following criteria shall be
recognized by the Board to satisfy Section II of these rules.
B. The national certification program:
1. Is national in the scope of its
credentialing;
2. Is accredited by
a national accreditation body as acceptable by the Board;
3. Has no requirement for an applicant to be
a member of any organization;
4.
Has an application process and credential review which includes documentation
that the applicant's education is in the advanced practice nursing category
being certified, and that the applicant's clinical practice is in the
certification category;
5.
Education requirements are consistent with the requirements of the advanced
practice role and population foci.
6. Uses an examination as a basis for
certification in the advanced practice nursing category which meets the
following criteria:
a. The examination is
based upon job analysis studies conducted using standard methodologies
acceptable to the testing community;
b. The examination represents entry-level
practice in the APRN role and population focus;
c. The examination represents the knowledge,
skills, and abilities essential for the delivery of safe and effective advanced
nursing care to clients;
d. The
examination content and its distribution are specified in a test plan
(blueprint), based on the job analysis study, that is available to
examinees;
e. Examination items are
reviewed for content validity and correct scoring using an established
mechanism, both before use and periodically;
f. Examinations are evaluated for
psychometric performance;
g. The
passing standard is established using acceptable psychometric methods, and is
re-evaluated at least every five (5) years;
h. Examination security is maintained through
established procedures; and
i. A
retake policy is in place.
7. Issues certification based upon passing
the examination and meeting all other certification requirements;
8. Provides for periodic recertification
which includes review of continued education, qualifications, and continued
competence;
9. Has mechanisms in
place for communication to the Board for timely verification of an individual's
certification status, changes in certification status, and changes in the
certification program, including qualifications, test plan, and scope of
practice;
10. Has an evaluation
process to provide quality assurance in its certification program.
C. The Board will notify the
appropriate certifying body when an APRN has disciplinary action taken on their
license or privilege to practice which restricts the APRN's ability to practice
(eg. suspension or revocation).
SECTION VIII
PRESCRIPTIVE
AUTHORITY
A.
INITIAL APPLICANT
An applicant for an initial certificate of prescriptive
authority shall:
1. Be currently
licensed as an advanced practice registered nurse in Arkansas.
2. Provide evidence from the national
certifying body that differential diagnosis and prescribing practices are
recognized as being within the scope of practice for the applicant's
certification category.
3. Provide
documentation of successful completion of pharmacology coursework which shall
include pharmacokinetics principles and their clinical application and the
prescription of pharmacological agents in the prevention and treatment of
illness, and the restoration and maintenance of health. The coursework shall
contain a minimum of:
a. Three (3) graduate
credit hour pharmacology course offered by an accredited college or university
within two years immediately prior to the date of application to the Board;
or
b. Forty-five (45) contact hours
[a contact hour is fifty (50) to sixty (60) minutes] in a pharmacology course
which includes a competency component, offered by an accredited college or
university, within two (2) years immediately prior to the date of application
to the Board; or
c. Three (3)
graduate credit hours pharmacology course, included as part of an advanced
practice nursing education program, within five (5) years immediately prior to
the date of application to the Board.
4. Provide documentation of a minimum of
three hundred (300) clock hours preceptorial experience in the prescription of
drugs, medicines and therapeutic devices with a qualified preceptor, to be
initiated with the pharmacology course and to be completed within one year of
the beginning of the course. Preceptorial experience completed as a part of the
formal educational program in which the pharmacology course is taught will meet
the three hundred (300) clock hour requirement.
5. Submit a collaborative practice agreement
with a practicing physician who is licensed under the Arkansas Medical
Practices Act, §
17-95-201
et seq., or a podiatrist licensed by the Arkansas Board of Podiatric Medicine
under Arkansas Code Annotated §
17-96-101,
et. seq., if employed by the podiatrist, and who has training within the scope,
specialty or expertise of the advanced practice registered nurse. APRNs who
will prescribe controlled substances shall seek a collaborative practice with a
physician or podiatrist who has an unrestricted DEA registration number. The
collaborative practice agreement shall include, but not be limited to:
a. Availability of the collaborating
physician(s) or podiatrist for consultation or referral or both;
b. Methods of management of the collaborative
practice, which shall include the use of protocols for prescriptive
authority;
c. Plans for coverage of
the health care needs of a client in the emergency absence of the advanced
practice registered nurse, podiatrist, or physician;
d. Provision for quality assurance;
e. Authorization for the APRN to prescribe
hydrocodone combination products which were reclassified from Schedule II I to
Schedule II as of October 6, 2014 if expressly authorized by the collaborating
physician; and
f. Authorization for
the APRN to prescribe drugs listed in Schedule II subject to the provisions in
Section VIII (D) if expressly authorized by the collaborating physician or
podiatrist.
g. Signatures of the
advanced practice registered nurse and collaborating physician(s) or
podiatrist, signifying mutual agreement to the terms of the collaborative
practice.
6. Submit the
nonrefundable processing fee with the application for a certificate of
prescriptive authority.
7. APRNs
issued a certificate of prescriptive authority after December 31, 2015 shall
obtain a minimum of three (3) hours of prescribing education which includes
information on maintaining professional boundaries and the prescribing rules
and laws that apply to APRNs in the state of Arkansas within two (2) years of
issuance of the prescriptive authority certificate.
B.
ENDORSEMENT APPLICANT
1. An applicant for endorsement of
prescriptive authority shall:
a. Provide
documentation of a three (3) graduate credit hour pharmacology course offered
by an accredited college or university or a forty-five (45) contact hour [a
contact hour is fifty (50) to sixty (60) minutes] pharmacology course which
includes a competency component offered by an accredited college or
university;
b. Provide evidence
that prescriptive authority is current and unencumbered in the jurisdiction
from which the applicant is moving;
c. Provide evidence of prescribing in a
clinical setting for at least 500 hours in the year prior to application for a
certificate of prescriptive authority;
d. Have an unencumbered advanced practice
registered nurse license to practice or the equivalent in the jurisdiction from
which the applicant is moving;
e.
Provide a copy of current DEA registration (if prescriber has DEA number) and
history of registration status; and
f. Meet requirements in Section VII I.A. 1,
2, 5, 6, 7.
2.
Endorsement applicants who do not meet all requirements established herein
shall be required to submit documentation acceptable to the Board according to
Section VIII.A.
C.
PROTOCOLS FOR PRESCRIPTIVE AUTHORITY
Protocols shall be made available upon request of the Board.
Such protocols shall, at a minimum, include:
1. Indications for and classifications of
legend drugs, controlled substances (if prescriber holds a DEA registration
number), and therapeutic devices which will be prescribed or administered by
the APRN;
2. Date the protocol was
adopted or last reviewed, which shall be at least annually.
D.
PRESCRIBING
PRIVILEGES
1. The APRN, applying for a
certificate of prescriptive authority, shall acknowledge in the application
that he or she is familiar with all state and federal laws and rules regarding
prescribing, and shall agree to comply with these laws and rules.
2. An advanced practice registered nurse with
a certificate of prescriptive authority may receive and prescribe legend drugs,
medicines or therapeutic devices appropriate to the APRN 's area of practice.
The prescriptive authority for controlled drugs shall extend to drugs listed in
Schedules II through V and hydrocodone combination products which were
reclassified from Schedule II I to Schedule II as of October 6, 2014.
3. Prescribing stipulations are as follows:
a. Legend drugs, therapeutic devices, and
controlled substances (Schedules II-V), and hydrocodone combination products,
which were reclassified from Schedule III to Schedule II as of October 6, 2014,
will be prescribed, administered, or ordered as established in protocols
provided that the APRN has an assigned DEA registration number which is entered
on each written prescription for a controlled substance.
b. The APRN shall not prescribe Schedule II
opioids for acute pain for more than a five (5) day period.
If additional Schedule II opioids are needed for management of
acute pain, the patient shall be referred to the collaborating
physician.
c. The APRN is
authorized to prescribe Schedule II drugs that are classified as stimulants
once the following criteria are met:
(1) The
prescription was originally initiated by a physician;
(2) The physician has evaluated the patient
within six (6) months before the APRN issues a prescription;
(3) The prescription by the APRN is to treat
the same condition as the original prescription.
d. The APRN shall not prescribe Schedule II
controlled substances for his/her own use or for the use of his/her immediate
family.
e. The APRN shall file
his/her DEA registration number with the Board upon receipt.
f. Advanced practice registered nurses shall
not delegate to unlicensed ancillary staff the calling in of prescriptions to
the pharmacy.
g. The APRN shall
notify the Board in writing within seven (7) days following termination of the
collaborative practice agreement. A new collaborative practice agreement is
required to be on file prior to reactivating prescriptive authority.
4. The APRN may prescribe a legend
drug, medicine or therapeutic devices not included in the written protocols
only as follows:
a. Upon a specific written or
verbal order obtained from the collaborating physician or podiatrist before the
prescription or order is issued by the APRN; and
b. Include documentation of consultation as
described above in the client's medical record to be signed by the
APRN;
c. Schedule I controlled
substances shall not be prescribed under the APRN's certificate of prescriptive
authority.
5. The APRN
shall note prescriptions on the client's medical record and include the
following information:
a. Medication and
strength;
b. Dose;
c. Amount prescribed;
d. Directions for use;
e. Number of refills; and
f. Initials or signature of APRN.
6. The APRN will keep accurate
records to include the medical history, physical examination, other evaluations
and consultations, treatment plan objective, informed consent noted in the
patient record, treatment, medications given, agreements with the patient and
periodic reviews.
7. The APRN will
periodically review the course of scheduled drug treatment of the patient and
any new information about etiology of the pain. If the patient has not
improved, the APRN may assess the appropriateness of continued prescribing of
scheduled medications or dangerous drugs, or trial of other
modalities.
8. The APRN will obtain
written informed consent from those patients he or she is concerned may abuse
controlled substances and discuss the risks and benefits of the use of
controlled substances with the patient, his or her guardian, or authorized
representatives.
9. Advanced
practice registered nurses in the category of certified registered nurse
anesthetists shall not be required to have prescriptive authority to provide
anesthesia care, including the administration of drugs or medicines necessary
for such care.
10. Advanced
practice registered nurses who prescribe prior to obtaining a certificate of
prescriptive shall be considered illegal practitioners and shall be subject to
the penalties provided for violation of the Nurse Practice
Act.
E.
PRESCRIPTION FORMAT
1. All
prescriptions issued by the APRN shall contain the name of the client, and the
APRN's name, title, address, telephone number, signature with the initials
"APRN" and shall include information contained in Subsection D.5.a-f of this
Section.
2. All prescriptions for
controlled substances shall be in accordance with federal rules. The APRN's
assigned DEA registration number shall be included on the prescription when a
controlled substance is prescribed.
F.
RECEIVING PREPACKAGED DRUG
SAMPLES
1. APRNs who have an active
prescriptive authority certificate may receive legend drug samples and
therapeutic devices appropriate to their area of practice, including controlled
substances contained in Schedules III through V and only hydrocodone
combination products, which were reclassified from Schedule III to Schedule II
as of October 6, 2014, which have been prepared, packaged, or fabricated by a
pharmaceutical manufacturer in accordance with the Arkansas pharmacy laws and
rules.
2. Records must comply with
all applicable federal and state laws and rules.
G.
TERMINATION OF PRESCRIPTIVE
AUTHORITY
1. Prescriptive authority may
be terminated by the Board when the prescriber:
a. Fails to maintain current active licensure
as an advanced practice registered nurse;
b. Violates provisions of this
Act and/or Rules established by the Arkansas
Department of Health, Nursing or Pharmacy Boards;
c. Violates any state or federal law or rules
applicable to prescriptions; or
d.
Fails to follow any conditions imposed.
2. To reinstate prescriptive authority, the
APRN must meet requirements of the Board at the time of
reinstatement.
H.
LAPSED CERTIFICATE OF PRESCRIPTIVE AUTHORITY
1. The certificate of prescriptive authority
is lapsed if:
a. The licensee's active
advanced practice registered nurse license is not renewed by the expiration
date;
b. The national certification
upon which licensure is based expires;
c. There is not a current collaborative
practice agreement on file with the board; or
d. The advanced practice license is placed on
inactive or retired status.
2. After reinstating a lapsed advanced
practice registered nurse license, the licensee shall submit to the Board a
current collaborative practice agreement to reactivate the certificate of
prescriptive authority.
3. Any
person engaged in prescribing during the time his or her certificate of
prescriptive authority has lapsed shall be considered an illegal practitioner
and shall be subject to the penalties provided for violation of the
Nurse Practice Act.
I.
INACTIVE STATUS
1. A certificate of prescriptive authority
will automatically be considered lapsed and subject to the requirements of
these rules when a licensee places his or her advanced practice registered
nurse license on inactive status.
2. While the certificate of prescriptive
authority or advanced practice registered nurse license is inactive, the
licensee shall not engage in any practice within the scope of the certificate
of prescriptive authority.
3. If
the nurse desires to resume practice in this state, he or she shall request a
renewal application which shall be completed and submitted with a renewal fee
and the reinstatement fee. Fees are nonrefundable.
4. All certification requirements for renewal
shall apply.
5. If disciplinary
proceedings on an inactive licensee have been initiated, the license shall not
be reinstated until the proceedings have been completed.
J.
REACTIVATION OF PRESCRIPTIVE
AUTHORITY
APRNs whose prescriptive authority is inactive shall
complete:
1. Five (5) contact hours of
pharmacotherapeutics continuing education in the APRN's area of certification
for each 12 months of non-prescribing activity in addition to the five (5)
contact hours required for APRN license renewal, as noted in Chapter 4,
III(F)(7), prior to reactivation of prescriptive authority.
2. Two (2) contact hours shall include
information on maintaining professional boundaries and the prescribing rules
and laws that apply to the APRNs in the state of Arkansas
K.
PRESCRIPTION DRUG MONITORING
PROGRAM
1. APRNs may delegate access to
the Prescription Drug Monitoring Program (PDMP) for running requested reports
to no more than two licensed nurses under his or her supervision or employment
at each practice location.
2. APRNs
with prescriptive authority shall review PDMP report from the Prescription Drug
Monitoring Program prior to prescribing:
a. An
opioid from Schedule II or Schedule III every time prescribing the medication
to a patient; and
b. A
benzodiazepine medication for the first time and every six (6) months
thereafter prescribing for a patient.
3. Review of the PDMP report shall be
documented in the patient's medical record.
4. Mandatory checking of the PDMP does not
apply when prescribing a controlled substance to a patient;
a. Immediately before or during surgery;
or
b. During recovery from surgery
while in a healthcare facility; or
c. In a healthcare facility; or
d. When necessary to treat a patient in an
emergency situation at the scene of an emergency, in a licensed ground
ambulance or air ambulance, or in the intensive care unit of a licensed
hospital; or
e. In palliative care
or hospice; or
f. In a licensed
nursing home facility; or
g. In
situations in which the PDMP is not accessible due to technological or
electrical failure.
SECTION IX
PRESCRIBING GUIDELINES FOR ANOREXIANT
DRUGS
An Advanced Practice Registered Nurse (APRN) must maintain
prescribing medication practices that are within the APRN's educational
preparation and certification. An APRN will be in violation of the Arkansas
Nurse Practice Act if he/she prescribes Schedule III and/or
Schedule IV drugs under the Uniform Controlled Substance Act for short-term
treatment of obesity, except in conformity with the requirements as set
below.
A.
PRESCRIBING
GUIDELINES
1. An established
APRN/patient relationship shall exist. The patient shall be age 18 or older, or
have written consent from a parent or guardian. The medication shall only be an
adjunct to a comprehensive weight loss program focused on appropriate nutrition
education, a change in lifestyle, counseling, and an individualized exercise
program. The APRN shall determine whether or not the patient has made a
substantial good faith effort to lose weight through diet and alteration of
lifestyle prior to beginning drug therapy.
2. The treating APRN shall take a complete
history of the patient, including a detailed family history, dietary history,
and shall perform a complete physical examination. The physical examination
shall include a minimum of checking the blood pressure and pulse, examining the
heart and lungs, recording height and weight, and administering any other
appropriate diagnostic tests to evaluate for a metabolic disorder. The history
and examination shall be sufficient to determine if the patient has previously
been drug dependent, to determine if there is a metabolic cause of the obesity
which would make anorexiant drugs inappropriate, and to determine if there are
other contraindications to use of anorexiant drugs exists.
3. The APRN shall discuss with the patient
different approaches to the treatment of obesity, and the risks and benefits
associated with each approach. Risks shall include potential side effects, such
as cardiovascular and pulmonary complications, as well as the potential for
lack of success with weight loss. The APRN shall be aware of potential drug
interactions between anorexiants, and other centrally acting drugs. The
treating APRN shall prescribe a diet for weight loss and appropriate counseling
regarding lifestyle change, and record these changes on the patient's medical
record. Consideration on the use of anorexiant medications shall take into
account the degree of overweight and associated medical conditions. The body
mass index (BMI) shall be used as a guide to determine the degree of overweight
status. In general, anorexiant medications shall only be used if the BMI is
more than 27. In the case of associated obesity-related medical conditions,
anorexiant medications may be considered with a BMI above 25. Obesity-related
medical conditions include, but are not limited to, diabetes, hypertension,
dyslipidemia, cardiovascular disease, sleep apnea, psychological conditions,
disc disease, and severe arthritis of the lower extremities.
4. The treating APRN shall prescribe a daily
dosage that does not exceed the dosage recommended in the manufacturer's
prescribing information for the drug prescribed.
5. The APRN shall not prescribe more than a
30-day supply for a patient at each visit and regular follow-up visits shall
not exceed 30 days. The patient shall be weighed at each visit prior to the
prescribing of an additional supply of the drug.
6. At the time of each return patient visit,
the treating APRN shall monitor progress of the patient. The patient's weight,
blood pressure, pulse, heart, and lungs shall be assessed. In addition to any
side effects of the medications, the APRN shall perform appropriate exams and
tests to monitor the safety of any weight loss. This may include a detailed
dietary questionnaire, serum electrolytes, blood glucose, and other tests
deemed appropriate. The APRN shall discontinue the anorexiant medications when
the patient reaches weight loss goals. These goals may be defined as a body
weight that is no longer considered "obese" (e.g. BMI of less than or equal to
27), or an improvement in medical conditions (e.g. normalization of blood
glucose). After the goal is reached, the APRN may continue to prescribe
anorexiant drugs for up to an additional sixty (60) days.
7. Except as otherwise provided by this
regulation, Schedule III and/or Schedule IV anorexiant drugs are only
recommended for short-term use (e.g. 90 days). In addition, anorexiant drugs
shall not be prescribed to a patient with a BMI of less than 27, unless
prescribing for obesity-related conditions with a BMI of above 25. The treating
APRN may extend therapy beyond 90 days under the following conditions:
a. When the anorexiant drugs are indicated
for treatment of diseases other than obesity; and
b. When, in the APRN's professional judgment,
the treating APRN is assessing and recording significant progress or benefit
from the drugs and no adverse effects occur that are related to the
treatment.
SECTION
XII
PRESCRIBING FOR CHRONIC NONMALIGNANT
PAIN
A. Chronic
nonmalignant pain is defined as pain requiring more than three consecutive
months of prescriptions for:
1. An opioid that
is written for more than the equivalent of ninety (90) tablets, each containing
five (5) milligrams of hydrocodone; or
2. A morphine equivalent dose of more than
fifteen mg (15 mg) per day: or
3.
Tramadol - an average dose of two hundred milligrams (200 mg) or greater per
day.
B. When opioids are
started, the lowest effective dosage should be prescribed. APRNs should use
caution when prescribing opioids at any dosage and carefully reassess evidence
of individual benefits and risks when considering increasing dosage to >50
morphine milligram equivalents (MME) per day. APRNs should avoid increasing
dosage to >90 MME/day or carefully justify a decision to titrate dosage to
>90 MME/day.
C. If opioids are
prescribed at a level defined by the Centers for Disease Control and Prevention
(CDC) as excessive (>50 MME/day) the following shall be documented in the
patient's medical record:
1. Objective
findings, which include, but are not limited to, imaging studies, lab testing
and results, nerve conduction testing, biopsy, and any other test that would
establish pain generating pathology.
2. Specific reasons for the need to prescribe
> 50 MME/day.
3. Documented
alternative treatment plans as well as alternative therapies tried and failed
prior to considering chronic opioid therapy.
4. Documented risk factor assessment
detailing that the patient was informed of the risk and addictive nature of the
prescribed drug.
5. Documented
assessment of the potential for abuse and/or diversion of the prescribed
drug.
6. Documented review of the
Prescription Drug Monitoring report prior to issuing the
prescription.
7. A detailed
clinical rational for the prescribing
D. Patient Treatment and Evaluation
1. The patient shall be evaluated through an
in-person examination at least every three (3) months by the APRN and at least
one (1) time every six (6) months by a physician who is licensed by the
Arkansas State Medical Board.
2. A
current Prescription Drug Monitoring Program report shall be reviewed at least
every six (6) months. The review shall be documented in the patient's medical
record.
3. A current pain contract
with the patient shall be maintained and include, at a minimum, requirements
for:
a. Random urine drug screens
and
b. Random pill
counts
E. The
requirements of this section shall not apply to a patient:
1. Whose pain medications are being
prescribed for a malignant condition:
2. With a terminal condition;
3. Who is a resident of a licensed healthcare
facility;
4. Who is enrolled in a
hospice program; or
5. Who is in an
inpatient or outpatient palliative care program.
SECTION XIII
MINIMUM STANDARDS FOR ESTABLISHING A PATIENT
RELATIONSHIP
A.
The APRN shall establish a proper APRN/patient relationship prior to providing
any patient care.
B. A proper
APRN/patient relationship, at a minimum requires that:
1. The APRN perform a history and an "in
person" physical examination of the patient adequate to establish a diagnosis
and identify underlying conditions and/or contraindications to the treatment
recommended/provided; OR
2. The
APRN perform a face-to-face examination using real-time audio and visual
telemedicine technology that provides information at least equal to such
information as would have been obtained by an in-person examination;
AND
3. Appropriate follow-up be
provided or arranged, when necessary, at medically necessary
intervals.
C. A proper
APRN/patient relationship is also deemed to exist in the following situations:
1. When treatment is provided in consultation
with, or upon referral by another health care provider who has an ongoing
relationship with the patient, and who has agreed to supervise the patient's
treatment, including follow-up care and the use of any prescribed
medications.
2. On-call or
cross-coverage situations arranged by the patient's health care
provider.
D. Recognizing
a Providers duty to adhere to the applicable standard of care, the following
situations are hereby excluded from the requirement of this regulation:
1. Emergency situations where the life or
health of the patient is in danger or imminent danger.
2. Providing information of a generic nature
not meant to be specific to an individual.
3. Providing prescriptions written or
medications issued for use in expedited heterosexual partner therapy for the
sexually transmitted diseases of gonorrhea and/or chlamydia.
4. Administration of vaccines containing
tetanus toxoid (e.g., DTaP, DTP, DT, Tdap, TD, or TT) or inactive influenza
vaccines.
SECTION
XIV
TELEMEDICINE
Requirement for all services provided by APRNs providing care
via telemedicine:
A. An APRN/patient
relationship shall be established in accordance with Chapter 4, Section XIII
before the delivery of services via telemedicine. A patient completing a
medical history online and forwarding it to an APRN is not sufficient to
establish the relationship, nor does it qualify as store-and-forward
technology.
B. The following
requirements apply to all services provided by APRNs using telemedicine:
1. The practice of nursing via telemedicine
shall be held to the same standards of care as traditional in-person
encounters.
2. The APRN shall
obtain a detailed explanation of the patient's complaint from the patient or
the patient's health care provider.
3. If a decision is made to provide
treatment, the APRN shall agree to accept responsibility for the care of the
patient.
4. If follow-up care is
indicated, the APRN shall agree to provide or arrange for such follow-up
care.
5. An APRN using telemedicine
may NOT issue a prescription for any controlled substances defined as any
scheduled medication under schedules III through V and only hydrocodone
combination products which were reclassified from Schedule III to Schedule II
as of October 6, 2014 unless the APRN has seen the patient for an in-person
exam or unless a relationship exists through consultation or referral; or
on-call or cross-coverage situations.
6. The APRN shall keep a documented medical
record, including medical history.
7. At the patient's request, the APRN shall
make available to the patient an electronic or hardcopy version of the
patient's medical record documenting the encounter. Additionally, unless the
patient declines to consent, the APRN shall forward a copy of the record of the
encounter to the patient's regular treating health care provider if that health
care provider is not the same one delivering the service via
telemedicine.
8. Services shall be
delivered in a transparent manner, including providing access to information
identifying the APRN in advance of the encounter, with licensure and board
certifications, as well as patient financial responsibilities.
9. If the patient, at the recommendation of
the APRN, needs to be seen in person for the current medical issue, the APRN
shall arrange to see the patient in person or direct the patient to their
regular treating health care provider. Such recommendation shall be documented
in the patient's medical record.
10. APRNs who deliver services through
telemedicine shall establish protocols for referrals for emergency
services.
11. APRNs providing care
via telemedicine to a patient located within the State of Arkansas shall be
licensed to practice nursing in the State of Arkansas.
SECTION XV
LICENSURE FOR CERTAIN MILITARY NURSES AND
SPOUSES
A.
EXPEDITED LICENSURE
1. Temporary
permits for an active duty military service member or their spouse stationed in
the State of Arkansas or a returning military veteran or their spouse applying
within one (1) year of his/her discharge from active duty shall be issued
within twenty-four (24) hours of receipt of all required documents.
2. The Board will give preference in the
order of processing to applications for full licensure filed by the following
individuals:
a. An active duty military
service member stationed in the State of Arkansas;
b. A returning military veteran applying
within one (1) year of his or her discharge from active duty; or
c. The spouse of a person under (a) or (b)
above
B.
EXTENSION OF LICENSURE EXPIRATION DATE
Upon written request and submission of appropriate
documentation, members of the Armed Forces of the United States who are ordered
to active duty outside of this state shall be allowed an extension of the
expiration date without penalty or assessment of a late fee for renewing the
service member's nursing license. The extension shall be effective for one
hundred eighty (180) days after the service member or spouse returns from
active deployment.
C.
CONSIDERATION OF MILITARY TRAINING AND EXPERIENCE
When considering an application for licensure from an active
duty military service member stationed in the State of Arkansas or a returning
military veteran applying within one (1) year of his or her discharge from
active duty, the Board shall:
1.
Consider whether or not the applicant's military training and experience in the
practice of nursing is substantially similar to the experience or education
required for licensure.
2. Accept
the applicant's military training and experience in the practice of nursing in
lieu of experience or education required for licensure, if the Board determines
that the military training and experience is a satisfactory substitute for the
experience or education required for licensure.
D.
WAIVER OF CONTINUING
EDUCATION
Upon written request and submission of appropriate
documentation the continuing education requirements for license renewal shall
be waived for:
1. An active duty
military service member deployed outside the State of Arkansas;
2. A returning military veteran renewing
within one (1) year of his/her discharge from active duty; or
3. The spouse of a person under (1) or (2)
above.