Prompted by the increased use in recent years of services performed by certified registered nurse practitioners ("CRNPs"), physician assistants ("PAs") and certified nurse midwives ("CNMs") (collectively "specified professional personnel"), on September 26, 2003, the Commonwealth of Pennsylvania Department of Health ("DOH") issued a Statement of Policy to clarify its interpretation of the current hospital regulations applicable to these specified professional personnel.
The Statement of Policy cautions hospitals that in order to use specified professional personnel to provide direct medical services, they must comply with existing regulatory and statutory standards, including pertinent requirements set forth in the Professional Nursing Law, the Medical Practice Act of 1985 and the Osteopathic Medical Practice Act and their implementing regulations. To monitor compliance with current statutory and regulatory standards, DOH launched an expansive evaluation of hospital practices germane to specified professional personnel. Beginning in late December 2003, DOH began reviewing hospitals' bylaws, policies, procedures and written agreements regarding specified professional personnel, both to ensure compliance with statutory and regulatory requirements and to verify that hospitals are complying with the procedures set forth in their own medical staff bylaws, rules and regulations.
DOH is also monitoring hospitals' compliance with the specific requirements discussed in the Statement of Policy. Specifically, DOH will permit CRNPs, PAs and CNMs to provide direct medical care in hospitals as "specified professional personnel" if the following requirements are met:
- The medical staff bylaws set forth the rules, regulations, qualifications, status, clinical duties and responsibilities of the specified professional personnel.
- The medical staff bylaws delineate the clinical privileges and duties of those specified professional personnel, as well as the responsibilities of the physician members of the medical staff in relation to the specified professional personnel.
- The medical staff bylaws specify who is authorized to evaluate the significance of medical histories, to authenticate medical histories, to perform and record physical examinations and to provide treatment.
If the above requirements are incorporated in the medical staff bylaws, CRNPs, PAs and CNMs are permitted to exercise judgment within their area of competence, provided that a physician member of the medical staff has the ultimate responsibility for patient care. The Statement of Policy also notes that some scope of practice rules for specified professional personnel require a written agreement between the physicians and specified professional personnel. These rules are clear and specific regarding the various provisions these agreements must include, as well as filing requirements and record-keeping requirements as to the agreements.
The Statement of Policy also emphasizes that the requirements in the scope of practice rules require the physician with whom a CRNP, PA or CNM has an agreement to remain on-site or readily available for consultation by telephone, radio, or telecommunications and, under certain circumstances, a physician must be physically present to direct PAs.
In addition, the Statement of Policy recognizes that specified professional personnel may write orders and record reports and progress notes in medical records of patients, within the limits established by the medical staff, and within the respective scope of practice limitations.
Lastly, the Statement of Policy requires hospitals to establish a committee in each area of practice, comprised of representatives from the medical and nursing staff and nursing administration, whose function is to establish standard written policies and procedures pertaining to the scope of practice of CRNPs in the medical management of the patient.
Is your facility ready for a DOH inspection? As a starting point, ask yourself the following questions:
- Do the files of your CRNPs, PAs and CNMs (whether employed or non-employed) contain all the required documentation (i.e., job description, delineation of privileges, collaborative agreement)?
- Is this documentation accurate and up-to-date?
- Do your medical staff bylaws incorporate the applicable rules, regulations and qualifications?
- Have you established committees, and are they appropriately staffed?
- Do the delineation of privileges; job descriptions; and the delegation of functions listed in your written agreements coincide?
- Have your agreements been approved by DOH and/or filed with DOH, as applicable?
- Do your agreements contain the appropriate provisions required by regulation or statute?
- Do you have copies of current licenses and certifications?