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Texas Board of Nursing Rules and Regulations relating to Nurse Education, Licensure and Practice

TITLE 22. EXAMINING BOARDS
PART 11. TEXAS BOARD OF NURSING

CHAPTER 211. GENERAL PROVISIONS

§211.1. Introduction.

(a) Name. The entity is the Board of Nurse Examiners for the State of Texas, hereafter referred to as the board. It is a decision-making board appointed by the Governor of the State of Texas in compliance with the Texas Occupations Code.

(b) Location. The administrative offices shall be located in Austin, Texas.

(c) Legal Authority. The board is established and functions under the authority of Chapters 301, 303 and 304 of the Texas Occupations Code.

(d) Composition. The board shall be composed of those persons appointed by the Governor with the advice and consent of the Senate.

(e) Fiscal year. For all fiscal and administrative purposes, the reporting year of the board shall be identical to that of the State of Texas. The provisions of this §211.1 adopted to be effective March 31, 2002, 27 TexReg 2236; amended to be effective May 17, 2004, 29 TexReg 4884.

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§211.2. Purpose and Functions.

(a) Purpose. The purpose of the board is to protect and promote the welfare of the people of Texas. This purpose supersedes the interest of any individual, the nursing profession, or any special interest group. The board fulfills its mission through two principle areas of responsibility:

(b) Functions. The board shall perform the following functions as outlined in Texas Occupations Code chapters 301, 303, and 304.

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§211.3. Organization and Structure.

(a) General. In accordance with Texas Occupations Code §§301.051 through 301.059, the board shall consist of members appointed by the Governor with the advice and consent of the Senate.

(b) Terms of office. The terms of board members shall be six years in length and shall be staggered so that the terms of as near to one-third of the members as possible shall expire on January 31 of each odd-numbered year. Upon completion of a term, a member may continue to serve until a successor has been appointed. A member may be reappointed to successive terms at the discretion of the Governor.

(c) Eligibility. Board member eligibility is governed by the Texas Occupations Code §§301.052 and 301.053.

(d) Compensation. Each member of the board shall receive per diem as provided by law for each day that the member engages in the business of the board and will be reimbursed for travel expenses incurred in accordance with the state of Texas and Board of Nurse Examiners' travel policies.

The provisions of this §211.3 adopted to be effective March 31, 2002, 27 TexReg 2236; amended to be effective May 17, 2004, 29 TexReg 4884. §211.4. Officers.

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§211.4. Officers.

(a) Selections and appointments. In accordance with the Texas Occupations Code §301.057, the Governor shall designate one of the members of the board as presiding officer. During the last meeting of the calendar year in even years, the board shall elect from among its membership a vice president. The term of the vice president shall be for two years. If the office of vice president becomes vacant during a two-year term, the members of the board shall elect a new vice president from among its membership to serve for the remainder of the term. All elections and any other issues requiring a vote of the board shall be decided by a simple majority of the members present and voting.

(b) Duties of the officers.

The provisions of this §211.4 adopted to be effective March 31, 2002, 27 TexReg 2236; amended to be effective May 17, 2004, 29 TexReg 4884; amended to be effective July 10, 2013, 38 TexReg 4319.

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§211.5. Meetings.

The board shall meet at least four times a year. It shall consider such matters as may be necessary. Special meetings shall be called by the president of the board or upon written request signed by three members of the board in accordance with Texas Occupations Code §301.058.

The provisions of this §211.5 adopted to be effective March 31, 2002, 27 TexReg 2236; amended to be effective May 17, 2004, 29 TexReg 4884.

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§211.6. Committees of the Board.

(a) The following are standing and permanent committees of the board, as established by the board in accordance with the Nursing Practice Act. The responsibilities and authority of these committees include those duties and powers as set forth including other responsibilities and charges which the board may from time to time delegate to these committees.

(b) Eligibility and Disciplinary Committee.

(c) Education Liaison. The three board members representing nursing educational programs shall serve as advisory to the staff on matters pertaining to faculty waivers, proposed curriculum revisions and other issues that may arise between regular board meetings. The recommendations of the liaison members are presented to the board at the next regular meeting for consideration.

(d) Advanced Practice Liaison. Three members shall be designated by the president to serve as advisory to the staff on matters pertaining to advanced practitioner waivers and other issues that may arise between regular board meetings. The recommendation of the liaison members are presented to the board at the next regular meeting for consideration.

(e) Other standing or ad hoc committees. The board may designate other standing or ad hoc committees as deemed necessary. Such committees shall have and exercise such authority as may be granted by the board.

(f) Advisory Committees. The president may appoint, with the authorization of the board, advisory committees for the performance of such activities as may be appropriate or required by law.

The provisions of this §211.6 adopted to be effective March 31, 2002, 27 TexReg 2236; amended to be effective May 17, 2004, 29 TexReg 4884; amended to be effective March 14, 2007, 32 TexReg 1302; amended to be effective September 26, 2007, 32 TexReg 6519; amended to be effective January 4, 2009, 33 TexReg 10432; amended to be effective July 12, 2010, 35 TexReg 6072.

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§211.7. Executive Director.

(a) The board shall determine qualifications for and retain an executive director who shall be the chief executive officer of the agency.

(b) The executive director shall have the authority and responsibility for the operations and administration of the agency and such additional powers and duties as prescribed by the board. As chief executive of the board the executive director shall manage all aspects of the agency, including personnel, financial and other resources, in support of the NPA, rules and policies, the board's mission and strategic plan. The executive director shall attend all meetings of the board and may offer recommendations to the board, but shall not vote on matters brought before the board.

(c) The executive director shall have the authority to dismiss a complaint if an investigation demonstrates that a violation did not occur, or the subject of the complaint is outside the board's jurisdiction. At each public meeting of the board, the executive director shall report to the board each complaint dismissed since the board's last public meeting.

(d) The Executive Director, or the Executive Director's designee, is authorized to offer proposed disciplinary orders upon evaluation of the investigation findings. Such an offer may be made:

(e) The Executive Director is authorized to accept the voluntary surrender of a license. Board ratification is not required. The Executive Director will report summaries of dispositions to the Board at its regular meetings.

(f) The Executive Director is authorized to accept the following orders on behalf of the Board and ratification by the Board is not necessary. The Executive Director will report summaries of dispositions to the Board at its regular meetings.

(g) The Executive Director may grant any motion for rehearing if he/she is of the opinion that the motion has merit based on the criteria of §213.16(j) of this title (relating to Respondent's Answer in a Disciplinary Matter). Otherwise, any motion considered untimely or without merit under the criteria of §213.16(j) of this title, would be scheduled without prejudice before the next practicable full Board or Eligibility and Disciplinary meeting for review and determination.

(h) The Executive Director may grant a request for a limited license or negotiate an agreed order to return a limited licensee back to direct patient care. The Executive Director may negotiate an agreed resolution to a request for an exception to a stipulation contained in an existing order of the Board. The Executive Director shall not grant a request for exception under this subsection unless he/she is of the opinion that the requested relief falls within, and is consistent with, public safety and the parameters of §213.33(b), (g), and (h) of this title (relating to Factors Considered for Imposition of Penalties/Sanctions). Otherwise, a request for exception to an existing order of the Board may be scheduled without prejudice before the next practicable Eligibility and Disciplinary Committee meeting for review and determination. The Executive Director shall establish guidelines for review and approval of requests for exceptions to existing Board orders, including how often such requests may be made. The Executive Director shall report summaries of decisions related to requests for exceptions to existing Board orders to the Board at its regularly scheduled meetings.

The provisions of this §211.7 adopted to be effective March 31, 2002, 27 TexReg 2236; amended to be effective September 26, 2007, 32 TexReg 6519; amended to be effective October 19, 2008, 33 TexReg 8501; amended to be effective November 15, 2009, 34 TexReg 7810; amended to be effective April 17, 2013, 38 TexReg 2359.

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§211.8. Conflict of Interest.

When matters to be discussed by or before the board concern a school and/or agency with which the board member is affiliated, the board member shall not enter into the discussion unless questioned by a member of the board and shall not vote on the matter.

The provisions of this §211.8 adopted to be effective March 31, 2002, 27 TexReg 2236.

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§211.9. General Considerations.

(a) Parliamentary procedure. Board and committee meetings shall be conducted pursuant to the provisions of Robert's Rules of Order Newly Revised.

(b) Minutes. Minutes of all board meetings will be prepared and transmitted to board members for their review prior to subsequent board meetings and shall be filed with the Legislative Reference Library and the Texas State Library. Proceedings of standing and ad hoc committee meetings and advisory committee meetings shall be recorded, distributed and filed in accordance with parliamentary procedure.

(c) Video Tape. All or any part of the proceedings of a public board meeting may be recorded by any person in attendance by means of a tape recorder, video camera, or any other means of sonic or visual reproduction.

(d) Executive Session.

(e) Contracts with Historically Underutilized Businesses (HUBs).

The provisions of this §211.9 adopted to be effective March 31, 2002, 27 TexReg 2236.

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CHAPTER 213. PRACTICE AND PROCEDURE

§213.1. Definitions.

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise:

The provisions of this §213.1 adopted to be effective August 15, 2002, 27 TexReg 7107; amended to be effective May 17, 2004, 29 TexReg 4884.

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§213.2. Construction.

(a) Unless otherwise expressly provided, the past, present or future tense shall each include the other; the masculine, feminine, or neuter gender shall each include the other; and the singular and plural number shall each include the other.

(b) These rules apply to all contested cases within the Board's jurisdiction and shall control practice and procedure before the Board and SOAH, unless pre-empted by rules promulgated by SOAH.

(c) Words and phrases shall be read in context and construed according to the rules of grammar and common usage. Words and phrases that have acquired a technical or particular meaning, whether by legislative definition or otherwise, shall be construed otherwise.

(d) A reference in statute revised by the Texas Occupations Code is considered to be a reference to the part of the Texas Occupations Code that revises that statute or part of statute.

(e) A reference in a rule or part of a rule revised by this subchapter is considered to be a reference to the part of this subchapter that revises that rule or part of that rule. The provisions of this §213.2 adopted to be effective August 15, 2002, 27 TexReg 7107. §213.3. Pleading.

The provisions of this §213.3 adopted to be effective August 15, 2002, 27 TexReg 7107.

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§213.3. Pleading.

(a) In disciplinary matters:

(b) In nondisciplinary matters:

The provisions of this §213.3 adopted to be effective August 15, 2002, 27 TexReg 7107.

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§213.4. Representation.

(a) A person may represent himself/herself or be represented by an attorney licensed to practice law in Texas.

(b) A party's attorney of record shall remain the attorney of record in the absence of a formal request to withdraw and an order of the judge approving the request.

(c) Notwithstanding the above, a party may expressly waive the right to assistance of counsel. The provisions of this §213.4 adopted to be effective August 15, 2002, 27 TexReg 7107.

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§213.5. Appearance.

(a) Any person appearing before the Board in connection with a contested case shall prefile written testimony at least 21 days prior to the appearance.

(b) In disciplinary and eligibility matters, appearances in contested cases may be made only by a party.

(c) In disciplinary and eligibility matters, a non-party may file an amicus brief with the executive director, with contemporaneous filing at SOAH if SOAH has acquired jurisdiction. Non-parties who file under this provision must disclose:

The provisions of this §213.5 adopted to be effective August 15, 2002, 27 TexReg 7107.

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§213.6. Agreements in Writing.

Unless otherwise provided by the NPA or these rules, no agreement between attorneys or parties concerning any action or matter pending before the Board will be enforced unless it is in writing, signed, and filed with the papers as a part of the record, or unless it is made in open hearing and entered on record.

The provisions of this §213.6 adopted to be effective August 15, 2002, 27 TexReg 7107.

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§213.7. Final Disposition.

Except for matters expressly delegated to the executive director, no agreed order regarding eligibility or discipline shall be final or effective until approved by the Board.

The provisions of this §213.7 adopted to be effective August 15, 2002, 27 TexReg 7107.

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§213.8. Filing of Documents.

(a) The original of all applications, petitions, complaints, motions, protests, replies, answers, notices, and other pleadings relating to any proceeding pending or to be instituted before the Board shall be filed with the executive director or designee. The date of filing is the date of actual receipt at the office of the Board.

(b) The original of all documents are to be filed at SOAH only after it acquires jurisdiction. (See §213.22(a) of this title (relating to Formal Proceedings) and SOAH rules, 1 TAC §155.7 (relating to Jurisdiction)). Filings and service to SOAH shall be directed to: Docket Division, State Office of Administrative Hearings, 300 West 15th Street, Room 504, P.O. Box 13025, Austin, Texas 78711-3025. Copies of all documents filed at SOAH must be contemporaneously served on the Board.

The provisions of this §213.8 adopted to be effective August 15, 2002, 27 TexReg 7107.

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§213.9. Computation of Time.

(a) In computing any period of time prescribed or allowed by these rules, by order of the Board, or by any applicable statute, the day of the act, event, or default which the designated period of time begins to run is not to be included. The last day of the period is to be included, unless it is a Saturday, Sunday, an official State holiday, or another day on which SOAH or the Board office is closed, in which case the time period will be deemed to end on the next day that SOAH or the Board office is open. When these rules specify a deadline or set a number of days for filing documents or taking other actions, the computation of time shall be by calendar days rather than business days, unless otherwise provided for by these rules, applicable law, SOAH rules, or judge order. However, if the period specified is five days or less, the intervening Saturdays, Sundays, and legal holidays are not counted.

(b) Extension. When by these rules, SOAH rules, or judge order, an act is required or allowed to be done at or within a specified time, the executive director or judge (if SOAH has acquired jurisdiction) may, for cause shown, order the period enlarged if application is made before the expiration of the specified period. In addition, where good cause is shown for the failure to act within the specified time period, the executive director or the judge may permit the act to be done after the expiration of the specified period.

The provisions of this §213.9 adopted to be effective August 15, 2002, 27 TexReg 7107.

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§213.10. Notice and Service.

(a) Notice must be in writing and addressed to the party. Notice to a licensee is effective and service is complete when sent by certified or registered mail, return receipt requested, to the licensee's address of record at the time of the mailing.

(b) Notice to a party holding a multistate licensure privilege is effective and service is complete when sent by certified or registered mail, return receipt requested, to the privilege holder's address of record maintained with the home state nurse licensing agency at the time of the mailing.

(c) Notice to a non-licensee is effective and service is complete when sent by certified or registered mail, return receipt requested, to the person's address as stated on his/her petition, application, or other pleading.

(d) Notice to any person other than the Board is effective and service is complete when sent by certified or registered mail, return receipt requested, to the person's attorney of record.

(e) Notice of a hearing in a contested case must comply with Texas Government Code §2001.052 (Texas Administrative Procedure Act). Service is complete when made pursuant to 1 TAC §155.25 (SOAH).

The provisions of this §213.10 adopted to be effective August 15, 2002, 27 TexReg 7107; amended to be effective May 17, 2004, 29 TexReg 4884.

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§213.11. Non-SOAH Motion for Continuance.

(a) No continuance shall be granted except for sufficient cause supported by affidavit as detailed in subsection (b) of this section, by consent of the parties, or by operation of law. A party that files a motion for continuance fewer than 10 days before the date of the event specified in any non-SOAH notice, must contact the other party and indicate in the motion whether there is any opposition to the motion.

(b) The motion shall be supported by a sworn affidavit detailing the reasons for the continuance. The affidavit shall also set forth the specific grounds upon which the party seeks the continuance and that the continuance is not sought for delay, but so that justice may be served.

The provisions of this §213.11 adopted to be effective August 15, 2002, 27 TexReg 7107.

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§213.12. Witness Fees and Expenses.

A witness who is not a party to the proceeding and who is subpoenaed to appear at a deposition or hearing or to produce books, papers, or other objects, shall be entitled to receive reimbursement for expenses incurred in complying with the subpoena as set by the legislature in the APA, Texas Government Code Annotated §2001.103. In addition, a subpoenaed witness is entitled to thirty dollars ($30) for each day or part of a day that the person is necessarily present, and to mileage reimbursement. The mileage reimbursement rate shall be equal to the maximum fixed mileage allowance specified in the revenue rulings issued by the Internal Revenue Service under the federal income tax regulations as announced by the Texas Comptroller for going to and returning from the place of the hearing or deposition if the place is more than 25 miles from the person's place of residence, and the person uses the person's personally owned or leased motor vehicle for the travel.

The provisions of this §213.12 adopted to be effective August 15, 2002, 27 TexReg 7107; amended to be effective January 8, 2008, 33 TexReg 179; amended to be effective June 24, 2008, 33 TexReg 4884.

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§213.13. Complaint Investigation and Disposition.

(a) Complaints shall be submitted to the Board in writing and should contain at least the following information: Nurse/Respondent Name, License Number, Social Security Number, Date of Birth, Employer, Dates of Occurrence(s), Description of Facts or Conduct, Witnesses, Outcome, Complainant Identification (Name, Address, and Telephone Number), and Written Instructions For Providing Information to the Board. Complaints may be made on the agency's complaint form.

(b) A preliminary investigation shall be conducted to determine the identity of the person named or described in the complaint.

(c) Complaints shall be assigned a priority status:

(d) Not later than the 30th day after a complaint is received, the staff shall place a time line for completion, not to exceed one year, in the investigative file and notify all parties to the complaint. Any change in time line must be noted in the file and all parties notified of the change not later than seven days after the change was made. For purposes of this rule, completion of an investigation in a disciplinary matter occurs when:

(e) Staff shall conduct a criminal background search of the party described in the complaint.

(f) The staff shall provide summary data of complaints extending beyond the complaint time line to the executive director.

The provisions of this §213.13 adopted to be effective August 15, 2002, 27 TexReg 7107; amended to be effective May 17, 2004, 29 TexReg 4884.

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§213.14. Preliminary Notice to Respondent in Disciplinary Matters.

(a) Except for proceedings conducted pursuant to the authority of Texas Occupations Code Annotated §301.455 (Temporary Suspensions) or unless it would jeopardize the investigation, prior to commencing disciplinary proceedings under §213.15 of this title (relating to Commencement of Disciplinary Proceedings), the staff shall serve the respondent with written notice in accordance with Texas Government Code §2001.054(c).

(b) Such notice shall contain a statement of the facts or conduct alleged to warrant an adverse licensure action. The notice shall invite the respondent to show compliance with all requirements of the law for retention of the license.

(c) Respondent shall file a written response within 20 days after service of the notice specified in subsection (a) of this section.

The provisions of this §213.14 adopted to be effective August 15, 2002, 27 TexReg 7107.

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§213.15. Commencement of Disciplinary Proceedings.

(a) If a complaint is not resolved informally, the staff may commence disciplinary proceedings by filing formal charges.

(b) The formal charges shall contain the following information:

(c) When formal charges are filed, the executive director shall serve respondent with a copy of the formal charges. The notice shall state that respondent shall file a written answer to the formal charges that meets the requirements of §213.16 of this title (relating to Respondent's Answer in a Disciplinary Matter).

(d) The staff may amend the formal charges at any time permitted by the APA. A copy of any formal amended charges shall be served on the respondent. The first charges filed shall be entitled "formal charges," the first amended charges filed shall be entitled "first amended formal charges," and so forth.

(e) Formal charges may be resolved by agreement of the parties at any time.

The provisions of this §213.15 adopted to be effective August 15, 2002, 27 TexReg 7107.

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§213.16. Respondent's Answer in a Disciplinary Matter.

(a) The respondent in a disciplinary matter shall file an answer to the formal charges and to every amendment thereof.

(b) The answer shall admit or deny each of the allegations in the charges or amendment thereof. If the respondent intends to deny only a part of an allegation, the respondent shall specify so much of it is true and shall deny only the remainder. The answer shall also include any other matter, whether of law or fact, upon which respondent intends to rely for his or her defense.

(c) If the Respondent fails to file a response to the Formal charges, the matter will be considered as a default case.

(d) In a case of default, the Respondent will be deemed to have

(e) The Executive Director may recommend that the Board enter a default order, based upon the allegations set out in the Formal charges, that adopts the sanction that was recommended in the Formal charges.

(f) Upon consideration of the case, the Board may:

(g) The respondent may amend his or her answer at any time permitted by the APA or SOAH rules.

(h) The first answer filed shall be entitled "answer," the first amended answer filed shall be entitled "first amended answer," and so forth.

(i) Any default judgment granted under this section will be entered on the basis of the factual allegations in the formal charges contained in the notice, and upon proof of proper notice to the Respondent. For purposes of this section, proper notice means notice sufficient to meet the provisions of the Texas Government Code §2001.054 and §213.10 of this title (relating to Notice and Service). Such notice shall also include the following language in capital letters in 12 point boldface type: FAILURE TO FILE A WRITTEN ANSWER TO THE FORMAL CHARGES, EITHER PERSONALLY OR BY LEGAL REPRESENTATIVE, WILL RESULT IN THE ALLEGATIONS CONTAINED IN THE FORMAL CHARGES BEING ADMITTED AS TRUE AND THE PROPOSED RECOMMENDATION OF STAFF SHALL BE GRANTED BY DEFAULT.

(j) A motion for rehearing which requests that the Board vacate its default order under this section shall be granted if movant proves by the preponderance of the evidence that the failure to answer the formal charges was not intentional or the result of conscious indifference, but due to accident or mistake—provided that movant has a meritorious defense to the factual allegations contained in the formal charges and the granting thereof will occasion no delay or otherwise work an injury to the Board.

The provisions of this §213.16 adopted to be effective August 15, 2002, 27 TexReg 7107.

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§213.17. Discovery.

(a) Parties to administrative proceedings shall have reasonable opportunity and methods of discovery described in the Texas Administrative Procedure Act (APA), Chapter 2001, Texas Government Code, the Texas Nursing Practice Act (NPA), and SOAH rule, 1 TAC §155.31 (relating to Discovery). Matters subject to discovery are limited to those which are relevant and material to issues within the Board's authority as set out in the NPA. Subject to prior agreement of parties or unless explicitly stated in Board rules, responses to discovery requests, except for notices of depositions, shall be made within 20 days of receipt of the request.

(b) Parties may obtain discovery by: request for disclosure, as described by Texas Revised Civil Procedures 194, oral or written depositions, written interrogatories to a party; requests of a party for admission of facts and the genuineness of identity of documents and things; requests and motions for production, examination, and copying of documents and other tangible materials; motion for mental or physical examinations; and requests and motions for entry upon and examination of real property.

(c) Parties are encouraged to make stipulations of evidence where possible and to agree to methods and time lines to expedite discovery and conserve time and resources.

The provisions of this §213.17 adopted to be effective August 15, 2002, 27 TexReg 7107.

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§213.18. Depositions.

(a) The deposition of any witness may be taken upon a commission issued by the executive director upon the written request of any party, a copy of which shall be served on the non-requesting party.

(b) The written request shall contain the name, address, and title, if any, of the witness; a description of the books, records, writings, or other tangible items the requesting party wishes the witness to produce at the deposition; the date and location where the requesting party wishes the deposition to be taken; and a statement of the reasons why the deposition should be taken and the items produced.

(c) Depositions may be taken by telephone and by non-stenographic recording. The recording or transcript thereof may be used by any party to the same extent as a stenographic deposition, provided all other parties are supplied with a copy of the recording and the transcript to be used. The witness in a telephonic or non-stenographic deposition may be sworn by any notary. The transcript of such deposition shall be submitted to the witness for signature in accordance with Texas Government Code Annotated §2001.099.

(d) Not withstanding any other provisions of these sections, the executive director may issue a commission to take a deposition prior to the filing of charges under §213.15 of this title (relating to Commencement of Disciplinary Proceedings) if, in the opinion of the executive director, such a commission is necessary for either party to preserve evidence and testimony or to investigate any potential violation or lack of compliance with the Act, the rules and regulations, or orders of the Board. The commission may be to compel the attendance of any person to appear for the purposes of giving sworn testimony and to compel the production of books, records, papers or other objects.

(e) A deposition in a contested case shall be taken in the county where the witness:

The provisions of this §213.18 adopted to be effective August 15, 2002, 27 TexReg 7107.

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§213.19. Subpoenas.

(a) Upon the written request of any party, the executive director may issue a subpoena to require the attendance of witnesses or the production of books, records, papers, or other objects as may be necessary and proper for the purposes of the proceedings.

(b) If the subpoena is for the attendance of a witness, the written request shall contain the name, address, and title, if any, of the witness and the date upon which and the location at which the attendance of the witness is sought. If the subpoena is for the production of books, records, writings, or other tangible items, the written request shall contain a description of the item sought; the name, address, and title, if any, of the person or entity who has custody or control over the items and the date on which and the location at which the items are sought to be produced. Each request, whether for a witness or for production of items, shall contain a statement of the reasons why the subpoena should be issued.

(c) Upon a finding that a party has shown good cause for the issuance of the subpoena, the executive director shall issue the subpoena in the form described in Texas Government Code §2001.089.

(d) Notwithstanding any other provisions of these sections, the executive director may issue a subpoena prior to the filing of formal charges under §213.15 of this title (relating to Commencement of Disciplinary Proceedings), if, in the opinion of the executive director, such a subpoena is necessary to preserve evidence and testimony to investigate any potential violation or lack of compliance with the NPA, the rules and regulations, or orders of the Board. The subpoena may be to compel the attendance of any person to appear for the purposes of giving sworn testimony and/or to compel the production of books, records, papers, or other objects.

The provisions of this §213.19 adopted to be effective August 15, 2002, 27 TexReg 7107.

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§213.20. Informal Proceedings and Alternate Dispute Resolution (ADR).

(a) The Board's policy is to encourage the resolution and early settlement of internal and external disputes, including contested cases, through voluntary settlement processes such as informal proceedings or alternative dispute resolution. Any matter within the Board's jurisdiction may be resolved informally by stipulation, agreed settlement, agreed order, dismissal, or default. These matters may also be resolved using any ADR procedure or combination of procedures described by Chapter 154, Civil Practice and Remedies Code.

(b) In disciplinary matters, the Board shall offer the complainant and the licensee the opportunity to be heard. The offer may be made at any time prior to disposition and may be included on the Board's complaint form, on any notice required by statute or these rules, or otherwise.

(c) Informal proceedings may be conducted in person, by attorney, or by electronic, telephonic, or written communication.

(d) Informal proceedings shall be conducted pursuant to the following procedural standards:

(e) Informal conferences may be conducted at any time by the executive director or designee.

(f) The Board's counsel or assistant attorney general shall participate in informal proceedings.

(g) Disposition of matters considered informally may be made at any time in an agreed order containing such terms as the executive director may deem reasonable and necessary. Except as to matters delegated to the executive director for ratification, said agreed order shall not be final and effective until the Board, or an eligibility and disciplinary committee, votes to accept the proposed disposition.

(h) Referral to peer assistance after report to the Board.

(i) ADR shall be conducted pursuant to the following procedural standards:

(j) If eligibility matters are not resolved informally, the petitioner may obtain a hearing before SOAH by submitting a written request to the staff.

(k) If disciplinary matters are not resolved informally, formal charges may be filed in accordance with §213.15 of this title (relating to Commencement of Disciplinary Proceedings) and the case may be set for a hearing before SOAH in accordance with §213.22 of this title (relating to Formal Proceedings).

(l) Pre-docketing conferences may be conducted by the executive director prior to SOAH acquiring jurisdiction over the contested case. The executive director, unilaterally or at the request of any party, may direct the parties, their attorneys or representatives to appear before the executive director at a specified time and place for a conference prior to the hearing for the purpose of:

The provisions of this §213.20 adopted to be effective August 15, 2002, 27 TexReg 7170; amended to be effective October 10, 2007, 32 TexReg 7058; amended to be effective November 15, 2009, 34 TexReg 7812.

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§213.21. Agreed Disposition.

Informal proceedings, complaints and formal charges may be resolved by stipulation, agreed settlement, agreed order, or dismissal pursuant to Texas Occupations Code Annotated §301.463.

The provisions of this §213.21 adopted to be effective August 15, 2002, 27 TexReg 7107.

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§213.22. Formal Proceedings.

(a) Formal administrative hearings in contested cases shall be conducted in accordance with the APA and SOAH rules. Jurisdiction over the case is acquired by SOAH when the staff or respondent files a Request to DocketCase Form accompanied by legible copies of all pertinent documents, including but not limited to the complaint,petition, application, or other document describing the agency action giving rise to a contested case.

(b) When a case has been docketed before SOAH, Board staff or respondent shall provide a notice of hearing to all parties in accordance with §2001.052, Texas Government Code, and applicable SOAH rules.

(c) In disciplinary cases, the respondent shall enter an appearance by filing a written answer or other responsive pleading with SOAH, with a copy to staff, within 20 days of the date on which the notice of hearing is served to the respondent.

(d) For purposes of this section, an entry of an appearance shall mean the filing of a written answer or other responsive pleading.

(e) The failure of the respondent to timely enter an appearance as provided in this section shall entitle the staff to a continuance at the time of the hearing in the contested case for such reasonable period of time as determined by the judge.

(f) The notice of hearing provided to a respondent for a contested case shall include the following language in capital letters in 12-point bold face type: FAILURE TO ENTER AN APPEARANCE BY FILING A WRITTEN ANSWER OR OTHER RESPONSIVE PLEADING TO THE FORMAL CHARGES WITHIN 20 DAYS OF THE DATE THIS NOTICE WAS MAILED, SHALL ENTITLE THE STAFF TO A CONTINUANCE AT THE TIME OF THE HEARING.

(g) If a respondent fails to appear in person or by attorney on the day and at the time set for hearing in a contested case, regardless of whether an appearance has been entered, the judge, pursuant to SOAH's rules, shall, upon adequate proof that proper notice under the APA and SOAH rules was served upon the defaulting party, enter a default judgment in the matter adverse to the respondent. Such notice shall have included in 12-point, bold faced type, the fact that upon failure of the party to appear at the hearing, the factual allegations in the notice will be deemed admitted as true and the relief sought in the proposed recommendation by the staff shall be granted by default.

(h) Any default judgment granted under this section will be entered on the basis of the factual allegations in the formal charges contained in the notice of hearing, and upon proof of proper notice to the respondent. For purposes of this section, proper notice means notice sufficient to meet the provisions of the Texas Government Code §§2001.051, 2001.052 and 2001.054, as well as §213.10 of this title (relating to Notice and Service). Such notice of hearing also shall include the following language in capital letters in 12-point boldface type: FAILURE TO APPEAR AT THE HEARING IN PERSON OR BY LEGAL REPRESENTATIVE, REGARDLESS OF WHETHER AN APPEARANCE HAS BEEN ENTERED, WILL RESULT IN THE ALLEGATIONS CONTAINED IN THE FORMAL CHARGES BEING ADMITTED AS TRUE AND THE PROPOSED RECOMMENDATION OF STAFF SHALL BE GRANTED BY DEFAULT.

(i) A motion to vacate a default judgment rendered by the judge must be filed within 10 days of service of notice of the default judgment.

(j) Because of the often voluminous nature of the records properly received into evidence by the judge, the party introducing such documentary evidence may paginate each such exhibit or flag pertinent pages in each such exhibit in order to expedite the hearing and the decision-making process.

(k) The schedule of sanctions set out in the NPA is adopted by the Board, and the judge shall use such sanctions as well as any sanctions adopted by the Board by rule.

(l) Within a reasonable time after the conclusion of the hearing, the judge shall prepare and serve on the parties a proposal for decision that includes the judge's findings of fact and conclusions of law and a proposed order recommending a sanction to be imposed, if any.

(m) Each hearing may be recorded by a court reporter in accordance with the APA and SOAH rules. The cost of the transcription of the statement of facts shall be borne by the party requesting the transcript and said request shall be sent directly to the court reporter and the requesting party shall notify the other party in writing of the request.

(n) A party who appeals a final decision of the Board shall pay all of the costs of preparation of the original and any certified copy of the record of the proceeding that is required to be transmitted to the reviewing court.

The provisions of this §213.22 adopted to be effective August 15, 2002, 27 TexReg 7107.

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§213.23. Decision of the Board.

(a) Except as to those matters expressly delegated to the executive director for ratification, either the Board or the Eligibility and Disciplinary Committee, may make final decisions in all matters relating to the granting or denial of a license or permit, discipline, temporary suspension, or administrative and civil penalties.

(b) Prior to the issuance of a proposal for decision, a party may submit proposed findings of fact and conclusions of law to the judge. The judge shall issue a ruling on each proposed finding of fact and conclusion of law and shall set forth the specific reason for not adopting a particular proposed finding of fact or conclusion of law.

(c) Any party of record who is adversely affected by the proposal for decision of the judge shall have the opportunity to file with the judge exceptions to the proposal for decision and replies to exceptions to the proposal for decision in accordance with 1 TAC §155.507. The proposal for decision may be amended by the judge in accordance with 1 TAC §155.507 without again being served on the parties.

(d) The proposal for decision may be acted on by the Board or the Eligibility and Disciplinary Committee, in accordance with this section, after the expiration of 10 days after the filing of replies to exceptions to the proposal for decision or upon the day following the day exceptions or replies to exceptions are due if no such exceptions or replies are filed.

(e) Following the issuance of a proposal for decision, parties shall have an opportunity to file written exceptions and/or briefs with the Board concerning a proposal for decision. An opportunity shall be given to file a response to written exceptions and/or briefs. The following requirements govern the submission of written exceptions and/or briefs to the Board:

(f) It is the policy of the Board to change a finding of fact or conclusion of law in a proposal for decision or to vacate or modify the proposed order of a judge when, the Board determines:

(g) If the Board modifies, amends, or changes the recommended proposal for decision or order of the judge, an order shall be prepared reflecting the Board's changes as stated in the record of the meeting and stating the specific reason and legal basis for the changes made according to subsection (f) of this section.

(h) An order of the Board shall be in writing and may be signed by the executive director on behalf of the Board.

(i) A copy of the order shall be mailed to all parties and to the party's last known employer as a nurse.

(j) The decision of the Board is immediate, final, and appealable upon the signing of the written order by the executive director on behalf of the Board where:

(k) A motion for rehearing shall not be a prerequisite for appeal of the decision where the order of the Board contains the finding set forth in subsection (j) of this section.

(l) Motions for rehearing under this section are controlled by Texas Government Code §2001.145.

The provisions of this §213.23 adopted to be effective August 15, 2002, 27 TexReg 7107; amended to be effective May 17, 2004, 29 TexReg 4884; amended to be effective November 15, 2009, 34 TexReg 7818; amended to be effective August 19, 2012, 37 TexReg 6028.

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§213.24. Rescission of Probation.

(a) At least 20 days prior to a hearing to rescind probation, the probationer shall be served with written notice of the allegations supporting rescission of the probation.

(b) The hearing shall be conducted in accordance with §213.22 of this title (relating to Formal Proceedings), and the decisions of the Board shall be rendered in accordance with §213.23 of this title (relating to Decision of the Board).

(c) After giving the probationer notice and an opportunity to be heard, the Board may set aside the stay order and impose the stayed discipline (revocation/suspension) of the probationer's license.

(d) If during the period of probation, an additional allegation, accusation, or petition is reported or filed against the probationer's license, the probationary period shall not expire and shall automatically be extended until the allegation, accusation, or petition has been acted upon by the Board.

(e) The Board may determine as part of probation that the public may be better protected if probationer is suspended from the practice of nursing for a specific time period in order to correct deficiencies in skills, education, or personal rehabilitation and to assure documented proof of rehabilitation. Prior to the lifting of the actual suspension of license, the probationer will provide documentation of completion of educational courses or treatment rehabilitation.

The provisions of this §213.24 adopted to be effective August 15, 2002, 27 TexReg 7107.

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§213.25. Monitoring.

(a) The Board shall identify and monitor licensees who present a risk to the public and who are subject to Board orders. The monitoring system shall track at least the name, license number, address, employer, and any other information necessary to demonstrate compliance or non-compliance with an order of the Board.

(b) Monitored licensees will pay a monthly fee as stated in the Board order. Said fee shall be paid on or before the 5th of each month.

The provisions of this §213.25 adopted to be effective August 15, 2002, 27 TexReg 7107.

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§213.26. Reissuance of a License.

(a) A person whose license to practice nursing in this state has been revoked, suspended, or surrendered may apply for reinstatement of the license. In the case of revocation, petition shall not be made prior to one year after the effective date of the revocation. The Board may approve or deny a petition. In the case of denial, the Board may set a reasonable time that must elapse before another petition may be filed. The Board may impose reasonable conditions that a petitioner must satisfy before reinstatement of an unencumbered license.

(b) A petition for reinstatement shall be in writing and in the form prescribed by the Board.

(c) Petitioner's appearance at any hearing concerning reinstatement of a license shall be in person unless otherwise approved by the executive director.

(d) The burden of proof is on the petitioner to prove present fitness to practice as well as compliance with all terms and conditions imposed as a part of any revocation, surrender, or suspension. A license may be reissued with a limited practice designation or with stipulations. If petition for reinstatement is denied, Petitioner may request a hearing before SOAH.

(e) In considering reinstatement of a surrendered, suspended, or revoked license, the Board will evaluate:

The provisions of this §213.26 adopted to be effective August 15, 2002, 27 TexReg 7107; amended to be effective May 17, 2004, 29 TexReg 4884.

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§213.27. Good Professional Character.

(a) Good professional character is the integrated pattern of personal, academic and occupational behaviors which, in the judgment of the Board, indicates that an individual is able to consistently conform his or her conduct to the requirements of the Nursing Practice Act, the Board's rules and regulations, and generally accepted standards of nursing practice including, but not limited to, behaviors indicating honesty, accountability, trustworthiness, reliability, and integrity.

(b) Factors to be used in evaluating good professional character in eligibility and disciplinary matters are:

(c) The following provisions shall govern the determination of present good professional character and fitness of a Petitioner, Applicant, or Licensee who has been convicted of a felony in Texas or placed on probation for a felony with or without an adjudication of guilt in Texas, or who has been convicted or placed on probation with or without an adjudication of guilt in another jurisdiction for a crime which would be a felony in Texas. A Petitioner, Applicant, or Licensee may be found lacking in present good professional character and fitness under this rule based on the underlying facts of a felony conviction or deferred adjudication, as well as based on the conviction or probation through deferred adjudication itself.

(d) The following provisions shall govern the determination of present good professional character and fitness of a Petitioner, Applicant, or Licensee who has been licensed to practice nursing in any jurisdiction and has been disciplined, or allowed to voluntarily surrender in lieu of discipline, in that jurisdiction.

(e) An individual who applies for initial licensure, reinstatement, renewal, or endorsement to practice professional or vocational nursing in Texas after the expiration of the three-year period in subsection (f) of this section, or after the completion of the disciplinary period assessed or ineligibility period imposed by any jurisdiction under subsection (d) of this section shall be required to prove, by a preponderance of the evidence:

(f) An individual who applies for initial licensure, reinstatement, renewal, or endorsement to practice professional or vocational nursing in Texas after a negative determination based on a felony conviction, felony probation with or without an adjudication of guilt, or professional misconduct, or voluntary surrender in lieu of disciplinary action and whose application or petition is denied and not appealed is not eligible to file another petition or application for licensure until after the expiration of three years from the date of the Board's order denying the preceding petition for licensure.

(g) The following disciplinary and eligibility sanction policies and guidelines shall be used by the Executive Director, the State Office of Administrative Hearings (SOAH), and the Board in evaluating good professional character in eligibility and disciplinary matters:

The provisions of this §213.27 adopted to be effective September 1, 1998, 23 TexReg 6444; amended to be effective November 14, 2002, 27 TexReg 10594; amended to be effective May 17, 2004, 29 TexReg 4884; amended to be effective October 10, 2007, 32 TexReg 7058; amended to be effective July 2, 2008, 33 TexReg 5007; amended to be effective July 10, 2013, 38 TexReg 4320.

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§213.28. Licensure of Persons with Criminal Offenses.

(a) This section sets out the considerations and criteria in determining the effect of criminal offenses on the eligibility of a person to obtain a license and the consequences that criminal offenses may have on a person's ability to retain or renew a license as a registered nurse or licensed vocational nurse. The Board may refuse to approve persons to take the licensure examination, may refuse to issue or renew a license or certificate of registration, or may refuse to issue a temporary permit to any individual that has been convicted of or received a deferred disposition for a felony, a misdemeanor involving moral turpitude, or engaged in conduct resulting in the revocation of probation.

(b) The practice of nursing involves clients, their families, significant others and the public in diverse settings. The registered and vocational nurse practices in an autonomous role with individuals who are physically, emotionally and financially vulnerable. The nurse has access to personal information about all aspects of a person's life, resources and relationships. Therefore, criminal behavior whether violent or non-violent, directed against persons, property or public order and decency is considered by the Board as highly relevant to an individual's fitness to practice nursing. The Board considers the following categories of criminal conduct to relate to and affect the practice of nursing:

(c) In considering whether a criminal offense renders the individual ineligible for licensure or renewal of licensure as a registered or vocational nurse, the Board shall consider:

(d) Crimes listed under subsections (b)(1)(A)(i) - (xxi), (b)(2)(A)(i) - (iii), and (b)(3)(A)(i) of this section are offenses identified under §301.4535 of the NPA. As such, these offenses require the board to suspend a nurse's license, revoke a license, or deny issuing a license to an applicant upon proof of initial conviction.

(e) In addition to the factors that may be considered under subsection (c) of this section, the Board, in determining the present fitness of a person who has been convicted of or received a deferred order for a crime, shall consider:

(f) It shall be the responsibility of the applicant, to the extent possible, to obtain and provide to the Board the recommendations of the prosecution, law enforcement, and correctional authorities as required under this Act. The applicant shall also furnish proof in such form as may be required by the Board that he or she has maintained a record of steady employment and has supported his or her dependents and has otherwise maintained a record of good conduct and has paid all outstanding court costs, supervision fees, fines, and restitution as may have been ordered in all criminal cases in which he or she has been convicted or received a deferred order.

(g) If requested by staff, it shall be the responsibility of the individual seeking licensure to ensure that staff is provided with legible, certified copies of all court and law enforcement documentation from all jurisdictions where the individual has resided or practiced as a licensed health care professional. Failure to provide complete, legible and accurate documentation will result in delays prior to licensure or renewal of licensure and possible grounds for ineligibility.

(h) The fact that a person has been arrested will not be used as grounds for disciplinary action. If, however, evidence ascertained through the Board's own investigation from information contained in the arrest record regarding the underlying conduct suggests actions violating the Nursing Practice Act or rules of the Board, the board may consider such evidence as a factor in its deliberations regarding any decision to grant a license, restrict a license, or impose licensure discipline.

(i) Behavior that would otherwise bar or impede licensure may be deemed a "Youthful Indiscretion" as determined by an analysis of the behavior using the factors set out in §213.27 of this title (relating to Good Professional Character), subsections (a) - (f) of this section and at least the following criteria:

(j) With respect to a request to obtain a license from a person who has a criminal history, the executive director is authorized to close an eligibility file when the applicant has failed to respond to a request for information or to a proposal for denial of eligibility within 60 days thereof.

(k) The board shall revoke a license or authorization to practice as an advanced practice nurse upon the imprisonment of the licensee following a felony conviction or deferred adjudication, or revocation of felony community supervision, parole, or mandatory supervision. (l) The board shall revoke or deny a license or authorization to practice as an advanced practice nurse for the crimes listed in Texas Occupations Code §301.4535.

(m) The following disciplinary and eligibility sanction policies and guidelines shall be used by the Executive Director, the State Office of Administrative Hearings (SOAH), and the Board in evaluating the impact of criminal conduct on nurse licensure in eligibility and disciplinary matters:

The provisions of this §213.28 adopted to be effective September 1, 1998, 23 TexReg 6444; amended to be effective July 20, 1999, 24 TexReg 5473; amended to be effective November 14, 2002, 27 TexReg 10594; amended to be effective May 17, 2004, 29 TexReg 4884; amended to be effective March 14, 2007, 32 TexReg 1304; amended to be effective October 10, 2007, 32 TexReg 7058; amended to be effective July 2, 2008, 33 TexReg 5007; amended to be effective July 10, 2013, 38 TexReg 4327.

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§213.29. Criteria and Procedure Regarding Intemperate Use and Lack of Fitness in Eligibility and Disciplinary Matters 25.

(a) A person desiring to obtain or retain a license to practice professional or vocational nursing shall provide evidence of current sobriety and fitness consistent with this rule.

(b) Such person shall provide a sworn certificate to the Board stating that he/she has read and understands the requirements for licensure as a registered or vocational nurse and that he/she has not:

(c) If a registered or vocational nurse is reported to the Board for intemperate use, abuse of drugs or alcohol, or diagnosis of or treatment for chemical dependency; or if a person is unable to sign the certification in subsection (b) of this section, the following restrictions and requirements apply:

(e) Prior intemperate use, mental illness, or diminished mental capacity is relevant only so far as it may indicate current intemperate use or lack of fitness.

(f) With respect to chemical dependency in eligibility and disciplinary matters, the executive director is authorized to:

(g) With respect to mental illness or diminished mental capacity in eligibility, disciplinary, and renewal matters, the executive director is authorized to propose conditional orders for individuals who have experienced mental illness or diminished mental capacity within the past five years provided:

(h) In renewal matters involving chemical dependency use, mental illness, or diminished mental capacity, the executive director shall consider the following information from the preceding renewal period:

(i) Upon receipt of items (h)(1) - (3) of this section, the executive director may renew the license.

(j) The following disciplinary and eligibility sanction policies and guidelines shall be used by the Executive Director, the State Office of Administrative Hearings (SOAH), and the Board in evaluating the appropriate licensure determination or sanction in eligibility and disciplinary matters:

The provisions of this §213.29 adopted to be effective September 1, 1998, 23 TexReg 6444; amended to be effective July 20, 1999, 24 TexReg 5473; amended to be effective November 14, 2002, 27 TexReg 10594; amended to be effective May 17, 2004, 29 TexReg 4884; amended to be effective October 10, 2007, 32 TexReg 7058; amended to be effective July 2, 2008, 33 TexReg 5007; amended to be effective November 15, 2009, 34 TexReg 7812; amended to be effective July 10, 2013, 37 TexReg 4335.

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§213.30. Declaratory Order of Eligibility for Licensure.

(a) For purposes of this section only, "petitioner" means an individual who:

(b) An individual who has reason to believe that he or she may be ineligible for initial licensure or licensure by endorsement may petition the Board for a declaratory order as to his or her eligibility.

(c) A petitioner must submit a petition on forms provided by the Board, which includes:

(d) Once the Board has received all necessary information, including the information required by subsection (c) of this section, an investigation of the petition and the petitioner's eligibility shall be conducted.

(e) The petitioner or the Board may amend the petition to include additional grounds for potential ineligibility at any time before a final determination is made.

(f) If an individual seeking licensure by endorsement pursuant to §217.5 of this title has been licensed to practice professional or vocational nursing in any jurisdiction and has been disciplined in that jurisdiction or allowed to surrender in lieu of discipline in that jurisdiction, the following provisions shall govern the eligibility of the petitioner with regard to §213.27 of this title (relating to Good Professional Character).

(g) If a petitioner's potential ineligibility is due to criminal conduct and/or conviction, including deferred adjudication, the following provisions shall govern the eligibility of the petitioner with regard to §213.28 of this title (relating to Licensure of Persons with Criminal Convictions).

(h) If the Executive Director proposes to find the petitioner ineligible for licensure, the petitioner may obtain a hearing before the State Office of Administrative Hearings (SOAH). The Executive Director shall have discretion to set a hearing and give notice of the hearing to the petitioner. The hearing shall be conducted in accordance with §213.22 of this chapter (relating to Formal Proceedings) and the rules of SOAH. When in conflict, SOAH's rules of procedure will prevail. The decision of the Board shall be rendered in accordance with §213.23 of this chapter (relating to Decision of the Board).

(i) A final Board order is issued after an appeal results in a Proposal for Decision from SOAH. The Board's final order must set out each basis for potential ineligibility and the Board's determination as to eligibility. In the absence of new evidence not disclosed by the petitioner or not reasonably available to the Board at the time the order is issued, the Board's ruling determines the petitioner's eligibility with respect to the grounds for potential ineligibility as set out in the order. An individual whose petition is denied by final order of the Board may not file another petition or seek licensure by endorsement or examination until after the expiration of three years from the date of the Board's order denying the petition. If the petitioner does not appeal or request a formal hearing at SOAH after a letter proposal to deny eligibility made by the Eligibility and Disciplinary Committee of the Board or the Executive Director, the petitioner may re-petition or seek licensure by endorsement or examination after the expiration of one year from the date of the proposal to deny eligibility, in accordance with this section and the Occupations Code §301.257.

(j) The Disciplinary Matrix and factors set forth in §213.33(b) and (c) of this chapter and the following disciplinary and eligibility sanction policies and guidelines shall be used by the Executive Director and SOAH when recommending a declaratory order of eligibility, and the Board in determining the appropriate declaratory order in eligibility matters:

(k) If an individual seeking licensure by endorsement under §217.5 of this title or licensure by examination under §217.2 or §217.4 of this title should have had an eligibility issue settled pursuant to the Occupations Code §301.257, the filed application will be treated and processed as a petition for declaratory order under this section, and the individual will be treated as a petitioner under this section and will be required to pay the nonrefundable fee required by this section.

(l) This section implements the requirements of the Occupations Code Chapter 53 Subchapter D and the Occupations Code §301.257.

The provisions of this §213.30 adopted to be effective August 15, 2002, 27 TexReg 7107; amended to be effective May 17, 2004, 29 TexReg 4884; amended to be effective February 19, 2006, 31 TexReg 847; amended to be effective October 10, 2007, 32 TexReg 7058; amended to be effective July 2, 2008, 33 TexReg 5007; amended to be effective November 15, 2009, 34 TexReg 7812; amended to be effective July 12, 2010, 35 TexReg 6074; amended to be effective July 10, 2013, 38 TexReg 4342.

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§213.31. Cross-reference of Rights and Options Available to Licensees and Petitioners.

Licensees subject to disciplinary action and petitioners seeking a determination of licensure eligibility have certain rights and options available to them in connection with these mechanisms. For example, licensees or petitioners have the right to request information in the Board's possession, including information favorable to licensee or petitioner, and the option to be represented by an attorney at their own expense. The following is a list of references to provisions of the Nursing Practice Act (Texas Occupations Code Annotated Chapter 301) and the Board's rules addressing these rights and options and related matters. Persons with matters before the Board should familiarize themselves with these provisions:

The provisions of this §213.31 adopted to be effective August 15, 2002, 27 TexReg 7107; amended to be effective May 17, 2004, 29 TexReg 4884.

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§213.32. Corrective Action Proceedings and Schedule of Administrative Fine(s).

A corrective action may be imposed by the Board as specified in the following circumstances.

The provisions of this §213.32 adopted to be effective August 15, 2002, 27 TexReg 7107; amended to be effective May 17, 2004, 29 TexReg 4884; amended to be effective November 15, 2009, 34 TexReg 7820.

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§213.33. Factors Considered for Imposition of Penalties/Sanctions.

(a) The Board and the State Office of Administrative Hearings (SOAH) shall utilize the Disciplinary Matrix set forth in subsection (b) of this section in all disciplinary and eligibility matters.

(b) The Disciplinary Matrix is as follows:

 

Texas Board of Nursing Disciplinary Matrix
In determining the appropriate disciplinary action, including the amount of any administrative penalty to assess, the Board will consider the threat to public safety, the seriousness of the violation, and any aggravating or mitigating factors. The Board currently lists factors to be considered in Rule 213.33, published at 22 Tex. Admit. Code §213.33. The Matrix may list additional aggravating or mitigating factors which may be considered in addition to the factors listed in Rule 213.33. Further, any aggravating or mitigating factors that may exist in a particular matter, but which are not listed in this Matrix or Rule 213.33, may also be considered by the Board, pursuant to the Occupations Code Chapters 53 and 301.

Additionally, the Board shall consider whether the person is being disciplined for multiple violations of either Chapter 301 or a rule or order adopted under Chapter 301; or has previously been the subject of disciplinary action by the Board and has previously complied with Board rules and Chapter 301. Further, the Board will consider the seriousness of the violation, the threat to public safety, and any aggravating or mitigating factors.

If the person is being disciplined for multiple violations of either Chapter 301, or a rule or order adopted under Chapter 301, the Board shall consider taking a more severe disciplinary action, including revocation of the person's license, than the disciplinary action that would be taken for a single violation; and

If the person has previously been the subject of disciplinary action by the Board, the Board shall consider taking a more severe disciplinary action, including revocation of the person's license, than the disciplinary action that would be taken for a person who has not previously been the subject of disciplinary action by the Board.

The Board may assess administrative penalties as outlined in 22 Tex. Admit. Code §213.32.

Although not addressed by this Matrix, the Board may also seek to assess costs of a contested case proceeding authorized by the Occupations Code §301.461.

Although not addressed by this Matrix, the Occupations Code §301.4521 authorizes the Board to require an individual to submit to an evaluation if the Board has probable cause to believe that the individual is unable to safely practice nursing due to physical impairment, mental impairment, chemical dependency, or abuse of drugs of alcohol. Section 301.4521 also authorizes the Board to request an individual to submit to an evaluation for other reasons, such as reported unprofessional conduct, lack of good professional character, or prior criminal history. The Board's rules regarding evaluations are published at 22 Tex. Admin. Code §213.29, §213.30, and §213.33.

This Matrix is also applicable to the determination of an individual's eligibility for licensure under the Occupations Code §301.257.

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§301.452(b)(1) a violation of Chapter 301, a rule or regulation not inconsistent with Chapter 301,
or an order issued under Chapter 301;
First Tier Offense:

Isolated failure to comply with procedural Board rule, such as failure to renew license within six (6) months of its due date/renewal date or failure to complete continuing competency requirements*.

Failure to comply with a technical, non-remedial requirement in a prior Board order or stipulation, such as failure to timely pay fine, failure to timely complete remedial education stipulation, missed employer reports, or employer notification forms.
Sanction Level I:

Remedial Education, with or without a fine of $250.00 or more for each additional violation.

If stipulations in prior Board order are still outstanding, full compliance with and continuation of prior Board order and a fine of $250 or more for each additional violation.
Sanction Level II:

Warning or Reprimand with Stipulations that may include remedial education; supervised practice; perform public service; abstain from unauthorized use of drugs and alcohol to be verified by random drug testing through urinalysis; limit specific nursing activities, periodic board review; and/or a fine of $500 or more for each additional violation.
Second Tier Offense:

Failure to comply with a substantive requirement in a prior Board order or stipulation. Substantive requirements are those stipulations in a Board Order designed to remediate, verify, or monitor the competency issue raised by the documented violation. Any violation of Board order that could pose a risk of harm to patients or public. Practice on a delinquent license for over two (2) years, but less than four (4) years.
Sanction Level I:

Requirement to complete conditions of original Board order and a fine of $500.00 or more for each additional violation. Respondent may be subject to next higher sanction and an extension of the stipulations. Violations of stipulations that are related to alcohol or drug misuse will result in next higher administrative sanction (ex: a violation of a Board approved Peer Assistance Order may result in an Enforced Suspension until the nurse receives treatment and obtains one (1) year of sobriety and then probation of the license with a fine and drug stipulations for three (3) years).
Sanction Level II:

Denial of Licensure, Suspension, Revocation, or Voluntary Surrender.
Third Tier Offense:

Violation of substantive probationary restriction required in a Board Order that limits the practice setting or scope of practice. Failing to comply with substantive probationary restriction required in a Board Order; for example, repeated failure to submit to random drug screens or intentional submission of false or deceptive compliance evidence. Substantive requirements are those stipulations in a Board Order designed to remediate, verify, or monitor the competency issue raised by the documented violation.
Sanction Level I:

Revocation or Voluntary Surrender.
Sanction Level II:
Emergency Suspension of nursing practice in light of violation that may be a continuing and imminent threat to public health and safety pursuant to the Occupations Code §301.455 or §301.4551, which may ultimately result in revocation.

Aggravating Circumstances for §301.452(b)(1): Multiple offenses; continued failure to register for available remedial classes; recurring failure to provide information required by order; patient vulnerability, impairment at time of incident, failure to cooperate with compliance investigator.

Mitigating Circumstances for §301.452(b)(1): Unforeseen financial or health issues;
not practicing nursing during stipulation period.
* Denotes a violation that is subject to disciplinary action, but may be eligible for a corrective action agreement (non-disciplinary action). The sanctions contained in this Matrix are disciplinary actions. Board rules regarding corrective actions (non-disciplinary actions) are located at 22 Tex. Admin. Code §213.32 and are not applicable to this Matrix. Further, a corrective action is not available as a sanction in a disciplinary action.

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§301.452(b)(2) fraud or deceit in procuring or attempting to procure a license
to practice professional nursing or vocational nursing;
First Tier Offense:

Failure to honestly and accurately provide
information that may have affected the Board determination of whether to grant a license. *
Sanction Level I:

Remedial Education and / or a fine of $250 or more for each additional violation.
Sanction Level II:

Denial of Licensure or Revocation of nursing license.
Second Tier Offense:

Intentional misrepresentation of previous nurse licensure, education, extensive criminal history, multiple violations / offenses, an offense which is listed in the Occupations Code §301.4535, or professional character, including when license has been or is requested to be issued based on fraudulent diploma or fraudulent educational transcript.
Sanction Level I:

Denial of Licensure or Revocation of nursing license.
Sanction Level II:

Emergency Suspension of nursing practice in light of violation that may be a continuing and imminent threat to public health and safety pursuant to the Occupations Code §301.455, which may ultimately result in revocation.
Aggravating Circumstances for §301.452(b)(2): Multiple offenses; the relevance or seriousness of the hidden information, whether the hidden information, if known, would have prevented licensure.
Mitigating Circumstances for §301.452(b)(2):Seriousness of the hidden violation; age of applicant at time applicant committed violation; and applicant's justified reliance upon advice of legal counsel.
* Denotes a violation that is subject to disciplinary action, but may be eligible for a corrective action agreement (non-disciplinary action). The sanctions contained in this Matrix are disciplinary actions. Board rules regarding corrective actions (non-disciplinary actions) are located at 22 Tex. Admin. Code §213.32 and are not applicable to this Matrix. Further, a corrective action is not available as a sanction in a disciplinary action.

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§301.452(b)(3) a conviction for, or placement on deferred adjudication, community supervision, or deferred disposition for, a felony or for a misdemeanor involving moral turpitude;
Eligibility and Discipline will be reviewed under Board's Disciplinary Guidelines for Criminal Conduct. The Board will also utilize 22 Tex. Admin. Code 213.28, the Occupations Code §301.4535, and the Occupations Code Chapter 53, including §53.021(b), which provides that a license holder's license shall be revoked on the license holder's imprisonment following a felony conviction, felony community supervision revocation, revocation of parole, or revocation of mandatory supervision.

 

§301.452(b)(4) conduct that results in the revocation of probation imposed because of conviction for a felony
or for a misdemeanor involving moral turpitude;
Eligibility and Discipline will be reviewed under the Board's Disciplinary Guidelines for Criminal Conduct . The Board will also utilize 22 Tex. Admin. Code §213.28, the Occupations Code §301.4535, and the Occupations Code Chapter 53, including §53.021(b), which provides that a license holder's license shall be revoked on the license holder's imprisonment following a felony conviction, felony community supervision revocation, revocation of parole, or revocation of mandatory supervision.

 

§301.452(b)(5) use of a nursing license, diploma, or permit, or the transcript of such a document, that has been fraudulently purchased, issued, counterfeited, or materially altered;
  Sanction:

Issuance of Cease and Desist Order with referral of all information to local law enforcement.
 

 

301.452(b)(6) impersonating or acting as a proxy for another person in the licensing examination
required under Section 301.253 or 301.255;
  Sanction:

Revocation of license for this offense.
 

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§301.452(b)(7) directly or indirectly aiding or abetting an unlicensed person in connection
with the unauthorized practice of nursing;
First Tier Offense:

Negligently or Recklessly aiding an unlicensed person in connection with unauthorized practice. For example, failing to verify credentials of those who are supervised by the nurse* or allowing Certified Nurse Aids to administer medications or otherwise practice beyond their appropriate scope.
Sanction Level I:

Remedial Education and/or a fine of $250 for a single or isolated incident. When there exists chronic violations or multiple violations then Warning or Reprimand with Stipulations that may include remedial education; supervised practice; limit specific nursing activities; periodic board review; and/or a fine of $250 or more for each additional violation.
Sanction Level II:

Denial of Licensure, Revocation or Voluntary Surrender when omission or violation is associated with high risk of patient injury or death.
Second Tier Offense:

Knowingly aiding an unlicensed person in connection with unauthorized practice of nursing.
Sanction Level I:

Denial of Licensure, Revocation or Voluntary Surrender.
Sanction Level II:

Emergency Suspension of nursing practice in light of violation that may be a continuing and imminent threat to public health and safety pursuant to the Occupations Code §301.455, which may ultimately result in revocation.
Aggravating Circumstances of §301.452(b)(7): Multiple offenses, intentional violation of institutional and BON rules, patient harm or risk of harm.
Mitigating Circumstances of §301.452(b)(7): The existence of institutional policies that allow certain practices by unlicensed persons with certified competency.
* Denotes a violation that is subject to disciplinary action, but may be eligible for a corrective action agreement (nondisciplinary action). The sanctions contained in this Matrix are disciplinary actions. Board rules regarding corrective actions (non-disciplinary actions) are located at 22 Tex. Admin. Code §213.32 and are not applicable to this Matrix. Further, a corrective action is not available as a sanction in a disciplinary action.

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§301.452(b)(8) revocation, suspension, or denial of, or any other action relating to, the person's license or privilege to practice nursing in another jurisdiction;
First Tier Offense:

Action in another jurisdiction results from a default order issued due to the nurse's failure to answer violations, and the violations are not those in which the other jurisdiction or Texas would have revoked the license but for the nurse's failure to respond.

Action in another jurisdiction is based on alcohol or substance misuse and the nurse is otherwise eligible for a stipulation of the license based on Board's rules and alcohol or substance misuse policy.

www.bon.state.tx.us/ disciplinaryaction/dsp.html.
Sanction Level I:

Warning or Reprimand with Stipulations, which may include remedial education; supervised practice; perform public service; verified abstinence from unauthorized use of drugs and alcohol to be verified through urinalysis; limit specific nursing activities; and/or periodic board review.

Order to participate in Board approved peer assistance program.

Action should be at least consistent with action from other jurisdiction.
Sanction Level II:

Revocation, Suspension, or Denial of Licensure when the individual doesn't respond or is not eligible for stipulated license.

Action should be at least consistent with action from other jurisdiction.
Second Tier Offense:

Revocation in another jurisdiction based on practice violations or unprofessional conduct that could result in similar sanction (revocation) in Texas.
Sanction Level I:

Revocation, denial of licensure, or voluntary surrender.
Sanction Level II:

Emergency Suspension of nursing practice in light of violation that may be a continuing and imminent threat to public health and safety pursuant to the Occupations Code §301.455 or §301.4551, which may ultimately result in revocation.
Aggravating Circumstances for §301.452(b)(8): Multiple offenses, patient vulnerability, impairment during the incident, the nature and seriousness of the violation in the other jurisdiction, and patient harm or risk of harm associated with the violation, criminal conduct.
Mitigating Circumstances for §301.452(b)(8): Nurse's failure to defend against the notice of violations and the resulting default order was not result of conscious indifference. The nurse has a meritorious defense against the unanswered violations outlined in the default order.

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§301.452(b)(9) intemperate use of alcohol or drugs that the Board determines endangers or could endanger a patient;
First Tier Offense:

Misuse of drugs or alcohol without patient interaction and no risk of patient harm or adverse patient effects. No previous history of misuse and no other aggravating circumstances.
Sanction Level I:

Referral to a Board approved peer assistance program for nurses pursuant to Board rules and policy on alcohol or substance abuse or misuse.

www.bon.state.tx.us/ disciplinaryaction/dsp.html.
Sanction Level II:

For individuals receiving a diagnosis of no chemical dependency and/or no substance abuse/misuse, Warning with Stipulations that may include remedial education; supervised practice; perform public service; abstain from unauthorized use of drugs and alcohol to be verified by random drug testing through urinalysis; limit specific nursing activities and/or periodic board review. Appropriate when individual declines participation in peer assistance program or are otherwise ineligible for the program.
Second Tier Offense:

Misuse of drugs or alcohol without patient interaction and no risk of patient harm or adverse patient effects. However, individual has a previous history of peer assistance program participation or previous Board order.
Sanction Level I:

Board ordered participation in a Board approved peer assistance program for nurses pursuant to Board rules and policy on alcohol or substance abuse or misuse. Includes individuals with non disciplinary history of peer assistance participation.

www.bon.state.tx.us/ disciplinaryaction/dsp.html.

For individuals receiving a diagnosis of no chemical dependency and/or no substance abuse/misuse, Reprimand with Stipulations which may include remedial education; supervised practice; perform public service; abstain from unauthorized use of drugs and alcohol to be verified by random drug testing through urinalysis; limit specific nursing activities, and/or periodic board review.
Sanction Level II:

Suspension of License until treatment and verifiable proof of at least one year sobriety; thereafter a stay of suspension with stipulations that may include remedial education; supervised practice; perform public service; abstain from unauthorized use of drugs and alcohol to be verified by random drug testing through urinalysis; limit specific nursing activities, and/or periodic board review. Includes individuals with prior disciplinary history with peer assistance participation.

For individuals receiving a diagnosis of no chemical dependency and/or no substance abuse/misuse, Suspension of License, which shall be probated, and stipulations which may include remedial education; supervised practice; perform public service; abstain from unauthorized use of drugs and alcohol to be verified by random drug testing through urinalysis; limit specific nursing activities, and/or periodic board review.

Emergency Suspension of nursing practice in light of violation that may be a continuing and imminent threat to public health and safety pursuant to the Occupations Code §301.455 or §301.4551, which may ultimately result in revocation.
Third Tier Offense:

Misuse of drugs or alcohol with a risk of patient harm or adverse patient effects. Misuse of drugs or alcohol and other serious practice violation noted.
Sanction Level I:

Referral to a Board approved peer assistance program if no actual patient harm, no previous history of drug or alcohol misuse, and no other aggravating circumstances.

Board ordered participation in an approved peer assistance program if no actual patient harm and no other aggravating circumstances.

For individuals receiving a diagnosis of no chemical dependency and/or no substance abuse/misuse, Warning or Reprimand with Stipulations that may include remedial education; supervised practice; perform public service; abstain from unauthorized use of drugs and alcohol to be verified by random drug testing through urinalysis; limit specific nursing activities, and/or periodic board review.

Denial of Licensure until applicant establishes he/she has received treatment and demonstrates one (1) year of verifiable sobriety, then license with stipulations that include supervision; limited practice; abstention from drugs/alcohol; and random drug testing through urinalysis.
Sanction Level II:

Suspension of License until treatment, verifiable proof of at least one year sobriety, thereafter a stay of suspension with stipulations that may include remedial education; supervised practice; perform public service; abstain from unauthorized use of drugs and alcohol to be verified by random drug testing through urinalysis; limit specific nursing activities; and/or periodic board review.

For individuals receiving a diagnosis of no chemical dependency and/or no substance abuse/misuse, Suspension of License, which shall be probated, and stipulations which may include remedial education; supervised practice; perform public service; abstain from unauthorized use of drugs and alcohol to be verified by random drug testing through urinalysis; limit specific nursing activities, and/or periodic board review.

Emergency Suspension of nursing practice in light of violation that may be a continuing and imminent threat to public health and safety pursuant to the Occupations Code §301.455 or §301.4551, which may ultimately result in revocation.
Fourth Tier Offense:

Misuse of drugs or alcohol with serious physical injury or death of a patient or a risk of significant physical injury or death.
Sanction Level I:

Denial of Licensure, Revocation or Voluntary Surrender.
Sanction Level II:

Emergency Suspension of nursing practice in light of violation that may be a continuing and imminent threat to public health and safety pursuant to the Occupations Code §301.455 or §301.4551, which may ultimately result in revocation.
Aggravating Circumstances for §301.452(b)(9): Actual harm; severity of harm; number of events; illegal substance; criminal action; criminal conduct or criminal action involved, criminal justice probation; inappropriate use of prescription drug; unsuccessful / repeated treatment; concurrent diversion violations. Ineligible to participate in approved peer assistance program because of program policy or Board policy.
Mitigating Circumstances for §301.452(b)(9): Self-remediation, including participation in inpatient treatment, intensive outpatient treatment, and after care program. Verifiable proof of sobriety by random, frequent drug/alcohol screens.

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§301.452(b)(10) unprofessional or dishonorable conduct that, in the board's opinion, is likely to deceive, defraud, or injure a patient or the public;
First Tier Offense:

Isolated failure to comply with Board rules regarding unprofessional conduct resulting in unsafe practice with no adverse patient effects.

Isolated violation involving minor unethical conduct where no patient safety is at risk, such as negligent failure to maintain client confidentiality or failure to honestly disclose or answer questions relevant to employment or licensure.*
Sanction Level I:

Remedial Education and/or a fine of $250 or more for each additional violation. Elements normally related to dishonesty, fraud or deceit are deemed to be unintentional.
Sanction Level II:

Warning with Stipulations that may include remedial education; supervised practice; perform public service; limit specific nursing activities; and/or periodic Board review; and/or a fine of $500 or more for each additional violation. Additionally, if the isolated violations are associated with mishandling or misdocumenting of controlled substances (with no evidence of impairment) then stipulations may include random drug screens to be verified through urinalysis and practice limitations.
Second Tier Offense:

Failure to comply with a substantive Board rule regarding unprofessional conduct resulting in serious risk to patient or public safety. Repeated acts of unethical behavior or unethical behavior which places patient or public at risk of harm. Personal relationship that violates professional boundaries of nurse/patient relationship.
Sanction Level I:

Warning or Reprimand with Stipulations which may include remedial education, supervised practice, and/or perform public service. Fine of $250 or more for each violation. If violation involves mishandling or misdocumenting of controlled substances, misdemeanor crimes or criminal conduct involving alcohol, drugs or controlled substances, then the stipulations will also include abstention from unauthorized use of drugs and alcohol, to be verified by random drug testing through urinalysis, limit specific nursing activities, and/or periodic Board review. Board will use its rules and disciplinary sanction polices related to drug or alcohol misuse in analyzing facts.

www.bon.state.tx.us/ disciplinaryaction/dsp.html.
Sanction Level II:

Denial of Licensure, Suspension, or Revocation of Licensure. Any Suspension would be enforced at a minimum until nurse pays fine, completes remedial education and presents other rehabilitative efforts as prescribed by the Board. If violation involves mishandling of controlled substances, misdemeanor crimes or criminal conduct involving alcohol, drugs or controlled substances then suspension will be enforced until individual has completed treatment and one year verifiable sobriety before suspension is stayed, thereafter the stipulations will also include abstention from unauthorized use of drugs and alcohol to be verified by random drug testing through urinalysis; limit specific nursing activities and/or periodic Board review.

Probated suspension will be for a minimum of two (2) or three (3) years with Board monitored and supervised practice depending on applicable Board policy. Financial exploitation of a patient or public will require full restitution before nurse is eligible for unencumbered license.
Third Tier Offense:

Failure to comply with a substantive Board rule regarding unprofessional conduct resulting in serious patient harm. Repeated acts of unethical behavior or unethical behavior which results in harm to the patient or public. Sexual or sexualized contact with patient. Physical abuse of patient. Financial exploitation or unethical conduct resulting in a material or financial loss to a patient of public in excess of $4,999.99.
Sanction Level I:

Denial of licensure or revocation of nursing license.

Nurse or individual is not subject to licensure or reinstatement of licensure until restitution is paid.
Sanction Level II:

Emergency Suspension of nursing practice in light of violation that may be a continuing and imminent threat to public health and safety pursuant to the Occupations Code §301.455 or §301.4551, which may ultimately result in revocation.
Aggravating Circumstances for §301.452(b)(10): Number of events, level of material or financial gain, actual harm, severity of harm, prior complaints or discipline for similar conduct, patient vulnerability, involvement of or impairment by alcohol, illegal drugs, or controlled substances or prescription medications, criminal conduct.
Mitigating Circumstances for §301.452(b)(10): Voluntary participation in established or approved remediation or rehabilitation program and demonstrated competency, full restitution paid.
* Denotes a violation that is subject to disciplinary action, but may be eligible for a corrective action agreement (non-disciplinary action). The sanctions contained in this Matrix are disciplinary actions. Board rules regarding corrective actions (non-disciplinary actions) are located at 22 Tex. Admin. Code §213.32 and are not applicable to this Matrix. Further, a corrective action is not available as a sanction in a disciplinary action.

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§301.452(b)(11) adjudication of mental incompetency;
Sanction Level I:

Denial of licensure or revocation of nursing license.
Sanction Level II:

Emergency Suspension of nursing practice in light of violation that may be a continuing and imminent threat to public health and safety pursuant to the Occupations Code §301.455, which may ultimately result in revocation.

 

§301.452(b)(12) lack of fitness to practice because of a mental or physical health condition that could result in injury to a patient or the public; or
First Tier Violation:

A physical condition or diagnosis of schizophrenia and or other psychotic disorder, bipolar disorder, paranoid personality disorder, antisocial personality disorder, and/or borderline personality disorder without patient involvement or harm; but less than two years of compliance with treatment and less than two years of verifiable evidence of competent functioning.
Sanction Level I:


Referral to the Board approved Peer Assistance Program or Warning with Stipulations for a minimum of one (1) year to include therapy and appropriate treatment and monitored practice that may include remedial education, supervised practice, perform public service, abstain from unauthorized use of drugs and alcohol to be verified by random drug testing through urinalysis, limit specific nursing activities and/or periodic Board review.
Sanction Level II:


Denial of license or Suspension of license until individual is able to provide evidence of competency, then probation that may include remedial education, supervised practice, perform public service, abstain from unauthorized use of drugs and alcohol to be verified by random drug testing through urinalysis, limit specific nursing activities and/or periodic Board review.
Second Tier Violation:

Lack of fitness based on any mental health or physical health condition with potential harm or adverse patient effects or other serious practice violations.

"Lack of fitness" includes observed behavior that includes, but is not limited to: slurred speech, unsteady gait, sleeping on duty, inability to focus or answer questions appropriately.
Sanction Level I:

With evidence of drug or alcohol misuse: Refer to Sanctions in §301.452(b)(9).

Warning or Reprimand with Stipulations for a minimum of one (1) year to include supervision, therapy, and monitored practice that may include remedial education, supervised practice, perform public service, abstain from unauthorized use of drugs and alcohol to be verified by random drug testing through urinalysis, limit specific nursing activities and/or periodic Board review.
Sanction Level II:
With evidence of drug or alcohol misuse: Refer to Sanctions in 301.452(b)(9).

Denial of license or Suspension of license until individual is able to provide evidence of competency, then probation that may include remedial education; supervised practice; perform public service; abstain from unauthorized use of drugs and alcohol to be verified by random drug testing through urinalysis; limit specific nursing activities and/or periodic Board review.
Third Tier Violation:

Lack of fitness based on any mental health or physical health condition with evidence of patient harm, significant risk of harm, or other serious practice violations.
Sanction Level I:

Denial of licensure or revocation of nursing license.
Sanction Level II:

Emergency Suspension of nursing practice in light of violation that may be a continuing and imminent threat to public health and safety pursuant to the Occupations Code §301.455 or §301.4551, which may ultimately result in revocation.
Aggravating Circumstances of §301.452(b)(12): Seriousness of mental health diagnosis, multiple diagnosis, recent psychotic episodes, lack of successful treatment or remediation, number of events or hospitalization, actual harm, severity of harm, prior complaints or discipline for similar conduct.
Mitigating Circumstances of §301.452(b)(12): Self report, length of time since condition was relevant, successful response to treatment, positive psychological/chemical dependency evaluation from a board approved evaluator who has opportunity to review the Board's file.

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§301.452(b)(13) failure to care adequately for a patient or to conform to the minimum standards of acceptable nursing practice in a manner that, in the Board's opinion, exposes a patient or other person
unnecessarily to risk of harm.
First Tier Offense:

Practice below standard with a low risk of patient harm.
Sanction Level I:

Remedial Education and/or fine of $250 when there is isolated incident or a fine of more than $250 for each additional violation.
Sanction Level II:

Warning or Reprimand with Stipulations that may include remedial education, supervised practice, perform public service, abstain from unauthorized use of drugs and alcohol to be verified by random drug testing through urinalysis, limit specific nursing activities and/or periodic board review and/or fine of $500 or more for each additional violation.
Second Tier Offense:

Practice below standard with patient harm or risk of patient harm.
Sanction Level I:

Warning or Reprimand with Stipulations that may include supervised practice, limited specific nursing activities and/or periodic board review and/or a fine of $500 or more for each additional violation.
Sanction Level II:

Denial, suspension of license, revocation of license, or request for voluntary surrender.
Third Tier Offense:

Practice below standard with a serious risk of harm or death that is known or should be known. Act or omission that demonstrates level of incompetence such that the person should not practice without remediation and subsequent demonstration of competency.

In addition, any intentional act or omission that risks or results in serious harm.
Sanction Level I:

Denial, suspension of license; revocation of license or request for voluntary surrender.
Sanction Level II:

Emergency Suspension of nursing practice in light of violation that may be a continuing and imminent threat to public health and safety pursuant to the Occupations Code §301.455 or §301.4551, which may ultimately result in revocation.
Aggravating Circumstances for §301.452(b)(13): Number of events, actual harm, impairment at time of incident, severity of harm, prior complaints or discipline for similar conduct, patient vulnerability, failure to demonstrate competent nursing practice consistently during nursing career.
Mitigating Circumstances for §301.452(b)(13): Outcome not a result of care, participation in established or approved remediation or rehabilitation program and demonstrated competency, systems issues.

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(c) The Board and SOAH shall consider the following factors in conjunction with the Disciplinary Matrix when determining the appropriate penalty/sanction in disciplinary and eligibility matters. The following factors shall be analyzed in determining the tier and sanction level of the Disciplinary Matrix for a particular violation or multiple violations of the Nursing Practice Act (NPA) and Board rules:

(d) Each specific act or instance of conduct may be treated as a separate violation.

(e) The Board may, upon the finding of a violation, enter an order imposing one or more of the following disciplinary actions, with or without probationary stipulations:

(f) Every disciplinary order issued by the Board shall require the person subject to the order to participate in a program of education or counseling prescribed by the Board, which at a minimum, will include a review course in nursing jurisprudence and ethics.

(g) The following disciplinary and eligibility sanction policies and guidelines shall be used by the Board and SOAH when determining the appropriate penalty/sanction in disciplinary and eligibility matters:

(h) To the extent that a conflict exists between the Disciplinary Matrix and a disciplinary and eligibility sanction policy described in subsection (g) of this section, the Disciplinary Matrix controls.

(i) Unless otherwise specified, fines shall be payable in full by cashier's check or money order not later than the 45th day following the entry of an Order.

(j) The payment of a fine shall be in addition to the full payment of all applicable fees and satisfaction of all other applicable requirements of the NPA and the Board's rules.

(k) If the Board has probable cause to believe that a person is unable to practice nursing with reasonable skill and safety because of physical impairment, mental impairment, chemical dependency, or abuse of drugs or alcohol, the Board may require an evaluation that meets the following standards:

(l) When determining evidence of present fitness to practice because of known or reported unprofessional conduct, lack of good professional character, or prior criminal history:

(m) Notwithstanding any other provision herein, a person's failure to appear in person or by attorney on the day and at the time set for hearing in a contested case shall entitle the Board to revoke the person's license.

The provisions of this §213.33 adopted to be effective August 15, 2002, 27 TexReg 710; amended to be effective March 14, 2007, 32 TexReg 1304; amended to be effective October 10, 2007, 32 TexReg 7058; amended to be effective July 2, 2008, 33 TexReg 5007; amended to be effective February 16, 2010, 35 TexReg 1208; amended to be effective April 18, 2011, 36 TexReg 2395; amended to be effective July 16, 2012, 37 TexReg 5272; amended to be effective July 11, 2013, 38 TexReg 4348.

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§213.34. Deferred Disciplinary Action Pilot Program.

(a) This section implements the deferred disciplinary action pilot program authorized by the Occupations Code §301.1607. The pilot program will commence on February 1, 2011, and will conclude no later than January 1, 2014.

(b) The purpose of the pilot program is to evaluate the efficacy and effect of Board deferral of final disciplinary actions against individuals for violations of the Nursing Practice Act and/or Board rules.

(c) The opportunity to enter into a deferred disciplinary order under the pilot program is at the sole discretion of the Executive Director.

(d) A deferred disciplinary action under the pilot program will be available:

(e) Violations involving sexual misconduct, criminal conduct, intentional acts, falsification, deception, chemical dependency, or substance abuse will not be eligible for resolution through a deferred disciplinary action under the pilot program.

(f) A deferred disciplinary action under the pilot program will not be available to:

(g) A deferred disciplinary order will be available to the public for a minimum of five years and until such time as an individual successfully completes all of the probationary stipulations required by the deferred disciplinary order and the originating complaint is dismissed by the Board. After such time, the deferred disciplinary order will not be available to the public.

(h) If an individual fails to comply with a probationary stipulation required by a deferred disciplinary order or if a subsequent complaint is filed against an individual during the pendency of the deferred disciplinary order, the Board will stay the dismissal of the originating complaint pending the resolution of the subsequent complaint. If the subsequent complaint is proposed for resolution through a disciplinary action under the Occupations Code Subchapter J, the Board will not dismiss the originating complaint, and the Board may treat the deferred disciplinary action as prior disciplinary action when considering the imposition of a disciplinary sanction.

(i) The outcome and effectiveness of the pilot program will be evaluated by the Board on a regular basis.

The provisions of this §213.34 adopted to be effective July 12, 2010, 35 TexReg 6077.

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CHAPTER 214. VOCATIONAL NURSING EDUCATION

§214.1. General Requirements

(a) The director/coordinator and faculty are accountable for complying with the Board's rules and regulations and the Nursing Practice Act.

(b) Rules for vocational nursing education programs shall provide reasonable and uniform standards based upon sound educational principles that allow the opportunity for flexibility, creativity, and innovation.

The provisions of this §214.1 adopted to be effective February 13, 2005, 30 TexReg 545; amended to be effective October 19, 2008, 33 TexReg 8501; amended to be effective October 21, 2012, 37 TexReg 8294.

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§214.2. Definitions

Words and terms, when used in this chapter, shall have the following meanings unless the context clearly indicates otherwise:

The provisions of this §214.2 adopted to be effective February 13, 2005, 30 TexReg 545; amended to be effective July 10, 2005, 30 TexReg 3996; amended to be effective February 19, 2008, 33 TexReg 1326; amended to be effective October 19, 2008, 33 TexReg 8501; amended to be effective December 27, 2010, 35 TexReg 11662; amended to be effective October 21, 2012, 37 TexReg 8294.

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§214.3. Program Development, Expansion, and Closure

(a) New Programs.

(b) Extension Site/Campus.

(c) Transfer of Administrative Control by the Governing Entity. The authorities of the governing entity shall notify the Board office in writing of an intent to transfer the administrative authority of the program. This notification shall follow Board Education Guideline 3.1.3.a. Notification of Transfer of Administrative Control of a Vocational Nursing Education Program or a Professional Nursing Education Program by the Governing Entity.

(d) Closing a Program.

(e) Approval of a Vocational Nursing Education Program Outside Texas' Jurisdiction to Conduct Clinical Learning Experiences in Texas.

The provisions of this §214.3 adopted to be effective February 13, 2005, 30 TexReg 545; amended to be effective July 10, 2005, 30 TexReg 3996; amended to be effective January 10, 2008, 33 TexReg 179; amended to be effective October 19, 2008, 33 TexReg 8501; amended to be effective December 27, 2010, 35 TexReg 11662; amended to be effective October 21, 2012, 37 TexReg 8294.

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§214.4. Approval

(a) The progressive designation of approval status is not implied by the order of the following listing. Approval status is based upon each program's performance and demonstrated compliance to the Board's requirements and responses to the Board's recommendations. Change from one status to another is based on NCLEX-PN® examination pass rates, compliance audits, survey visits, and other factors listed under subsection (b) of this section. Types of approval include:

(b) Factors Jeopardizing Program Approval Status.

(c) Ongoing Approval Procedures. Ongoing approval status is determined biennially by the Board on the basis of information reported or provided in the program's NEPIS and CANEP, NCLEX-PN® examination pass rates, and other pertinent data.

(d) Notice of a program's approval status shall be sent to the director or coordinator and others as determined by the Board. The chief administrative officer of the governing entity shall be notified by the Board when there is a change in approval status of the program.

The provisions of this §214.4 adopted to be effective February 13, 2005, 30 TexReg 545; amended to be effective January 10, 2008, 33 TexReg 179; amended to be effective October 19, 2008, 33 TexReg 8501; amended to be effective December 27, 2010, 35 TexReg 11662; amended to be effective October 21, 2012, 37 TexReg 8294.

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§214.5. Philosophy/Mission and Objectives/Outcomes

(a) The philosophy/mission and objectives/outcomes of the vocational nursing education program shall be consistent with the philosophy/mission of the governing entity. They shall reflect the diversity of the community served and shall be consistent with professional, educational, and ethical standards of nursing.

(b) Program objectives/outcomes derived from the philosophy/mission shall reflect the Differentiated Essential Competencies of Graduates of Texas Nursing Programs Evidenced by Knowledge, Clinical Judgment, and Behaviors: Vocational (VN), Diploma/Associate Degree (Diploma/ADN), Baccalaureate Degree (BSN), October 2010 (DECs).

(c) Clinical objectives/outcomes shall be stated in behavioral terms and shall serve as a mechanism for evaluating student progression.

(d) The conceptual framework shall provide the organization of major concepts from the philosophy/mission of the program that provides the underlying structure or theme of the curriculum and facilitates the achievement of program objectives/outcomes.

(e) The director/coordinator and the faculty shall periodically review the philosophy/mission and objectives/outcomes and shall make appropriate revisions to maintain currency.

The provisions of this §214.5 adopted to be effective February 13, 2005, 30 TexReg 545; amended to be effective October 19, 2008, 33 TexReg 8501; amended to be effective December 27, 2010, 35 TexReg 11662; amended to be effective October 21, 2012, 37 TexReg 8294.

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§214.6. Administration and Organization

(a) The governing entity of a vocational nursing education program shall be licensed/approved or deemed exempt by the TWC or the THECB.

(b) There shall be an organizational chart indicating lines of authority between the vocational nursing education program and the governing entity.

(c) The vocational nursing education program shall have comparable status with other education units within the governing entity in such areas as budgetary authority, rank, promotion, tenure, leave, benefits, and professional development.

(d) Salaries shall be adequate to recruit, employ, and retain sufficient qualified nursing faculty members with the expertise necessary for students to meet program goals.

(e) The governing entity shall provide financial support and resources needed to operate a vocational nursing education program which meets the requirements of the Board and fosters achievement of program goals. The financial resources shall support adequate educational facilities, equipment, and qualified administrative and instructional personnel.

(f) Each vocational nursing education program shall be administered by a qualified individual who is accountable for the planning, implementation, and evaluation of the vocational nursing education program. The director/coordinator shall:

(g) When the director/coordinator or of the program changes, the director/coordinator shall submit to the Board office written notification of the change indicating the final date of employment.

(h) A newly appointed director/coordinator or interim director/coordinator of a vocational nursing education program shall attend the next scheduled education workshop provided by the Board related to the education rules and the role and responsibilities of newly appointed directors/coordinators.

(i) The director/coordinator shall have the authority to direct the vocational nursing education program in all its phases, including approval of teaching staff, selection of appropriate clinical sites, admission, progression, probation, dismissal of students, and enforcement of student policies. Additional responsibilities include, but are not limited to:

(j) The director or coordinator of the nursing program shall notify Board Staff immediately when there is a change in the name of the vocational nursing education program or the governing entity, or when there are changes in contact information.

The provisions of this §214.6 adopted to be effective February 13, 2005, 30 TexReg 545; amended to be effective January 10, 2008, 33 TexReg 179; amended to be effective October 19, 2008, 33 TexReg 8501; amended to be effective December 27, 2010, 35 TexReg 11662; amended to be effective October 21, 2012, 37 TexReg 8294.

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§214.7. Faculty

(a) There shall be written personnel policies for nursing faculty that are in keeping with accepted educational standards and are consistent with the policies of the governing entity.

(b) A vocational nursing education program shall employ sufficient faculty members with educational preparation and expertise necessary to enable the students to meet the program goals. The number of faculty members shall be determined by such factors as:

(c) Faculty Qualifications and Responsibilities.

(d) Faculty Waivers.

(e) Military faculty. Federal laws and regulations regarding licensure of military nursing personnel shall apply to Texas based military faculty members functioning within vocational nursing education programs.

(f) Non-nursing faculty are exempt from meeting the faculty qualifications of this chapter as long as the teaching assignments are not nursing content or clinical nursing courses.

(g) All nursing faculty, as well as non-nursing faculty, who teach non-clinical nursing courses that are part of the nursing curriculum, e.g., biological, physical, social, behavioral and nursing sciences, including, body structure and function, microbiology, pharmacology, nutrition, signs of emotional health, and human growth and development, shall have sufficient educational preparation verified by the program director/coordinator as appropriate to these areas of teaching responsibility.

(h) Non-nursing faculty assigned to teach didactic nursing content shall be required to co-teach with nursing faculty in order to meet nursing course objectives.

(i) Teaching assignments shall be commensurate with the faculty member's education and experience in nursing.

(j) Faculty shall be responsible for:

(k) Teaching activities shall be coordinated among full-time faculty, part-time faculty, and clinical preceptors.

(l) There shall be a minimum of one (1) full-time nursing instructor for the program.

(m) A director/coordinator without major teaching or clinical responsibilities shall not be considered a full-time instructor for purposes of meeting the Board's requirements related to having a sufficient number of nursing faculty for a vocational nursing education program.

(n) Substitute faculty may be employed to meet emergent program needs. Substitute faculty beyond ten (10) consecutive working days and/or on an interim basis shall meet qualifications as specified in subsection (c)(2) of this section.

(o) Faculty Organization:

The provisions of this §214.7 adopted to be effective February 13, 2005, 30 TexReg 545; amended to be effective January 9, 2007, 32 TexReg 91; amended to be effective October 19, 2008, 33 TexReg 8501; amended to be effective December 27, 2010, 35 TexReg 11662; amended to be effective October 21, 2012, 37 TexReg 8294.

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§214.8. Students

(a) The number of students admitted to the program shall be determined by the number of qualified faculty, adequate educational facilities and resources, and the availability of appropriate clinical learning experiences for students. Programs shall not accept admissions after the third day of class.

(b) Individuals enrolled in approved vocational nursing education programs preparing students for licensure shall be provided verbal and written information regarding conditions that may disqualify graduates from licensure and of their rights to petition the Board for a Declaratory Order of Eligibility. Required eligibility information includes:

(c) The program shall have well-defined, written nursing student policies based upon statutory and Board requirements, including nursing student admission, dismissal, progression, and graduation policies that shall be developed, implemented, and enforced.

(d) Reasons for dismissal from the program shall be clearly stated in written nursing student policies and shall include any demonstration of the following, including, but not limited to:

(e) Policies shall facilitate mobility/articulation, be consistent with acceptable educational standards, and be available to students and faculty.

(f) Student policies shall be furnished manually or electronically to all students at the beginning of the students' enrollment in the vocational nursing education program.

(g) Acceptance of transfer students and evaluation of allowable credit for advanced placement remains at the discretion of the director or coordinator of the program and the governing entity. Upon completing the program's requirements, the transferred student is considered to be a graduate of the program.

(h) Students shall have mechanisms for input into the development of academic policies and procedures,curriculum planning, and evaluation of teaching effectiveness.

(i) Students shall have the opportunity to evaluate faculty, courses, and learning resources and these evaluations shall be documented.

The provisions of this §214.8 adopted to be effective February 13, 2005, 30 TexReg 545; amended to be effective October 19, 2008, 33 TexReg 8501; amended to be effective December 27, 2010, 35 TexReg 11662; amended to be effective October 21, 2012, 37 TexReg 8294.

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§214.9. Program of Study

(a) The program of study shall include both didactic and clinical learning experiences and shall be:

(b) The faculty shall be responsible for the development, implementation, and evaluation of the curriculum based upon the following guidelines:

(c) Instruction shall include, but not be limited to: organized student/faculty interactive learning activities, formal lecture, audiovisual presentations, nursing skills laboratory instruction and demonstration, simulated laboratory instruction, and faculty-supervised, hands-on patient care clinical learning experiences.

(d) Educational mobility shall be a consideration in curriculum design.

(e) The program of study shall include, but not be limited to, the five (5) areas described as follows. Faculty supervised, hands-on patient care clinical learning experiences in acute and non-acute settings may include long-term care, rehabilitation settings, clinics, respite or day care settings, or other settings where the clinical objectives can be met.

(f) The selection and organization of the learning experiences in the curriculum shall provide continuity, sequence, and integration of learning.

(g) Course content shall be appropriate to the role expectations of the graduate.

(h) Faculty shall develop and implement evaluation methods and tools to measure progression of students' cognitive, affective, and psychomotor achievements in course/clinical objectives, according to Board Education Guideline 3.7.3.a. Student Evaluation Methods and Tools.

(i) Curriculum changes shall be developed by the faculty according to Board standards and shall include information outlined in the Board Education Guideline 3.7.1.a. Proposals for Curriculum Changes. The two (2) types of curriculum changes are:

(j) Documentation of governing entity approval and appropriate approval from either the TWC or the THECB, if approved/licensed by the TWC or the THECB, must be provided to the Board prior to implementation of changes, as appropriate.

(k) Vocational nursing education programs that have full approval status and are undergoing major curriculum changes shall submit an abbreviated proposal, as outlined in Board Education Guideline 3.7.1.a., to the Board office for approval at least four (4) months prior to implementation. The abbreviated proposal shall contain at least the following:

(l) Vocational nursing education programs not having full approval status, but proposing a major curriculum change shall submit a full curriculum change proposal, as outlined in Board Education Guideline 3.7.1.a, to the Board office and meet the requirements as outlined in subsection (i) of this section.

(m) All vocational nursing education programs implementing any curriculum change shall submit to Board Staff an evaluation of the outcomes of the implemented curriculum change through the first graduating class under the new curriculum.

The provisions of this §214.9 adopted to be effective February 13, 2005, 30 TexReg 545; amended to be effective July 10, 2005, 30 TexReg 3996; amended to be effective October 19, 2008, 33 TexReg 8501; amended to be effective December 27, 2010, 35 TexReg 11662; amended to be effective October 21, 2012, 37 TexReg 8294.

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§214.10. Clinical Learning Experiences

(a) Faculty shall be responsible and accountable for managing clinical learning experiences and observation experiences of students.

(b) Faculty shall develop criteria for the selection of affiliating agencies/clinical facilities or clinical practice settings which address safety and the need for students to achieve the program outcomes (goals) and course objectives through the practice of nursing care or observation experiences. Consideration of selection of a clinical site shall include:

(c) Faculty shall select and evaluate affiliating agencies/clinical facilities or clinical practice settings which provide students with opportunities to achieve the goals of the program.

(d) The faculty member shall be responsible for the supervision of students in clinical learning experiences and scheduling of student time and clinical rotations.

(e) Clinical learning experiences shall include the administration of medications, health promotion and preventive aspects, nursing care of persons throughout the life span with acute and chronic illnesses, and rehabilitative care.

(f) Faculty shall be responsible for student clinical practice evaluations. Clinical evaluation tools shall be correlated with level and/or course objectives and shall include a minimum of a formative and a summative evaluation for each clinical in the curriculum.

(g) The following ratios only apply to clinical learning experiences involving direct patient care:

(h) Clinical preceptors may be used to enhance clinical learning experiences after a student has received clinical and didactic instruction in all basic areas of nursing, or after a student has received clinical and didactic instruction in the basic areas of nursing for the related course or specific learning experience.

(i) When faculty use clinical preceptors to enhance clinical learning experiences and to assist faculty in the clinical supervision of students, the following applies:

(j) During clinical learning experiences, programs shall not permit utilization of students for health care facility staffing.

(k) The affiliating agency shall:

The provisions of this §214.10 adopted to be effective February 13, 2005, 30 TexReg 545; amended to be effective May 2, 2007, 32 TexReg 2361; amended to be effective October 19, 2008, 33 TexReg 8501; amended to be effective October 21, 2012, 37 TexReg 8294.

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§214.11. Facilities, Resources, and Services

(a) The governing entity shall be responsible for providing:

(b) An appropriately equipped skills laboratory shall be provided to accommodate the maximum number of students allowed for the program.

(c) The director/coordinator and faculty shall have adequate secretarial and clerical assistance to meet the needs of the program.

(d) The physical facilities shall be adequate to meet the needs of the program in relation to the size of the faculty and the student body.

(e) The learning resources, library, and departmental holdings shall be current, use contemporary technology appropriate for the level of the curriculum, and be sufficient for the size of the student body and the needs of the faculty.

The provisions of this §214.11 adopted to be effective February 13, 2005, 30 TexReg 545; amended to be effective October 19, 2008, 33 TexReg 8501; amended to be effective October 21, 2012, 37 TexReg 8294.

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§214.12. Records and Reports

(a) Accurate and current records shall be maintained for a minimum of two (2) years in a confidential manner and be accessible to appropriate parties, including Board representatives. These records shall include, but are not limited to:

(b) Record forms may be developed by an individual school.

(c) Hospital employment forms are not to be used for student records.

(d) Records shall be safely stored to prevent loss, destruction, or unauthorized use.

(e) Copies of the program's NEPIS, CANEP, and important Board communications shall be maintained as appropriate.

The provisions of this §214.12 adopted to be effective February 13, 2005, 30 TexReg 545; amended to be effective January 10, 2008, 33 TexReg 179; amended to be effective October 19, 2008, 33 TexReg 8501; amended to be effective October 21, 2012, 37 TexReg 8294.

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§214.13. Total Program Evaluation

(a) There shall be a written plan for the systematic evaluation of the total program. The plan shall include evaluative criteria, methodology, frequency of evaluation, assignment of responsibility, and indicators (benchmarks) of program and instructional effectiveness. The following broad areas shall be periodically evaluated:

(b) All evaluation methods and instruments shall be periodically reviewed for appropriateness.

(c) Implementation of the plan for total program evaluation shall be documented in the minutes.

(d) Major changes in the vocational nursing education program shall be evidence-based and supported by rationale.

The provisions of this §214.13 adopted to be effective February 13, 2005, 30 TexReg 545; amended to be effective October 19, 2008, 33 TexReg 8501; amended to be effective October 21, 2012, 37 TexReg 8294.

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CHAPTER 215. PROFESSIONAL NURSING EDUCATION

§215.1. General Requirements

(a) The dean/director and faculty are accountable for complying with the Board's rules and regulations and the Nursing Practice Act.

(b) Rules for professional nursing education programs shall provide reasonable and uniform standards based upon sound educational principles that allow the opportunity for flexibility, creativity, and innovation.

The provisions of this §215.1 adopted to be effective January 9, 2005, 29 TexReg 12190; amended to be effective October 19, 2008, 33 TexReg 8509; amended to be effective October 23, 2012, 37 TexReg 8304.

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§215.2. Definitions

Words and terms, when used in this chapter, shall have the following meanings unless the context clearly indicates otherwise:

The provisions of this §215.2 adopted to be effective January 9, 2005, 29 TexReg 12190; amended to be effective February 19, 2008, 33 TexReg 1328; amended to be effective October 19, 2008, 33 TexReg 8509; amended to be effective December 27, 2010, 35 TexReg 11668; amended to be effective October 23, 2012, 37 TexReg 8304.

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§215.3. Program Development, Expansion, and Closure

(a) New Programs.

(b) Extension Site/Campus.

(c) Transfer of Administrative Control by Governing Entity. The authorities of the governing entity shall notify the Board office in writing of an intent to transfer the administrative authority of the program. This notification shall follow Board Education Guideline 3.1.3.a. Notification of Transfer of Administrative Control of a Professional Nursing Education Program or a Professional Nursing Education Program by the Governing Entity.

(d) Closing a Program.

(e) Approval of a Professional Nursing Education Program Outside Texas' Jurisdiction to Conduct Clinical Learning Experiences in Texas.

The provisions of this §215.3 adopted to be effective January 9, 2005, 29 TexReg 12190; amended to be effective February 19, 2008, 33 TexReg 1328; amended to be effective October 19, 2008, 33 TexReg 8509; amended to be effective December 27, 2010, 35 TexReg 11668; amended to be effective October 23, 2012, 37 TexReg 8304.

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§215.4. Approval

(a) The progressive designation of approval status is not implied by the order of the following listing. Approval status is based upon each program's performance and demonstrated compliance to the Board's requirements and responses to the Board's recommendations. Change from one status to another is based on NCLEX-RN® examination pass rates, compliance audits, survey visits, and other factors listed under subsection (b) of this section. Types of approval include:

(b) Factors Jeopardizing Program Approval Status.

(c) Ongoing Approval Procedures. Ongoing approval status is determined biennially by the Board on the basis of information reported or provided in the program's NEPIS and CANEP, NCLEX-RN® examination pass rates, and other pertinent data.

(d) Notice of a program's approval status shall be sent to the dean or director and others as determined by the Board. The chief administrative officer of the governing entity shall be notified when there is a change of approval status of the program.

The provisions of this §215.4 adopted to be effective January 9, 2005, 29 TexReg 12190; amended to be effective February 19, 2008, 33 TexReg 1328; amended to be effective October 19, 2008, 33 TexReg 8509; amended to be effective December 27, 2010, 35 TexReg 11668; amended to be effective October 23, 2012, 37 TexReg 8304.

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§215.5. Philosophy/Mission and Objectives/Outcomes

(a) The philosophy/mission and objectives/outcomes of the professional nursing education program shall be consistent with the philosophy/mission of the governing entity. They shall reflect the diversity of the community served and shall be consistent with professional, educational, and ethical standards of nursing.

(b) Program objectives/outcomes derived from the philosophy/mission shall reflect the Differentiated Essential Competencies of Graduates of Texas Nursing Programs Evidenced by Knowledge, Clinical Judgment, and Behaviors: Professional (VN), Diploma/Associate Degree (Diploma/ADN), Baccalaureate Degree (BSN), October 2010 (DECs).

(c) Clinical objective/outcomes shall be stated in behavioral terms and shall serve as a mechanism for evaluating student progression.

(d) The conceptual framework shall provide the organization of major concepts from the philosophy/mission of the program that provides the underlying structure or theme of the curriculum and facilitates the achievement of the program objectives/outcomes.

(e) The dean/director and the faculty shall periodically review the philosophy/mission and objectives/outcomes and shall make appropriate revisions to maintain currency.

The provisions of this §215.5 adopted to be effective January 9, 2005, 29 TexReg 12190; amended to be effective October 19, 2008, 33 TexReg 8509; amended to be effective December 27, 2010, 35 TexReg 11668; amended to be effective October 23, 2012, 37 TexReg 8304.

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§215.6. Administration and Organization

(a) The governing entity of a professional nursing education program, not including a diploma program, must be accredited by an agency recognized by the THECB or hold a certificate of authority from the THECB under provisions leading to accreditation of the institution in due course.

(b) There shall be an organizational chart which demonstrates the relationship of the professional nursing education program to the governing entity and indicates lines of responsibility and authority.

(c) In colleges and universities, the professional nursing education program shall have comparable status with other academic units within the governing entity in such areas as budgetary authority, rank, promotion, tenure, leave, benefits, and professional development.

(d) Salaries shall be adequate to recruit, employ, and retain sufficient qualified nursing faculty members with graduate preparation and expertise necessary for students to meet program goals.

(e) The governing entity shall provide financial support and resources needed to operate a professional nursing education program which meets the requirements of the Board and fosters achievement of program goals. The financial resources shall support adequate educational facilities, equipment, and qualified administrative and instructional personnel.

(f) Each professional nursing education program shall be administered by a qualified individual who is accountable for the planning, implementation, and evaluation of the professional nursing education program. The dean or director shall:

(g) When the dean/director of the program changes, the dean/director shall submit to the Board office written notification of the change indicating the final date of employment.

(h) A newly appointed dean/director or interim dean/director of a professional nursing education program shall attend the next scheduled education workshop provided by the Board related to the education rules and the role and responsibilities of newly appointed deans/directors.

(i) The dean/director shall have the authority to direct the professional nursing education program in all its phases, including approval of teaching staff, selection of appropriate clinical sites, admission, progression, probation, dismissal of students, and enforcement of student policies. Additional responsibilities include, but are not limited to:

(1) providing evidence of faculty expertise and knowledge to teach curriculum content; (2) verifying students' completion of program requirements; (3) completing and submitting the Texas Board of Nursing Affidavit of Graduation; and (4) completing and submitting the NEPIS and CANEP by the required dates.

(j) The dean or director of the nursing program shall notify Board Staff immediately when there is a change in the name of the professional nursing education program or the governing entity, or when there are changes in the contact information.

The provisions of this §215.6 adopted to be effective January 9, 2005, 29 TexReg 12190; amended to be effective August 11, 2005, 30 TexReg 4480; amended to be effective January 10, 2008, 33 TexReg 183; amended to be effective October 19, 2008, 33 TexReg 8509; amended to be effective October 23, 2012, 37 TexReg 8304.

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§215.7. Faculty

(a) There shall be written personnel policies for nursing faculty that are in keeping with accepted educational standards and are consistent with the policies of the governing entity.

(b) A professional nursing education program shall employ sufficient faculty members with graduate preparation and expertise necessary to enable the students to meet the program goals. The number of faculty members shall be determined by such factors as:

(c) Faculty Qualifications and Responsibilities.

(d) Faculty Waivers.

(e) Non-nursing faculty are exempt from meeting the faculty qualifications of this chapter as long as the teaching assignments are not nursing content or clinical nursing courses.

(f) All nursing faculty, as well as non-nursing faculty, who teach non-clinical nursing courses that are part of the nursing curriculum, e.g., biological, physical, social, behavioral and nursing sciences, including pathophysiology, pharmacology, research, nutrition, human growth and development, management, and statistics, shall have sufficient graduate level educational preparation verified by the program dean or director as appropriate to these areas of responsibility.

(g) Non-nursing faculty assigned to teach didactic nursing content shall be required to co-teach with nursing faculty in order to meet nursing course objectives.

(h) Teaching assignments shall be commensurate with the faculty member's education and experience in nursing.

(i) Faculty shall be responsible for:

(j) Teaching activities shall be coordinated among full-time faculty, part-time faculty, clinical preceptors, and clinical teaching assistants.

(k) There shall be a minimum of one (1) full-time nursing instructor for the program.

(l) A dean/director without major teaching or clinical responsibilities shall not be considered a full-time instructor for purposes of meeting the Board's requirements related to having a sufficient number of nursing faculty for a professional nursing education program.

(m) Substitute faculty may be employed to meet emergent program needs. Substitute faculty shall meet qualifications as specified in subsection (c)(2) of this section.

(n) Faculty Organization:

The provisions of this §215.7 adopted to be effective January 9, 2005, 29 TexReg 12190; amended to be effective August 11, 2005, 30 TexReg 4480; amended to be effective January 9, 2007, 32 TexReg 92; amended to be effective October 19, 2008, 33 TexReg 8509; amended to be effective October 23, 2012, 37 TexReg 8304.

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§215.8. Students

(a) The number of students admitted to the program shall be determined by the number of qualified faculty, adequate educational facilities and resources, and the availability of appropriate clinical learning experiences for students.

(b) Individuals enrolled in approved professional nursing education programs preparing students for licensure shall be provided verbal and written information regarding conditions that may disqualify graduates from licensure and of their rights to petition the Board for a Declaratory Order of Eligibility. Required eligibility information includes:

(c) The program shall have well-defined, written nursing student policies based upon statutory and Board requirements, including nursing student admission, dismissal, progression, and graduation policies that shall be developed, implemented, and enforced.

(d) Reasons for dismissal from the program shall be clearly stated in written nursing student policies and shall include any demonstration of the following, including, but not limited to:

(e) Policies shall facilitate mobility/articulation, be consistent with acceptable educational standards, and be available to students and faculty.

(f) Student policies shall be furnished manually or electronically to all students at the beginning of the students' enrollment in the professional nursing education program.

(g) Acceptance of transfer students and evaluation of allowable credit for advanced placement remains at the discretion of the dean or director of the program and the governing entity. Upon completing the program's requirements, the transferred student is considered to be a graduate of the program.

(h) Students shall have mechanisms for input into the development of academic policies and procedures, curriculum planning, and evaluation of teaching effectiveness.

(i) Students shall have the opportunity to evaluate faculty, courses, and learning resources and these evaluations shall be documented.

The provisions of this §215.8 adopted to be effective January 9, 2005, 29 TexReg 12190; amended to be effective October 19, 2008, 33 TexReg 8509; amended to be effective December 27, 2010, 35 TexReg 11668; amended to be effective October 23, 2012, 37 TexReg 8304.

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§215.9. Program of Study

(a) The program of study shall include both didactic and clinical learning experiences and shall be:

(b) The faculty shall be responsible for the development, implementation, and evaluation of the curriculum based upon the following guidelines:

(c) Instruction shall include, but not be limited to: organized student/faculty interactive learning activities, formal lecture, audiovisual presentations, nursing skills laboratory instruction and demonstration, simulated laboratory instruction, and faculty-supervised, hands-on patient care clinical learning experiences.

(d) Associate degree nursing education programs shall develop formal articulation agreements to enable graduates to earn a bachelor's degree in nursing in a timely manner.

(e) The program of study shall include, but not be limited to, the following areas:

(f) The selection and organization of the learning experiences in the curriculum shall provide continuity, sequence, and integration of learning.

(g) The curriculum plan and course content shall be appropriate to the role expectations of the graduate and shall be kept current and available to faculty and Board representatives.

(h) Faculty shall develop and implement evaluation methods and tools to measure progression of students' cognitive, affective, and psychomotor achievements in course/clinical objectives, according to Board Education Guideline 3.7.3.a. Student Evaluation Methods and Tools.

(i) Curriculum changes shall be developed by the faculty according to Board standards and shall include information outlined in the Board Education Guideline 3.7.1.a. Proposals for Curriculum Changes. The two (2) types of curriculum changes are:

(j) Documentation of governing entity approval and appropriate approval from either the TWC or the THECB, if approved/licensed by the TWC or the THECB, must be provided to the Board prior to implementation of changes, as appropriate.

(k) Professional nursing education programs that have full approval status and are undergoing major curriculum changes shall submit an abbreviated proposal, as outlined in Board Education Guideline 3.7.1.a, to the Board office for approval at least four (4) months prior to implementation. The abbreviated proposal shall contain at least the following:

(l) Professional nursing education programs not having full approval status, but proposing a major curriculum change, shall submit a full curriculum change proposal, as outlined in Board Education Guideline 3.7.1.a, to the Board office and meet the requirements as outlined in subsection (i) of this section.

(m) All professional nursing education programs implementing any curriculum change shall submit to Board Staff an evaluation of the outcomes of the implemented curriculum change through the first graduating class under the new curriculum.

The provisions of this §215.9 adopted to be effective January 9, 2005, 29 TexReg 12190; amended to be effective October 19, 2008, 33 TexReg 8509; amended to be effective December 27, 2010, 35 TexReg 11668; amended to be effective October 23, 2012, 37 TexReg 8304.

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§215.10. Clinical Learning Experiences

(a) Faculty shall be responsible and accountable for managing clinical learning experiences and observation experiences of students.

(b) Faculty shall develop criteria for the selection of affiliating agencies/clinical facilities or clinical practice settings which address safety and the need for students to achieve the program outcomes (goals) and course objectives through the practice of nursing care or observation experiences. Consideration of selection of a clinical site shall include:

(c) Faculty shall select and evaluate affiliating agencies/clinical facilities or clinical practice settings which provide students with opportunities to achieve the goals of the program.

(d) The faculty member shall be responsible for the supervision of students in clinical learning experiences and for scheduling of student time and clinical rotations.

(e) Clinical learning experiences shall include the administration of medications, health promotion and preventive aspects, nursing care of persons throughout the life span with acute and chronic illnesses, and rehabilitative care.

(f) Faculty shall be responsible for student clinical practice evaluations. Clinical evaluation tools shall be correlated with level and/or course objectives and shall include a minimum of a formative and a summative evaluation for each clinical in the curriculum.

(g) The following ratios only apply to clinical learning experiences involving direct patient care:

(h) Clinical preceptors may be used to enhance clinical learning experiences after a student has received clinical and didactic instruction in all basic areas of nursing, or after a student has received clinical and didactic instruction in the basic areas of nursing for the related course or specific learning experience.

(i) Clinical teaching assistants may assist qualified, experienced faculty with clinical learning experiences.

(j) When faculty use clinical preceptors or clinical teaching assistants to enhance clinical learning experiences and to assist faculty in the clinical supervision of students the following applies:

The provisions of this §215.10 adopted to be effective January 9, 2005, 29 TexReg 12190; amended to be effective May 2, 2007, 32 TexReg 2361; amended to be effective October 19, 2008, 33 TexReg 8509; amended to be effective October 23, 2012, 37 TexReg 8304.

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§215.11. Facilities, Resources, and Services

(a) The governing entity shall be responsible for providing:

(b) An appropriately equipped skills laboratory shall be provided to accommodate the maximum number of students allowed for the program.

(c) The dean/director and faculty shall have adequate secretarial and clerical assistance to meet the needs of the program.

(d) The physical facilities shall be adequate to meet the needs of the program in relation to the size of the faculty and the student body.

(e) The learning resources, library, and departmental holdings shall be current, use contemporary technology appropriate for the level of the curriculum, and be sufficient for the size of the student body and the needs of the faculty.

The provisions of this §215.11 adopted to be effective January 9, 2005, 29 TexReg 12190; amended to be effective October 19, 2008, 33 TexReg 8509; amended to be effective October 23, 2012, 37 TexReg 8304.

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§215.12. Records and Reports

(a) Accurate and current records shall be maintained for a minimum of two (2) years in a confidential manner and be accessible to appropriate parties, including Board representatives. These records shall include, but are not limited to:

(b) Record forms may be developed by an individual school.

(c) Hospital employment forms are not to be used for student records.

(d) Records shall be safely stored to prevent loss, destruction, or unauthorized use.

(e) Copies of the program's CANEP, NEPIS, and important Board communications shall be maintained as appropriate.

The provisions of this §215.12 adopted to be effective January 9, 2005, 29 TexReg 12190; amended to be effective January 10, 2008, 33 TexReg 183; amended to be effective October 19, 2008, 33 TexReg 8509; amended to be effective October 23, 2012, 37 TexReg 8304.

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§215.13. Total Program Evaluation

(a) There shall be a written plan for the systematic evaluation of the total program. The plan shall include evaluative criteria, methodology, frequency of evaluation, assignment of responsibility, and indicators (benchmarks) of program and instructional effectiveness. The following broad areas shall be periodically evaluated:

(b) All evaluation methods and instruments shall be periodically reviewed for appropriateness.

(c) Implementation of the plan for total program evaluation shall be documented in the minutes.

(d) Major changes in the professional nursing education program shall be evidence-based and supported by rationale.

The provisions of this §215.13 adopted to be effective January 9, 2005, 29 TexReg 12190; amended to be effective October 19, 2008, 33 TexReg 8509; amended to be effective October 23, 2012, 37 TexReg 8304.

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CHAPTER 216. CONTINUING COMPETENCY

§216.1. Definitions

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise:

The provisions of this §216.1 adopted to be effective August 16, 2009, 34 TexReg 5524; amended to be effective October 4, 2010, 35 TexReg 8917.

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§216.2. Purpose

The purpose of continuing competency is to ensure that nurses stay abreast of current industry practices, enhance their professional competence, learn about new technology and treatment regimens, and update their clinical skills. Continuing education in nursing includes programs beyond the basic preparation which are designed to promote and enrich knowledge, improve skills and develop attitudes for the enhancement of nursing practice, thus improving health care to the public. Nursing certification is another method of demonstrating continuing competence. Pursuant to authority set forth in the Occupations Code §301.303, the board requires participation in continuing competency activities for license renewal. The procedures set forth in these rules provide guidance to fulfilling the continuing competency requirement. The board encourages nurses to choose continuing education courses that relate to their work setting and area of practice or to attain, maintain, or renew an approved national nursing certification in their practice area, which benefits the public welfare.

The provisions of this §216.2 adopted to be effective August 16, 2009, 34 TexReg 5524.

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§216.3. Requirements

(a) A nurse must meet either the requirements of this subsection or subsection (b) of this section. A nurse may choose to complete 20 contact hours of continuing education within the two years immediately preceding renewal of registration in his or her area of practice. These hours shall be obtained by participation in programs approved by a credentialing agency recognized by the board. A list of these agencies/organizations may be obtained from the board's office or web site.

(b) A nurse must meet either the requirements of this subsection or subsection (a) of this section. A nurse may choose to demonstrate the achievement, maintenance, or renewal of an approved national nursing certification in the nurse's area of practice. A list of approved national nursing certification criteria may be obtained from the board's office or web site.

(c) Requirements for the Advanced Practice Registered Nurse. The licensee authorized by the board as an advanced practice registered nurse (APRN) is required to obtain 20 contact hours of continuing education or attain, maintain or renew the national certification recognized by the board as meeting the certification requirement for the advanced practice registered nurse's role and population focus area of licensure within the previous two years of licensure. National certification as discussed in this section will only meet the requirement for licensure renewal.

(d) Forensic Evidence Collection.

(e) A nurse who is 65 years old or older and who holds or is seeking to hold a valid volunteer retired (VR) nurse authorization in compliance with the Occupations Code §112.051 and §217.9(d) of this title (relating to Inactive Status):

(f) Tick-Borne Diseases. An APRN, whose practice includes the treatment of tick-borne diseases, is encouraged to participate in continuing education relating to the treatment of tick-borne diseases. The continuing education course(s) should contain information relevant to treatment of the disease within the role and population focus area applicable to the APRN and may represent a spectrum of relevant medical clinical treatment relating to tick-borne disease. Completion of continuing medical education in the treatment of tick borne disease that meets the requirements of this subsection shall be credited as continuing education under this chapter.

The provisions of this §216.3 adopted to be effective August 16, 2009, 34 TexReg 5524; amended to be effective October 4, 2010, 35 TexReg 8917; amended to be effective July 16, 2012, 37 TexReg 5274.

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§216.4. Criteria for Acceptable Continuing Education Activity

Continuing Education programs must be approved by a credentialing agency or an affiliated entity of one of these agencies. Proof of successful completion shall contain the name of the provider; the program title, date, and location; number of contact hours; provider number; and credentialing agency.

The provisions of this §216.4 adopted to be effective August 16, 2009, 34 TexReg 5524.

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§216.5. Additional Criteria for Specific Continuing Education Programs

In addition to those programs reviewed by a board-approved entity, a licensee may attend an academic course that meets the following criteria:

The provisions of this §216.5 adopted to be effective August 16, 2009, 34 TexReg 5524.

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§216.6. Activities Which are not Acceptable as Continuing Education

The following activities do not meet continuing education requirements for licensure renewal.

The provisions of this §216.6 adopted to be effective August 16, 2009, 34 TexReg 5524.

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§216.7. Responsibilities of Individual Licensee

(a) It shall be the licensee's responsibility to select and participate in continuing competency activities that will meet the criteria listed in this chapter.

(b) The licensee shall be responsible for maintaining a record of CE activities. These records shall document attendance as evidenced by original certificates of attendance, contact hour certificates, academic transcripts, or grade slips and copies of these shall be submitted to the board upon audit.

(c) These records shall be maintained by the licensee for a minimum of two consecutive renewal periods or four years.

The provisions of this §216.7 adopted to be effective August 16, 2009, 34 TexReg 5524.

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§216.8. Relicensure Process

(a) Renewal of license.

(b) Persons licensed by examination. A candidate licensed by examination shall be exempt from the CE or approved national nursing certification requirement for issuance of the initial license and for the immediate renewal period following licensure.

(c) Persons licensed by endorsement. An applicant licensed by endorsement shall be exempt from the CE or approved national nursing certification requirement for the issuance of the initial Texas license and for the immediate renewal period following initial Texas licensure.

(d) Delinquent license.

(e) Reactivation of a license.

(f) Reinstatement of a license. A licensee whose license has been revoked and subsequently applies for reinstatement must show evidence that the continuing competency requirement and other board requirements have been met prior to reinstatement of the license by the board.

The provisions of this §216.8 adopted to be effective August 16, 2009, 34 TexReg 5524.

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§216.9. Audit Process

The board shall select a random sample of licensees 90 days prior to each renewal month. Audit forms shall be sent to selected licensees to substantiate compliance with the continuing competency requirements.

The provisions of this §216.9 adopted to be effective August 16, 2009, 34 TexReg 5524.

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§216.10. Appeals

(a) Any individual who wishes to appeal a determination of non-compliance with continuing competency requirements must submit a letter of appeal within 20 days of notification of the audit results.

(b) The board or its designee shall conduct a review in which the appellant may appear in person to present reasons why the audit decision should be set aside or modified.

(c) The decision of the board after the appeal shall be considered final and binding.

The provisions of this §216.10 adopted to be effective August 16, 2009, 34 TexReg 5524.

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§216.11. Consequences of Non-Compliance

Failure to comply with the board's continuing competency requirements will result in the denial of renewal.

The provisions of this §216.11 adopted to be effective August 16, 2009, 34 TexReg 5524.

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CHAPTER 217. LICENSURE, PEER ASSISTANCE AND PRACTICE

§217.1. Definitions

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise:

The provisions of this §217.1 adopted to be effective September 1, 1999, 24 TexReg 4001; amended to be effective July 5, 2004, 29 TexReg 6296; amended to be effective April 11, 2005, 30 TexReg 2065.

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§217.2. Licensure by Examination for Graduates of Nursing Education Programs Within the United States, its Territories or Possessions

(a) All applicants for initial licensure by examination shall:

(b) Should it be ascertained from the application filed, or from other sources, that the applicant should have had an eligibility issue determined by way of a petition for declaratory order pursuant to the Occupations Code §301.257, then the application will be treated and processed as a petition for declaratory order under §213.30 of this title (relating to Declaratory Order of Eligibility for Licensure), and the applicant will be treated as a petitioner under that section and will be required to pay the non-refundable fee required by that section.

(c) An applicant for initial licensure by examination shall pass the NCLEX-PN or NCLEX-RN within four years of completion of requirements for graduation.

(d) An applicant who has not passed the NCLEX-PN or NCLEX-RN within four years from the date of completion of requirements for graduation must complete a board approved nursing education program in order to take or retake the examination.

(e) Upon initial licensure by examination, the license is issued for a period ranging from six months to 29 months depending on the birth month. Licensees born in even-numbered years shall renew their license in even numbered years; licensees born in odd-numbered years shall renew their licenses in odd-numbered years.

(f) The U.S. Army Practical Nurse Course (formerly the 91C Clinical Specialist Course) is the only military program acceptable for vocational nurse licensure by examination.

The provisions of this §217.2 adopted to be effective September 1, 1999, 24 TexReg 4001; amended to be effective July 14, 2003, 28 TexReg 5532; amended to be effective September 28, 2004, 29 TexReg 9189; amended to be effective April 16, 2006, 31 TexReg 3031; amended to be effective September 26, 2007, 32 TexReg 6519; amended to be effective May 14, 2009, 34 TexReg 2767; amended to be effective July 12, 2010, 35 TexReg 6083.

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§217.3. Temporary Authorization to Practice/Temporary Permit

(a) A new graduate who completes an accredited basic nursing education program within the United States, its Territories or Possessions and who applies for initial licensure by examination in Texas may be temporarily authorized to practice nursing as a graduate nurse (GN) or graduate vocational nurse (GVN) pending the results of the licensing examination.

(b) A nurse who has not practiced nursing for four or more years may be issued a temporary permit for the limited purpose of completing a refresher course, extensive orientation to the practice of professional or vocational nursing, whichever is applicable, or academic course. The permit is valid for six months and is nonrenewable.

(c) A nurse whose license has been suspended, revoked, or surrendered through action by the board, may be issued a temporary permit for the limited purpose of meeting any requirement(s) imposed by the board in order for the nurse's license to be reissued. The permit is valid for six months and is nonrenewable.

The provisions of this §217.3 adopted to be effective September 1, 1999, 24 TexReg 4001; amended to be effective July 5, 2004, 29 TexReg 6296.

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§217.4. Requirements for Initial Licensure by Examination for Nurses Who Graduate from Nursing Education Programs Outside of United States' Jurisdictions

(a) Nurse applicants for initial licensure applying under this section.

(b) An applicant who has completed the requirements for graduation and has practiced as a second-level or first level general nurse for at least two years but has not practiced as a second-level or first-level general nurse within the four years immediately preceding the filing of an application for initial licensure will be issued a six month limited permit (temporary authorization) upon passing the NCLEX-PN or NCLEX-RN examination and must complete a nurse refresher course that meets the criteria defined by the Board in order to be eligible for licensure under this section.

(c) An applicant who has not passed the NCLEX-PN or NCLEX-RN within four years of completion of the requirements for graduation or within four years of the date of eligibility must complete an appropriate nursing education program in order to be eligible to take or retake the examination.

(d) Should it be ascertained from the application filed, or from other sources, that the applicant should have had an eligibility issue determined by way of a petition for declaratory order pursuant to the Occupations Code §301.257, then the application will be treated and processed as a petition for declaratory order under §213.30 of this title (relating to Declaratory Order of Eligibility for Licensure), and the applicant will be treated as a petitioner under that section and will be required to pay the non-refundable fee required by that section.

(e) Accustomation Permit.

(f) Upon initial licensure by examination, the license is issued for a period ranging from six months to 29 months depending on the birth month. Licensees born in even-numbered years shall renew their licenses in even numbered years; licensees born in odd-numbered years shall renew their licenses in odd-numbered years.

The provisions of this §217.4 adopted to be effective September 1, 1999, 24 TexReg 4001; amended to be effective July 14, 2003, 28 TexReg 5532; amended to be effective September 28, 2004, 29 TexReg 9189; amended to be effective April 11, 2005, 30 TexReg 2065; amended to be effective April 16, 2006, 31 TexReg 3031; amended to be effective September 26, 2007, 32 TexReg 6519; amended to be effective May 14, 2009, 34 TexReg 2767; amended to be effective July 12, 2010, 35 TexReg 6083; amended to be effective April 4, 2011, 36 TexReg 2123.

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§217.5. Temporary License and Endorsement

(a) A nurse who has practiced nursing in another state within the four years immediately preceding a request for temporary licensure and/or permanent licensure by endorsement may obtain a non-renewable temporary license, which is valid for 120 days, and/or a permanent license for endorsement by meeting the following requirements:

(b) A nurse who has not practiced nursing in another state within the four years immediately preceding a request for temporary licensure and/or permanent licensure by endorsement will be required to:

(c) The Board adopts by reference the following forms, which comprise the instructions and requirements for a refresher course, extensive orientation to the practice of nursing, and a nursing program of study required by this section, and which are available at www.bon.state.tx.us/olv/forms.html:

(d) A nurse who has had disciplinary action at any time by any licensing authority is not eligible for temporary licensure until completion of the eligibility determination.

(e) Upon initial licensure by endorsement, the license is issued for a period ranging from six months to 29 months depending on the birth month. Licensees born in even-numbered years shall renew their licenses in even-numbered years; licensees born in odd-numbered years shall renew their licenses in odd-numbered years.

(f) Should it be ascertained from the application filed, or from other sources, that the applicant should have had an eligibility issue determined by way of a petition for declaratory order pursuant to the Occupations Code §301.257, then the application will be treated and processed as a petition for declaratory order under §213.30 of this title (relating to Declaratory Order of Eligibility for Licensure), and the applicant will be treated as a petitioner under that section and will be required to pay the non-refundable fee required by that section.

The provisions of this §217.5 adopted to be effective September 1, 1999, 24 TexReg 4001; amended to be effective September 28, 2004, 29 TexReg 9189; amended to be effective April 16, 2006, 31 TexReg 3031; amended to be effective September 26, 2007, 32 TexReg 6519; amended to be effective July 12, 2010, 35 TexReg 6083; amended to be effective July 26, 2011, 36 TexReg 4660.

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§217.6. Failure to Renew License

(a) A nurse who is not practicing nursing in Texas and who fails to maintain a current Texas license for a period of time less than four years may bring his or her license up-to-date by filing such forms as the Board may require, showing evidence of having completed 20 contact hours of acceptable continuing education that meets the requirements of Chapter 216 of this title (relating to Continuing Competency) within the two years immediately preceding the application for reactivation, and paying the current licensure fee plus a late fee and any applicable fines, which are not refundable.

(b) A nurse who is not practicing nursing and who fails to maintain a current license from any licensing authority for four or more years will be required to:

(c) The Board adopts by reference the following forms, which comprise the instructions and requirements for a refresher course, extensive orientation to the practice of nursing, and a nursing program of study required by this section, and which are available at www.bon.state.tx.us/olv/forms.html: (1) Application for Six Month Temporary Permit (RN); and (2) Application for Six Month Temporary Permit (LVN).

(d) A nurse who fails to maintain a current Texas license for four years or more and who is licensed and has practiced in another state during the previous four years preceding the application for reactivation in Texas must comply with the requirements of subsection (b)(3) - (7) of this section.

(e) The issuance of a license reactivation may be refused to an individual who:

(f) The Board's refusal to reactivate a license for the reasons specified in subsection (e) of this section does not entitle an individual to a hearing at the State Office of Administrative Hearings.

(g) An individual who is refused a license reactivation and who wishes to reactivate his or her license will be required to:

(h) Special Reactivation Provisions for Actively Deployed Nurses.

(i) A nurse whose license has been expired for more than one year and who has been initially or finally convicted of, or has entered a plea of guilty or nolo contendere for, an offense specified in the Occupations Code §301.4535(a); surrendered a license or a privilege in another state or had a license or privilege revoked, suspended, or denied in another state; or been imprisoned following a felony conviction, felony community supervision revocation, revocation of parole, or revocation of mandatory supervision may not renew the license until the Board has completed an investigation and reached a final resolution of the matter.

(j) Military Spouse.

The provisions of this §217.6 adopted to be effective September 1, 1999, 24 TexReg 4001; amended to be effective July 5, 2004, 29 TexReg 6296; amended to be effective July 10, 2005, 30 TexReg 3997; amended to be effective October 11, 2010, 35 TexReg 9093; amended to be effective January 17, 2012, 37 TexReg 120.

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§217.7. Change of Name and/or Address

(a) A nurse/applicant for licensure shall notify the board in writing within ten days of a change of name by submitting a legal document reflecting this name change.

(b) A nurse/applicant for licensure shall notify the board in writing within 10 days of a change of address, providing the new address and his or her license number.

The provisions of this §217.7 adopted to be effective September 1, 1999, 24 TexReg 4001; amended to be effective July 5, 2004, 29 TexReg 6296.

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§217.8. Duplicate or Substitute Credentials

(a) A nurse whose original certificate of registration or wallet-sized license is lost or destroyed may obtain a duplicate by filing a form containing identifying information, notarized affidavit, and paying a non-refundable fee.

(b) A nurse who wants to change his/her name on the original certificate of registration or current wallet-sized license must submit:

The provisions of this §217.8 adopted to be effective September 1, 1999, 24 TexReg 4001; amended to be effective July 5, 2004, 29 TexReg 6296.

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§217.9. Inactive and Retired Status

(a) A nurse may change his/her licensure status from "active" to "inactive" status by:

(b) A nurse may change his/her licensure status from "active" or "inactive" to "retired" or "volunteer retired" status. A nurse who elects to change his/her licensure status from "active" or "inactive" to "retired" or "volunteer retired" status may do so only if he/she is in good standing with the Board. For purposes of this section, good standing means that the nurse's license is not in delinquent status and that there is no current disciplinary action, disciplinary probation, or pending investigation/s on his/her nursing license/s or authorization/s. A nurse will not be eligible for "retired" or "volunteer retired" status until all outstanding disciplinary issues have been resolved. Further, a nurse who wishes to change his/her licensure status from "inactive" to "retired" or "volunteer retired" status may do so only if his/her license was in good standing with the Board on the date his/her license became inactive.

(c) Retired Status. A nurse who wishes to change his/her licensure status to "retired" status and is eligible to do so under subsection (b) of this section must submit the following information to the Board:

(d) A nurse whose license is in "retired" status may not practice as a nurse for compensation (monetary or nonmonetary benefits).

(e) Volunteer Retired Authorization. In compliance with the Occupations Code §112.051, the Board shall adopt rules providing for reduced fees and continuing education requirements for retired health care practitioners whose only practice is voluntary charity care. The Board shall also define voluntary charity care.

(f) A nurse who has not practiced nursing in Texas and whose license has been in an inactive status for less than four years may reactivate the license by completing the reactivation application form, paying the required reactivation fee and the current licensure fee which are non-refundable, and submitting verification of completion of 20 contact hours of continuing education that meets the requirements of Chapter 216 of this title (relating to Continuing Competency) within the two years immediately preceding the application for reactivation.

(g) A nurse who has not practiced nursing and whose license has been in an inactive status for four or more years must submit to the Board:

(h) The Board adopts by reference the following forms, which comprise the instructions and requirements for a refresher course, extensive orientation to the practice of nursing, and a nursing program of study required by this section, and which are available at www.bon.state.tx.us/olv/forms.html:

The provisions of this §217.9 adopted to be effective September 1, 1999, 24 TexReg 4001; amended to be effective July 5, 2004, 29 TexReg 6296; amended to be effective January 2, 2006, 30 TexReg 8880; amended to be effective October 11, 2010, 35 TexReg 9093; amended to be effective January 17, 2012, 37 TexReg 122.

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§217.10. Restrictions to Use of Designations for Licensed Vocational or Registered Nurse

(a) Use of title

(b) Display of Designations.

(c) Duty to Document Designations. While functioning in a nursing role, each licensed nurse shall document in his/her written communications:

The provisions of this §217.10 adopted to be effective September 1, 1999, 24 TexReg 4001; amended to be effective July 5, 2004, 29 TexReg 6296.

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§217.11. Standards of Nursing Practice

The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted.

The provisions of this §217.11 adopted to be effective September 28, 2004, 29 TexReg 9192; amended to be effective November 15, 2007, 32 TexReg 8165.

The Board has adopted position statements and interpretive guidelines that are intended to clarify § 217.11
or address specific practice-related issues. These items are located at the Board's web site, www.bon.texas.gov,
in the "Nursing Practice" section of the "Table of Contents."

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§217.12. Unprofessional Conduct

The unprofessional conduct rules are intended to protect clients and the public from incompetent, unethical, or illegal conduct of licensees. The purpose of these rules is to identify unprofessional or dishonorable behaviors of a nurse which the board believes are likely to deceive, defraud, or injure clients or the public. Actual injury to a client need not be established. These behaviors include but are not limited to:

The provisions of this §217.12 adopted to be effective September 28, 2004, 29 TexReg 9192.

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§217.13. Peer Assistance Program

(a) A peer assistance program for nurses approved by the Board under chapter 467, Health and Safety Code, will identify, monitor, and assist with locating appropriate treatment for those nurses whose practice is impaired or suspected of being impaired by chemical dependency, mental illness or diminished mental capacity so that they may return to practice safe nursing.

(b) Role of the Board of Nursing and Peer Assistance Program.

(c) General Criteria for Approved Peer Assistance Program.

(d) Evaluation of Peer Assistance Program.

(e) Participants entering the approved peer assistance program for chemical dependency or chemical abuse must agree to the following minimum conditions:

(f) Referral to Board of Noncompliance with Peer Assistance Program.

(g) Eligibility for Program Participation.

(h) Successful Completion of the Program. A participant successfully completes the program when the participant fully complies with all of the terms of the program agreement for the period as specified in the agreement. When a participant successfully completes the program, the program shall notify the participant of the successful completion in writing. Once the participant receives this written notification of successful completion of the program, the participant shall no longer be required to comply with the program agreement. The program shall notify the board when a nurse who the board has ordered to attend or referred to the program successfully completes the peer assistance contract.

The provisions of this §217.13 adopted to be effective February 18, 2008, 33 TexReg 1333.

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§217.14. Registered Nurses Performing Radiologic Procedures

(a) A registered nurse who performs radiologic procedures other than in a hospital that participates in the federal Medicare program or that is accredited by The Joint Commission shall submit an application for registration to the board and shall submit evidence including, but not limited to, the following:

(b) After review by the board, notification of registration shall be mailed to the registered nurse informing him/her that the registration with the board has been completed.

(c) The registered nurse who is registered to perform radiologic procedures pursuant to subsection (a) of this section shall notify the board within 30 days of any changes that would render the information on the nurse's application incorrect, including but not limited to any changes in the identity of the practitioner or director of radiological procedures under whose instruction or direction the radiologic procedures are performed.

(d) The registered nurse whose functions include radiologic procedures must act within the scope of the Texas Nursing Practice Act and the Board's rules and shall comply with the training requirements and limitations of the Medical Radiologic Technologist Certification Act and the Texas Department of State Health Rules, 25 TAC §§140.517 - 140.522. In addition, the registered nurse must be in compliance with the Texas Medical Practice Act, the Texas Pharmacy Act, and any applicable laws of the State of Texas.

(e) Any nurse who violates these rules shall be subject to disciplinary action by the board under the Occupations Code Chapter 301 and the Board's rules.

The provisions of this §217.14 adopted to be effective September 1, 1999, 24 TexReg 4001; amended to be effective July 10, 2013, 38 TexReg 4356.

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§217.15. Copying the License/Permit/Permanent Certificate of a Licensed Vocational Nurse/ Registered Nurse/ Graduate Nurse/ Advanced Practice Nurse

(a) The licensee or permit holder has the responsibility to protect his or her license/permit/permanent certificate from loss and potential fraudulent or unlawful use.

(b) A licensee or permit holder shall only allow his or her license/permit certificate to be copied for the purpose of licensure verification by employers, licensing boards, professional organizations, nursing programs, and third party payors for credentialing and reimbursement purposes. Other persons and/or agencies may contact the board's office in writing or by phone to verify licensure.

The provisions of this §217.15 adopted to be effective September 1, 1999, 24 TexReg 4001; amended to be effective July 5, 2004, 29 TexReg 6296.

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§217.16. Reporting of Minor Incidents

(a) Purpose. The Board believes protection of the public is not enhanced by the reporting of every minor incident that may be a violation of the Texas Nursing Practice Act or a board rule. This is particularly true when there are mechanisms in place in the nurse's practice setting to identify nursing errors, detect patterns of practice, and take corrective action to remediate deficits in a nurse's judgment, knowledge, training, or skill. This rule is intended to provide guidance to nurses, nursing peer review committees and others in determining whether a nurse has engaged in conduct that indicates the nurse's continued practice would pose a risk of harm to patients or others and should be reported to the board.

(b) Definition. A "minor incident" as defined under Nursing Practice Act §301.401(2) means conduct by a nurse that may be a violation of the Nursing Practice Act or a Board rule but does not indicate the Nurse's continued practice poses a risk of harm to a patient or another person.

(c) Factors to be Considered in Evaluating if Conduct Must Be Reported to the Board.

(d) Conduct Required to be Reported.

(e) Conduct Normally Not Required to Be Reported to the Board.

(f) Documentation of Minor Incidents. A minor incident should be documented as follows:

(g) Nursing Peer Review Committee.

(h) A Right to Report. Nurses and other persons are encouraged not to report minor incidents to the Board unless required to do so by this rule, but nothing in this rule is intended to prevent reporting of a potential violation directly to the Board or to a nursing peer review committee.

(i) Mis-classifying to Avoid Reporting. Intentionally mis-classifying an incident to avoid reporting may result in violation of the mandatory reporting statute.

(j) Chief Nursing Officer or Nurse Administrator Responsibility. The Chief Nursing Officer, Nurse Administrator or registered nurse by any title who is responsible for nursing services shall be responsible for taking reasonable steps to assure that minor incidents are handled in compliance with this rule and any other applicable law.

(k) Nurses Reported to the Board. If a nurse is reported to the board, the board shall review the nurse's conduct to determine if it indicates the nurse's continued practice poses a risk of harm to a patient or another person. If it does not the board may elect not to proceed with filing formal charges.

The provisions of this §217.16 adopted to be effective September 1, 1999, 24 TexReg 4001; amended to be effective February 19, 2003, 28 TexReg 1378; amended to be effective July 5, 2004, 29 TexReg 6296; amended to be effective May 17, 2006, 31 TexReg 3873; amended to be effective January 4, 2009, 33 TexReg 10432.

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§217.17. Texas Nursing Jurisprudence Exam

(a) Exam Development.

(b) Grading Procedures.

(c) Taking the NJE.

(d) Notice of Results.

The provisions of this §217.17 adopted to be effective November 15, 2007, 32 TexReg 8167; amended to be effective October 19, 2008, 33 TexReg 8512.

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§217.18. Assisting at Surgery

(a) Nurse First Assistants.

(b) Assisting at Surgery by Other Nurses.

The provisions of this §217.18 adopted to be effective March 13, 2002, 27 TexReg 1735; amended to be effective February 20, 2003, 28 TexReg 1381; amended to be effective February 19, 2006, 31 TexReg 850.

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§217.19. Incident-Based Nursing Peer Review and Whistleblower Protections

(a) Definitions.

(b) Purpose. The purpose of this rule is to:

(c) Applicability of Incident-Based Peer Review. TOC §303.0015 (NPR Law) requires a person who regularly employs, hires or contracts for the services of ten (10) or more nurses (for peer review of an RN, at least 5 of the 10 must be RNs) to conduct nursing peer review for purposes of TOC §301.401(1) and §301.402(e) (NPA) (relating to alternate reporting by nurses to nursing peer review when a nurse engages in conduct subject to reporting), §301.403 (relating to nursing peer review committee reporting), §301.405(c) (relating to nursing peer review of external factors as part of employer reporting), and §301.407(b) (relating to alternate reporting by state agencies to peer review).

(d) Minimum Due Process.

(e) Use of Informal Work Group In Incident Based Peer Review. A facility may choose to initiate an informal review process utilizing a workgroup of the nursing incident-based peer review committee provided there are written policies for the informal workgroup that require:

(f) Exclusions to Minimum Due Process Requirements. The minimum due process requirements set out in subsection (d) of this section do not apply to:

(g) Incident-Based Peer Review of a Nurse's Impaired Practice/Lack of Fitness.

(h) Confidentiality of Proceedings.

(i) Committee Responsibility to Evaluate and Report.

(j) Nurse's Duty to Report.

(k) State Agency Duty to Report. A state agency that has reason to believe that a nurse has engaged in conduct subject to reporting shall report the nurse in writing to:

(l) Integrity of Incident-Based Peer Review Process.

(m) Reporting Conduct of other Practitioners or Entities: Whistleblower Protections.

The provisions of this §217.19 adopted to be effective May 11, 2008, 33 TexReg 3633; amended to be effective January 9, 2012, 37 TexReg 62.

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§217.20. Safe Harbor Peer Review for Nurses and Whistleblower Protections

(a) Definitions.

(b) Purpose. The purpose of this rule is to:

(c) Applicability of Safe Harbor Nursing Peer Review.

(d) Invoking Safe Harbor.

(e) Safe Harbor Protections.

(f) Exclusions to Safe Harbor Protections.

(g) Nurse's Right to Refuse to Engage in Certain Conduct Pending Nursing Safe Harbor Peer Review Determination.

(h) Minimum Due Process.

(i) Safe Harbor Timelines.

(j) General Provisions.

(k) Use of Informal Work Group In Safe Harbor Nursing Peer Review. A facility may choose to initiate an informal review process utilizing a workgroup of the nursing peer review committee provided that the final determination of the nurse's duty complies with the time lines set out in this rule and there are written policies for the informal workgroup that require:

(l) Reporting Conduct of other Practitioners or Entities; Whistleblower Protections.

The provisions of this §217.20 adopted to be effective May 11, 2008, 33 TexReg 3633; amended to be effective July 29, 2008, 33 TexReg 5930; amended to be effective January 9, 2012, 37 TexReg 62.

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§217.21. Remedial Education Course Providers and Remedial Education Courses

(a) Purpose. In situations where an individual has demonstrated a knowledge, judgment, or skills deficit, the Board believes that educational courses can serve as an effective form of remediation provided that the courses are well developed, based on sound educational principles, and taught by qualified instructors. This section establishes the requirements for the approval of remedial education course providers and remedial education courses.

(b) Definitions. The following words and terms, when used in this section, shall have the following meanings, unless the context clearly indicates otherwise:

(c) Approval Required. A remedial education course in nursing jurisprudence and ethics, medication administration, physical assessment, pharmacology, and nursing documentation must be approved by the Board. A remedial education course provider seeking to offer one of these remedial education courses must be approved by the Board prior to offering the course to an individual.

(d) Remedial Education Course Providers. A remedial education course provider applicant seeking initial approval from the Board must submit a completed remedial education course provider application to the Board. The provider applicant must verify the application by attesting to the truth and accuracy of the information in the application.

(e) Remedial Education Courses. A remedial education course provider must submit a completed remedial education course application to the Board for each course the provider wishes to offer and pay the required fee specified by §223.1 of this title (relating to Fees), which is not refundable.

(f) Remedial education courses may consist of classroom, classroom equivalent, or clinical courses, as specified by the Board.

(g) Renewal. Unless withdrawn or otherwise provided herein, a remedial education course is approved until the approval of the sponsoring remedial education course provider expires. The approval of a remedial education course may be renewed simultaneously with the renewal of the approval of the sponsoring remedial education course provider if the provider certifies on the renewal application that the remedial education course continues to meet the requirements of this section. The approval of a remedial education course that has been approved by the Board prior to, or on the effective date of this section, will expire on March 31, 2013, and must be timely renewed. Its renewal will be valid for up to twenty four months from the date of issuance and shall expire on the last day of the month of March in odd numbered years. All remedial education course providers must pay the required remedial education course renewal fee specified by §223.1 of this title, which is not refundable.

(h) Withdrawal of Approval. The Board may withdraw the approval of a remedial education course provider that fails to maintain compliance with the requirements of this section. If the Board withdraws the approval of a remedial education course provider, the provider shall cease offering all remedial education courses upon notice from the Board. The Board may withdraw the approval of a remedial education course if it fails to comply with the requirements of this section. If the Board withdraws the approval of a remedial education course, the sponsoring remedial education course provider shall cease offering the course upon notice from the Board. Notice is presumed to be effective on the third day after the date on which the Board mails the notice.

The provisions of this §217.21 adopted to be effective August 11, 2011, 36 TexReg 4953.

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§217.22. Special Accommodations

(a) The Board will provide reasonable accommodations for its licensing examinations as set forth in this section.

(b) Individuals requesting special accommodations must submit the following information to the Board:

(c) An individual requesting special accommodations must submit the information required by this section to the Board at least 30 calendar days prior to registering for the licensing examination. The Board will process the accommodation request once all of the required information and documentation is received.

(d) The Board's requirements for diagnosticians and the forms referenced in subsection (b) of this section may be found on the Board's website, located at www.bon.texas.gov/olv/pdfs/SPECACC.pdf.

The provisions of this §217.22 adopted to be effective January 9, 2012, 37 TexReg 66.

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CHAPTER 219. ADVANCED PRACTICE NURSE EDUCATION

§219.1. General Requirements and Purpose

(a) General Requirements. Advanced practice nursing educational programs in the State of Texas shall be approved by the Board until the program is accredited or approved by a national advanced practice nursing education accrediting body recognized by the Board.

(b) The director and faculty are accountable for complying with the Nursing Practice Act and Board rules and regulations.

(c) Advanced practice nursing educational programs shall provide reasonable and uniform standards based upon sound educational principles.

(d) Purpose. This rule has been developed for use by nurse practitioner and clinical nurse specialist programs seeking approval by the Board in order to:

The provisions of this §219.1 adopted to be effective September 13, 2001, 26 TexReg 6889; amended to be effective January 8, 2008, 33 TexReg 184.

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§219.2. Definitions

The following words and terms, when used in this chapter, shall have the following meanings unless the context clearly indicates otherwise:

The provisions of this §219.2 adopted to be effective September 13, 2001, 26 TexReg 6889; amended to be effective January 8, 2008, 33 TexReg 184.

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§219.3. Program Development, Closure, and Transfer of Administrative Control

(a) New Programs.

(b) Transfer of Administrative Control by Governing Institutions. A governing institution that wishes to transfer administrative control of the advanced practice nursing educational program to another governing institution shall follow the procedures specified in Board guidelines.

(c) Closing a Program or Portion Thereof.

The provisions of this §219.3 adopted to be effective September 13, 2001, 26 TexReg 6889; amended to be effective January 8, 2008, 33 TexReg 184.

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§219.4. Approval

(a) Approval status is based upon each program's performance and demonstrated compliance to the Board's requirements and responses to the Board's recommendations . Change from one status to another is based on survey visits or other factors listed under this subsection. Types of approval include:

(b) Factors Jeopardizing Program Approval Status. Approval may be changed or denied for any of the following reasons:

(c) Determination of Approval Status.

(d) Withdrawal from the Approval Process.

The provisions of this §219.4 adopted to be effective September 13, 2001, 26 TexReg 6889; amended to be effective January 8, 2008, 33 TexReg 184.

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§219.5. Mission/Philosophy and Objectives/Outcomes

(a) The philosophy/mission and objectives/outcomes of the advanced practice nursing educational program shall be developed by the faculty.

(b) The philosophy/mission and objectives/outcomes shall be consistent with:

(c) The program objectives/outcomes shall be consistent with the program's philosophy/mission and shall describe the capabilities of the graduates of the program. Objectives/Outcomes shall be stated in behavioral terms and shall serve as a mechanism for evaluating student progression.

(d) The written philosophy/mission and objectives/outcomes shall be used as a basis for planning, organizing, implementing and evaluating the program and shall be shared with the students.

(e) The faculty shall periodically review the philosophy/mission and objectives/outcomes, consider student input as appropriate, and make necessary revisions.

The provisions of this §219.5 adopted to be effective September 13, 2001, 26 TexReg 6889; amended to be effective January 8, 2008, 33 TexReg 184.

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§219.6. Administration and Organization

(a) The advanced practice nursing educational program shall operate within or be affiliated with a college or university authorized to award graduate degrees.

(b) The governing institution shall be regionally accredited by an agency recognized by the Texas Higher Education Coordinating Board.

(c) There shall be an organizational chart that demonstrates the relationship of the advanced practice nursing educational program to the governing institution and indicates lines of responsibility and authority.

(d) The governing institution shall provide financial support and resources needed to operate a program that meets the legal and educational requirements of the Board and fosters achievement of program goals. The financial resources shall support adequate educational facilities, equipment and qualified administrative and instructional personnel.

(e) In colleges and universities, the program shall have comparable status with other academic units in order to adequately recruit, employ, and retain sufficient qualified faculty members with graduate preparation and expertise necessary for students to meet program goals.

(f) Program faculty shall have comparable status with other academic units in areas such as rank, promotion, tenure, leave, benefits, academic rights, and professional development.

(g) Each advanced practice nursing educational program shall be administered by a qualified individual who is accountable for the planning, implementation and evaluation of the advanced practice nursing educational program. The director shall:

(h) Sufficient time shall be provided for the director to administer the program. The teaching load shall not negatively impact program administration responsibilities.

(i) If the director of the program changes, the director shall submit to the Board written notification of the change indicating the final date in the position.

The provisions of this §219.6 adopted to be effective September 13, 2001, 26 TexReg 6889; amended to be effective January 8, 2008, 33 TexReg 184.

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§219.7. Faculty Qualifications and Faculty Organization

(a) There shall be written personnel policies for nursing faculty that are in keeping with accepted educational standards and are consistent with those of the governing institution to the extent possible. Variations of these policies may be necessary because of the nature of the curriculum for which the faculty must have authority and responsibility.

(b) An advanced practice nursing educational program shall employ sufficient faculty members with appropriate graduate preparation and expertise necessary to enable students to meet the program goals. The number of faculty members shall:

(c) Faculty Qualifications and Responsibilities.

(d) The faculty shall be organized with written policies and procedures and/or bylaws to guide the faculty and program's activities. The policies, procedures, and/or bylaws shall be consistent with the governing institution.

(e) The faculty shall meet regularly and function in such a manner that all members participate in planning, implementing, and evaluating the program. Such participation includes, but is not limited to, the initiation and/or change of academic policies, personnel policies, curriculum, utilization of affiliate agencies, and program evaluation.

(f) There shall be written plans for faculty orientation, development, and evaluation.

The provisions of this §219.7 adopted to be effective September 13, 2001, 26 TexReg 6889; amended to be effective January 8, 2008, 33 TexReg 184.

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§219.8. Students

(a) Students should have a mechanism for input into the development of academic policies and procedures, curriculum planning, and evaluation of teaching effectiveness.

(b) The number of students admitted to the program shall be determined by the number of qualified faculty, adequate educational facilities and resources, and the availability of appropriate clinical learning experiences for students.

(c) Written policies regarding student admission and progression shall be developed and implemented in accordance with the requirements that the governing institution must meet to maintain accreditation. Student policies that differ from those of the governing institution shall be in writing and shall be made available to faculty and students.

(d) Students shall hold a current, valid license or privilege to practice as a registered nurse in the state(s) in which they participate in any clinical learning experiences, including, but not limited to, laboratory or observational experiences involving patient contact or having the potential to involve patient contact, including contact via telehealth.

(e) There shall be written policies for student grievance, health, safety, and welfare.

(f) Students shall have the opportunity to evaluate faculty, courses, and learning resources and these evaluations shall be documented.

The provisions of this §219.8 adopted to be effective September 13, 2001, 26 TexReg 6889; amended to be effective January 8, 2008, 33 TexReg 184.

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§219.9. Program of Study

(a) The program of study shall be:

(b) For clinical nurse specialist programs, the program of study must also qualify the graduate for a minimum of a master's degree in nursing.

(c) The curriculum content shall include:

(d) For clinical nurse specialist programs, the curriculum must also contain a minimum of nine (9) semester credit hours or the equivalent in a specific clinical major. Clinical major courses must include didactic content and offer clinical experiences in a specific clinical specialty/practice area recognized by the Board.

(e) If a clinical nurse specialist program has as a goal or outcome the preparation of graduates for approval for prescriptive authority, then the program must also include at a minimum a separate course in diagnosis and management of diseases and conditions within the clinical specialty area recognized by the Board. This course(s) must be an advanced level academic course(s) with a minimum of 45 clock hours.

(f) Individuals prepared in more than one advanced practice role and/or specialty (including blended role or dual specialty programs) shall be considered to have completed separate advanced practice nursing educational programs of study for each role and/or specialty area.

(g) The program of study shall include a minimum of 500 separate, non-duplicated clinical hours for each advanced role and specialty within the advanced practice nursing education program.

(h) Post-master's preparation may be offered as graduate level course work through master's or higher level advanced practice nursing educational programs that include the desired role and specialty and otherwise meet the standards in this chapter.

(i) Board staff approval is required prior to implementation of major curriculum changes. Proposed changes shall include information outlined in Board guidelines and shall be reviewed using Board standards. Changes that require approval include:

The provisions of this §219.9 adopted to be effective September 13, 2001, 26 TexReg 6889; amended to be effective January 8, 2008, 33 TexReg 184.

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§219.10. Management of Clinical Learning Experiences and Resources

(a) Faculty shall be responsible and accountable for managing clinical learning experiences of students.

(b) Faculty shall develop criteria for the selection of affiliating agencies/clinical facilities or clinical practice settings that address safety and the need for students to achieve the program outcomes (goals) through advanced practice nursing.

(c) Faculty shall select and evaluate affiliating agencies/clinical facilities or clinical practice settings that provide students with opportunities to achieve the goals of the program.

(d) Written agreements between the program and the affiliating agencies shall specify the responsibilities of the program to the agency and the responsibilities of the agency to the program. Such agreements shall be developed jointly with the affiliating agency, reviewed periodically according to the policies of the program and the affiliating agency, and include provisions for adequate notice of termination.

(e) When clinical preceptorships are used in an advanced practice nursing educational program, the following conditions shall be met:

(f) The maximum number of students that one advanced practice nursing educational program faculty member supervises in a clinical course should not exceed six students.

The provisions of this §219.10 adopted to be effective September 13, 2001, 26 TexReg 6889; amended to be effective January 8, 2008, 33 TexReg 184.

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§219.11. Facilities, Resources, and Services

(a) The governing institution shall be responsible for providing:

(b) The physical facilities shall be adequate to meet the needs of the program in relation to the size of the faculty and the student body.

(c) The director and faculty shall have appropriate technology and support services, including but not limited to secretarial and clerical assistance, appropriate to the needs of the program.

(d) The learning resources, library, and program holdings shall be current, use contemporary technology appropriate for the level of the curriculum, and be sufficient for the size of the student body and the needs of the faculty.

The provisions of this §219.11 adopted to be effective September 13, 2001, 26 TexReg 6889; amended to be effective January 8, 2008, 33 TexReg 184.

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§219.12. Records and Reports

(a) Accurate and current records shall be maintained in a confidential manner and be accessible to appropriate parties. Records shall include, but are not limited to:

(b) Records shall be safely stored to prevent loss, destruction, or unauthorized use.

The provisions of this §219.12 adopted to be effective September 13, 2001, 26 TexReg 6889; amended to be effective January 8, 2008, 33 TexReg 184.

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§219.13. Total Program Evaluation

(a) There shall be a written plan for the systematic evaluation of the total program. The plan shall include evaluative criteria, methodology, frequency of evaluation, assignment of responsibility, and indicators (benchmarks) of program and instructional effectiveness. The following broad areas shall be periodically evaluated:

(b) All methods and instruments used for evaluative purposes shall be periodically reviewed and revised as necessary.

(c) Implementation of the plan for total program evaluation shall be documented in the minutes.

(d) There shall be documentation that the data obtained from the total program evaluation is reviewed and used for ongoing program improvement.

(e) Major changes in the nursing program shall be evidence-based and supported by rationale.

The provisions of this §219.13 adopted to be effective September 13, 2001, 26 TexReg 6889; amended to be effective January 8, 2008, 33 TexReg 184.

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CHAPTER 220. NURSE LICENSURE COMPACT

§220.1. Definitions

For the purpose of the Compact, the following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise:

The provisions of this §220.1 adopted to be effective January 1, 2000, 24 TexReg 10331.

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§220.2. Issuance of a License by a Compact Party State

(a) As of July 1, 2005, no applicant for initial licensure will be issued a license granting a multistate privilege to practice unless the applicant first obtains a passing score on the applicable NCLEX examination or its predecessor examinations used for licensure.

(b) A nurse applying for a license in a home party state shall produce evidence of the nurse's primary state of residence. Such evidence shall include a declaration signed by the licensee. Further evidence that may be requested may include but are not limited to:

(c) A nurse on a visa from another country applying for licensure in a party state may declare either the country of origin or the party state as the primary state of residence. If the foreign country is declared the primary state of residence, a single state license will be issued by the party state.

(d) A license issued by a party state is valid for practice in all other party states unless clearly designated as valid only in the state which issued the license.

(e) When a party state issues a license authorizing practice only in that state and not authorizing practice in other party states (i.e. a single state license), the license shall be clearly marked with words indicating that it is valid only in the state of issuance.

(f) A nurse changing primary state of residence, from one party state to another party state, may continue to practice under the former home state license and multistate licensure privilege during the processing of the nurse's licensure application in the new home state for a period not to exceed ninety (90) days.

(g) The licensure application in the new home state of a nurse under pending investigation by the former home state shall be held in abeyance and the ninety (90) day period stated in subsection (f) of this section shall be stayed until resolution of the pending investigation.

(h) The former home state license shall no longer be valid upon the issuance of a new home state license.

(i) If a decision is made by the new home state denying licensure, the new home state shall notify the former home state within ten business days and the former home state may take action in accordance with that state's laws and rules.

The provisions of this §220.2 adopted to be effective January 1, 2000, 24 TexReg 10331; amended to be effective April 11, 2005, 30 TexReg 2066; amended to be effective April 14, 2009, 34 TexReg 2378; amended to be effective April 21, 2013, 38 TexReg 2361.

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§220.3. Limitations on Multistate Licensure Privilege-Discipline

(a) All home state Board disciplinary orders, agreed or otherwise, which limit the scope of licensee's practice or require monitoring of the licensee as a condition of the order shall include the requirement that the licensee will limit his or her practice to the home state during the pendency of the order. This requirement may allow the licensee to practice in other party states with prior written authorization from both the home state and party state Boards.

(b) An individual who had a license which was surrendered, revoked, suspended, or an application denied for cause in a prior state of primary residence, may be issued a single state license in a new primary state of residence until such time as the individual would be eligible for an unrestricted license by the prior state(s) of adverse action. Once eligible for licensure in the prior state(s), a multistate license may be issued.

The provisions of this §220.3 adopted to be effective January 1, 2000, 24 TexReg 10331; amended to be effective April 14, 2009, 34 TexReg 2378.

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§220.4. Information System

(a) Levels of access.

(b) The licensee may request in writing to the home state Board to review the data relating to the licensee in the Information System. In the event a licensee asserts that any data relating to him or her is inaccurate, the burden of proof shall be upon the licensee to provide evidence that substantiates such claim. The Board shall verify and within ten business days correct inaccurate data to the Information System.

(c) The Board shall report to the Information System within 10 business days, a disciplinary action, agreement or order requiring participation in alternative programs or which limit practice or require monitoring (except agreements and orders relating to participation in alternative programs required to remain nonpublic by contributing state authority), dismissal of complaint, and changes in status of disciplinary action, or licensure encumbrance.

(d) Current significant investigative information shall be deleted from the Information System within ten business days upon report of disciplinary action, agreement or order requiring participation in alternative programs or agreements which limit practice or require monitoring or dismissal of a complaint.

(e) Changes to licensure information in the Information System shall be completed within ten business days upon notification by a Board.

The provisions of this §220.4 adopted to be effective January 1, 2000, 24 TexReg 10331.

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CHAPTER 221. ADVANCED PRACTICE NURSES

§221.1. Definitions

The following words and terms, when used in this chapter, shall have the following meanings unless the context clearly indicates otherwise:

The provisions of this §221.1 adopted to be effective February 25, 2001, 26 TexReg 1509; amended to be effective June 29, 2010, 35 TexReg 5561.

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§221.2. Authorization and Restrictions to Use of Advanced Practice Titles

(a) Effective January 1, 2006, a registered nurse holding him or herself out to be an advanced practice nurse shall be authorized to practice and hold a title in the following categories:

(b) A registered nurse who holds current authorization to practice as an advanced practice nurse issued by the board in any of the categories indicated in the previous subsection shall use that title when functioning in the advanced practice role. A registered nurse who was granted authorization to practice in an advanced role and specialty not indicated in the previous subsection prior to January 1, 2006, may continue to use the advanced practice title approved by the Board provided all requirements for maintenance of advanced practice authorization are met. "Advanced practice nurse" shall not be used as a title.

(c) Unless authorized as an advanced practice nurse by the board as provided for by §§221.4 - 221.8 of this chapter (relating to Full Authorization, Provisional Authorization; Interim Approval; Petitions for Waiver; and Maintaining Active Authorization as an Advanced Practice Nurse), a registered nurse shall not:

(d) A registered nurse who violates subsection (c) of this section may be subject to an administrative penalty under §301.501 of the Nursing Practice Act.

The provisions of this §221.2 adopted to be effective February 25, 2001, 26 TexReg 1509; amended to be effective May 15, 2005, 30 TexReg 2668.

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§221.3. Education

(a) In order to be eligible to apply for authorization as an advanced practice nurse, the registered nurse must have completed a post-basic advanced educational program of study appropriate for practice in an advanced nursing specialty and role recognized by the Board. RN to BSN programs shall not be considered post-basic programs for the purpose of this rule.

(b) Individuals prepared in more than one advanced practice role and/or specialty (including blended role or dual specialty programs) shall be considered to have completed separate advanced educational programs of study for each role and/or specialty area.

(c) Applicants for licensure to practice in an advanced practice role and population focus area recognized by the Board must submit verification of completion of all requirements of an advanced educational program that meets the following criteria:

(d) Applicants for licensure as clinical nurse specialists must submit verification of the following requirements in addition to those specified in subsection (c) of this section:

(e) Those applicants who completed nurse practitioner or clinical nurse specialist programs on or after January 1, 1998 must demonstrate evidence of completion of the following curricular requirements:

(f) Those applicants who complete nurse practitioner or clinical nurse specialist programs on or after January 1, 2003 must demonstrate evidence of completion of a minimum of 500 separate, non-duplicated clinical hours for each advanced role and specialty within the advanced educational program.

The provisions of this §221.3 adopted to be effective February 25, 2001, 26 TexReg 1509; amended to be effective January 2, 2006, 30 TexReg 8881; amended to be effective June 29, 2010, 35 TexReg 5561.

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§221.4. Advanced Practice Registered Nurse Licensure Requirements

(a) Advanced practice registered nurse licensure is issued for the purpose of authorizing a registered nurse to practice in a specific advanced practice role and population-focus area.

(b) The applicant for licensure as an advanced practice registered nurse shall:

(c) Applicants who completed their advanced practice nursing educational programs on or after January 1, 1996 must submit evidence of current certification in an advanced practice role and population focus area recognized by the Board that is congruent with the advanced practice nursing educational preparation. The certification examination shall be recognized by the Board for the role and population-focus area. If a specific certification examination does not exist for the role and population focus area, the board reserves the right to designate a national certification examination in a closely related population focus area. If the Board has not designated an alternate examination, the applicant may petition the board for waiver from the certification requirement, according to the exceptions specified in this chapter.

(d) Advanced practice registered nurse applicants who wish to practice in more than one role and/or population-focus area shall complete additional education in the desired area(s) of licensure in compliance with the educational requirements set forth in this chapter and meet all requirements for licensure in each additional role or population-focus area. To apply for licensure for more than one title, the applicant shall submit a separate application and fee for each desired title. Additional licensure is required for those licensed advanced practice registered nurses seeking to include an additional:

(e) After review by the board and verification that all requirements have been met, a certificate verifying licensure shall be sent to the advanced practice registered nurse.

The provisions of this §221.4 adopted to be effective February 25, 2001, 26 TexReg 1509; amended to be effective March 14, 2002, 27 TexReg 1736; amended to be effective February 20, 2003, 28 TexReg 1383; amended to be effective November 23, 2008, 33 TexReg 9237

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§221.6. Interim Approval

(a) Interim approval is a time-limited permit to practice nursing in a specific advanced practice role and population-focus area. The Board may grant interim approval to eligible advanced practice registered nurse applicants.

(b) Interim approval permits the advanced practice registered nurse applicant to practice without prescriptive authority while the application is reviewed.

(c) An advanced practice registered nurse applicant who submits a request for waiver from the requirements for licensure set forth in this chapter shall not be eligible for interim approval unless otherwise indicated in this chapter.

(d) If an advanced practice registered nurse applicant is deemed ineligible for licensure, the interim approval will be rescinded immediately, effective on the date the notice is sent by mail. The applicant must cease practicing as an advanced practice registered nurse and may no longer use any titles that imply to the public that he/she is an advanced practice registered nurse.

The provisions of this §221.6 adopted to be effective February 25, 2001, 26 TexReg 1509; amended to be effective November 23, 2008, 33 TexReg 9237; amended to be effective July 26, 2011, 36 TexReg 4665

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§221.7. Petitions for Waiver and Exemptions

(a) A registered nurse who submits a request for waiver from requirements of the rules must submit documentation as required by the board to support his or her petition and assure the board that he or she possesses the knowledge, skills and abilities appropriate for the role and specialty desired. Those petitioners who are under investigation or current board order are not eligible for waiver.

(b) Petitions for waiver from the program accreditation requirements of §221.3 of this chapter (relating to Education), may be granted by the board for individuals who completed their educational programs on or before December 31, 1996. Petitioners must meet the length of academic program requirements of §221.3 of this chapter and obtain national certification in the advanced role and specialty area.

(c) Petitions for waiver from the current certification requirements of §221.4 of this chapter (relating to Requirements for Full Authorization to Practice) and §221.8 of this chapter (relating to Maintaining Active Authorization as an Advanced Practice Nurse) may be granted by the board.

(d) Waivers from the master's degree requirement will be granted to qualified certificate-prepared nurse-midwives and women's health care nurse practitioners who complete their programs on or after January 1, 2003 through December 31, 2006. Applicants must meet all other requirements as stated in §221.4 of this chapter.

(e) Exemptions granting authorization to utilize titles not authorized by §221.2 of this chapter may be granted to qualified applicants who complete their advanced educational programs prior to January 1, 2010. Applicants must meet all other requirements as stated in §221.4 of this chapter,

The provisions of this §221.7 adopted to be effective February 25, 2001, 26 TexReg 1509; amended to be effective May 15, 2005, 30 TexReg 2668

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§221.8. Maintaining Active Authorization as an Advanced Practice Nurse

(a) In conjunction with RN license renewal, the advanced practice nurse seeking to maintain active advanced practice authorization(s) shall:

(b) Failure to renew the registered nurse license or to provide the required fee and documentation for maintaining authorization shall result in expiration of the board's authorization as an advanced practice nurse and limited prescriptive authority where applicable. The individual whose advanced practice authorization has expired may not practice as or use titles to imply that he/she is an advanced practice nurse.

The provisions of this §221.8 adopted to be effective February 25, 2001, 26 TexReg 1509

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§221.9. Inactive Status

(a) The advanced practice nurse may choose to change advanced practice nurse status to inactive by providing a written request for such change.

(b) Inactive advanced practice status means that the registered professional nurse may not practice in the advanced practice specialty and role and may not hold himself/herself out to be an advanced practice nurse by using titles which imply that he/she is an advanced practice nurse. The inactive advanced practice nurse may not utilize his/her limited prescriptive authority.

The provisions of this §221.9 adopted to be effective February 25, 2001, 26 TexReg 1509

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§221.10. Reinstatement or Reactivation of Advanced Practice Nurse Status

(a) To reinstate an authorization which has expired due to non-payment of renewal fees for registered nurse licensure and/or advanced practice authorization, the advanced practice nurse shall meet the requirements as stated in §221.8 of this chapter (relating to Maintaining Active Authorization as an Advanced Practice Nurse) and pay all required fees.

(b) If less than four years but more than two years have lapsed since completion of the advanced educational program and/or the applicant does not have 400 hours of current practice in the advanced role and specialty during the previous biennium, the advanced practice nurse shall meet the requirements as stated in §221.8 of this chapter and pay all required fees. The applicant shall be required to demonstrate proof of completion of 400 hours of current practice as well as the continuing education requirement as outlined in Chapter 216 of this title (relating to Continuing Education). The 400 hours of current practice shall be obtained under the direct supervision of an advanced practice nurse authorized by the board in the same role and specialty or by a physician the same specialty.

(c) If more than four years have lapsed since completion of the advanced practice educational program and/or the applicant has not practiced in the advanced role during the previous four years, the applicant shall apply for reactivation and meet current requirements for maintaining authorization to practice under §221.8 of this chapter and shall:

The provisions of this §221.10 adopted to be effective February 25, 2001, 26 TexReg 1509

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§221.11. Identification

When providing advanced practice nursing care to patients, the advanced practice nurse shall wear clear identification which indicates the individual is a registered nurse with the appropriate advanced practice designation authorized by the board.

The provisions of this §221.11 adopted to be effective February 25, 2001, 26 TexReg 1509

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§221.12. Scope of Practice

The advanced practice nurse provides a broad range of health services, the scope of which shall be based upon educational preparation, continued advanced practice experience and the accepted scope of professional practice of the particular specialty area. Advanced practice nurses practice in a variety of settings and, according to their practice specialty and role, they provide a broad range of health care services to a variety of patient populations.

(1) The scope of practice of particular specialty areas shall be defined by national professional specialty organizations or advanced practice nursing organizations recognized by the Board. The advanced practice nurse may perform only those functions which are within that scope of practice and which are consistent with the Nursing Practice Act, Board rules, and other laws and regulations of the State of Texas.

(2) The advanced practice nurse's scope of practice shall be in addition to the scope of practice permitted a registered nurse and does not prohibit the advanced practice nurse from practicing in those areas deemed to be within the scope of practice of a registered nurse.

The provisions of this §221.12 adopted to be effective February 25, 2001, 26 TexReg 1509

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§221.13. Core Standards for Advanced Practice

(a) The advanced practice nurse shall know and conform to the Texas Nursing Practice Act; current board rules, regulations, and standards of professional nursing; and all federal, state, and local laws, rules, and regulations affecting the advanced role and specialty area. When collaborating with other health care providers, the advanced practice nurse shall be accountable for knowledge of the statutes and rules relating to advanced practice nursing and function within the boundaries of the appropriate advanced practice category.

(b) The advanced practice nurse shall practice within the advanced specialty and role appropriate to his/her advanced educational preparation.

(c) The advanced practice nurse acts independently and/or in collaboration with the health team in the observation, assessment, diagnosis, intervention, evaluation, rehabilitation, care and counsel, and health teachings of persons who are ill, injured or infirm or experiencing changes in normal health processes; and in the promotion and maintenance of health or prevention of illness.

(d) When providing medical aspects of care, advanced practice nurses shall utilize mechanisms which provide authority for that care. These mechanisms may include, but are not limited to, Protocols or other written authorization. This shall not be construed as requiring authority for nursing aspects of care.

(e) The advanced practice nurse shall retain professional accountability for advanced practice nursing care.

The provisions of this §221.13 adopted to be effective February 25, 2001, 26 TexReg 1509

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§221.14. Nurse-Midwives Providing Controlled Substances

(a) In this section "provide" means to supply, for a term not to exceed 48 hours, one or more unit doses of a controlled substance for the immediate needs of a patient;

(b) An advanced practice nurse recognized by the board as a nurse-midwife may provide one or more unit doses of a controlled substance during intra-partum or immediate post-partum care subject to the following conditions:

The provisions of this §221.14 adopted to be effective February 25, 2001, 26 TexReg 1509

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§221.15. Provision of Anesthesia Services by Nurse Anesthetists in Licensed Hospitals or Ambulatory Surgical Centers

(a) In a licensed hospital or ambulatory surgical center, consistent with facility policy or medical staff bylaws, a nurse anesthetist may select, obtain, and administer drugs including determination of appropriate dosages, techniques and medical devices for their administration and in maintaining the patient in sound physiologic status pursuant to a physician's order for anesthesia or an anesthesia-related service. This order need not be drug specific, dosage specific, or administration-technique specific.

(b) Pursuant to a physician's order for anesthesia or an anesthesia-related service, the nurse anesthetist may order anesthesia-related medications during perianesthesia periods in the preparation for or recovery from anesthesia. Another RN may carry out these orders.

(c) In providing anesthesia or an anesthesia-related service, the nurse anesthetist shall select, order, obtain and administer drugs which fall within categories of drugs generally utilized for anesthesia or anesthesia-related services and provide the concomitant care required to maintain the patient in sound physiologic status during those experiences.

The provisions of this §221.15 adopted to be effective February 25, 2001, 26 TexReg 1509

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§221.16. Provision of Anesthesia Services by Nurse Anesthetists in Outpatient Settings

(a) Purpose. The purpose of these rules is to identify the roles, and responsibilities of certified registered nurse anesthetists authorized to provide anesthesia services in outpatient settings and to provide the minimum acceptable standards for the provision of anesthesia services in outpatient settings.

(b) Roles and Responsibilities

(c) Standards

(d) Registration.

(e) Inspections and Advisory Opinions.

The provisions of this §221.16 adopted to be effective February 25, 2001, 26 TexReg 1509

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§221.17. Enforcement

(a) The board may conduct an audit to determine compliance with §221.4 of this chapter (relating to Requirements for Full Authorization to Practice), §221.8 of this chapter (relating to Maintaining Active Authorization as an Advanced Practice Nurse), and §221.16 of this chapter (relating to Provision of Anesthesia Services by Nurse Anesthetists in Outpatient Settings).

(b) Any nurse who violates the rules set forth in this chapter shall be subject to disciplinary action and/or termination of the authorization by the board under Texas Occupations Code, §301.452.

These provisions of this §221.17 adopted to be effective February 25, 2001, 26 TexReg 1509

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CHAPTER 222. ADVANCED PRACTICE REGISTERED NURSES WITH PRESCRIPTIVE AUTHORITY

§222.1. Definitions

Repealed Date: 11/20/2013

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

(1) Advanced health assessment course--A course that offers content supported by related clinical experience such that students gain the knowledge and skills needed to perform comprehensive assessments, including histories and physical examinations, to make diagnoses and formulate effective clinical management plans.

(2) Advanced pathophysiology course--A course that offers content that provides a comprehensive, systems-based study of pathophysiology that provides students with the knowledge and skills to analyze the relationship between normal physiology and pathophysiological phenomena.

(3) Advanced pharmacotherapeutics course--A course that offers advanced content in pharmacokinetics and pharmacodynamics, encompassing a broad range of drug classifications, including the application of drug therapy to the treatment of disease and/or the promotion of health.

(4) Advanced practice registered nurse--A registered nurse who:

(5) Alternate site--A practice site:

(6) Board--The Texas Board of Nursing.

(7) Controlled substance--A substance, including a drug, an adulterant, and a dilutant, listed in Schedules I through V or Penalty Groups 1, 1-A, or 2 through 4 of chapter 481 Texas Health and Safety Code (Texas Controlled Substances Act). The term includes the aggregate weight of any mixture, solution, or other substance containing a controlled substance.

(8) Dangerous drug--A device or a drug that is unsafe for self medication and that is not included in schedules I-V or penalty groups I-IV of chapter 481 Texas Health and Safety Code (Texas Controlled Substances Act). The term includes a device or a drug that bears or is required to bear the legend: "Caution: federal law prohibits dispensing without prescription" or "RX only" or another legend that complies with federal law.

(9) Diagnosis and management course--A course offering both didactic and clinical content in clinical decision-making and aspects of medical diagnosis and medical management of diseases and conditions. Supervised clinical practice must include the opportunity to provide pharmacological and non-pharmacological management of diseases and conditions considered within the scope of practice of the advanced practice registered nurse's population focus area and role.

(10) Eligible sites--Sites serving medically underserved populations; a physician's primary practice site; an alternate site; or a facility-based practice site.

(11) Facility-based practice site--A licensed hospital or licensed long term care facility that serves as the practice location for the advanced practice registered nurse.

(12) Health Manpower Shortage Area--An urban or rural area, population group, or public or nonprofit private medical facility or other facility that the Secretary of the United States Department of Health and Human Services (USDHHS) designates as having a health manpower shortage, as described by 42 USC Section 254e(a)(1) or a successor federal statute or regulation.

(13) Medically Underserved Area (MUA)--

(14) Physician's primary practice site--

(15) Population focus area--The section of the population with which the advanced practice registered nurse has been licensed to practice by the Board.

(16) Prescribing--Determining the dangerous drugs or controlled substances that shall be used by or administered to a patient exercised in compliance with state and federal law.

(17) Protocols or other written authorization--Written authorization to provide medical aspects of patient care that are agreed upon and signed by the advanced practice registered nurse and the physician, reviewed and signed at least annually, and maintained in the practice setting of the advanced practice registered nurse. Protocols or other written authorization shall be defined to promote the exercise of professional judgment by the advanced practice registered nurse commensurate with his/her education and experience. Such protocols or other written authorization need not describe the exact steps that the advanced practice registered nurse must take with respect to each specific condition, disease, or symptom and may state types or categories of drugs that may be prescribed rather than just list specific drugs.

(18) Shall and must--Mandatory requirements.

(19) Should--A recommendation.

(20) Signing a prescription drug order--Completing a prescription drug order presigned by the delegating physician or the signing of a prescription by an advanced practice registered nurse. The advanced practice registered nurse must be designated to the Texas Medical Board by the delegating physician as a person delegated to sign a prescription.

(21) Site serving a medically underserved population--

The provisions of this §222.1 adopted to be effective November 26, 2003, 28 TexReg 10502; amended to be effective February 14, 2010, 35 TexReg 866

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§222.2. Approval for Prescriptive Authority

Repealed Date: 11/20/2013

(a) Credentials: To be approved by the Board to sign prescription drug orders and issued a prescription authorization number, a Registered Nurse (RN) shall:

(b) Sites: Prescribing privileges are limited to eligible sites to include sites serving certain medically underserved populations, physician's primary practice sites, alternate sites, and facility-based practice sites.

(c) Exceptions Granted by the Texas Medical Board: Requirements for utilizing prescriptive authority may be modified or waived if a delegating physician has received a modification or waiver from the Texas Medical Board of any site or supervision requirements for a physician to delegate the carrying out or signing of prescription drug orders to the advanced practice registered nurse.

The provisions of this §222.2 adopted to be effective November 26, 2003, 28 TexReg 10502; amended to be effective February 14, 2010, 35 TexReg 866

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§222.3. Renewal of Prescriptive Authority

Repealed Date: 11/20/2013

(a) The advanced practice registered nurse shall renew the privilege to sign prescription drug orders in conjunction with the RN and advanced practice license renewal application.

(b) The advanced practice registered nurse seeking to maintain prescriptive authority shall attest, on forms provided by the Board, to completing at least five contact hours of continuing education in pharmacotherapeutics within the preceding biennium.

(c) The continuing education requirement in subsection (b) of this section, shall be in addition to continuing education required under Chapter 216 of this title (relating to Continuing Competency).

The provisions of this §222.3 adopted to be effective November 26, 2003, 28 TexReg 10502; amended to be effective February 14, 2010, 35 TexReg 866

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§222.4. Minimum Standards for Signing Prescriptions

Repealed Date: 11/20/2013

(a) The advanced practice registered nurse with a valid prescription authorization number:

(b) Protocols or other written authorization shall be defined in a manner that promotes the exercise of professional judgement by the advanced practice registered nurse commensurate with the education and experience of that person.

(c) Prescription Information: The format and essential elements of the prescription shall comply with the requirements of the Texas State Board of Pharmacy. The following information must be provided on each prescription:

(d) Generic Substitution. The advanced practice registered nurse shall authorize or prevent generic substitution on a prescription in compliance with the current rules of the Texas State Board of Pharmacy relating to Generic Substitution.

(e) An advanced practice registered nurse may prescribe medications for sexually transmitted diseases for partners of an established patient, if the advanced practice registered nurse assesses the patient and determines that the patient may have been infected with a sexually transmitted disease. Nothing in this subsection shall be construed to require the advanced practice registered nurse to issue prescriptions for partners of patients.

(f) Advanced practice registered nurses may prescribe only those medications that are FDA approved unless done through protocol registration in a United States Institutional Review Board or Expanded Access authorized clinical trial. "Off label" use, or prescription of FDA-approved medications for uses other than that indicated by the FDA, is permitted when such practices are:

The provisions of this §222.4 adopted to be effective November 26, 2003, 28 TexReg 10502; amended to be effective February 14, 2010, 35 TexReg 866

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§222.5. Prescriptions for Dangerous Drugs

Repealed Date: 11/20/2013

Advanced practice registered nurses with full licensure and valid prescription authorization numbers are eligible to sign prescription drugs orders for dangerous drugs in accordance with the standards and requirements set forth in this chapter.

The provisions of this §222.5 adopted to be effective November 26, 2003, 28 TexReg 10502; amended to be effective February 14, 2010, 35 TexReg 866

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§222.6. Prescriptions for Controlled Substances

Repealed Date: 11/20/2013

(a) Advanced practice registered nurses with full licensure and valid prescription authorization numbers are eligible to obtain authority to prescribe certain categories of controlled substances. The advanced practice registered nurse must comply with all federal and state laws and regulations relating to the prescribing of controlled substances in Texas, including but not limited to, requirements set forth by the Texas Department of Public Safety and the United States Drug Enforcement Administration.

(b) Advanced practice registered nurses who authorize or issue prescriptions for controlled substances shall:

(c) Advanced practice registered nurses with valid prescription authorization must comply with all federal and state laws and regulations relating to the prescribing of controlled substances in Texas, including but not limited to, requirements set forth by the Texas Department of Public Safety and the United States Drug Enforcement Administration.

The provisions of this §222.6 adopted to be effective November 26, 2003, 28 TexReg 10502; amended to be effective February 14, 2010, 35 TexReg 866

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§222.7. Prescribing at Sites Serving Certain Medically Underserved Populations

Repealed Date: 11/20/2013

When signing prescription drug orders at a site serving a medically underserved population, the advanced practice registered nurse shall:

(1) maintain Protocols or other written authorization that must be reviewed and signed by both the advanced practice registered nurse and the delegating physician at least annually;

(2) have access to the delegating physician or alternate delegating physician for consultation, assistance with medical emergencies, or patient referral;

(3) provide a daily status report to the physician on any problems or complications encountered that are not covered by protocol; and

(4) be available during on-site visits by the physician which shall occur at least once every 10 business days that the advanced practice registered nurse is on site providing care.

The provisions of this §222.7 adopted to be effective November 26, 2003, 28 TexReg 10502; amended to be effective February 14, 2010, 35 TexReg 866

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§222.8. Prescribing at Physicians' Primary Practice Sites

Repealed Date: 11/20/2013

When signing prescription drug orders at a physician's primary practice site, the advanced practice registered nurse shall:

(1) maintain Protocols or other written authorization that must be reviewed and signed by both the advanced practice registered nurse and the delegating physician at least annually; and

(2) sign or co-sign prescription drug orders only for those patients with whom the physician has established or will establish a physician-patient relationship although the physician is not required to see the patient within a specified time period.

The provisions of this §222.8 adopted to be effective November 26, 2003, 28 TexReg 10502; amended to be effective February 14, 2010, 35 TexReg 866

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§222.9. Prescribing at Alternate Sites

Repealed Date: 11/20/2013

When signing prescription drug orders at an alternate site, the advanced practice registered nurse shall:

(1) maintain Protocols or other written authorization that must be reviewed and signed by both the advanced practice registered nurse and the delegating physician at least annually;

(2) be available on-site with the physician at least 10 percent of the hours of operation of the site each month that the advanced practice registered nurse is acting with delegated prescriptive authority; and

(3) have access to the delegating physician through direct telecommunication for consultation, patient referral, or assistance with a medical emergency.

The provisions of this §222.9 adopted to be effective November 26, 2003, 28 TexReg 10502; amended to be effective February 14, 2010, 35 TexReg 866

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§222.10. Prescribing at Facility-based Practice Sites

Repealed Date: 11/20/2013

When signing prescription drug orders at a facility-based practice site, the advanced practice registered nurse shall:

(1) maintain Protocols or other written authorization developed in accordance with facility medical staff policies and review the authorizing documents with the appropriate medical staff at least annually;

(2) sign or co-sign prescription drug orders in the facility in which the delegating physician is the medical director, the chief of medical staff, the chair of the credentialing committee, or a department chair; or a physician who consents to the request of the medical director or chief of the medical staff to delegate; and

(3) sign or co-sign prescription drug orders for the care or treatment of only those patients for whom physicians have given their prior consent.

The provisions of this §222.10 adopted to be effective November 26, 2003, 28 TexReg 10502; amended to be effective February 14, 2010, 35 TexReg 866

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§222.11. Conditions for Obtaining and Distributing Drug Samples

Repealed Date: 11/20/2013

The advanced practice registered nurse with a valid prescription authorization number may request, receive, possess and distribute prescription drug samples provided:

(1) all requirements for the advanced practice registered nurse to sign prescription drug orders are met;

(2) Protocols or other physician orders authorize the advanced practice registered nurse to sign the prescription drug orders;

(3) the samples are for only those drugs that the advanced practice registered nurse is eligible to prescribe in accordance with the standards and requirements set forth in this chapter; and

(4) a record of the sample is maintained and samples are labeled as specified in the Dangerous Drug Act (Health and Safety Code, Chapter 483) or the Controlled Substances Act (Health and Safety Code, Chapter 481) and 37 Texas Administrative Code, Chapter 13.

The provisions of this §222.11 adopted to be effective November 26, 2003, 28 TexReg 10502; amended to be effective February 14, 2010, 35 TexReg 866

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§222.12. Enforcement

Repealed Date: 11/20/2013

(a) Any advanced practice registered nurse who violates these sections or prescribes in a manner that is not consistent with the standard of care shall be subject to removal of the authority to prescribe under this section and disciplinary action by the Board under Texas Occupations Code §301.452.

(b) The Board shall report to the Texas Department of Public Safety and the United States Drug Enforcement Administration any of the following:

(c) The practice of the advanced practice registered nurse approved by the Board to sign prescription drug orders is subject to monitoring by the Board on a periodic basis.

The provisions of this §222.12 adopted to be effective November 26, 2003, 28 TexReg 10502; amended to be effective February 14, 2010, 35 TexReg 866

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CHAPTER 223. FEES

§223.1. Fees

(a) The Texas Board of Nursing has established reasonable and necessary fees for the administration of its functions.

(b) All fees are non-refundable.

The provisions of this §223.1 adopted to be effective August 11, 2005, 30 TexReg 4481; amended to be effective January 2, 2006, 30 TexReg 8882; amended to be effective September 25, 2007, 32 TexReg 6520; amended to be effective April 8, 2008, 33 TexReg 2820; amended to be effective June 24, 2008, 33 TexReg 4884; amended to be effective October 19, 2008, 33 TexReg 8512; amended to be effective May 14, 2009, 34 TexReg 2769; amended to be effective July 7, 2010, 35 TexReg 5832; amended to be effective August 11, 2011, 36 TexReg 4960; amended to be effective October 11, 2011, 36 TexReg 6766; amended to be effective October 1, 2013, 38 TexReg 6598

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§223.2. Charges for Public Records

In accordance with Texas Government Code §552.262, the Board of Nurse Examiners will make copies of public records and charge the fees established by the Attorney General's Office.

The provisions of this §223.2 adopted to be effective December 12, 1994, 19 TexReg 9492; amended to be effective July 5, 2004, 29 TexReg 6298; amended to be effective January 2, 2006, 30 TexReg 8882

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CHAPTER 224. DELEGATION OF NURSING TASKS BY REGISTERED PROFESSIONAL NURSES TO UNLICENSED PERSONNEL FOR CLIENTS WITH ACUTE CONDITIONS OR IN ACUTE CARE ENVIRONMENTS

§224.1. Application of Chapter

This chapter applies to situations where:

(1) the client has an acute health condition that is unstable or unpredictable; or

(2) the client is in an acute care environment where nursing services are continuously provided including, but not limited to, hospitals, rehabilitation centers, skilled nursing facilities, clinics, and private practice physician offices.

The provisions of this §224.1 adopted to be effective February 19, 2003, 28 TexReg 1384

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§224.2. Exclusions from Chapter

This chapter does not apply to:

(1) tasks provided in compliance with Government Code §531.051(f) (relating to Voucher Program for Payment of Certain Services for Persons With Disabilities); or

(2) RNs who:

The provisions of this §224.2 adopted to be effective February 19, 2003, 28 TexReg 1384

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§224.3. Purpose

The Texas Board of Nurse Examiners (BNE or Board) recognizes that changes in health care delivery have and will continue to influence the way nursing care is delivered. The Board believes that the registered nurse (RN) is in a unique position to develop and implement a nursing plan of care that incorporates a professional relationship between the RN and the client. The Board recognizes that the RN's responsibility may vary from that of the nurse providing care at the bedside of an acutely ill client to that of the nurse managing health care delivery in institutional and community settings. Assessment of the nursing needs of the client, the plan of nursing actions, implementation of the plan, and evaluation are essential components of professional nursing practice and are the responsibilities of the RN. The full utilization of the services of a RN may require delegation of selected nursing tasks to unlicensed personnel. The scope of delegation and the level of supervision by the RN may vary depending on the setting, the complexity of the task, the skills and experience of the unlicensed person, and the client's physical and mental status. The following sections govern the RN in delegating nursing tasks to unlicensed personnel across a variety of settings where nursing care services are delivered.

Source Note: The provisions of this §224.3 adopted to be effective February 19, 2003, 28 TexReg 1384

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§224.4. Definitions

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.

(1) Activities of daily living--Limited to the following activities: bathing, dressing, grooming, routine hair and skin care, meal preparation, feeding, exercising, toileting, transfer/ambulation, positioning, and range of motion.

(2) Client--the individual receiving care.

(3) Delegation--Authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. It does not include situations in which an unlicensed person is directly assisting a RN by carrying out nursing tasks in the presence of a RN.

(4) Unlicensed person--An individual, not licensed as a health care provider:

The provisions of this §224.4 adopted to be effective February 19, 2003, 28 TexReg 1384

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§224.5. RN Accountability for Delegated Tasks

(a) The RN's accountability to the BNE with respect to its taking disciplinary action against the RN's license is met when the delegating RN has complied with and can verify compliance with this chapter and specifically with §224.6 and §224.8(b)(1) of this title (relating to General Criteria for Delegation and Discretionary Delegation Tasks) as appropriate.

(b) This chapter does not change or apply to a RN's civil liability.

The provisions of this §224.5 adopted to be effective February 19, 2003, 28 TexReg 1384

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§224.6. General Criteria for Delegation

The following standards must be met before the RN delegates nursing tasks to unlicensed persons. These criteria apply to all instances of RN delegation. Additional criteria, if appropriate to the particular task being delegated, may also be found in §224.8(b)(1) of this title (relating to Discretionary Delegation Tasks).

(1) The RN must make an assessment of the client's nursing care needs. The RN should, when the client's status allows, consult with the client, and when appropriate the client's family and/or significant other(s), to identify the client's nursing needs prior to delegating nursing tasks.

(2) The nursing task must be one that a reasonable and prudent RN would find is within the scope of sound nursing judgment to delegate. The RN should consider the five rights of delegation: the right task, the right person to whom the delegation is made, the right circumstances, the right direction and communication by the RN, and the right supervision as determined by the RN.

(3) The nursing task must be one that, in the opinion of the delegating RN, can be properly and safely performed by the unlicensed person involved without jeopardizing the client's welfare.

(4) The nursing task must not require the unlicensed person to exercise professional nursing judgment; however, the unlicensed person may take any action that a reasonable, prudent non-health care professional would take in an emergency situation.

(5) The unlicensed person to whom the nursing task is delegated must be adequately identified. The identification may be by individual or, if appropriate, by training, education, and/or certification/permit of the unlicensed person.

(6) The RN shall have either instructed the unlicensed person in the delegated task, or verified the unlicensed person's competency to perform the nursing task. The verification of competence may be done by the RN making the decision to delegate or, if appropriate, by training, education, experience and/or certification/permit of the unlicensed person.

(7) The RN shall adequately supervise the performance of the delegated nursing task in accordance with the requirements of §224.7 of this title (relating to Supervision).

(8) If the delegation continues over time, the RN shall periodically evaluate the delegation of tasks. For example, the evaluation would be appropriate when the client's Nursing Care Plan is reviewed and revised. The RN's evaluation of a delegated task(s) will be incorporated into the client's Nursing Care Plan.

The provisions of this §224.6 adopted to be effective February 19, 2003, 28 TexReg 1384

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§224.7. Supervision

The registered professional nurse shall provide supervision of all nursing tasks delegated to unlicensed persons in accordance with the following conditions. These supervision criteria apply to all instances of RN delegation for clients with acute conditions or in acute care environments.

(1) The degree of supervision required shall be determined by the RN after an evaluation of appropriate factors involved including, but not limited to, the following:

(2) The RN or another equally qualified RN shall be available in person or by telecommunications, and shall make decisions about appropriate levels of supervision using the following examples as guidelines:

The provisions of this §224.7 adopted to be effective February 19, 2003, 28 TexReg 1384

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§224.8. Delegation of Tasks

(a) Tasks Which are Most Commonly Delegated. By way of example, and not in limitation, the following nursing tasks are ones that are most commonly the type of tasks within the scope of sound professional nursing practice to be considered for delegation, regardless of the setting, provided the delegation is in compliance with §224.6 of this title (relating to General Criteria for Delegation) and the level of supervision required is determined by the RN in accordance with §224.7 of this title (relating to Supervision):

(b) Discretionary Delegation Tasks.

(c) Nursing Tasks Prohibited from Delegation By way of example, and not in limitation, the following are nursing tasks that are not within the scope of sound professional nursing judgment to delegate:

The provisions of this §224.8 adopted to be effective February 19, 2003, 28 TexReg 1384

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§224.9. The Medication Aide Permit Holder

(a) A RN may delegate to medication aides the administration of medication to clients in long term care facilities and home health agencies if:

(b) The following tasks may not be delegated to the Medication Aide Permit Holder unless allowed and in compliance with Chapter 225 of this title (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions):

The provisions of this §224.9 adopted to be effective February 19, 2003, 28 TexReg 1384

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§224.10. Supervising Unlicensed Personnel Performing Tasks Delegated by Other Practitioners

(a) The following applies to the registered professional nurse who practices in a collegial relationship with another licensed practitioner who has delegated tasks to an unlicensed person over whom the RN has supervisory responsibilities. The RN's accountability to the BNE, with respect to its taking disciplinary action against the RN's license, is met if the RN:

(b) If the RN cannot verify the unlicensed person's capability to perform the delegated task, the RN must communicate this fact to the licensee who delegated the task.

The provisions of this §224.10 adopted to be effective February 19, 2003, 28 TexReg 1384

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§224.11. Application of Other Laws and Regulations

BNE §217.11(1) of this title (relating to Standards of Professional Nursing Practice) requires RNs to know and conform to all laws and regulations affecting their area of practice. The RN delegating tasks to an unlicensed person should be aware that, in addition to this chapter, various laws and regulations may apply to, including but not limited to, laws and regulations governing home and community support services agencies, Medicare and Medicaid regulations, and Medication Aide regulations. In situations where a RN's practice is governed by multiple laws and regulations that impose different requirements, the RN must comply with them all and if inconsistent, the most restrictive requirement(s) governs. For example, if one regulation requires an RN to make a supervisory visit every 14 days and another leaves it to the RN's professional judgment, the RN would have to visit at least every 14 days or more frequently, if that is what the RN's professional judgment indicated.

Source Note: The provisions of this §224.11 adopted to be effective February 19, 2003, 28 TexReg 1384

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CHAPTER 225. RN DELEGATION TO UNLICENSED PERSONNEL AND TASKS NOT REQUIRING DELEGATION IN INDEPENDENT LIVING ENVIRONMENTS FOR CLIENTS WITH STABLE AND PREDICTABLE CONDITIONS

§225.1. Application of Chapter

(a) This chapter applies only to situations meeting the following criteria:

(b) If the situation does not meet the above criteria in subsection (a) of this section, any delegation of nursing tasks by the RN to an unlicensed person must comply with BNE Chapter 224 of this title (relating to Delegation of Tasks Relating to Acute Conditions or Settings Other Than Independent Living Environments).

(c) Should a client develop an acute condition that is unstable or unpredictable, this chapter may still be applicable to tasks that relate solely to the client's stable and predictable condition(s) and not to the acute condition(s).

The provisions of this §225.1 adopted to be effective February 19, 2003, 28 TexReg 1386

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§225.2. Exclusions from Chapter

This chapter does not apply to:

(1) tasks performed for acute, unstable, or unpredictable conditions;

(2) settings where nursing services are continuously provided;

(3) tasks provided in compliance with Government Code §531.051(f) (relating to certain tasks performed for clients under certain state-funded programs not constituting practice of professional nursing);

(4) RNs who:

The provisions of this §225.2 adopted to be effective February 19, 2003, 28 TexReg 1386

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§225.3. Purpose

(a) The Texas Board of Nurse Examiners (BNE or Board) recognizes that public preference in the provision of health care services includes a greater opportunity for clients to share with the RN in the choice and control for delivery of services in the community based setting. The Board also appreciates that the provision of health care is dynamic in nature and continually evolving. As professional nurses, regardless of practice setting, RNs are obligated to assess the nursing needs of the client, develop a plan of nursing actions, implement this plan, and evaluate the outcome. These are essential components of RN practice that identify professional nursing as a process discipline. Professional nursing while inclusive of tasks is not focused on tasks but rather on interventions or client-centered actions initiated to assist the client in accomplishing the goals defined in the nursing care plan.

(b) In the independent living environment, RNs encounter clients across the spectrum of health to illness. The primary goal is to assist the choice of the client to achieve the most integrated setting/least restrictive environment throughout the life span. This is regularly accomplished, in part, through the assistance of unlicensed personnel who work with the client to complete a variety of tasks on a daily basis. Some tasks that are considered nursing tasks in the acute care setting are considered support services necessary to assist the client to maintain client health, and thus the highest degree of independence and quality of life possible, in the independent living environment.

(c) The purpose of this chapter is to provide guidance to RNs practicing in independent living environments in incorporating the use of unlicensed personnel to achieve optimal health benefits for the client. Clients in these settings have needs that may be categorized as activities of daily living (ADLs), health maintenance activities (HMAs), or nursing tasks. For some clients, ADLs and HMAs may be of a routine and supportive nature that minimizes the need for RN involvement.

(d) The RN shall collaborate with the client and/or the client's responsible adult in pursuit of the highest possible degree of independent living for the client. By adequately and accurately assessing the needs of the client in this setting, and considering the inter-related factors impacting the client's environment, the RN can effectively make decisions in utilizing unlicensed personnel to accomplish quality supportive services and care.

The provisions of this §225.3 adopted to be effective February 19, 2003, 28 TexReg 1386

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§225.4. Definitions

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.

(1) Activities of daily living (ADLs)--limited to the following activities: bathing, dressing, grooming, routine hair and skin care, meal preparation, feeding, exercising, toileting, transfer/ambulation, positioning, range of motion, and assistance with self administered medications. The term does not include more specific tasks defined as health maintenance activities under paragraph (8) of this section (relating to Health Maintenance Activities).

(2) Administration of Medications--removal of an individual/unit dose from a previously dispensed, properly labeled container; verifying it with the medication order; giving the correct medication and the correct dose to the proper client at the proper time by the proper route; and accurately recording the time and dose given.

(3) Assistance with self-administered medication--any needed ancillary aid provided to a client in the client's self-administered medication or treatment regimen, such as reminding a client to take a medication at the prescribed time, opening and closing a medication container, pouring a predetermined quantity of liquid to be ingested, returning a medication to the proper storage area, and assisting in reordering medications from a pharmacy.

(4) Client--the individual receiving care.

(5) Client's Responsible Adult--an individual, 18 or older, normally chosen by the client, who is willing and able to participate in decisions about the overall management of the client's health care and to fulfill any other responsibilities required under this chapter for care of the client. The term includes but is not limited to parent, foster parent, family member, significant other, or legal guardian.

(6) Delegation--authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. It does not include situations in which an unlicensed person is directly assisting a RN by carrying out nursing tasks in the presence of a RN.

(7) Functional Disability--a mental, cognitive, or physical disability that precludes the physical performance of self-care tasks, including health maintenance activities and ADLs.

(8) Health Maintenance Activities (HMAs)--limited to the following tasks that enable the client to remain in an independent living environment and that go beyond ADLs because of the higher skill level required to perform:

(9) Independent living environment--A client's individual residence which may include a home or homelike setting such as the client's home, an entity licensed or regulated by a state or federal agency or exempt from such licensure or regulation, (such as a group home, foster home, or assisted living facility), and includes where the client works, attends school, or engages in other community activities. The term does not include settings in which nursing services are continuously provided.

(10) Not Requiring Delegation--a determination by a RN that the performance of an ADL or HMA for a particular client does not constitute the practice of professional nursing based on criteria established by the Board/this chapter.

(11) Stable and predictable--a situation where the client's clinical and behavioral status is determined to be non-fluctuating and consistent. A stable/predictable condition involves long term health care needs which are not recuperative in nature and do not require the regularly scheduled presence of a registered nurse or licensed vocational nurse. Excluded by this definition are situations where the client's clinical and behavioral status is expected to change rapidly or in need of the continuous/continual assessment and evaluation of a registered nurse or licensed vocational nurse. The condition of clients receiving hospice care in an independent living environment where deterioration is predictable shall be deemed to be stable and predictable.

(12) Unlicensed person--an individual, not licensed as a health care provider:

The provisions of this §225.4 adopted to be effective February 19, 2003, 28 TexReg 1386

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§225.5. RN Accountability

(a) The RN is responsible for proper performance of the assessment required by §225.6 of this title (relating to RN Assessment of the Client) and for the RN's decisions made as a result of that assessment including determining that performance of a particular ADL or HMA for a particular client qualifies as not requiring delegation.

(b) The RN is not accountable for an unlicensed person's actual performance of ADLs or HMAs not requiring delegation.

(c) The RN's accountability to the BNE with respect to its taking disciplinary action against the RN's license is met when the RN can verify compliance with this chapter.

(d) This chapter does not change a RN's civil liability.

The provisions of this §225.5 adopted to be effective February 19, 2003, 28 TexReg 1386

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§225.6. RN Assessment of the Client

(a) The RN, in consultation with the client if 16 or older, and when appropriate the client's responsible adult, must make an assessment to determine if the care:

(b) In making this determination, the RN shall consider each of the following elements of assessment to develop an overall picture of the client's health status:

(c) While each element must be assessed, strength in one factor may compensate/offset a weakness in another factor. The assessment under this section does not require the RN to know either the specific unlicensed person who will perform the tasks or the specific qualifications of the unlicensed person who will perform the tasks, thus the RN is not required to determine the competency of the unlicensed person.

The provisions of this §225.6 adopted to be effective February 19, 2003, 28 TexReg 1386

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§225.7. Activities of Daily Living Not Requiring Delegation

(a) Activities of daily living (ADLs), as defined in this chapter, that do not fall within the practice of professional nursing may be performed by an unlicensed person in accordance with this section without being delegated. The Board has determined that in situations governed by this chapter ADLs do not fall within the practice of professional nursing when:

(b) If the above criteria cannot be met, an ADL may still be performed as a delegated task if it meets the criteria of §225.9 of this title (relating to Delegation Criteria).

The provisions of this §225.7 adopted to be effective February 19, 2003, 28 TexReg 1386

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§225.8. Health Maintenance Activities Not Requiring Delegation

(a) Health Maintenance Activities (HMAs), as defined in this chapter that do not fall within the practice of professional nursing, may be performed by an unlicensed person in accordance with this section without being delegated. The Board has determined that in situations governed by this chapter HMAs do not fall within the practice of professional nursing when:

(b) If the above criteria cannot be met, an HMA may still be performed as a delegated task if it meets the criteria of §225.9 of this title (relating to Delegation Criteria).

Source Note: The provisions of this §225.8 adopted to be effective February 19, 2003, 28 TexReg 1386

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§225.9. Delegation Criteria

(a) When determining whether to delegate a nursing task or those ADLs or HMAs requiring delegation, the RN, in addition to the assessment under §225.6 of this title (relating to RN Assessment of the Client), shall:

(b) The RN or another RN qualified to supervise the unlicensed person shall be available, in person or by telecommunications when the unlicensed person is performing the task.

(c) If the RN is employed, the employing entity must have a written policy acknowledging that the final decision to delegate shall be made by the RN in consultation with client or client's responsible adult.

The provisions of this §225.9 adopted to be effective February 19, 2003, 28 TexReg 1386

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§225.10. Tasks That May Be Delegated

A RN may delegate the following tasks unless the RN's assessment under §225.6 of this title (relating to RN Assessment of the Client) and §225.9 of this title (relating to Delegation Criteria) determines that the task is not a task a reasonable and prudent nurse would delegate. Tasks include:

The provisions of this §225.10 adopted to be effective February 19, 2003, 28 TexReg 1386

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§225.11. Delegation of Administration of Medications From Pill Reminder Container And Administration of Insulin

(a) In addition to complying with all previous criteria listed, when delegating the administration of oral unit dose medications from the client's daily pill reminder container, the RN must:

(b) In addition to complying with all previous criteria listed, when delegating administration of insulin subcutaneously, nasally, or via insulin pump the RN must:

The provisions of this §225.11 adopted to be effective February 19, 2003, 28 TexReg 1386

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§225.12. Tasks Prohibited From Delegation

The following are nursing tasks that are not within the scope of sound professional nursing judgment to delegate:

(1) physical, psychological, and social assessment, which requires professional nursing judgment, intervention, referral, or follow-up;

(2) formulation of the nursing care plan and evaluation of the client's response to the care rendered;

(3) specific tasks involved in the implementation of the care plan that require professional nursing judgment or intervention;

(4) the responsibility and accountability for client or client's responsible adult health teaching and health counseling which promotes client or client's responsible adult education and involves the client's responsible adult in accomplishing health goals; and

(5) the following tasks related to medication administration:

The provisions of this §225.12 adopted to be effective February 19, 2003, 28 TexReg 1386

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§225.13. Supervising Unlicensed Personnel Performing Tasks Delegated by Other Practitioners

(a) The following applies to the registered nurse who practices in a collegial relationship with another licensed practitioner who has delegated tasks to an unlicensed person over whom the RN has supervisory responsibilities. The RN's accountability to the BNE, with respect to its taking disciplinary action against the RN's license, is met if the RN:

(b) If the RN cannot verify the unlicensed person's capability to perform the delegated task, the RN must communicate this fact to the licensee who delegated the task.

The provisions of this §225.13 adopted to be effective February 19, 2003, 28 TexReg 1386

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§225.14. Application of Other Laws and Regulations

BNE §217.11(1) of this title (relating to Standards of Professional Nursing Practice) requires RNs to know and conform to all laws and regulations affecting their area of practice. The RN authorizing an unlicensed person to perform tasks in independent living environments should be aware to that, in addition to this chapter, various laws and regulations may apply including, but not limited to, laws and regulations governing home and community support service agencies and Medicare and Medicaid regulations. In situations where a RN's practice is governed by multiple laws and regulations that impose different requirements, the RN must comply with them all and if inconsistent, the most restrictive requirement(s) governs. For example, if one regulation requires a RN to make a supervisory visit every 14 days and another leaves it to the RN's professional judgment, the RN would have to visit at least every 14 days or more frequently, if that is what the RN's professional judgment indicated.

The provisions of this §225.14 adopted to be effective February 19, 2003, 28 TexReg 1386

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CHAPTER 226. PATIENT SAFETY PILOT PROGRAMS ON NURSE REPORTING SYSTEMS

§226.1. Patient Safety Pilot Programs on Nurse Reporting Systems

The purpose of this rule is to establish the procedures to assure that patient safety pilot programs conducted under Tex. Occ. Code §301.1606 are conducted in a manner consistent with the Board's role of protection of the public and are structured appropriately to evaluate the efficacy and effect on protection of the public of reporting systems designed to encourage identification of system errors.

The provisions of this §226.1 adopted to be effective December 29, 2003, 28 TexReg 11587

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§226.2. Initiation of Application and Approval of Patient Safety Pilot Programs

(a) Patient safety pilot programs under this rule may be conducted:

(b) If by application, the application must be submitted on an application form developed by the Board and comply with all conditions set by the Board for applying for a pilot.

(c) If by request for proposal, the submitted proposal must comply with all conditions set out in the request for proposal.

(d) The Board shall have the right to limit the number of pilots that are approved and to refuse to accept an application on the basis that the Board is not accepting new pilot program applications.

(e) If an application or proposal is submitted with incomplete information, the Board may:

(f) As a condition of approving an application or proposal, the Board may request changes be made in how the pilot is designed so as to better meet the purpose for pilots conducted under this rule as set out in §226.1.

The provisions of this §226.2 adopted to be effective December 29, 2003, 28 TexReg 11587

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§226.3. General Selection Criteria

(a) Applications will be approved based on the patient safety pilot program's ability to meet the purpose of the rules. Selection criteria shall be based on:

(b) Program Length Programs shall have a defined length, not to exceed two years. Programs may be extended upon approval of a written application submitted to the Board.

The provisions of this §226.3 adopted to be effective December 29, 2003, 28 TexReg 11587

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§226.4. Limited Exception to Mandatory Reporting Requirements

(a) In approving a pilot program, the Board may grant a program an exception to the mandatory reporting requirements of sections 301.401-301.409 or to a rule adopted under chapters 301 or 303 that relate to the practice of professional nursing, including education and reporting requirements for registered nurses.

(b) The Board may not grant the exception to:

(c) To be eligible for an exception to mandatory reporting Sections 301.401-301.409 or to a rule adopted under Chapter 301 or Chapter 303 and in addition to the General Selection Criteria of §226.3, a pilot program must provide a replacement methodology designed to promote patient safety consistent with the exception requested. The criteria shall also be based on the ability of the patient safety pilot program to provide a framework for addressing the following issues:

The provisions of this §226.4 adopted to be effective December 29, 2003, 28 TexReg 11587

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§226.5. Application and Review Process

(a) The Board shall establish a pilot program review panel to evaluate and make recommendations to the Board. The Board may solicit recommendations from an advisory committee or others on topics for patient safety pilot programs, on priorities of those programs, and on the administration of the application and review process.

(b) The Executive Director shall screen applications and proposals to determine if they meet the criteria of sections 226.3 and 226.4. The Executive Director shall forward qualified applications and proposals to the pilot program review panel for evaluation within 30 days of the closing date of the Request for Proposal or receipt of an application. Eliminated applicants shall be so notified by the Board.

(c) The Board shall select individuals qualified in the patient safety pilot program topic areas to serve on the review panel based on the content of proposals submitted. Individuals who serve on the review panel shall demonstrate appropriate credentials to evaluate patient safety pilot program applications. At a minimum, there will be one panel member from each of the following areas: a registered nurse, a doctoral level researcher, a human factors expert, and a consumer representative. Review panel members shall not evaluate any applications or proposals for which they have a conflict of interest. Review panel members serve without compensation at the discretion of the Board.

(d) The Board shall use the pilot program review panel to evaluate the quality of applications and proposals based on the sections 226.3 and 226.4 listed above. The pilot program review panel shall evaluate applications and proposals, and assign scores based on the sections 226.3 and 226.4 as listed above. All evaluations and scores of the review panel are final.

(e) The Executive Director shall use the review scores to recommend a prioritized list of applications and proposals to the Board for consideration. The decision-making process of the Board shall give weight to scores and must provide a statement of explanation if the Board does not agree with the peer review recommendations.

(f) Not withstanding any provision stated herein, no patient safety pilot program will be approved by the Board if it does not provide consumers adequate protection from registered nurses whose continued practice is a threat to public safety.

The provisions of this §226.5 adopted to be effective December 29, 2003, 28 TexReg 11587

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§226.6. Monitoring and Evaluating Patient Safety Pilot Programs

(a) All patient safety pilot programs shall be subject to monitoring and evaluating by the Board to ensure compliance with the criteria of this rule and obtain evidence that research goals are being pursued.

(b) The Board may require that the entity conducting a patient safety pilot program under this rule reimburse the Board for the cost of monitoring and evaluating the patient safety pilot program.

(c) The Board may contract with a third party to perform the monitoring and evaluating of patient safety pilot programs.

(d) The Board may arrange for a patient safety pilot program to directly reimburse a third party for monitoring and evaluating of a patient safety pilot program.

The provisions of this §226.6 adopted to be effective December 29, 2003, 28 TexReg 11587

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§226.7. Contract Discussions

(a) Contracts Following the approval of an application or proposal by the Board, the successful applicant must sign a contract issued by the Executive Director and based on the information contained in the application.

(b) Subcontracts With the prior written approval of the Board, the successful applicant may enter into third party contracts and subcontracts to conduct the patient safety pilot program.

(c) Cancellation or Suspension of Programs The Board has the right to reject all applications and proposals, and cancel any patient safety pilot program solicitations before a contract is signed. Breach of contract will result in termination of the patient safety pilot program.

(d) Requirements for Applications The full text of the administrative regulations and funding requirements for this patient safety pilot program are contained in the official Request for Proposal available on request from the Board.

The provisions of this §226.7 adopted to be effective December 29, 2003, 28 TexReg 11587

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CHAPTER 227. PILOT PROGRAMS FOR INNOVATIVE APPLICATIONS TO PROFESSIONAL NURSING EDUCATION

§227.1. Pilot Programs for Innovative Applications to Professional Nursing Education

The purpose of this rule is to establish the procedures to assure that pilot programs for innovative applications to professional nursing education conducted under Tex. Occ. Code §301.1605 are conducted in a manner consistent with the Board's role of protection of the public and are structured appropriately to evaluate the efficacy and effect on professional nursing students through the innovative application of professional nursing education programs.

The provisions of this §227.1 adopted to be effective July 4, 2005, 30 TexReg 3871

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§227.2. Initiation of Approval for Innovative Applications to Professional Nursing Education Programs

(a) Innovative Applications in Professional Nursing Education Programs under this rule may be conducted:

(b) If by application, the application must be submitted on an application form developed by the Board and comply with all conditions set by the Board for applying for a pilot.

(c) If by request for proposal, the submitted proposal must comply with all conditions set out in the request for proposal.

(d) The Board shall have the right to limit the number of pilots that are approved and to refuse to accept an application on the basis that the Board is not accepting new pilot program applications.

(e) If an application or proposal is submitted with incomplete information, the Board may:

(f) As a condition of approving an application or proposal, the Board may request changes be made in how the pilot is designed so as to better meet the purpose for pilots conducted under this rule as set out in §227.1.

The provisions of this §227.2 adopted to be effective July 4, 2005, 30 TexReg 3871

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§227.3. General Selection Criteria

(a) Applications will be approved based on the innovative application to a professional nursing program's ability to meet the purpose of the rules. Selection criteria shall be based on:

(b) Programs shall have a defined length, not to exceed two years. Programs may be extended upon approval of a written application submitted to the Board.

The provisions of this §227.3 adopted to be effective July 4, 2005, 30 TexReg 3871

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§227.4. Application and Review Process

(a) The Executive Director shall screen and evaluate the quality of applications and proposals to determine if they meet the criteria of §227.3. The Executive Director shall forward qualified applications and proposals to the Board for evaluation. Eliminated applicants shall be notified by the Board.

(b) The Board may approve the proposal, defer action on the proposal, or deny further consideration of the proposal.

(c) If the proposed pilot receives approval, the nursing education program must submit a written report of outcomes resulting from the innovative educational application within 90 days from completion of the pilot.

(d) If the nursing education program requests that the innovative professional nursing education pilot program become a permanent part of an approved nursing program, a proposal shall be submitted to the Board by the Director of the program after the final evaluation of the project has been submitted and no less then 60 days prior to a regularly scheduled meeting of the Board. The proposal shall include information outlined in Board guidelines.

The provisions of this §227.4 adopted to be effective July 4, 2005, 30 TexReg 3871

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§227.5. Monitoring and Evaluating Innovative Applications for Professional Nursing Education Programs

(a) All nursing education pilot programs shall be subject to monitoring and evaluation by the Board to ensure compliance with the criteria of this rule and obtain evidence that research goals are being pursued.

(b) The Board may require that the entity conducting a nursing education pilot program under this rule reimburse the Board for the cost of monitoring and evaluating the nursing education pilot program.

(c) The Board may contract with a third party to perform the monitoring and evaluation of nursing education pilot programs.

(d) The Board may arrange for a nursing education pilot program to directly reimburse a third party for the monitoring and evaluation of a nursing education pilot program.

The provisions of this §227.5 adopted to be effective July 4, 2005, 30 TexReg 3871

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§227.6. Contract Discussions

(a) Contracts following the approval of an application or proposal by the Board: the successful applicant must sign a contract issued by the Executive Director and based on the information contained in the application.

(b) Subcontracts with the prior written approval of the Board: the successful applicant may enter into third party contracts and subcontracts to conduct the nursing education pilot program.

(c) Cancellation or suspension of programs: the Board has the right to reject all applications and proposals, and cancel any nursing education pilot program solicitations before a contract is signed. Breach of contract will result in termination of the nursing education pilot program.

(d) Requirements for applications: the full text of the administrative regulations and funding requirements for this nursing education pilot program is contained in the official Request for Proposal available on request from the Board.

The provisions of this §227.6 adopted to be effective July 4, 2005, 30 TexReg 3871

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