Download chapter 1: licensure issues

CHAPTER 1: LICENSURE ISSUES
Regulatory Bodies:
Illinois Department of Financial and Professional Regulation
www.ildfpr.com
Applicant Information - (217)782-8556
Licensee Information - (217)782-0458
Springfield Office:
320 West Washington St
Springfield, IL 62786
(217)785-0800
(217)524-6735 TDD
Chicago Office:
James R. Thompson Ctr
100 W. Randolph St
Suite 9-300
Chicago, IL 60601
(312)814-4500
U.S. Department of Justice, Drug Enforcement Agency, Drug Diversion Control Program
http://www.deadiversion.usdoj.gov/drugreg/index.html
Toll-free number in Washington, DC: 1-800-882-9539
Chicago Field Division:
Klucyzynski Federal Building
230 S. Dearborn Street, Suite 1200
Chicago, IL 60604
Telephone: (312) 353-5839
Fax: (312) 353-1235
Responsibilities of the Illinois Department of Financial and
Professional Regulation
The state agency that regulates nursing and numerous other health professionals in
Illinois is the Illinois Department of Financial and Professional Regulation (IDFPR).
IDFPR’s website is: www.ildfpr.com (yes, “.com”, not “.gov”). IDFPR regulates as
many as 165 different professions, the majority of which are not related to health
care. This system is different from many states where health professions are
regulated by freestanding boards (e.g., Board of Nursing, Board of Medicine, etc.)
that are staffed by state employees. In Illinois such boards are advisory in nature
and board members serve in a voluntary capacity where their only compensation, in
general, is reimbursement of travel expenses. In 1998, the Nursing Act stipulated
that there would be two boards: The Board of Nursing, which advises IDFPR on
nursing practice of licensed practical nurses (LPNs) and registered nurses (RNs) who
are not APNs, and the Advanced Practice Nursing Board, which focuses on APN
practice. This dichotomy of nursing boards was short-lived. As a result of Sunset Bill
2007, these two boards were merged into a single board that would advise IDPFR on
the regulation of nurses of all levels. Required seats on the board included members
to represent nursing in terms of LPN and RN education, practice, and administration.
Representation of the four APN specialties of certified nurse anesthetists, certified
nurse midwives, certified nurse practitioners, and clinical nurse specialists were
retained from the APN Board. A single public member is now required; however,
physician representation is no longer required.
As noted before, the Board of Nursing is an advisory in nature. The Nursing Act does
stipulate, however, that two employee positions in IDFPR be filled by registered
nurses with master’s degrees in nursing: the Nursing Act Coordinator and the
assistant(s) to the Nursing Act Coordinator. There have been prolonged vacancies in
these positions over the years, although the Nursing Act Coordinator position is
presently filled. Should either position be vacant, inquiries about nursing issues are
handled by other IDFPR employees.
IDFPR’s website is extremely informative and careful review of the website is often
more efficient than making a phone call to IDFPR. In addition to obtaining licensure
applications from this site, one can download copies of the Illinois Nursing and
Advanced Practice Nursing Act (“Nursing Act”), Controlled Substance Act, as well as
the practice acts for all other health professionals regulated by IDFPR (e.g.,
physicians, physician assistants, pharmacists, physical therapists, etc.).
Furthermore, all practices acts have their own rules for administration that are also
downloadable--but usually in a separate file. For one to truly understand the
regulations of a profession, it is vital to read both the practice act and its rules.
Nursing Act Citations in this Primer
While parts of practice acts are written in legal jargon, most of the verbiage can be
comprehended by someone who has education at the level of a licensed nurse.
Every nurse in Illinois should possess a copy of the Nursing Act and its accompanying
Rules for ready reference (downloadable at www.ildfpr.com) and read these
documents at least once. Fortunately, most of the language specific to APN practice
is contained in one section of the Nursing Act, which has the legal name of “225
Illinois Compiled Statutes 65” (225 ILCS 65/). Each section of the Nursing Act is
numbered by “articles” and “sections.” Most of the discussion regarding APN practice
is found under the heading “Article 65: Advanced Practice Nurses (not to be confused
with Statute 65 which is part of the legal name of the entire practice act). Thus, the
sections under Article 65 all have the numbering system of 65/65- (e.g., 65/65-5,
65/65-10, 65/65-15, etc.). To facilitate the reader’s substantiating the information
provide below, Nursing Act references have been included using this type of citation
convention. That said, some of the requirements related to APNs are contained in
sections of the Nursing Act other than Article 65.
The Rules for Administration for the Nursing and Advanced Practice Nursing Act have
a slightly different convention. For the time being, Part 1300 refers to the rules for
the Registered Professional Nurse and Licensed Practice Nurse. Part 1305 refers to
the rules for the Advanced Practice Nurse, so those sections have the numbering
system of 1305.____ (e.g., 1305.10, 1305.15, 1305.20, etc.). The Rules for the
2007 Nursing Act have yet to be written; when that happens, it is likely these
numbers will change.
APN Titles in Illinois
(65/50-10. Definitions)
In order to practice in Illinois, advanced practice nurses must possess at least two
current licenses as a: (a) Registered Professional Nurse (RN), and (b) Licensed
Advanced Practice Nurse (APN). (Note: The issue of the Illinois Controlled Substance
License will be discussed elsewhere). Registered Nurse and Advanced Practice Nurse are
“protected titles” in Illinois and only those who are currently licensed accordingly
may use those titles. Other protected titles include the APN specialties of: Certified
Nurse Midwife (CNM), Certified Nurse Practitioner (CNP), Certified Registered Nurse
Anesthetist (CRNA), and Clinical Nurse Specialist (CNS). It should be noted that
some APNs may be licensed in more than one specialty.
Throughout the first decade of APN licensure, APNs often asked the question, “How
should I sign my name?” Much of the confusion lies in the fact that other states
have other designations (e.g., APRN, ARNP) and certifying bodies assign a myriad of
other “credentials” (e.g., NP-C, FNP, PNP, GNP, WHNP, ANP, ACNP, etc.).
Furthermore, academic preparation also is identified by a variety of designations
(e.g., MS, MSN, ND, PhD, DNP, etc.). However, since 1998, the only “legal”
abbreviations (i.e., those that are recognized and/or required for charting or
prescribing) in Illinois have been those of RN, APN, and the APN’s respective
specialty of CRNA, CNM, CNP, or CNS. The 2007 Nursing Act is more specific and the
title of “APN” now assumes prominence. Therefore, regardless of specialty, every
practicing advanced practice nurse is expected to be identified first and foremost as
an APN, while including the specialty title is optional.
There are those, including this author, who lament that nursing appears to be
drowning in its own alphabet soup. Much effort was expended by many APNs and
other nurses over many years to obtain legal recognition. University of Illinois (a
state-funded university) and other institutions had been preparing APNs since the
early 1970s. Yet prior to 1998, when one inquired about APN licensure in Illinois,
IDFPR staff was known to say “APNs don’t exist in Illinois.” While APNs certainly did
exist at that time, APN licensure did not exist, nor was there was any clear reference
to APN practice in the Nursing Act. Therefore, my strong suggestion is that only the
titles noted in the Nursing Act be used in clinical practice and all other designations
be reserved for those situations where they would be recognized (e.g., scholarly
presentations or publications).
Regardless of academic preparation or certification, if a person does not possess a
current license as an APN, s/he may not use the any of the titles of “Advanced
Practice Nurse,” “Certified Nurse Midwife,” “Certified Nurse Practitioner,” “Certified
Registered Nurse Anesthetist,” or “Clinical Nurse Specialist” or any of the
abbreviations for those titles. Moreover, the Nursing Act says that “An Advanced
Practice Nurse shall verbally identify himself or herself as an advanced practice
nurse, including specialty certification, to each patient” (65/65-50, c). The 1998
Nursing Act included the admonishment that “No advanced practice nurse shall use
the title of doctor or associate his or her name or any other term to indicate to other
persons that he or she is qualified to engage in the general practice of medicine.”
Similar language has always been part of the physician assistant practice act. The
wording of this stipulation irked many APNs whose education included doctoral
preparation, especially since no such restriction existed for other professionals who
were not physicians (e.g., psychologists). Senate Bill 360 replaced the specific
restriction regarding using the title “Doctor,” so that the 2007 Nursing Act say simply
that: “No advanced practice nurse shall indicate to other persons that he or she is
qualified to engage in the practice of medicine” (65/65-50, a).
Reinforcing the fact that one is not a physician may require a concerted effort on an
APN’s part. Many patients just assume that an APN is a physician, even when the
APN has made every effort to identify him/herself appropriately. And some patients
insist on referring to their APN provider as “doctor,” even though they know perfectly
well that the provider is not a physician. Adherence to the law requires that the APN
make a sincere attempt to clarify his/her proper title.
Written Collaborative Agreements and Collaborative Relationships
(65/65-35. Written Collaborative Agreements)
In addition to being properly licensed, for the first time the 1998 Nursing Act
required APNs who are CNMs, CNPs, or CNSs to practice only if they have a written
collaborative agreement (WCA) with a “physician licensed to practice medicine in all
of its branches.” A physician licensed to practice medicine in all of its branches refers
to medical doctors (MDs) and doctors of osteopathy (DOs). As the nature of CRNA
practice tends to be different from that of other APNs, it was understood that a
typical collaborative agreement was of no benefit in guiding the work of CRNAs in
hospitals and ambulatory surgical treatment centers (ASTCs). Furthermore, there are
practice settings where CRNAs were allowed to provide anesthesia services “pursuant
to the order of” a licensed dentist or licensed podiatrist, which were collaborative
relationships not afforded other APNs. However, a CRNA who wished to have
prescriptive authority (meaning the authority to hand a patient a written
prescription) had to meet the same WCA requirements expected of other APNs.
The 2007 Nursing Act expanded the types of “doctors” with whom an APN may have
a WCA to include podiatrists. As had been accepted for the preceding decade, CRNAs
were still allowed to work with podiatrists and dentists. Added in 2007 was the ability
for other APNs (i.e., NPs and CNSs) to collaborate with podiatrists, as well as MDs
and DOs. However, NPs and CNSs who collaborate with podiatrists must still adhere
to the requirement that “The services of the advanced practice nurse shall be
services that the collaborating physician or podiatrist is authorize to and generally
provides to his or her patient in the normal course of his or her clinical medical
practice…” (65/65-35, b). In other words, an APN collaborating with a podiatrist is
not allowed to provide primary care or other services not generally considered the
purview of a podiatrist. The chief advantage to including podiatrists as a
collaborating doctor is for those APNs whose practice includes wound care, which is
common area of expertise for many CNSs and some NPs.
Throughout the decade following Illinois’ recognition of APNs, the employment
opportunities for all specialties of APNs surged in hospitals and some ASTCs
throughout the nation. As a result of these increased numbers of APNs of all
specialties in institutions, the Joint Commission on Accreditation on Health
Organizations (now called Joint Commission) issued a standard that APNs be
credentialed and privileged by the institutions where they worked. Typical
institutional credentialing and privileging process is very detailed; indeed, the
application process was standardized in Illinois by the Health Care Professional
Credentials Data Collection Act in 1999, the same year the Nursing Act was revised
to recognize APNs. It became obvious that the usual collaborative agreement was
superfluous to the entire credentialing and privileging process; thus, in 2007, the
requirement for a signed WCA was removed for all specialties of APNs who are
employed and privileged by hospitals and ASTCs. The purpose of this exception was
to facilitate the typical practice of APNs whose work in these institutions may involve
“writing orders,” including those for medication, but does not involve handing
patients prescriptions to be filled by pharmacies outside of the institution. If,
however, an APN is so privileged, but his/her position includes the actual writing of
prescriptions, s/he also is required to have a WCA. This provision regarding being
privileged in a hospital or ASCT is a real boon for APNs who work with several
physicians (e.g., the entire staff of the OB/Gyne department), as well as those APNs
such as some CNSs, whose practice is primarily to support other nursing services,
rather than providing care typically seen as the purview of medicine. However, the
Nursing Act does state: “If an advanced practice nurse engages in clinical practice
outside of a hospital or ambulatory surgical treatment center in which he or she is
authorized to practice, the advanced practice nurse must have a written collaborative
agreement” (65/65-35, a-5).
An APN may apply for an APN license before getting a written collaborative
agreement signed or becoming privileged, but s/he may NOT practice as an APN nor
should s/he identify himself or herself to patients as an APN without having an APN
license and without having a WCA or privileging in place.
Points that are to be included in the WCA are as follows (65/65-35):
“The agreement shall be defined to promote the exercise of professional
judgment by the advanced practice nurse commensurate with his or her
education and experience.”
“…describe the working relationship of the advanced practice nurse with the
collaborating physician or podiatrist and shall authorize the categories of care,
treatment, or procedures to be performed by the advanced practice nurse.”
(There is also language about a collaborative agreement with a dentist that
refers to subsection c-10 in this section. Subsection c-10 refers to CRNAs
exclusively.)
“Collaboration means the relationship under which an advanced practice
nurse works with a collaborating physician or podiatrist in an active clinical
practice to deliver health care services in accordance with (i) the advanced
practice nurse’s training, education, and experience and (ii) collaboration and
consultation as documented in a jointly developed written collaborative
agreement.”
“The agreement need not describe the exact steps that an advanced practice
nurse must take with respect to each specific condition, disease, or symptom
but must specify which authorized procedures require the presence of the
collaborating physician or podiatrist as the procedures are being performed.”
“The collaborative relationship under an agreement shall not be construed to
require the personal presence or podiatrist at all times at the place where
services are rendered. Methods of communication shall be available for
consultations with the collaborating physician or podiatrist in person or by
telecommunications in accordance with established written guidelines as set
forth in the written agreement.”
The 2007 Nursing Act added language that “The agreement must contain provisions
detailing notice for termination or change of status involving a written collaborative
agreement, except when such notice is for just cause.” The purpose of this language
was to provide some sort of protection against either the APN or collaborating
physician suddenly terminating their relationship and adversely affecting the practice
(and livelihood) of each, as well as the well-being of the patients under their care.
A sample (but not necessarily a model) WCA was provided at the very end of the
Rules of the 1998 Nursing Act. As noted before, the Rules have not yet been re-
written to conform to the language of the 2007 Nursing Act. In any case, the sample
WCA should be revised to reflect the nature of an APN’s practice of in a particular
setting. For example, language regarding CRNA practice is included in this sample,
so if there are no CRNAs working at a particular setting, that language should be
deleted.
Many attorneys feel that a WCA should be just specific enough to describe an APN’s
general scope of practice without being overly detailed. The WCA is not an
employment contract; therefore particulars about salary, benefits, work hours, etc.
should not be included in the WCA. The language in the sample WCA under “scope of
practice” has been written in general terms to cover what most APNs are prepared to
do, but APNs (and their legal counsel) will likely wish to include a few more details in
their own WCAs. For example, if an APN’s practice will be limited to only pediatric
patients or female patients, it makes sense to note that fact. Other descriptions of
scope of practice might clarify if the APN will be working with a select group of
patients (e.g., HIV-positive patients, rheumatology patients, etc.).
The sample WCA also includes sample attachments: (a) “Practice sites” (if the APN
will be working at more than one site), (b) Joint Orders or Guidelines”, and (c)
Delegation of Prescriptive authority. While the scope of practice is typically written
in very general language, the joint orders or guidelines provide more detail of the
parameters of the APN’s practice. This section is not as daunting to complete as it
would appear. A common approach is to list a few comprehensive references that
cover most of the clinical situations that the APN would be expected to handle.
Citing some of the very detailed textbooks that APNs relied on in their educational
programs is appropriate. Over time many “evidenced-based” guidelines are being
generated by national panels of experts for certain conditions, such as diabetes,
asthma, cardiovascular and lipid disease; thus, it makes sense to allude to the fact
that national standards of care will also serve to direct the APN’s care of patients. It
is important, however, to keep this list of references current, as it would be
imprudent to suggest that one is practicing according to outdated standards.
It is wise that the list of guidelines not be too lengthy, otherwise the APN is at risk
for failing to abide by some set of guidelines on the list. Furthermore, if an APN does
not follow the practice that is recommended by the references on the list, there
should be documentation (usually in the patient’s chart) why there was a deviation in
the usual standard of care. There are numerous, clinically-sound reasons why
patients might need individualized treatment not recommended by commonly
accepted standards of care. To minimize liability, APNs, as well as other providers,
simply need to substantiate their clinical reasoning for such deviation. Furthermore,
if an APN’s plan of care was developed as a result of a specific consultation with a
physician or other health care provider (in person or by telecommunication), it make
sense for the APN to document that communication.
A copy of the WCA is not routinely sent to IDFPR, as it has no storage space for the
WCAs of the thousands of APNs licensed in Illinois. However, a copy of the WCA,
signed by both the APN and the collaborating physician, must be available should
IDFPR request it. Both the advanced practice nurse and the collaborating physician
should have copies of the WCA. The 2007 Nursing Act replaces the requirement that
the WCA updated annually with the provision that it be updated “periodically.”
Role of the Collaborating Physician
The section on WCAs (65/65-35) further describes the relationship between an APN
and a collaborating physician as follows:
Collaboration does not require an employment relationship between the
collaborating physician and the advanced practice nurse. Collaboration means
the relationship under which an advanced practice nurse works with a
collaborating physician in an active clinical practice to deliver health care
services in accordance with (i) the advanced practice nurse’s training,
education, and experience, and (ii) collaboration and consultation as
documented in a jointly developed written collaborative agreement.
Thus, the APN always needs to have a mechanism for consultation and referral with
at least one physician, and that relationship is identified by the fact that both the
physician’s and the APN’s signatures must appear on the WCA. If the APN's
"ordained" collaborating physician is not available, there must be some physician(s)
available to provide the consultation and referral in the collaborating physician's
absence. This arrangement is noted in the sample WCA found at the end of the
Rules: “The advanced practice nurse shall consult with the collaborating physician by
telecommunication or in person as needed. In the absence of the designated
collaborating physician, another physician shall be available for consultation.”
Logistically, it is far easier if there is only one physician who has the designation of
collaborating physician because the collaborating physician has certain "duties" to
perform, such as the meeting monthly with the APN. The 1998 Nursing Act described
the monthly meeting as “monthly site visits,” which strongly suggested that the visit
had to be at the site where the APN actually rendered service. That implication posed
a particular problem for those APNs who had only one collaborating physician, but
worked at more than one geographic location. When the Rules were being written
between 1999 and 2001, the APN board wanted to clarify that the point of the 1998
law was that the APN and the collaborating physician needed to meet at least once a
month, but not necessarily at the location(s) of the APN’s practice. Thus, the Rules
included language that the site of the monthly visit was to be stipulated in the
collaborative agreement. Despite this attempt at clarification, many APNs (and
physicians and legal counsels) remained confused about monthly site visits, largely
because many who study the Nursing Act fail to include also reading its Rules.
Therefore, the 2007 Nursing Act language says that the collaborating physician or
podiatrist must meet “in person with the advanced practice nurse to provide
collaboration and consultation.” This 2007 language also replaced the expectation
that that the collaborating physician had to also provide “medical direction,” which
many APNs found objectionable.
In any case, it is clear that it is the signature of the official collaborating physician is
required on the WCA, but the Nursing Act does not stipulate that the collaborating
physician and the whole host of consulting physicians have to sign the WCA. In any
case, it seems logical that the reference to consulting physicians should be as
general as possible. Take, for example, if an APN were working in a large group
practice (XYZ Medical Practice) that employs several physicians. The APN would
specifically name the one physician who is her/his actual collaborating physician, but
note in the agreement that there are occasions where s/he will consult with any or all
physicians employed by XYZ Medical Practice (or all the physicians in a particular
department of XYZ Medical Practice). The point is that the WCA should not have to
be changed every time one of the consulting physicians leaves or joins the practice.
If an APN works with only one physician who has physician colleagues from other
practices take call or cover for his/her patients when s/he's out of town, an APN
might describe this situation in a generic fashion such as "in Dr. Jones' absence, will
consult with the physicians associated with ABD Medical Practice."
It is important that consulting physicians clearly understand their role. If an APN is
consulting with physicians within their own (large) practice, this is easily
accomplished because there are probably other internal documents that apprise
those physicians that they may be called upon to work with the APN from time to
time. However, if the APN is going to consult outside of the practice, then it would
probably be a good idea to have some signed document that indicates that this is
acceptable to those outside physicians. The main reason for such a document is to
prevent some physician from coming back at a later date claiming that s/he did not
agree to be the APN's consultant in the absence of the collaboration physician. Again,
this document should indicate that these other physicians are NOT the official
collaborating physician, to make it clear that these other physicians will not be
responsible for monthly site visits or ongoing oversight of the APN's practice.
As noted previously, the services that an APN provides to patients have to be similar
to those that the collaborating physician "generally provides to his or her patients in
the normal course of his or her clinical medical practice" (65/65-35). For example, if
an APN sees patients of all ages, and there isn’t a family practitioner available to be
the APN’s collaborating physician, then the APN would need to collaborate with at
least two collaborating physicians (e.g., a pediatrician and an internist). If the APN
works for multiple employers, the APN must have separate WCAs for each practice
setting which are signed by physicians affiliated with each practice setting.
Furthermore, the APN must provide copies of each WCA to each physician with whom
s/he has a collaborative relationship.
The 2007 Nursing Act reinforces certain 1998 notions about what constitutes
“adequate” collaboration and consultation if a collaborating physician or podiatrist
does the following: “Participates in the joint formulation and joint approval of orders
or guidelines with the advanced practice nurse and he or she periodically reviews
such orders and the services provided with patients under such orders in accordance
with accepted standards of medical practice and advanced nursing practice” (65/6535, c). However, what has changed in this language is that the collaborating
physician needs to only “periodically” review the WCA versus doing so on an annual
basis, as stipulated in 1998.
It is common for hospital or health systems to develop unnecessary policies that are
steeped in long-held traditions that are based on hearsay, versus actual statutory
requirements. For example, the Nursing Act does not require that a physician co-sign
an APN’s charting or perform chart audits. Nor, for that matter, do Joint Commission
or most reimbursers have such a requirement.
Furthermore, as noted in the citation above, the Nursing Act promotes the concept of
joint formulation and joint approval of orders or guidelines, thus implying that the
collaborative process is a two-way street, not a passive process for the APN.
Advanced practice nurses and their collaborating physicians should rejoice that the
Nursing Act allows variation and individuality in how they define their collaborative
relationships and seize the opportunity to develop creative and productive activities
that promote excellent, evidence-based care, that is enriching to all parties.
PRESCRIPTIVE AUTHORITY ISSUES
(65/65-40. Prescriptive authority.)
In Illinois, any licensed health professional who wishes to prescribe controlled
substances must possess three things: (a) a professional license that authorizes him
or her to do so, (b) an Illinois Controlled Substance License (CSL) which comes from
IDFPR and, (c) a federal Drug Enforcement Agency (DEA) number. Theoretically,
APNs who do not ever intend to prescribe controlled substances are not legally
required to obtain a CSL or DEA number. However, having a DEA number on a
prescription—even for a non-controlled substance—greatly facilitates a patient’s
getting the prescription filled. While the practice is controversial, most reimbursers,
including Medicaid, will not pay for a prescription without a DEA number, because
they use that number for tracking purposes. Furthermore, pharmacists are more
comfortable filling prescriptions with DEA numbers, because it provides some
assurance that the APN prescriber does, indeed, have prescriptive authority. As a
result, if a pharmacy does not have an APN’s DEA number on file, most pharmacists
will ask for it, even if the prescription is not for a controlled substance.
My suggestion is that all Illinois APNs endeavor to obtain a CSL and DEA number,
even if they never will prescribe a controlled substance. When one applies for both
documents, s/he must indicate which Schedule level s/he is authorized to prescribe.
Simply by applying for the “lowest” Schedule (i.e. Schedule V), s/he will still get a
DEA number. This may be an acceptable compromise between an APN and certain
collaborating physicians, because it will facilitate the APN’s writing prescriptions,
while the physician may feel more comfortable delegating authority to only those
drugs with the lowest abuse potential.
It should be noted that there is a difference between being a “prescriber” versus a
“transcriber.” All RNs in Illinois have the authority to be a “transcriber,” meaning
that they can provide a prescription in the same way that they write a verbal order in
a hospital where they sign the order (prescription) with the doctor’s name/their
name (e.g., J. Jones, MD/J. Doe, RN). Of course, no RN (including APNs) should ever
sign a prescription in this manner unless s/he has been specifically authorized to do
so by the physician whose name appears on the prescription.
However, prescriptions signed in this manner are considered to have been “written”
by the physician. Since APNs are RNs, they too might provide prescriptions in this
manner, and some institutions and physicians rely on this system rather than
delegating prescriptive authority in the APN’s collaborative agreement. The problem
with an APN’s being relegated to the transcriber status is that it fosters the
invisibility of typical APN practice to the rest of the world, and denies a key
distinction between an RN and an RN/APN; namely, that APNs are educated to be
prescribers. It poses logistical problems, too, since pharmacists will consider the
physician to be the prescriber, and will call the physician—not the APN—if there are
questions about how the prescription is written.
It should also be noted that the Nursing Act allows the prescription and dispensing of
legend drugs and legend controlled substances. The word “dispensing” is significant,
because in the past “dispensing” was considered the purview of only pharmacists and
physicians. The purpose of including the word “dispense” was to clarify that APNs
could sign for samples of medications provided by the sales staff of pharmaceutical
companies, as well has hand such samples to patients.
As noted previously, in Illinois, any health professional who wishes to prescribe
controlled substances must possess an Illinois CSL and a federal DEA number. The
CSL must be obtained first and information about that process is available on the
IDFPR website. Immediately upon receiving the CSL, the APN should submit an
application for the DEA number. It is possible to apply for a DEA number on-line—if
one is willing to use a credit card for payment. Alternatively, one can print the
application forms (PDF format—must have Adobe Acrobat Reader software) and
submit the information and payment by mail.
The DEA lumps APNs and Physician Assistants under the umbrella term “Mid-Level
Practitioners” (MLPs). Controlled substances fall into certain classes, “narcotic” or
“non-narcotic”, and are assigned to certain categories, called “schedules,” ranked
from Schedule I to Schedule V. The schedule numbers are in inverse order of their
restrictiveness. Schedule I controlled substances have no accepted medical use in
the U.S. and are considered to have a high abuse potential. Examples include heroin,
LSD, peyote and—in the DEA’s opinion--marijuana. Schedule V substances are
considered to have the least abuse potential and consist primarily of preparations
containing limited quantities of narcotic and stimulant drugs, such as those used for
antitussive, antidiarrheal, and analgesic purposes. A more complete list of which
narcotics fall into which Schedules can be found on the DEA website in the
instructions for completing the DEA application.
In Illinois, MLPs have delegated prescriptive authority. Therefore, an APN’s authority
must be noted in the written collaborative agreement that is signed by the APN and
her/his collaborating physician(s). For PAs, that authority must be delegated by the
PA’s supervisory physician(s). (More about the distinctions between APNs and PAs is
provided elsewhere.) If the collaborating physician intends to delegate prescriptive
authority for non-scheduled drugs (also called “legend” drugs) and scheduled drugs,
that authority must be clear in the APN’s collaborative agreement in order for the
APN to apply for a CSL and DEA number.
While the 1991 Nursing Act was historic in its scope of authority for APNs, there was
one notable shortcoming; namely, it limited an APN’s authority to prescribe
scheduled drugs to only Schedules III, IV, and V. Thus, those APNs who cared for
patients with ADHD or worked in settings involving pain control, faced a huge
challenge to their practice. While Illinois APNs have not completely won the battle of
full plenary prescriptive authority, the 2007 Nursing Act has opened the door for
prescribing Schedule II drugs. A collaborating physician or podiatrist may (but is not
required) to delegate authority to an APN to prescribe up to 5 Schedule II controlled
substances by oral dosage. These substances must be those that the collaborating
physician or podiatrist prescribes in his/her practice. Other restrictions include:
“Any prescription must be limited to no more than a 30-day oral dosage, with any
continuation authorized only after prior approval of the collaborating physician”
(65/65-40, d, 3).
“The advanced practice nurse must discuss the condition of any patients for whom a
controlled substance is prescribed monthly with the delegating physician”(65/65-40,
d, 4).”
While this language regarding Schedule II substances is ponderous, it certainly is a
step in the right direction. However, it must be noted that no APN should be
writing prescriptions for Schedule II substances yet! First of all, as has been
noted previously, these finer points in the Nursing Act are not really law until Rules
have been written to hammer out the details. Secondly, since the passage of the
new Nursing Act in October, 2007, we have since learned that the DEA has some
“issues” with the new language of the Act, the details of which have not become
public knowledge. The Illinois Society for Advanced Practice Nursing’s lobbying team
is prepared introduced a bill early in 2008 to rectify this discrepancy. Due to the
complex political climate of the Illinois General Assembly in 2008, there was no
movement on this bill (as was true for many, many of bills not related to health care
or nursing). We expect that once certain political distractions are resolved, the bill
will be passed in a timely fashion.
HOW PRESCRIPTIONS SHOULD “LOOK”
The nursing act stipulates that the prescriptions written by the APN prescriber need
to have the following information (1304.50 Prescriptive Authority):
The APN’s name
The APN’s collaborating physician’s name
The APN’s signature, but not the collaborating physician’s signature.
The above information is all that is specifically stipulated in the Rules of the Nursing
Act. As a result, the appearance of prescription pads that APNs use vary greatly and
are largely dependent on where the APN practices. Having the APN’s name and
physician’s name commercially printed on the prescription enhances legibility, but
having this information pre-printed is not required. As noted previously, patients
have an easier time getting prescriptions filled if the DEA number is included. Some
practices have a great deal of information on pre-printed prescription pads such as
the name of the practice, the address(es) of the practice, the names of all the
prescribers in the practice (e.g., all the doctors and all the APNs), and the DEA
number of each prescriber. Some practices, however, are not comfortable with
having DEA numbers pre-printed, for fear that the pads might be stolen and used for
fraudulent prescriptions. In such practices, the prescriber should hand-write the DEA
number.
While not stipulated in either the Nursing Act or Rules, other information has been
provided during meetings of the IDFPR APN Board. For example, in 1998 the DEA
informed IDFPR that if the APN is the prescriber, it is never appropriate to affix the
collaborating physician’s DEA number on a prescription. In other words, the DEA
number must be the one assigned to the person who is considered to be the actual
prescriber. Furthermore, it is acknowledged that pharmacists do not have access to
an APN’s collaborative agreement to see if the medication s/he has prescribed is
within his or her scope of practice. Pharmacists are held to a “good faith” standard;
namely, if prescription does not appear blatantly incorrect or inappropriate, they are
at liberty and expected to fill it. Obviously, it is the APN’s responsibility to see that
s/he prescribes only those medications that s/he is familiar with, are within the scope
of practice described in her/his collaborative agreement and be consistent with the
delegation noted in her/his CSL application.
Despite an APN’s best efforts, there can be complications in adhering to the law. In
2003, one APN was visited by IDFPR investigators responding to a complaint that she
had indicated that she was qualified “to engage in the general practice of medicine.”
The problem arose from the fact that although she was writing prescriptions exactly
according to the letter of the law, various pharmacies were putting printed labels on
the medication bottles with her name behind the word “Dr.” Obviously, these labels
were generated by computer software where the prescriber’s name was typed in a
space that followed the template of “Dr.” As the APN worked in a rural practice, she
was able to immediately contact every pharmacy where her patients were likely to
get their prescriptions filled, about seven sites in all. The pharmacies’ initial reaction
was that they were unable to change the default template. However, after receiving
a written letter from the APN explaining that if they did not find a way to list her by
her name, followed by CNP or APN, she would have to insist that the patients take
their business elsewhere. Virtually every pharmacy complied with her request within
24 to 48 hours.
APN and RN License Renewal
No one can practice as an APN unless his/her RN and APN licenses are both current.
RN and APN licenses are on a 2-year cycle, renewable during the even-numbered
years. Although the Nursing Act was revised in 1998, the Rules for the revised
language were not promulgated until 2001. As a result, the first APN licenses were
issued “off-cycle,” and so were in effect for a one time-only cycle of three years.
Thus, in 2004, the APN license became in sync with RN license cycle. Controlled
substance licenses, for the APNs who have them, are also renewable in the evennumbered years. Renewing these licenses require completing separate applications
and paying certain fees for each license. License renewal can be done by mail with
check or credit card payment, or over the telephone with a credit card payment only.
It should be noted that DEA numbers, however, are renewed every three years, and
has this number comes from the federal government, the renewal process is entirely
separate from that of an state CSL.
Basic Requirements for an APN License
When the bill that revised the Nursing Act was negotiated in the years of 1997-1998,
there was general consensus among all those at the negotiating table that the gold
standard of APN credentials should be graduate education and certification in the
APN’s specialty. However, there were many APNs at the time who had been
practicing for years who could not meet either or both of these standards. The
overwhelming majority of practicing CNMs and CRNAs were certified, as their
specialties had more or less mandated certification years before; however, many did
not have graduate degrees. Clinical nurse specialists, on the other hand, were
generally master’s-prepared, because for years academia had defined the education
of the CNS to be at the master’s level. However, only a minority of CNS were
certified. The practice of CNSs varies widely and includes so many subspecialties that
if a CNS was certified at all, chances are the certification was a specific nursing
subspecialty and available to RNs who were not truly educated as CNSs (e.g.,
orthopedics, critical care, etc.). Finally, there was the case of nurse practitioners
whose education ran the gamut. In the mid-1960s and early 1970s, some had been
trained in 1:1 apprenticeships or employer-based programs that lasted less than a
year, while others had bachelor’s or master’s degree preparation. And like CNSs, not
all nurse practitioners were certified.
When the Nursing Act was passed in 1998, there was “grandfathering” language that
would allow those currently practicing to apply for an APN license if they didn’t meet
both the certification and graduate education requirements, provided they did so by
July, 2001. At the time, the negotiators for the bill thought a three-year
grandfathering provision was reasonable, since they never envisioned that the first
APN licenses would not be obtainable until April, 2001. The window of
grandfathering was expected to be three years, not three months. The
grandfathering language was part of the Nursing Act statute, not the Rules; thus, it
could be changed only by passing another bill by the Illinois General Assembly, which
was not legislatively feasible. As a result, there were some APNs who had not been
following the permutations of the Nursing Act over the years and failed to apply by
the July, 2001, deadline. As a result, those APNs could no longer use an APN title,
nor could they engage in practice that was clearly APN in nature.
In 2003, in answer to a serious shortage of anesthesia providers in Illinois, the
Nursing Act was revised to grant CRNAs a brief window exempting them from the
graduate degree requirement. This exemption was only for those CRNAs who
completed their anesthesia program prior to January 1, 1999 and continually
maintained active, up-to-date recertification status as a CRNA. This exemption was
designed to especially encourage CRNAs from out-of-state to practice in Illinois and
expired on December 31, 2006.
Changing the Collaborating physician Named on the Controlled
Substance License and DEA Number
Collaborative agreements are null and void if an APN changes jobs or his/her
collaborating physician leaves the practice, or for any other reason a physician is no
longer available to collaborate with the APN. When it appears that a collaborative
arrangement will be dissolved, the APN should go to the IDFPR website
(www.ildfpr.com) and download two documents: (a) Termination of Delegation of
Prescriptive Authority, and (b) Delegation of Prescriptive Authority. The
"Termination" form has to be signed by the soon-to-be "outgoing" collaborating
physician. There's a place to indicate the date that the termination will take place, so
the APN should be sure to get this form signed before s/he and the collaborating
physician part company. Then the APN should get the "Delegation" form signed by
her/his new collaborating physician prior to prescribing under that relationship.
These forms will generate a new form from IDFPR (gets mailed to the "outgoing" and
"incoming" collaborating physicians) that clarifies the APN's authority related to
her/his controlled substance license. The DEA doesn't need to know about a change
in collaborating physicians; that's handled through the controlled substance license.
However, it might need to know a change of employment--if an former employer’s
address that was indicated on the DEA application.
Continuing Education Requirements for APNs
(65/15-45; 1305:100)
The first time that APNs needed to obtain 50 hours of Continuing Education (CE) was
during the licensing cycle 2004 - 2006. However, this CE requirement for licensure
has nothing to do with keeping one’s certification current. It is up to the APN to
differentiate how to comply with Illinois license requirements and his/her respective
certification requirements. IDFPR does not intend to have everyone submit proof of
CE as is done with some certifying bodies. However, at any given time the IDFPR has
the right to perform random audits. Therefore, it behooves all APNs to always be
prepared to show proof of their CE.
A list organizations from which continuing education credit is acceptable is contained
in the Rules (1305.100) In general, if a certain type of continuing education credit is
allowed by the certifying bodies accepted by IDFPR, chances are that credit will be
accepted for licensure renewal.
Temporary APN Licensure
Some APNs who have not yet taken or have not received results from a certification
examination wonder if they might temporarily practice under an "APN license
pending status.” Adding to the confusion is that the section on APN license pending
status follows immediately after the list of “Qualifications for APN licensure,” so a few
new graduates have misinterpreted this sequence of verbiage as a sequence of steps
to be taken for licensure. And adding even more confusion is that IDPFR does not
use consistent vocabulary. The Nursing Act refers to “APN license pending status”,
but information on applying for this status is buried within the APN licensure packet
on page 4, under the heading "Temporary Permit." There is not a specific link for this
form on the website anywhere. Most APN graduates should NOT bother to apply for a
temporary permit. The way IDFPR has interpreted the law regarding license pending
is such that it will benefit very few people to apply for this status (permit).
Furthermore, it may take several weeks to get a temporary permit, so it will not
greatly facilitate an APN’s job search. Of course, instructions and application for
licensure can be found at www.ildfpr.com).
The best advice is that new APN graduates take their certification examinations just
as soon as they possibly can. It is possible to submit an APN license application with
every section completed except the box indicating the name of the certifying
organization and the date of certification. This box can be completed by indicating
when the applicant expects to take the certification examination. IDFPR creates files
for applicants once the application is received; however, a license is not generated
until all necessary documents (and payment) are received. The applicant may get a
jumpstart on the process by submitting all available documents, so the file will be
ready to process just as soon as s/he sends proof of certification.
New graduates should not fall into the trap of planning to study for several months
post-graduation, thinking that they will be better prepared to take their exam. While
some study is a good idea and taking courses for certification examination
preparation can be helpful, for the overwhelming majority of APNs, taking their
certification examination shortly after graduation is the best bet. The greater the
time that passes between graduation and taking the examination usually means the
less the graduate remembers.
The only people who might benefit from the temporary permit are those people who
for some reason or another, simply cannot take their certification examinations in a
timely fashion. However, it must be understood that APNs working under a
temporary permit can not write prescriptions.
Credentialing and Privileging
Credentialing and privileging (C & P) is a process that all physicians who wish to
admit and treat patients in a hospital have to undergo. Due to the nature of their
practices, CNMs and CRNAs are familiar with the C & P process; however, other APNs
traditionally have not been expected to undergo this process. While the C & P
process is ponderous, there are many reasons that all APNs should insist that a
mechanism be developed for them. First of all, the C & P process refutes the notion
that a “nurse is a nurse is a nurse.” Secondly, Joint Commission strongly
recommends that providers such as APNs and PAs go through the process.
Many hospitals struggle with the best way handle the C & P process for APNs. Some
have the APNs complete the process entirely through their institution’s medical staff
office. Others have a process that is completed through their nursing office and
forwarded to the medical staff office. Some hospitals still let the human resources
department handle the process; however, not all human resource departments are
sufficiently trained to do so.
The C & P process reminds us that when APNs “order” medications in the hospital, it
is not the same as “prescribing” as delineated in the Nursing Act. Prescribing is the
act of writing a prescription that a patient takes to his/her pharmacy for outpatient
use. Ordering is a process that exists in the inpatient setting. The definition of
prescribing is noted in the Pharmacy Act, whereas that same act does not address
the act of ordering in a hospital. Ordering of medications (as opposed to writing
orders in general) isn't really covered in the Hospital Licensing Act, either.
It should be noted that even when there was no mechanism for APNs to "prescribe"
Schedule II medications, several hospitals had chosen to credential and privilege
their APN employees to order some Schedule II medications. For example, some
CNMs have a collaborative agreement and privileging document that alludes to their
ability to "provide pain management for the purpose of labor and delivery"; as a
result, they are in a position to order morphine and other Schedule II analgesic
agents. Concomitantly, this provision would be noted in the CNM’s C & P application.
The other issue is whether APNs can write orders in a hospital. Unless an APN has
undergone the C & P process, s/he could only "write" any orders is like any other RN
in the hospital; namely, as a verbal order, "J.Jones, MD/J. Steuer, CNP." Many
hospitals rely on this "old-fashioned" way of doing things rather than ponder the
thorny issues of how APNs should be allowed to practice in a hospital, which often
requires a change in medical staff bylaws.
Legal Differences Between APNs and Physician Assistants
(225 Illinois Compiled Statutes 95/ -- The Physician Assistant Practice)
In Illinois, the relationship between physicians and APNs is distinctly different from
the relationship between physicians and physician assistants (PAs). Physician
assistants by law are supervised by physicians, whereas APNs collaborate with
physicians. The different verbiage in the Physician Assistant Act and the Nursing Act
is not an accident; rather it is a result of long hours of negotiation between APN
leaders and representatives from physician associations. Another major difference
between the Physician Assistant Practice Act and the Nursing Act is the issue of
“ratios.” A physician is allowed to supervise only two PAs, although PAs may have
more than one supervisory physician (thus allowing a PA to have more than one
employer). Such ratios do not exist for APNs, as a result of intense political
negotiations back in 1997 and 1998.
Furthermore, the Physician Assistant Practice Act has specific language regarding
reimbursement for services.
A physician assistant shall not be allowed to bill patients or in any way charge for services.
Nothing in this Act, however, shall be so construed as to prevent the employer of a physician
assistant from charging for services rendered by the physician assistant. Payment for services
shall be made to his or her employer if the payor would have made payment had the services
been provided by a physician licensed to practice medicine in all its branches.
The Nursing Act has no such restrictions regarding reimbursement; indeed, many
APNs in Illinois have their own practices and receive payment directly from insurance
companies and patients.
Finally, there is a difference in educational requirements of APNs versus PAs. A
physician assistant is defined as a person “who has been certified as a physician
assistant by the National Commission on the Certification of Physician Assistants or
equivalent successor agency and performs procedures under the supervision of a
physician as defined in this Act” (225 ILCS 95/4). The act itself does not delineate
any educational requirements, but it is known that the degrees that PAs programs
award are varied, ranging from associate degrees to master’s degrees.
As discussed previously, with the exception of the extended grandfathering for the
CRNA, APN education is required to be at the graduate level.
Finally, it should be noted that the authority for APNs to prescribe Schedule II
medications added to the 2007 Nursing Act (albeit with some restrictions) was not
extended to physician assistants.