Three States Auditing NPs for Compliance with Regulations
Three States Auditing NPs for Compliance with Regulations
Boards of nursing or medical boards in Alabama, North Carolina, and Virginia are conducting audits of nurse practitioners (NPs) to determine whether they and their physician collaborators are complying with state regulations.
In Alabama, a registered nurse employed by the state board of medical examiners conducts the visits. The visits focus on the requirements of Alabama Regulation 610-X-5-.08, which requires, among other things, the following:
If the auditor finds noncompliance with a part of the regulation, she reports the physician to the board of medical examiners and the physician is reprimanded.
This regulation, coupled with the audits, tends to put a chill on physicians who are considering hiring an NP. The regulation requires an additional layer of record-keeping. While the regulation has been there for years, I suspect that few were actually going through the hassles of keeping detailed records of physician hours and site visits when no one was checking. Now, everyone must attend to these details.
In North Carolina, an NP may get a visit from either the medical board or the board of nursing or both. The NP gets 24 hours' notice. The site visit form, which is at www.ncbon.com, addresses the following, among other things:
In Virginia, the board of nursing is conducting the audits, which focus on verification of 3 things: professional certification, continuing education, and that the NP has protocols. A protocol is defined as a written statement, jointly developed by the collaborating physician and the NP, that directs and describes the procedures to be followed and the delegated medical acts appropriate to the specialty practice area to be performed by the NP in the care and management of patients. The protocol is not the same as a practice agreement. In Virginia, an NP must submit a practice agreement to the board of nursing for the NP to prescribe, and the board must approve the agreement. NPs in Virginia must develop protocols and keep them at the practice site but need not submit them to the board.
It appears that the Virginia board is conducting the audits by mail, and requires that the NP submit the specified documents. However, the board, in a notice to NPs stating that the board would be conducting the audits, reminded NPs of the requirement that a physician regularly practice in the location where the NP prescribes, unless the practice fits an exception or, in the case of the excepted sites, the physician must make a quarterly site visit. In addition, the physician must conduct a monthly, random review of patient charts on which the NP has entered a prescription.
Are these audits a trend toward increased scrutiny of NPs? Maybe, but they do not surprise me. It is rare that regulations exist without enforcement activities. In many states, there has been a surprising lack of attention to enforcement of the regulations regarding NP collaboration. This can lead to a false sense of independence for NPs. For example, if a state requires an NP to have a physician collaborator and meet with the collaborator quarterly, but no one ever checks to determine whether the meetings occur, NPs tend to forget that there is such a requirement. NPs may never have reason to consult with their collaborator and therefore feel like they practice independently. They don't see why they should bother trying to get rid of outdated and unnecessary legal requirements, because everything is running smoothly as is.
The trouble with letting such laws stand is twofold. First, if an NP is found to be in violation of a regulation (for example, the board of nursing asks for documentation of quarterly visits with the collaborator and the NP cannot produce it), the NP could be risking his or her license. At minimum, the NP will need to bear the cost of the defense and, even in the best-case scenario, the NP will have a record of a violation with the board.
Second, “collaboration’ may be a sham for some NPs (unnecessary, unwanted, and unused), but the legal requirement comes back to haunt NPs whenever an agency or facility wants to start a new program featuring NPs, an NP wants to start a practice, or NPs try to get reimbursed by private payers. Physicians bring it up whenever they need to, when trying to shut NPs out of opportunities. NPs tend to understand it when a NP says: “I practice independently and make my own decisions. Even though a physician collaborator is required by law, I never consult my collaborator.’ However, most people would not have a positive response to that statement. Legislators, judges, businesspeople, and the public expect laws to be followed.
So, in my opinion, these audits needed to happen. If NPs and the physicians who employ NPs have to go through the hassles required by outdated statutes and regulations, perhaps they will be receptive to changing the laws.
Boards of nursing or medical boards in Alabama, North Carolina, and Virginia are conducting audits of nurse practitioners (NPs) to determine whether they and their physician collaborators are complying with state regulations.
In Alabama, a registered nurse employed by the state board of medical examiners conducts the visits. The visits focus on the requirements of Alabama Regulation 610-X-5-.08, which requires, among other things, the following:
The collaborating physician be present with the NP at an approved collaborative practice site (office) for not less than 10% of the NP's scheduled hours.
The physician visit each site not less than quarterly.
A written standard protocol specific to the specialty practice area of the NP and the physician identifies all sites where the NP will practice, identifies the physician principal practice site, and includes a formulary of drugs, devices, medical treatments, tests, and procedures that may be prescribed, ordered, and implemented by the NP.
If the auditor finds noncompliance with a part of the regulation, she reports the physician to the board of medical examiners and the physician is reprimanded.
This regulation, coupled with the audits, tends to put a chill on physicians who are considering hiring an NP. The regulation requires an additional layer of record-keeping. While the regulation has been there for years, I suspect that few were actually going through the hassles of keeping detailed records of physician hours and site visits when no one was checking. Now, everyone must attend to these details.
In North Carolina, an NP may get a visit from either the medical board or the board of nursing or both. The NP gets 24 hours' notice. The site visit form, which is at www.ncbon.com, addresses the following, among other things:
Whether there is a signed and dated agreement for each back-up physician.
If the NP has “interim status,’ whether there is documentation of weekly face-to-face consultations with the primary supervising physician, and whether there is evidence of physician countersigning of notations of medical acts within 2 working days of the NP-patient visit.
Documentation of 100 contact hours of continuing education every 2 years.
Drugs and devices being prescribed are included in the collaborative practice agreement.
Proof of current DEA license.
If an NP dispenses, proof of current board of pharmacy permit to dispense.
If a collaborative practice agreement is older than 1 year, annual review is indicated by a signature sheet signed by the NP and the supervising physicians.
When a Collaborative Practice Agreement has continued for at least 6 months, evidence that that the NP and primary supervising physician have met every 6 months and documentation of the clinical problems they discussed and progress toward improving outcomes and recommendations, if any, for changes in treatment, with documentation retained for 5 previous calendar years.
In Virginia, the board of nursing is conducting the audits, which focus on verification of 3 things: professional certification, continuing education, and that the NP has protocols. A protocol is defined as a written statement, jointly developed by the collaborating physician and the NP, that directs and describes the procedures to be followed and the delegated medical acts appropriate to the specialty practice area to be performed by the NP in the care and management of patients. The protocol is not the same as a practice agreement. In Virginia, an NP must submit a practice agreement to the board of nursing for the NP to prescribe, and the board must approve the agreement. NPs in Virginia must develop protocols and keep them at the practice site but need not submit them to the board.
It appears that the Virginia board is conducting the audits by mail, and requires that the NP submit the specified documents. However, the board, in a notice to NPs stating that the board would be conducting the audits, reminded NPs of the requirement that a physician regularly practice in the location where the NP prescribes, unless the practice fits an exception or, in the case of the excepted sites, the physician must make a quarterly site visit. In addition, the physician must conduct a monthly, random review of patient charts on which the NP has entered a prescription.
Are these audits a trend toward increased scrutiny of NPs? Maybe, but they do not surprise me. It is rare that regulations exist without enforcement activities. In many states, there has been a surprising lack of attention to enforcement of the regulations regarding NP collaboration. This can lead to a false sense of independence for NPs. For example, if a state requires an NP to have a physician collaborator and meet with the collaborator quarterly, but no one ever checks to determine whether the meetings occur, NPs tend to forget that there is such a requirement. NPs may never have reason to consult with their collaborator and therefore feel like they practice independently. They don't see why they should bother trying to get rid of outdated and unnecessary legal requirements, because everything is running smoothly as is.
The trouble with letting such laws stand is twofold. First, if an NP is found to be in violation of a regulation (for example, the board of nursing asks for documentation of quarterly visits with the collaborator and the NP cannot produce it), the NP could be risking his or her license. At minimum, the NP will need to bear the cost of the defense and, even in the best-case scenario, the NP will have a record of a violation with the board.
Second, “collaboration’ may be a sham for some NPs (unnecessary, unwanted, and unused), but the legal requirement comes back to haunt NPs whenever an agency or facility wants to start a new program featuring NPs, an NP wants to start a practice, or NPs try to get reimbursed by private payers. Physicians bring it up whenever they need to, when trying to shut NPs out of opportunities. NPs tend to understand it when a NP says: “I practice independently and make my own decisions. Even though a physician collaborator is required by law, I never consult my collaborator.’ However, most people would not have a positive response to that statement. Legislators, judges, businesspeople, and the public expect laws to be followed.
So, in my opinion, these audits needed to happen. If NPs and the physicians who employ NPs have to go through the hassles required by outdated statutes and regulations, perhaps they will be receptive to changing the laws.
