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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.