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PA Prescribing of Category II Controlled Substances: BME Opinion

By Paul F. Jacques, DHSc, PA-C


Pharmacists have the legal right to refuse to fill a prescription if they are concerned about the “legitimate” nature of the prescription. The language in the PA practice act has led many pharmacists in the community to question the implementation of the language specified in the law. One concern is the legal ramifications should a pharmacist fill a CNII prescription written by a PA that is not compliant with the PA Practice act. As an example, if a PA wrote for a 30 day supply of a CNII which is an initial prescription; would the pharmacists be liable?

The concerns of the pharmacists in the community were communicated by SC DHEC to LLR to ask for a legal opinion. LLR in turn referred the question to the Healthcare Collaborative Committee which has representatives from the Boards of Pharmacy, Nursing, and Medical Examiners, as well as DHEC. This committee met on October 18, 2013 and debated the issue. Supposedly, this committee determined that the pharmacist’s role is not to determine if the prescription is within the legal confines of the SC PA Practice Act, it is the responsibility of the individual healthcare providers to remain compliant with the PA practice act. Therefore, the responsibility for writing prescriptions, which are legally appropriate, remains with the physician assistant and his/her supervising physician.

The SC Board of Medical Examiners issued the following policy related to PAs writing controlled substances:

The Board of Medical Examiners does not interpret the language of the Physician Assistant’s practice act, as amended, to impose an obligation upon the pharmacy in question to verify compliance with 40-47-965. Licensees under the Board of Medical Examiners, supervising physicians and physician assistants are expected to comply with the medical practice act and are subject to discipline if they do not. Pharmacies may choose to implement their own verification procedures for prescriptions in accordance with the requirements of Pharmacy practice act.


Physician Assistants who experience pharmacists not filling Controlled Substance prescriptions should contact the SC Board of Medicine at: medboard@llr.sc.gov. The phone number is 803-896-4300. In addition, please notify SCAPA at scapa@sc.rr.com. Before calling make certain you are in compliance with Section 40-47-965 of the SC Medical Practice Act.

Please see the following document which includes the SC Medical Practice Act: Legislative Update



More Good News From Columbia

By Paul F. Jacques, DHSc, PA-C

 

During the 2013 legislative sessions, while SCAPA was busy advocating for the "Modernization of the PA Practice Act” several bills were submitted by other entities that should have mentioned physician assistants. Since SCAPA was on the forefront in meeting with legislators and know the role of PAs in the healthcare arena, they readily adopted amendments to include PAs where appropriate. Therefore, PAs were included in H 3725 and H 3061 and both bills were ratified and signed by Governor Hailey.

 

Click here for more information: Legislation Update

 

 

Ceremonial Signing of the Our New Legislation

By Jamie Woody PA-C

 

SCAPA leaders recently met with the Governor of South Carolina. SCAPA leaders were invited to attend a ceremonial signing of bill S. 448 by Governor Nikki Haley. The bill, which was officially signed into law on Tuesday May 25th, resulted in the modernization of the South Carolina PA Practice Act. The ceremonial signing with SCAPA leaders took place on August 5, 2013 at the office of the governor at the South Carolina State House.

 

Governor Haley remarked at the historical meeting that she supports South Carolina PAs and is very proud of what PAs do within the healthcare system in our state. The governor also said that she hopes to be of assistance to PAs and was excited to sign a bill that is progressive for our profession and which allows PAs to better serve patients. If you are not yet familiar with the new practice laws for PAs in South Carolina, you can learn more below:

 

 


 

 Ceremonial Signing of the New Bill with Governor Haley on August 5, 2013

 

 

 

Implementation of the Revised South Carolina PA Practice Act

By Paul F. Jacques, DHSc, PA-C, SCAPA Legislative Committee

July 2013

 

On Friday, July 12th Rebecca Zerwick Johnson and I attended the meeting of the PA Advisory Committee (PAAC) to discuss with the PAAC the implementation of the revisions to the practice act. Ieshia Watson, Administrative Assistant for the Board of Medical Examiners (BME) and the person who provides the primary support for the PAAC, and Sheridan Spoon, Esq, Advise Attorney for the BME, graciously answered our inquiries. They have been actively working on making substantive changes to the processes and acknowledge they have more work to do. However, they both articulated the intent of the changes and spoke of administrative changes that have occurred. Several new forms have been published to the LLR website that represents significant improvements. (http://www.llronline.com/POL/Medical/index.asp?file=pub.htm)

 

 

Change or Add an Additional Supervising Physician

 

The application to change or add an additional supervising physician is a one page form. This form, with attached practice guidelines, is all that is needed for a SC licensed PA to change practice sites, add a new supervising physician or change from one supervising physician to another within the same practice site. The review process of submitted documents by the PAAC or BME committee members has now entered the 21st Century. LLR is using a secure website wherein PAAC and BME members can logon and reviews documents and then submit approvals or denials to LLR. No longer is the paperwork emailed, postal mailed or faxed to the members. This should greatly expedite the process and facilitate the BME meeting the 10 business day requirement for approval of practice guidelines and their amendments. The 10 business day requirement is stipulated within the PA practice act.

 

Category II Prescribing

 

For PAs who currently have authority to prescribe Cat III – V controlled substances the process to include Cat II is straight forward. Fill out page 1 of the: "Controlled Substances Prescriptive Authority Form”. This form includes wording that indicates your practice guidelines are amended to include Cat II. PAAC will acknowledge in writing the approved amendment and you will need to submit that letter to SC DHEC Drug Control. Upon receipt of a written response from SC DHEC you will next need to notify the Federal DEA. Mrs. Watson mentioned that the first PA approval for Cat II has been issued by the BME.

 

Off-Site Practice

 

PAs who will be working in an off-site practice must submit the two page form: "Notification of Off-Site Practice”.

 

Adding New Tasks to Your Practice Guidelines

 

The On the Job Training requirement has been significantly modified. A PA and supervising physician may work collaboratively and increase the skill set of the PA. PAs may be educated by the supervising physician and the PA may be engaged in learning new skills with the direct supervision of the physician. However, it they want to add an additional task to the practice guidelines, so that PA can provide the task or service without supervision, they must acquire BME approval. There is a 1 page "Additional Task Request Form” that needs to be submitted. The PA and supervising physician should receive a response from the BME within 10 business days. Several requests for new tasks were approved during the PAAC meeting.

 

Ending a PA/Physician Agreement

 

When a PA and his/her supervising physician terminate their relationship the BME requires notification. To simplify the process, there is now a 1 page form titled: "Primary Supervisor Termination Notification”.

 

PAAC Physician Vacancy

The PA Advisory Committee has 9 members. There are 3 PAs, 4 physicians and 2 public members. There is currently an opening on the PAAC for a physician member. The PAAC requested that SCAPA help recruit a member for this vacancy.

 

 

Modernization of the South Carolina Physician Assistant Practice Act

What it means for PAs

By Paul F. Jacques, DHSc, PA-C, SCAPA Legislative Committee

May 2013

 

Tuesday, May 25th, Governor Haley signed bill S. 448 which results in the modernization of the PA practice act. After a year of negotiations with the South Carolina Medical Association (SCMA), South Carolina Academy of Family Physicians (SCAFP), South Carolina College of Emergency Physicians (SCCEP), and the SC Board of Medical Examiners (BME) the SCAPA bill was passed by both the House and Senate by a unanimous affirmative vote. Implementation of the laws falls to the SC Board of Medical Examiners and they will turn to the PA Advisory Committee (PAAC), Chaired by Martha Green, PA-C to obtain guidance on its implementation.

 

The bills wording was intended to accomplish several far reaching changes:

 

The first item is separation of licensure from approval to practice with the supervision of a licensed physician. PAs will no longer need to first identify a supervising physician in order to obtain a license. PAs will need to demonstrate they have graduated from an approved program, passed the examination demonstrating they understand the practice act, passed the NCCPA PA National Certification Exam (PANCE), and been interviewed by a member of the BME. This interview will no longer require the presences of the supervising physician.

 

Approval to begin practicing with a supervising physician is dependent upon approval of the scope of practice (SOP) guidelines. By law, the BME has 10 working days to approve the guidelines. If the BME has questions about the SOP, a physician member of the BME must contact the supervising physician and ask for clarification or other documentation before it can be processed. The 10 day timeline begins again when the BME is in receipt of that material. With a well worded and constructed SOP guideline, it is feasible that the PA can begin work within 2 weeks, if they already possess a SC license.

 

Prescribing of controlled substances II-V is delegated to the PA by his/her supervising physician. This must be specified in the SOP guidelines and signed off by the BME. Category II medications have some restrictions which were expressed as important to SCMA. According to a survey conducted by SCAPA, the PAs of SC were most interested in being able to manage acute pain. The law specifies that if delegated by the supervising physician in the guidelines, a PA may initiate a Cat II prescription, however they can only write for a 3 day supply. If the patient requires additional medications then the supervising physician will need to see the patient and determine the next course of action. PAs may prescribe for continuing therapy – if a patient presents to the office and has been on a continuing prescription for a Cat II med, the PA can write for another 30 day supply. A classic example where this situation would apply would be a patient on Ritalin or Adderall, wherein the physician has initiated the therapy. PAs who work in the hospital setting may write for a one-time parental dose of Cat II medication within a 24 hour period. Although not ideal in terms of patient care, this was justified for PAs working in the post-operative setting or the emergency department needing to manage acute pain in the physical absence of the supervising or alternate supervising physician. In order to write the controlled substance, besides having it stipulated in the practice guidelines, the PA must obtain their DHEC DEA and Federal DEA numbers. Completion of a 15 hour CME on controlled substances is a prerequisite for obtaining the SC DHEC DEA approval.

 

Physician supervision no longer specifies the percentage of time the physician must be physically present in either the onsite or offsite practice settings. An offsite practice can now be within a 60 mile radius from the primary practice setting. However, the physician must co-sign, at a minimum, 10% of the charts. If a physician/PA team wants the PA to work in an offsite practice site, they must work as a team for 6 months before requesting approval by the BME. The practice guidelines should stipulate the percent of charts to be co-signed; however, it should not be less than 10%. If specified in the SOP, PAs may practice in public places, a private place, or a facility where the supervising physician regularly sees patients. PAs may also make house calls, perform hospital duties, and perform any functions performed by the supervising physician, if the PA is also qualified to perform those functions.

 

The physician and PA work together to determine the initial tasks and functions for which the PA should be qualified within the practice setting and these should be included in the practice guidelines. If a new skill set is needed to be added to the practice guidelines, the physician and PA must demonstrate to the PAAC and BME that the PA has competency in that skill set in order to provide the new task or function. This can be demonstrated by documentation of attending a seminar or workshop, or by the physician training the PA in that particular skill set. With demonstration of the PAs competency in that particular skills set, if the BME approves, that task or function can be added to the practice guidelines and the PA can proceed with providing that task or function without direct supervision.

 

The PA profession was designed to increase access to healthcare. With this in mind, the number of PAs which a physician may supervise was increased from 2 to 3. The number of PAs which the physician may employ is 3 full time equivalents (FTEs), however only 3 may be providing clinical services at one time. There are a number of PAs who work part-time in various settings. Therefore, it is possible for a physician to employ 21 PAs, if each one only worked one day per week and the office was open 7 days a week. It would be up to the supervising physician to determine the number of PAs they would meet the needs of the practice and to limit the number of PAs providing services to 3 at one time.

 

If you have any questions about the specific language, you should refer to the PA Practice Act of 2013 (H 448 signed by Governor Haley), as posted on the SCAPA website. This version has the new language underlined and old language stricken. If you have difficulty sorting through the legalese please feel free to contact the SCAPA office.

 

As these modifications are implemented, there will be additional changes to be considered for future changes to the PA Practice Act. Please relay your recommendations for changes to the SCAPA Board.


Click here to view the PA Practice of 2013:  Bill 448

 

 

How the Modernization of the PA Act Evolved

 


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