Update on APRN Supervision Rules for Hospitals with Physician Practices
Hospitals with physician practices should be mindful of the requirements for supervision of mid-level practitioners in light of the dynamic regulatory environment relating to physician supervision of Advance Practice Registered Nurses (APRNs). There are potential changes to APRN supervision requirements coming from the Louisiana State Board of Medical Examiners (LSBME) for physicians who work with these mid-level practitioners. The following chart, and the article below provide a summary of the current state of the supervision regulations relating to both APRNs and Physician Assistants (PAs), followed by a discussion of the proposed changes.| Ratio | On-Site visits required | |
| PA Supervision | Primary Supervising Physician 1:2 Supervising Physician 1:4 | For PA’s with prescriptive authority whose primary practice site is different than the supervising physician, the supervising physician must visit site weekly and verify PA is utilizing prescriptive authority within clinical practice guidelines |
| APRN Supervision (CURRENT) | None | No on-site visits required; for APRNs with prescriptive authority, a physician shall be available by telephone or direct telecommunications for consultation, assistance with medical emergencies or patient referral, as delineated in CPA; if collaborating physician is unavailable, the APRN will not prescribe |
| APRN Supervision (PROPOSED) | If APRN and physician do not share a practice site, 1:4 proposed unless an exception applies. | If APRN and physician do not share a practice site, quarterly visit required; review 10% or 20 charts, whichever is less |
LSBN Regulations on APRN Supervision
Historically, the Louisiana State Board of Nursing (LSBN) has regulated APRN practice in Louisiana. APRNs are generally required to have an LSBN-approved Collaborative Practice Agreement in place with a physician and are subject to other limitations in light of their scope of practice. Although previously the LSBN imposed a limit on the number of APRNs who could be supervised by a single physician, that limit was removed in the early 2000’s, which was consistent with national trends. Since then, there has been no ratio requirement/limitation. The LSBN rules do not require on-site visits where the APRN practices in a location different from that of the physician.
For APRNs with prescriptive authority, the Collaborative Practice Agreement must document the availability of the collaborating physician for consultation, medical emergency assistance or patient referrals when the physician is not physically present. See LAC 46:XLVII.4513(D)(1)(e)(vi)(c). If neither the collaborating physician nor back-up collaborating physicians are present, the APRN is prohibited from prescribing. See LAC 46:XLV.451109A)(4).
LSBME Regulations on PA Supervision
Although the LSBME has not historically regulated APRN practice, it does regulate PA practice in Louisiana, and these supervision requirements are generally more onerous than the ones imposed by the LSBN on APRN supervision. Under the current regulations, a Supervising Physician (SP) may not serve as a Primary Supervising Physician (PSP) for more than two PAs and may not act as a SP for more than four PAs simultaneously. See LAC 46:XLV.4507(D). Within 24 hours of the patient encounter, the SP must cosign every patient encounter entered by the PA. See LAC 46:XLV.4511(A)(4).
If the PA has prescriptive authority and has a primary practice site different than that of the SP, the SP must visit the PA’s primary practice site weekly. See LAC 46:XLV.4511(A)(5)(a). Notably, some practitioners view the co-signature requirement and the SP:PA supervision limitation as onerous and arbitrary, and would like to see a better balance between healthcare regulation and the delivery of integrated team care. See Margo Pierce, Frustrated Dream or Possible Reality? Healthcare Journal of Baton Rouge, May/June 2014, at 39-40
Proposed LSBME Regulations on APRN Supervision
In its March 17, 2014 meeting, the LSBME introduced draft regulations relating to APRN supervision by physicians. These proposed regulations are currently continuing through the administrative rulemaking process. If promulgated, the draft rules will place more obligations on physicians who supervise APRNs by limiting the number of APRNs who can be supervised and requiring closer monitoring. A copy of the draft rule is available here.
The regulation would impose the most notable new requirements where the supervising physician and APRN do not share a practice site. In those situations, the supervising physician would be limited to supervising four APRNs and would be required to maintain a practice site that is geographically located in order to accommodate patient referrals by the APRN. See Proposed LAC 77:XLV.7715(B). Further, the supervising physician would be required to make quarterly visits to the APRN’s practice site during office hours and review at 10% or 20 charts, whichever is less except for physician collaboration for patients of a hospital, nursing home or hospice licensed by the Louisiana Department of Health and Hospitals.
The impact of the draft rule is limited by a large number of exceptions:
- It is inapplicable when the APRN does not engage in acts of medical diagnosis or prescriptions (Proposed LAC 77:XLV.7707(1))
- It is inapplicable for APRNs who are exempt from collaborative practice pursuant to La. R.S. 37:930, which governs Certified Registered Nurse Anesthetist administration of anesthesia (Proposed LAC 77:XLV.7707(1)).
- It does not apply to patients in any facility or clinic maintained or operated by the United States or any of its departments, offices or agencies (Proposed LAC 77:XLV.7707(2)).
- It is inapplicable in a declared emergency or disaster (Proposed LAC 77:XLV.7707(3)).
- The requirements relating to non-shared practice sites do not apply in home health or hospice settings (Proposed LAC 77:XLV.7715(C)).
- The 1:4 ratio requirements do not apply to clinics maintained by the state of Louisiana, parish health departments and other governmental entities (i.e., in those settings, one physician can supervise more than 4 APRNs.) (Proposed LAC 77:XLV.7715(B)(3)).
- Thus, the proposed regulation has the most significant application where a physician supervises the practice of an APRN in a clinical setting, where the clinic is not operated by a governmental entity, and where the physician and APRN do not share a practice site.
Notably, in the recent legislative session, legislation was introduced that would have prevented the LSBME from limiting “the right of a physician and an advanced practice registered nurse to engage in a collaborative practice agreement as provided in R.S. 37:913.” See House Bill 1215, 2014 Regular Legislative Session. The legislation failed to pass. Accordingly, it is anticipated that the LSBME’s draft rule will continue to proceed through the rulemaking process. Hospitals with clinics staffed by physicians and mid-level providers should be mindful of these regulations which are making their way through the administrative rulemaking process.
