Standardized procedures for Nurse Practitioners (CA)

SUD Specialty Group – CA, Mental Health Specialty Group, P.A., and Mental Health Specialty Group NJ, PC (collectively, “Group”) contracts with Rula for management and administrative support services.  This policy applies to the Group and Rula. 

Policy Statement

In compliance with the  Nursing Practice Act (NPA) (Section 2725), California Code of Regulation (CCR) Title 16, CCR Section 1480 and through the Business and Profession code, this policy sets out the following for the establishment of Standardized Procedures that are utilized by registered nurses and nurse practitioners in order to perform functions which would otherwise be considered the practice of medicine. 

Standardized Procedure Guidelines

Following are the standardized procedure guidelines jointly promulgated by the Division of Allied Health Professions of the Board of Medical Quality Assurance and by the Board of Registered Nursing:

1. Standardized procedures shall include a written description of the method used in developing and approving them and any revision thereof.
2. Each standardized procedure shall:
   • Be in writing, dated and signed by the organized health care system personnel authorized to approve it.
   • Specify which standardized procedure functions registered nurses may perform and under what circumstances.
   • State any specific requirements which are to be followed by registered nurses in performing particular standardized procedure functions.
   • Specify any experience, training, and/or education requirements for performance of standardized procedure functions.
   • Establish a method for initial and continuing evaluation of the competence of those registered nurses authorized to perform standardized procedure functions.
   • Provide for a method of maintaining a written record of those persons authorized to perform standardized procedure functions.
   • Specify the scope of supervision required for performance of standardized procedure functions, for example, immediate supervision by a physician.
   • Set forth any specialized circumstances under which the registered nurse is to immediately communicate with a patient's physician concerning the patient's condition.
   • State the limitations on settings, if any, in which standardized procedure functions may be performed.
   • Specify patient record keeping requirements.
   • Provide for a method of periodic review of the standardized procedures.

Applicability

This policy applies to team members who are credentialed as PMHNPs that provide direct care and services to patients in collaboration with supervising physicians. For purposes of this policy, the Group’s and Rula’s team members include individuals who would be considered part of the workforce such as employees, independent contractors, business team members, and other persons whose work performance is under the direct purview of Rula or the Group’s  business practices. 

Policy

1. Standardized Procedure Development, Review/Revision and Approval
   1. Standardized Procedures are developed collaboratively by Rula, PMHNPs, supervising physicians and administration.
   2. All standardized procedures are to be reviewed periodically and as practice or regulations changes, at a minimum of three years. Review and revision, when necessary, will be approved by the Medical Director (or Supervising Physician) and Head of Psychiatric Services. They are authorized to develop, review/revise, and approve standardized procedures and be accompanied by a dated and signed approval sheet. Additional qualified team members may contribute to the development, revision/review, and approval of Standardized Procedures.

2. Standardized Procedure Functions and Requirements
   1. PMHNPs will assume primary responsibility for patient care under Rula Standardized Procedures and in collaboration with a Supervising Physician. 
   2. The PMHNP will assume patient care by providing: Assessments, Diagnosis, Treatment Plans, and overall management of patient needs. Including but not limited to the following:
      1. Psychiatric assessments/evaluations of mental health disorders, substance use disorders, intellectual and developmental disabilities
      2. Comprehensive psychiatric, medical, substance, social and family history, review of systems and mental status exam
      3. Health promotion and education practices
      4. Management of both acute and chronic behavioral health illness
      5. Use of psychotherapeutic, psychosocial rehabilitation and recovery techniques 
      6. Proper documentation in accordance to Rula documentation procedure is to be followed for all patient interactions, including interventions used, goals monitoring and evaluation of clinical outcomes/effectiveness of treatment 
      7. Order and interpret patient laboratory studies, and ensure proper care coordination, referrals and consultations are completed.
      8. Utilization of quality measures and evidence-based care
   3. PMHNPs are responsible for providing patients and when applicable legal guardians with mental health education related to psychotropic medications, diagnosis and prognosis
   4. When needed, PMHNPs will furnish medications in accordance with Rula protocols for the use of the following psychoactive medications including but not limited to: Antidepressants, Anxiolytics, Antipsychotic, Mood Stabilizers, Stimulant medications and those used in Co-Occurring Substance Use Treatment.
   5. Standardized Procedures are to be followed in conjunction with general oversight practices as supported by Supervising Physician. California drug and device furnishing requires a limit of four PMHNPs per Supervising Physician 
3. Education and Training Requirements
   1. PMHNPs performing Standardized Procedure functions must possess the following:
      1. A Valid California Registered Nursing license
      2. At minimum, a Masters Degree from a BRN accredited Nurse Practitioner training program with a specialization in psychiatric mental health 
      3. A california BRN Certification as a Nurse Practitioner
      4. Furnishing number issued by the California BRN
      5. Current Drug Enforcement Agency (DEA) registration certificate
      6. X-waiver administered by the DEA if applicable
      7. CURES registration
      8. National Board Certification  
   2. PMHNPs who will be treating child and adolescent populations must have appropriate psychiatric training and previous experience treating psychiatric conditions in children and youth under the age of 18.
   3. Rula will monitor the SAM and OIG exclusion list to verify PMHNP credentials each month in accordance with Rula's credentialing policy.
4. Process for Initial and Continued Evaluation of Clinical Practice
   1. All licensures and certifications will be evaluated by the credentialing committee upon hire and annually thereafter unless a higher frequency is necessary
   2. General Competency is evaluated initially by an interdisciplinary hiring team and then continuously by Rula Medical Director or by an assigned supervising physician who is responsible for quarterly evaluating clinical decision making.
   3. PMHNPs practicing in adult and geriatric populations will be paired with a Supervising Physician who holds a board certification in general psychiatry.
   4. PMHNPs practicing with children and youth under the age of 18 will be paired with a Supervising Physician who holds a board certification in child and adolescent psychiatry.
   5. Rula has established a quality assurance Peer Review Policy to ensure that the highest quality of care is maintained
   6. Quality concerns can be identified through patient or parent/guardian reports, complaints/grievances, supervising physician reviews, management/peer observation, and PMHNP self evaluation.
5. Record of Individuals Authorized to Perform Standardized Procedures: A record of all PMHNPs authorized by these Standardized Procedures will be maintained and kept securely by Human Resources. 
6. Supervision Physician, Consultation, and Communication 
   1. PMHNPs are authorized to implement Rula Standardized Procedures in collaboration with a Supervising physician. 
   2. Consultation with a Supervising Physician will occur under the following conditions or when deemed necessary, including but not limited to the following:
      1. Situations which are above the bounds outlined in the Standardized procedures
      2. Situations that are outside the scope of practice, experience or competence of the PMHNP
      3. Acute patient decompensation or Crisis situation
      4. Conditions requiring immediate medical intervention
      5. Challenging cases with unanticipated outcomes to various interventions trialed
      6. Inconsistent history, physical or lab findings
      7. At request of the PMHNP, Supervising Physician or patient, the patient’s legal representative or family member
      8. Supervising Physicians are available to PMHNPs by phone, instant messaging, email or video conference.  
7. Setting: PMHNPs will follow Standardized Procedures at any setting operated by SUD Specialty Group, remote or otherwise. 
8. Record Keeping Requirements: PMHNPs are responsible for timely completion (within 72 hours of patient encounter) of documentation of all patient encounters in the Electronic Health Record (EHR).
9. Agreement and Approval of the Standardized Procedures
   1. All PMHNPs and Supervising Physicians at Rula will indicate agreement to the Standardized Procedures upon hire. Providing agreement signifies acceptance of the protocols and policies outlined. Additionally, agreement indicates intent to uphold and implement these standardized Procedures while maintaining a collaborative working environment. 
   2. All appropriate signatures will be be documented 
10. Standardized Protocol for Outpatient Health Care Management
    1. Definition: PMHNPs are authorized to manage mental health and substance use conditions under this protocol. This outpatient protocol includes the process for management of common acute, episodic and chronic mental health and substance use conditions seen in outpatient settings. Conditions include: depression, anxiety, psychotic disorders, mood disorders, trauma-related disorders, personality disorders, substance use disorders, intellectual disabilities, and attention deficit hyperactivity disorder. 
    2. Assessment/Diagnosis 
       1. Gathering of necessary information consistent with both subjective and objective findings to identify a diagnosis of mental health and substance use conditions and develop differential diagnosis.
          1. Subjective: Obtaining information relevant to chief complaint including history of present illness, risk assessment, substance history, and past psychiatric/medical/family/social history. 
          2. Objective: MSE, review of systems, review of available medical and diagnostic data. Obtaining collateral information when necessary.
       2. If diagnosis is not clear, assessment to level of surety plus differential diagnosis
       3. Assessment of condition severity including any functional impairment should be documented
    3. Treatment Plan
       1. Ordering diagnostic laboratory testing when appropriate
       2. Providing patient education and counseling to mental health and/or substance use condition, treatment and prognosis
       3. Follow up appointment for further evaluation and treatment if indicated
       4. Coordination of Care: Consultation and referral when appropriate (i.e. psychiatrist, psychotherapy, primary care, neurology, sleep clinic, IOP/PHP etc)
    4. Consultation with Supervising Physician: As described above. 
    5. Furnishing Medication
       1. Ordering and dispensing medications by the PMHNP will be done in consideration but not limited to the following:
          1. Current medication
          2. Medications deemed appropriate for treatment of presenting illness
          3. History of medication allergies
          4. Contraindications
          5. Medication side effects
          6. Medication dose and therapeutic range guidelines individualized per patient individual needs
          7. Assessment of pregnancy and lactation status
          8. Presence of other patient health conditions
       2. Medication ordered will be within the scope and educational expertise of the PMHNP
       3. PMHNPs responsible for monitoring effectiveness of any medications prescribed, proper documentation, proper follow up schedule and patient education on pertinent side effects
       4. Schedule III: Ordering of Schedule III substances are to be used in acute, maintenance, and chronic mental health and substance use conditions
       5. Schedule II: PMHNPs must follow the Prescription of Schedule II Controlled Substances Policy. 
    6. Dispensing Medication: PMHNPS may dispense Schedule II-V controlled Substances under the following conditions:
       1. Drug uses required pharmacy containers and labeling
       2. Documentation of dispensed medications completed
       3. Dispensing encompasses all Federal and State policies

Attachments: 

A. Prescription of Schedule II Controlled Substances Policy

B. Peer Review Policy

Standardized Procedures Approval Signatures:

Medical Director

__________________________ 

Printed Name 

__________________________      _____________ 

Signature           Date 

Head of Psychiatric Services:

__________________________ 

Printed Name 

__________________________      _____________ 

Signature           Date 

Head of Clinical Operations:

_________________________ 

Printed Name 

__________________________      _____________ 

Signature           Date 

STATEMENT OF AGREEMENT 

This document was developed by an interdisciplinary team at Rula, in accordance with the codes regulating nursing practice.

Signature on this statement implies: 

• Approval of the Standardized Procedures and all the policies and protocols contained in this document. 
• Agreement to maintain a collaborative and collegial relationship.
• Agreement to abide by the Standardized Procedures in theory and practice. 

Nurse Practitioner:

__________________________ 

Printed Name 

__________________________      _____________ 

Signature           Date 

Supervising Physician:

__________________________ 

Printed Name 

__________________________      _____________ 

Signature           Date