The broadly written laws and rules allow nurses to practice to their full scope of practice in any setting. It is impossible for the Nursing Care Quality Assurance Commission (NCQAC) to provide a comprehensive listing of the duties that licensed nurses are permitted to perform since nursing practice is reflective of the dynamic changes occurring in healthcare and society. The Revised Code of Washington (RCW) 18.79 and Washington Administrative Code (WAC) 246-840 provide the statutory and legal basis of nursing practice. The nursing commission provides advisory opinions and interpretive statements about specific areas of nursing practice.
These commonly asked questions and answers offer information and general guidance regarding the practice of professional nursing in the State of Washington and do not constitute legal advice. You should contact your legal advisor to obtain advice with respect to any particular issue or problem.
Advanced Registered Nurse Practitioner (ARNP) Practice Information
The nursing commission recognizes and licenses 4 ARNP designations in accordance with WAC 246-840-302 which include:
- Nurse practitioner (NP)
- Certified nurse-midwife (CNM)
- Certified registered nurse anesthetist (CRNA)
- Clinical nurse specialist (CNS)
Advanced Practice Subcommittee Information
The Advanced Practice subcommittee meets every 3rd Wednesday of the month from 7:00 - 8:00 PM (PST).
Resources and Links
- Clinical Nurse Specialist
- Why did the Nursing Care Quality Assurance Commission (NCQAC) add a new designation of clinical nurse specialist (CNS) to advanced registered nurse practitioner licensure?
The National Council of State Boards of Nursing (NCSBN) Advanced Practice Registered Nurse (APRN) Consensus Model describes a model of regulation with four roles:
- certified registered nurse anesthetist (CRNA),
- certified nurse-midwife (CNM),
- certified nurse practitioner (CNP), and
- clinical nurse specialist (CNS).
The NCQAC is a member board of the NCSBN and supports alignment with the APRN Consensus Model, viewing it as an important step to promote uniformity in nursing regulation.
- When did the new rules go into effect?
The NCQAC approved the rules on January 8, 2016. The new rules became effective April 30, 2016. See WAC 246-840-300 through 455 for more information.
- How do I apply for licensure as an ARNP CNS?
You must be licensed, or obtain a current/active Washington RN license, and submit the:
- appropriate ARNP license application (initial application or endorsement),
- required fees, and
- employment verification of advanced practice hours (when applicable).
Your university and certifying body must send official transcripts and proof of national certification directly to the NCQAC. See the advanced registered nurse practitioner webpage for information, instructions, and application forms.
- What requirements do I need to meet to get my initial licensure as an ARNP CNS?
The requirements for initial ARNP CNS licensure include:
- An active Washington State registered nurse (RN) license without sanctions or restrictions
- A graduate degree from an advanced nursing education program accredited by a national nursing, accreditation body recognized by the U.S. Department of Education
- National certification as a CNS from a NCQAC approved certification body
- If requesting prescriptive authority:
- If you graduated within the past two years when applying, your official transcripts must show a completed pharmacology course
- If you are endorsing, you must show proof of 30 continuing education hours of pharmacology completed within the past two years
- If you graduated within one year of applying, no employment verification is needed
- If you graduated more than one year ago, you must show proof of 250 hours of ARNP CNS practice hours within the last two years.
- If you do not have the completed hours, you must complete supervised hours (125 hours for every year out of practice [maximum 1,000 hours])
- I received my advanced practice education and license outside of the United States. What requirements do I need to meet in order to get an ARNP CNS license?
The requirements for ARNP CNS licensure for an applicant who received an education and license as an advanced practice nurse outside of the United States include:
- Holding an active RN license without sanctions or restrictions issued by a regulatory entity outside the United States and proof of practicing as an ARNP CNS,
- Applying for and being granted a Washington State RN license,
- Submitting a course-by-course evaluation of education from a NCQAC approved credential evaluating service,
- Holding a national certification as a CNS from a NCQAC approved entity, and
- Completing at least 250 hours of advanced clinical practice hours within two years before the date of application.
- Do I need national certification to be licensed as an ARNP CNS?
Yes. ARNP CNS licensure requires national certification by a NCQAC-approved entity:
- I have a Washington State RN license and meet CNS requirements. I have not been practicing in an advanced role. I plan to apply for the ARNP CNS license. Will I need to meet the practice hour requirement in advanced practice?
If you do not apply within one year of earning your graduate degree from an advanced nursing education program, you will need to meet the 125 hours advanced clinical practice hours for each year following graduation (not to exceed 1,000 hours). The nursing rules define advanced clinical practice as practicing at an advanced level of nursing in a clinical setting performing direct patient care. Advanced nursing practice means the delivery of nursing care at an advanced level of independent nursing practice that maximizes the use of graduate educational preparation, and in-depth nursing knowledge and expertise in such roles as autonomous clinical practitioner, professional and clinical leader, expert practitioner, and researcher.
- I have a license and practice as a CNS advanced practice nurse in a state that does not require national certification. Is there a way to get my ARNP license without the national certification through NCQAC?
Applicants for ARNP licensure in the CNS designation must meet the national certification requirements. Qualifications and requirements are determined by the certifying body:
- I do not meet the advanced clinical practice hours required for ARNP CNS licensure but meet the other requirements. How can I get advanced practice hours?
An ARNP, a physician, or an osteopathic physician licensed in Washington State (or equivalent licensure from another state or United States jurisdiction) may provide supervised practice hours. You may also take a course at a university to obtain the needed practice hours. The supervisor must meet the following requirements:
- Be in the same practice specialty of the applicant,
- Have an active advanced practice or physician license, without sanction or restrictions,
- Not be a relative of the applicant,
- Not have a personal or financial relationship with the applicant,
- Not have a current disciplinary action on the license, and
- Submit a written evaluation to the NCQAC verifying the applicant's successful completion of the required supervised clinical practice hours attesting that the applicant's knowledge and skills are at a safe and appropriate level to practice as an ARNP CNS.
The NCQAC must approve the supervisor and the clinical supervision site. You may not use the designation of ARNP during the time of supervised practice hours.
- Am I required to apply for prescriptive authority as an ARNP CNS?
No. Prescriptive authority is not a requirement for ARNP CNS licensure. You may indicate your preference in the ARNP application. If you choose to apply for prescriptive authority, you must have documentation of 30 contact hours of education in advanced pharmacology. The education must include didactic and clinical application and consist of pharmacodynamics, pharmacokinetics, pharmacotherapeutics, and pharmacology management of individual patients related to your scope of practice. Pharmacology education must be completed within the last two years before the application for prescriptive authority.
- I am an RN currently working in a position titled CNS. I do not meet the educational requirements to qualify as an ARNP CNS. May I continue to work in this position and use the title CNS?
The title “clinical nurse specialist” or “CNS” is not a protected title. You may continue to work in a CNS-titled position and identify yourself using the term clinical nurse specialist or CNS. You may continue to practice at scope of practice for an RN within your legal and individual competencies. You may not use the title ARNP.
- I am an RN with the ANCC specialty certification in public health nursing-advanced (APHN). Does this certification meet the requirements for an ARNP CNS?
No. Nurses with a non-CNS specialty certification, who do not meet the qualifications as an ARNP, may not be licensed as an ARNP CNS.
ANCC and other approved certification bodies may have several categories of certifications, including CNS, and also provide numerous non-CNS specialty certifications. Examples include: nurse executive-advanced-board certified (NEA-BC), forensics nursing-advanced (AFN-BC), and registered nurse-board certified (RN-BC). The requirements for specialty certification differ between the non-CNS and the CNS certification. Other entities may also provide certifications that are not an approved body. Examples include nursing certifications through the Wound, Ostomy, and Continence Certification Board: advanced practice wound, ostomy or continence nurse (CWCN-AP®) and certified foot care nurse (CFCN®).
- Am I required to apply for an ARNP CNS if I have the national certification and meet the other requirements?
You are not required to apply for an ARNP CNS license. However, you will not be able to practice at the advanced level without the ARNP license.
- May I be certified as a CNS in more than one CNS specialty practice area?
You may be certified as an ARNP in more than the CNS specialty practice area. Just as with other ARNP categories, the ARNP CNS must obtain and maintain education, training, and practice in each area.
- How do I decide what graduate school to attend to qualify for licensure as an ARNP CNS?
Find out if the nursing education program is aligned with the APRN Consensus Model and whether its program will qualify you to test for the NCQAC-approved certification bodies.
- Is there a "grandfathering" option?
The rule does not include a “grandfathering” option. All applicants must meet the current requirements for ARNP licensure.
- May I request a hearing if my application for licensure as an ARNP with the CNS designation is denied?
Yes. If an application for licensure is denied, the NCQAC sends a notice of decision, which includes instructions about how to request a hearing to appeal the denial.
- Perioperative Nursing Care
- Is certification required for the Registered Nurse (RN) or Advanced Practice Registered Nurse (ARNP) to perform in the role of a Registered Nurse First Assistant (RNFA) or surgical first assistant?
The nursing laws and rules do not require the perioperative RN or ARNP to obtain certification to function in the role as a RNFA/surgical first assistant. The Nursing Care Quality Assurance Commission recommends the RN or ARNP obtain the CRNFA or other equivalent certification to demonstrate training and competency. The institution may require certification and/or specific training. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within the nurse's scope of practice. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within the nurse's scope of practice.
- Is the hospital or institution required to perform the credentialing and privileging process for the Registered Nurse or ARNP to function in the role of the RNFA/surgical first assistant?
The institution may require the perioperative RN or ARNP to complete the credentialing and privileging process to function in the role of the RNFA/first assistant. Credentialing is the process of assessing and confirming the license or certification, education, training, and other qualifications or a licensed or certified healthcare practitioner. Privileging is the process of authorizing a health care practitioner's specific scope and content of patient care services. The nursing laws and rules do not require credentialing and privileging. Other state facility laws/rules, federal requirements/regulations (such as the Centers for Medicare & Medicaid Services), and accreditation standards (such as Joint Commission) may require certification, credentialing, and privileging of the RN or ARNP performing in the RNFA/first assistant role. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within the nurse's scope of practice.
- Can the RN or ARNP function in the role of a RNFA/surgical first assistant to perform the functions of the MUM during robotic surgery without the RNFA Certification or without going through the credentialing or privileging process?
Within the role of the RNFA/surgical first assistant there are specialty surgical areas that may require additional training. It is within the scope of practice of the appropriately prepared and competent RN or ARNP to perform the functions in the role of a RNFA or surgical first assistant to perform the functions of the MUM. The Nursing Care Quality Assurance Commission recommends the RN or ARNP obtain the CRNFA or other equivalent certification to demonstrate training and competency. The institution may require certification and/or specific training.
The institution may require RN or ARNP to complete the credentialing and privileging process to function in the role of the RNFA or first assistant. Credentialing is the process of assessing and confirming the license or certification, education, training, and other qualifications or a licensed or certified healthcare practitioner. Privileging is the process of authorizing a health care practitioner's specific scope and content of patient care services. Other state or federal requirements/regulations and accreditation standards (such as the Centers for Medicare & Medicaid Services or Joint Commission) may require certification, credentialing, and privileging of the RN or ARNP performing in the RNFA/first assistant role.
The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within the nurse's scope of practice.
- Physician's Order for Life Sustaining Treatment
- What is a Physician's Order for Life Sustaining Treatment (POLST) form?
POLST is a set of medical orders, executed by an adult patient (or legal surrogate) and the patient's medical provider, to guide medical treatment based on the patient's current medical condition and goals. The POLST form is usually for persons with serious illness or frailty. The “rule of thumb” is to recommend POLST for patients if their provider would not be surprised if they die within a year.
The POLST concept was originally created to guide emergency medical services (EMS) personnel in emergency situations. EMS staff was not able to honor advance directives or family member instructions for no cardiopulmonary resuscitation (CPR), because EMS must follow medical orders. POLST was developed to allow EMS to honor patients' no-CPR decisions by turning them into medical orders.
POLST is intended to prevent unwanted or futile treatment, reduce patient and family suffering, and help ensure that individual's wishes regarding end-of-life care are honored. A POLST is valid in all care settings and is portable from one care setting to another. It does not replace advance directives or a durable power of attorney. It is valid with or without advance directives or durable power of attorney. In Washington, it is a bright green form (photocopies and faxes of signed POLST forms are also legal and valid) and should be located in a prominent, easily noticeable location in the home or bedside and in the medical record.
- What medical orders are included in a POLST?
The POLST order allows patients to specify whether they desire CPR or whether they prefer to allow a natural death to occur if they are in cardiopulmonary arrest. It contains additional instructions as well, indicating if they have a pulse and/or are breathing, whether they want comfort measures only, specific limited additional interventions, or full treatment.
The POLST form is separated into four sections:
- Section A identifies what action to take if the person is not breathing and does not have a pulse (CPR/Attempt Resuscitation or DNAR (Do Not Attempt Resuscitation) (Allow Natural Death).
- Section B identifies what action to take if the person has a pulse and/or is breathing, such use of oxygen, suction, intravenous fluids, airway support, and advanced interventions such as intubation, mechanical ventilation, and other intensive care-related procedures.
- Section C includes validation and signatures.
- Section D identifies non-emergency medical treatment preferences including whether the patient should receive antibiotics, medically assisted nutrition and hydration, and dialysis.
- How should the decisions in a POLST be made?
The patient (or surrogate decision-maker) and the health care provider should discuss information to assure the POLST reflects the patient's wishes, as expressed in an advance directive or through communications with family or others. The patient's most recent communications, made in the context of their current medical condition, are the most likely to reflect their current wishes. If the patient's wishes are not known, the POLST should direct care in the patient's best interest. RCW 7.70.065(1)(c).
- Is POLST mandated by law?
No. Preparing and signing a POLST is always voluntary for patients. Care providers should follow a POLST as they would follow any other medical order. Chapter 43.70.480 RCW Emergency Medical Personnel - Futile Treatment and Natural Death Directives - Guidelines requires the Washington State Department of Health to adopt guidelines and protocols for how emergency medical personnel respond for the treatment of a person with a POLST.
- Does the law provide legal immunity for health care workers who follow POLST orders?
Currently, only emergency medical responders are protected from legal liability when following the POLST orders. However, if a POLST order reflects a patient's wishes stated in an advance directive, the caregiver honoring those wishes would have legal protection under the Natural Death Act RCW 70.122. POLST is a medical order, and caregivers should follow it according to the standard of care. According to the Washington State POLST Task Force, no healthcare provider has reported being sued for following a POLST order since POLST was established in Washington State in 2000.
- May facilities require POLST as a part of the admission process?
No. Preparing and signing a POLST is always voluntary. The Federal Patient Self-Determination Act (PSDA) and the Joint Commission require that health care facilities take steps to educate all adult patients on their right to accept or refuse medical care. Facilities must ask on admission whether a patient has made an advance directive, maintain policies and procedures on advance directives, and provide information to patients. The PDSA prohibits providers from conditioning care on whether or not an individual has an advance directive. The PDSA definition of advance directive has been interpreted to include a variety of advance planning documents, including POLST.
- Should facilities write a new POLST for each patient or resident when they are admitted?
Not necessarily. The patient or resident's POLST is portable, and facilities should incorporate the patient's existing POLST into their records. Facilities may adopt policies requiring a provider with privileges to counter-sign the POLST.
A POLST should be reviewed upon admission. If a POLST has a recent date (within a year generally) and no major changes to the patient's condition have happen since the signing, it is acceptable to consider a confirmation of the POLST as meeting the requirement for inquiry of advance directives on admission.
There is a section on the POLST providers may initial to indicate that a review has been conducted and no changes are required.
- What should facility policies do if a patient or resident has no POLST at the time of admission?
If a patient or resident has no POLST at the time of admission, suggest a care planning conference to evaluate whether POLST would be appropriate. These planning conferences should include the patient's medical provider, the patient and surrogate decision-maker, and key family members. These discussions should include a review of the patient's medical history and recommendations from treating providers. A POLST should generally not be written as part of routine admission paperwork without medical professional involvement and extensive discussion.
- May facilities refuse to honor a POLST?
Yes. The Natural Death Act RCW 70.122 allows health care facilities or personnel to refuse to participate in withholding or withdrawing life-sustaining treatment due to moral or ethical objections. Residents or patients must be informed of this policy or practice when the provider or facility becomes aware of the existence of a directive or POLST order they do not intend to honor. If an individual provider objects, the facility should try to make a willing staff member available to provide care according to the patient's POLST order. If the facility objects, it should cooperate with the patient or resident and family in finding and transferring the patient to another facility willing to honor the POLST order.
- When should a POLST be changed?
The POLST should be reviewed if the patient is transferred from one care setting or care level to another; if there is substantial change in the patient's health status; or if the patient's or decision-maker's treatment preferences change. There is a section on the POLST providers may initial to indicate that a review has been conducted and no changes are required. RNs and LPNs may explain or review the POLST form or existing POLST with the patient or surrogate.
Discussions about the appropriateness of the POLST or making significant changes to a POLST should include the patient's medical provider, the patient and surrogate decision-maker, and key family members. These discussions should include a review of the patient's medical history and recommendations from treating providers.
Discussions should consider whether the patient has advanced dementia, osteoporosis, bleeding disorder or other conditions and situations in which chest compressions or other CPR interventions may cause more harm than benefit to the patient. If the patient or surrogate and provider conclude this patient should not receive CPR even in case of choking or other accident, note “DNAR-No Exceptions” in Section A of the POLST. This note should be initialed by the provider authorized to sign the POLST.
- What if a family member tells the caregiver to do CPR when the POLST says DNAR?
A competent adult patient or the legal surrogate may always change their medical decisions and request alternative treatment. However, in an emergency situation, it may be difficult to determine whether or not the family member is the legal surrogate. Facilities should establish policies to manage legal risk in these situations.
- What is the purpose of the NCQAC POLST advisory opinion?
The purpose of this advisory opinion is to provide guidance about POLST for advanced registered nurse practitioners (ARNPs), registered nurses (RNs), licensed practical nurses, LPNs), and nursing assistants (NAs). Advisory opinions do not have the force of law.
- Is it within the scope of practice for an ARNP to sign POLST orders?
Yes. A licensed ARNP, physician or physician assistant may sign a POLST. The health care practitioner signing the form assumes full responsibility for obtaining informed consent from the patient or surrogate decision-maker. The form must also be signed by the patient or surrogate to be valid. Verbal orders are acceptable with a follow-up signature following facility policy.
The ARNP should periodically review the POLST instructions with the individual or family for any treatment preference changes and consistency with any advance directive, especially if there are substantial changes in the person's health status. The Washington State Medical Association provides many resources and references in helping individuals receive the end-of-life care they specify.
- May an ARNP, LPN or registered nurse (RN) follow POLST orders?
Yes. ARNPs, LPNs and RNs may follow valid POLST orders as they would follow any other medical orders, in any setting, based on their regulatory and individual scope of practice.
- May a RN or LPN delegate POLST orders to nursing assistants or other unlicensed assistive personnel (UAP)?
Delegation is not required for a nursing assistant to follow the CPR/DNAR POLST orders in Section A. Sections B and D of the POLST may require delegation of some tasks using the delegation process.
- May a RN, LPN or NA pronounce death?
An ARNP, RN or LPN may pronounce death. ARNPs may file a death certification. It is not within the nursing assistant's scope of practice to pronounce death.
- May a nursing assistant follow a POLST order stating DNAR?
Yes. Nursing Assistants may follow the CPR/DNAR order in Section A of the POLST. Nursing assistants and other non-credentialed UAP may use nursing judgment in emergency situations. A patient without a heartbeat, even if death is expected, is in an emergency situation. A nursing assistant with appropriate training may assess the patient's vital signs and decide if a heartbeat is present. If there is no heartbeat, a nursing assistant may follow a patient's POLST order Section A to start CPR or to provide comfort measures and allow a natural death, depending on the patient's POLST.
- May a nursing assistant follow orders in Sections B and D of POLST?
Section B of a POLST include orders on medical interventions, including use of oxygen, suction, IV fluids, airway support and advanced interventions such as intubation, mechanical ventilation, and other intensive care-related procedures. Section D includes non-emergency treatment decisions including whether the patient should receive antibiotics, medically assisted nutrition and hydration, and dialysis. Some of these POLST orders may indicate medical interventions outside the scope of a nursing assistant. Specific activities may require delegation of certain medical interventions identified in the POLST sections B and D, depending on the task, equipment available, and competency of the nursing assistant.
- What training about POLST is available for nursing assistants and unlicensed assistive personnel?
The Washington State Department of Social and Health Services (DSHS) and POLST stakeholders have developed a short training video for home care aides and other bedside caregivers. The video includes instruction on how these staff should respond when they find a resident who is nonresponsive. This video will be part of a continuing education program which DSHS plans to approve in 2015.
- May nursing assistants perform nursing activities that require nursing judgment?
Yes. Nursing assistants and other UAP may perform activities that require nursing judgment only in emergency situations. When a patient has no heartbeat, it is an emergency situation in which a nursing assistant may use nursing judgment to follow a POLST order to either perform CPR or to provide comfort care while allowing natural death to occur.
- In many community-based settings personal care may be given by nursing assistants without nurse direction or supervision. Can nursing assistant follow POLST instructions if a nurse is not directing and supervising the care?
An individual is working under their nursing assistant credential only when being directed and supervised by a nurse. In situations where the nurse is not directing and supervising the care, the individual is not working under the nursing assistant credential. The employer or facility should have policies and procedures in place to address this situation.
- What should nursing assistants do if they find a patient who is non-responsive or has no heartbeat?
- They should call the nursing supervisor, 911, or hospice for emergency help, and stay with the patient. This plan should be made in advance as part of the patient plan of care.
- If the POLST says DNAR, nursing assistants should not initiate CPR. They should provide comfort care and wait for assistance to arrive.
- If the POLST says CPR/Attempt Resuscitation, nursing assistants should begin CPR and continue until help arrives.
- What if a person stops breathing because of an accident, such as choking? Do I follow a POLST order to not give CPR?
In most circumstances, if a person's heartbeat stops during a witnessed choking incident or other accident, perform basic first aid measures per standard training. If the person has no pulse or becomes nonresponsive, begin CPR even if the POLST says “No CPR/allow natural death.” Continue CPR until licensed staff or emergency medical responders arrive.
However, some patients may want to refuse CPR under all circumstances including choking or accidents. This may be the medically appropriate decision for patients with advanced dementia at risk for aspiration, patients with osteoporosis, or other conditions and situations in which chest compressions or other CPR interventions may cause more harm than benefit to the patient.
Each patient's care plan should include details specifying if the POLST DNAR order applies in all circumstances. The POLST should include a note in Section A stating “DNAR-No Exceptions” initialed by an authorized provider. Bedside caregivers and supervisors should be familiar with this detail in the patient care plan and POLST.
- What if someone starts CPR on a patient with a POLST indicating "Do Not Attempt Resuscitation"?
If a patient's POLST order indicates no CPR, CPR should not be initiated. In the event that CPR is initiated for a person in violation of a POLST with a DNAR order, CPR should be discontinued if no pulse is detectable. This is an example of a situation where all health care providers caring for the patient must be aware of the medical orders for the patient. Facilities should establish policies to manage legal risk in such a situation.
- Prevention and Treatment of Opioid-Related Overdoses
- Is the Advanced Registered Nurse Practitioner required to carry naloxone?
RCW 69.41.095 does not require the Advanced Registered Nurse Practitioner to carry an opioid antagonist (such as naloxone). For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Can the Advanced Registered Nurse Practitioner prescribe naloxone for their staff to have available as stock inventory in the event of a suspected opioid-related overdose?
RCW 69.41.095 allows the Advanced Registered Nurse Practitioner, with prescriptive authority, to prescribe, dispense, and distribute an opioid overdose reversal medication to any person or entity. See the Washington State Department of Health Overdose Education and Naloxone Distribution Webpage for more information.
- Can the Advanced Registered Nurse Practitioner have a collaborative agreement (CDTA) with a pharmacist to prescribe, dispense, and distribute opioid overdose medication?
RCW 69.41.095 allows the Advanced Registered Nurse Practitioner to have a collaborative agreement (CDTA) with a pharmacist to prescribe, dispense, and distribute opioid overdose medications to anyone who requests it. See the Washington State Department of Health Overdose Education and Naloxone Distribution Webpage for more information.
- Is it required for the Advanced Registered Nurse Practitioner to prescribe naloxone when prescribing an opioid for a patient?
WAC 246-840-4980 requires the Advanced Registered Nurse Practitioner to confirm or provide a current prescription for naloxone when fifty milligrams Morphine Equivalent Dose (MED) or above, or when prescribed to a high-risk patient. The Advanced Registered Nurse Practitioner should counsel and provide an option for a current prescription for naloxone to patients being prescribed opioids as clinically indicated. See the Washington State Department of Health Overdose Education and Naloxone Distribution Webpage for more information.
- Can the Advanced Registered Nurse Practitioner prescribe naloxone to a third-party, such as a family member, friend, or caregiver of an individual?
WAC 246-840-4980 allows the Advanced Registered Nurse Practitioner with prescriptive authority to prescribe an opioid antagonist to a third party. See the Washington State Department of Health Overdose Education and Naloxone Distribution Webpage for more information.
- In writing a prescription for a family member of someone who is at risk of an opioid overdose, is the prescription written in the name of the person who requests it or for the family member?
The prescription for an opioid antagonist must be written in the name of the person who requests it. See the Washington State Department of Health Overdose Education and Naloxone Distribution Webpage for more information.
- Can the Advanced Registered Nurse Practitioner prescribe subcutaneous and intramuscular formulas of naloxone?
Off-label drugs lack the Food and Drug (FDA) approval. Off- label delivery methods may be legally prescribed, dispensed, distributed, or administered by the Advanced Registered Nurse Practitioner with prescriptive authority. The Advanced Registered Nurse Practitioner is expected to use professional judgment. The Center for Drug Evaluation and Research and the FDA support this practice. Off-label use should be done with careful insight and understanding of the risks and benefits to the patient considering high-quality evidence supporting efficacy, effectiveness, and safety. More information about off-label use may be found at the Therapeutic Intranasal Drug Delivery website.
- Are there other alternatives for an individual or an organization to get a prescription for naloxone other than from their primary health care practitioner?
RCW 69.41.095 allows the State Health Officer for Washington State, to issue a state-wide standing order that can be used as a prescription for naloxone. People may take this standing order to a pharmacy to get the drug, instead of going to a healthcare provider to get the prescription. Organizations may also use this standing order to get naloxone and give it to people who are at risk of overdosing or who spend time with people at risk of overdosing. Organizations who want to use this standing order to get and use naloxone must send an email to Washington State Department of Health at email@example.com. The department will keep a list of organizations who use the order and notify them if anything in the order changes. See the Washington State Department of Health Overdose Education and Naloxone Distribution Webpage for more information.
- Telehealth During the COVID-19 Emergency
- Can the advanced registered nurse practitioner (ARNP) provide telehealth services during the coronavirus (COVID-19) emergency?
The ARNP with a Washington state license may deliver advanced nursing care using telehealth services within their designated scope of practice based on the ARNP's national certifying body. Modalities include live video, store-and forward, remote patient monitoring, and mobile health. The Nursing Care Quality Assurance Commission does not have formal guidance regarding telehealth services. During the coronavirus (COVID-19) emergency the nurse practitioner licensed in another state can provide telehealth services under the Emergency Volunteer Health Practitioners Program within their scope of practice and within the parameters of the Emergency Volunteer Health Practitioners Program or must have a Washington state registered nurse and ARNP license to provide care to patients residing in Washington state. For additional information, go to:
Washington Medical Commission
Center for Coordinated Health Policy
- Does the ARNP need to follow the HIPAA when they are providing telehealth services or can they perform telehealth services from their home using Skype, Zoom, or similar applications during the COVID-19 emergency?
The U.S. Office of Health and Human Services-Office of Civil Rights Frequently Asked Questions on Telehealth and HIPAA provides information on waivers and exceptions and guidance during the pandemic about HIPAA and telehealth services during the COVID-19 emergency.
- Can the advanced registered nurse practitioner (ARNP) provide telehealth services to a patient in another state during the coronavirus (COVID-19) emergency without a license in that state?
The NCQAC does not have authority regarding practice in another state. The ARNP should check with the other state to see they would need a license in that state to provide a care to a patient in that state using telehealth services during the COVID-19 emergency.
- Can the advanced registered nurse practitioner (ARNP) be reimbursed for telemedicine services during the coronavirus (COVID-19) emergency?
The Nursing Care Quality Assurance Commission does not have authority regarding reimbursement. The ARNP should contact the insurance provider, Centers for Medicare and Medicaid Services (CMS), or the Health Care Authority (HCA) for information and requirements about reimbursement during the COVID-19 emergency. See the following resources:
- Can telehealth be used to prescribe a controlled substances during the coronavirus (COVID-19) emergency?
While a prescription for a controlled substance issued using telehealth services must generally be predicated on an in-person medical evaluation (21 U.S.C. 829(e)), the Controlled Substances Act contains certain exceptions to this requirement. One such exception occurs when the Secretary of Health and Human Services has declared a public health emergency under 42 U.S.C. 247d (section 319 of the Public Health Service Act), as set forth in 21 U.S.C. 802(54)(D). Secretary Azar declared a Public Health Emergency (PHE) with regard to COVID-19 on January 31, 2020. For as long as the Secretary's designation of a public health emergency remains in effect, Drug Enforcement Administration (DEA)-registered practitioners may issue prescriptions for controlled substances to patients for whom they have not conducted an in-person medical evaluation, provided all of the following conditions are met:
- The prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of his/her professional practice
- The telehealth communication is conducted using an audio-visual, real-time, two-way interactive communication system.
- The practitioner is acting in accordance with applicable Federal and State law.
Provided the practitioner satisfies the above requirements, the practitioner may issue the prescription using any of the methods of prescribing currently available and in the manner set forth in the DEA regulations. Thus, the practitioner may issue a prescription either electronically (Schedules II-V) or by calling in an emergency Schedule II prescription to the pharmacy, or by calling in a Schedule III-V prescription to the pharmacy.
If the prescribing practitioner has previously conducted an in-person medical evaluation of the patient, the practitioner may issue a prescription for a controlled substance after having communicated with the patient via telemedicine, or any other means, regardless of whether a public health emergency has been declared by the Secretary of Health and Human Services, so long as the prescription is issued for a legitimate medical purpose and the practitioner is acting in the usual course of his/her professional practice. In addition, for the prescription to be valid, the practitioner must comply with any applicable state laws
- Telemedicine Training Requirements
- Is a registered nurse (RN), licensed practical nurse (LPN), or Advanced Registered Nurse Practitioner (ARNP) required to take telemedicine training?
Yes, licensed nurses (RN, LPN, or ARNP) in Washington state are required to take telemedicine training if the nurse provides telemedicine services. RCW 43.70.495 requires the nurse who provides clinical services through telemedicine independently or under the direction of an authorized health care practitioner to complete telemedicine training. “Telemedicine” as defined in RCW 70.41.020(13) means, “the delivery of health care services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment [but] does not include the use of audio-only telephone, facsimile, or email.”
The Washington State Telehealth Collaborative uses the following slightly different Medicaid definition of telemedicine in the training:
“Telemedicine is when a health care practitioner uses HIPAA-compliant, interactive, real-time audio and video telecommunications (including web-based applications) or store and forward technology to deliver covered services that are within his or her scope of practice to a client at a site other than the site where the provider is located.” WAC 182-531-1730(1). It does not include “the use of audio-only telephone, facsimile, or email.”
- Does the training requirement apply to a nurse who provides telephone triage?
No, the telemedicine training requirement doesn't apply to audio-only telephone (telephone triage), facsimile, or email. However, the Nursing Care Quality Assurance Commission (NCQAC) recommends licensed nurses complete the telemedicine training if they provide services such as; telephone triage, remote patient monitoring (“RPM”, which enables recording and monitoring health data remotely), asynchronous telehealth (such as Store and Forward technology that allows patient data to be collected, stored, and later retrieved by another professional), Mobile Health (“mHealth,” using smart devices such as smartphones and smart wearables that allow continuous data collection about a person's behavior or condition) or other types of telehealth. The telemedicine training provides a valuable overview of the roles, responsibilities, liability, and legal requirements when providing telehealth services.
- Does the nurse need to send in the certification to the Nursing Care Quality Assurance Commission (NCQAC)?
The law, RCW 43.70.495, requires the nurse to sign and retain an attestation of completion. The nurse does not need to send the attestation or documentation to the NCQAC unless requested.
- When is completion of telemedicine training required?
The Nursing Care Quality Assurance Commission (NCQAC) recommends telemedicine training be completed as soon as possible as a demonstration of competency. The licensed nurse (RN, LPN, or ARNP) providing telemedicine clinical services licensed prior to January 1, 2021, will need to complete telemedicine training by December 31, 2021. The newly licensed RN, LPN, or ARNP or the RN, LPN, or ARNP licensed through the endorsement process who provides clinical services will need to meet the requirement one year after the initial license is issued. The Nursing Care Quality Assurance Commission (NCQAC) recommends all Washington nurses complete the telemedicine training as a demonstration of competence as soon as practical to provide an overview of the roles, responsibilities, liability, and legal requirements for providing telehealth services.
- Does telemedicine training taken prior to January 1, 2021 meet the telemedicine training requirement?
Telemedicine training taken prior to January 1, 2021 meets the requirement if it includes the content defined in RCW 43.70.495(2). The RN must be appropriately trained and competent to provide nursing telehealth services. To learn more about the different training options available and access additional resources, see the Washington State Telehealth Collaborative Training webpage. To complete the free and publicly available telemedicine training, see the Washington State Medical Professional Telemedicine Training website.
- What are the options to meet telemedicine training requirements?
To learn more about the different training options available and access additional resources, please visit the Washington State Telehealth Collaborative Training webpage. To complete the free and publicly available telemedicine training, see the Washington State Medical Professional Telemedicine Training webpage.