Attachment 13 - IHSC CP and PA Agreement - template.pdf

Advanced Practice Provider Collaborative Practice and Prescriptive Authority Agreement

Advanced Practice Providers (APP) are health care professionals who have successfully completed a Nurse Practitioner (NP) or Physician Assistant (PA) training program and have a valid state license to practice medicine.

This document serves to establish the collaborative practice and prescriptive authority agreement for APPs within the ICE Health Service Corps (IHSC) who provide health care to ICE detainees. General practice APPs do not practice as licensed independent practitioners within the IHSC system. Health care for ICE detainees falls under the clinical supervision of physicians and is governed by IHSC policy and established standards of care.

The collaborative practice agreement (CPA) addresses parameters of collaborative practice that are mutually agreed upon by the APP and the collaborating physician. The prescriptive authority agreement (PAA) outlines parameters in which the APP will order and prescribe medications. The original CPA/PAA document should be maintained in the credential file of the APP.

The CPA and PAA are effective from the date of signature for one year or until:

1) The collaborating physician status changes, or

2) The certification or license of the APP or collaborating physician changes /expires or,

3) The APP or collaborating physician has a period of absence from duty greater than or equal to

180 days, or

4) The APP or collaborating physician provides a 30-day advance written notice to terminate the agreement.

This agreement is between (see also final page(s) for additional collaborating physicians):

Collaborating physician name:

Physician clinical practice area:

Physician state / territory of license:

Physician license number / expiration:

DEA license number/expiration:

APP name:

APP board certification / expiration:

APP state / territory of license:

APP license number / expiration:

DEA license number / expiration:

Facility name / address:

Name of APP: ___________________________________________________________ IHSC Form 910 FEB2019

IHSC COLLABORATIVE PRACTICE AGREEMENT

State of Practice: IHSC is a federal agency, however NPs and PAs are licensed by state regulatory boards. Separate documents or processes to establish collaborative practice may be required by individual states. The APP is expected to maintain current state licensure to practice medicine. Federal or contract physicians may provide clinical supervision to both contract-employed and federally-employed APPs.

Advanced Practice Provider: The APP is expected to maintain competency and practice within established standards and practice guidelines. The APP should ensure that all acts of health care delivery adhere to IHSC guidance and that practice is within the scope of the APP certification, state licensure, and DEA certification. The APP should provide emergency care to stabilize and prevent deterioration of a patient’s condition and shall review the emergency care provided with the collaborating physician. The APP agrees to seek consultation from the physician consistent with the standard of care of a reasonable and prudent APP and per IHSC guidance. When the physician is consulted by the APP, notation to that effect should be made in the patient health record and should be signed by both parties.

Collaborating Physician: The collaborating physician is expected to maintain competency, practice within established standards and practice guidelines, and oversee the clinical care provided by the APP. The collaborating physician or designee may provide clinical supervision in person, by telephone, or via other electronic means of communication.

Alternate Collaborating Physician: The collaborating physician should designate an alternate if he / she will not be available for consultation. If the APP is serving TDY, the physician at the TDY site should serve as the alternate collaborating physician for the duration of the TDY.

Malpractice Insurance: The contract-employed APP should obtain information about malpractice coverage from their employer. Federally-employed APPs including U.S. Public Health Service and civil service staff are covered under the Federal Tort Claims Act (FTCA). For more information about FTCA, access the following link: US Department of Homeland Security Office of General Counsel

Complaints against License: The collaborating physician and the APP agree to immediately notify the other if they encounter any disciplinary action that results in restricted privileges to provide medical care. The APP listed in this agreement has disclosed to the collaborating physician any prior disciplinary action by a licensing board as follows (mark n/a if not applicable):

Clinical Practice Guidelines: The APP and collaborating physician agree to adhere to guidance provided by IHSC policy, IHSC specialists, and IHSC clinical guidelines. In addition, the APP and physician may agree to use established clinical guidance from experts within the medical community. The Up To Date® program will be provided to all APPs and physicians for clinical reference.

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Name of APP: ___________________________________________________________ IHSC Form 910 FEB2019

Quality Assurance Plan: Collaboration between the physician and the APP to maintain the standards of patient care and compliance with IHSC guidance will be ongoing and will include:

1) Attendance at meetings and/or review of meeting minutes as required.

2) Attendance at live trainings and/or review of training materials as required.

3) Signature and/or co-signature of medical documentation as required.

4) Notation in the patient health record when the physician is consulted by the APP.

5) Participation in the continuous quality improvement program including annual peer review.

6) Record review: IHSC policy requires all health assessments, medical housing unit admissions, and discharge notes be routed for review and co-signature by the physician.

Core Scope of Practice: The core scope of practice is expected of all IHSC general practice APPs.

Supplemental clinical procedures will be approved based upon training or experience that meets the collaborating physician’s requirement(s) for competency.

• Triage and prioritize health care services to ensure the appropriate provision of care.

• Provide acute, chronic, and urgent care health services.

• Compile and review medical history and complete comprehensive health evaluation.

• Formulate diagnosis and treatment plan for management of outpatient health conditions.

• Initiate and follow up with specialty consultation and referrals.

• Order, interpret, and follow up laboratory and diagnostic testing appropriate to patient conditions.

• Collect specimens for pathological and cytological evaluation.

• Provide comprehensive education to patients about assessment and treatment plans.

• Provide preventative health services and education to include vaccinations.

• Provide emergency care to stabilize and prevent deterioration of a patient’s condition.

• Coordinate emergency transfers as indicated.

• Provide on-call telephone support services to the assigned facility.

• Provide emergency first aid attention to facility staff or visitors if indicated.

Core clinical areas: (cross through and initial any that do not apply):

Cardiovascular Otorhinolaryngology Neurologic

Pulmonary Ophthalmologic Musculoskeletal

Gastrointestinal Rheumatologic Dermatologic

Genitourinary Psychiatric Women’s Health

Gynecologic Endocrine Pediatric (if training/education allows)

Infectious Disease Hematologic

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Name of APP: ___________________________________________________________ IHSC Form 910 FEB2019

Core Clinical Procedures: (cross through and initial any that do not apply):

Physical Exam Genital exam Obtain fetal heart tones

Venipuncture (peripheral) Pelvic exam IV fluid and medications

Suturing/adhesive (simple) Digital rectal exam Administer local anesthetic

Stapling (simple) Ear lavage Ocular trauma management (simple)

Suture/staple removal Foley catheterization Foreign body removal (simple)

Temporary splinting Nail removal Wart treatment/cryotherapy

Emergency stabilization Nail trimming Wound management

Supplemental Clinical Procedures (initial what applies):

Procedure APP Request (APP initials)

Collaborating Physician (physician initials)

Approved Disapproved Pediatric: sterile bladder catheterization Pediatric: foreign body removal – nose Pediatric: foreign body removal – ear Pediatric: foreign body removal – eye Pediatric: sterile blood collection Aspiration of joints / cysts Injection of joints / cysts Anesthetic administration for digital block Excisional biopsy Incision and drainage of abscess Laceration repair: layered closure Single nare packing Anoscopy Thrombosed hemorrhoid management Intrauterine device (IUD) insertion Intrauterine device (IUD) removal Implanted subdermal contraception Other: Specify:

Name of APP: ___________________________________________________________ IHSC Form 910 FEB2019

IHSC PRESCRIPTIVE AUTHORITY AGREEMENT

The prescriptive authority agreement (PAA) serves to establish the authority for the ordering and prescribing of medications and treatments by the APP under the clinical supervision of the collaborating physician. The collaborating physician serves as the delegating physician for the PAA.

State of Practice: Separate documents or processes to establish prescriptive authority for the APP may be required by the APP’s state of licensure. The APP is expected to maintain current state licensure. Federal or contract physicians may provide prescriptive authority to both contract-employed and federally-employed APPs.

Advanced Practice Provider: The APP is expected to order and prescribe treatments using professional judgement commensurate with the education, experience, certification, and licensure of the APP. The APP should ensure that all acts of ordering or prescribing adhere to standards of care, IHSC guidance, and the IHSC formulary. The APP is expected to provide patient education about reasons for medication and any associated risks. The APP should seek consultation from the physician when clinically necessary and per IHSC guidance. When the physician is consulted by the APP, notation to that effect should be made in the patient health record and should be signed by both parties.

Collaborating Physician: The collaborating physician agrees to provide clinical supervision and consultation consistent with standards of care and will supervise the APP prescriptive authority commensurate with the APPs education, experience, certification, licensure, and the relationship between the APP and physician.

IHSC Guidance: The APP and collaborating physician agree to adhere to the IHSC clinical guidelines and prescriptions should follow the guidance in the IHSC Pharmaceutical Services Directive 09-02 and the IHSC Formulary. All guidance can be found here: IHSC POLICY.

CONTROLLED MEDICATION PRESCRIPTIVE AUTHORITY

IHSC APPs are authorized to order and prescribe controlled medications within the IHSC system for ICE detainees in accordance with the PAA. The Drug Enforcement Agency (DEA) sets federal requirements for the content and manner of prescriptions as well as registration requirements for individual prescribers. Federal APPs may be able to prescribe controlled medications under the facility’s pharmacy DEA license. State regulatory boards for APPs have various requirements and restrictions. It is the responsibility of the APP to understand and adhere to all DEA, state licensure, and IHSC requirements.

Controlled medications are not dispensed to ICE detainees and are administered under directly observed therapy. All orders and prescriptions for controlled medications should adhere to IHSC Clinical Guidelines, the IHSC Pharmaceutical Services Directive 09-02, and the IHSC Formulary located here: IHSC POLICY.

https://sp.ice.dhs.gov/sites/ihsc/SiteAssets/apps/policy/policy-app.aspx

Name of APP: ___________________________________________________________ IHSC Form 910 FEB2019

CONTROLLED MEDICATION PRESCRIPTIVE AUTHORITY (continued)

The 2015 U.S. Presidential Memorandum Addressing Prescription Drug Abuse and Heroin Use-mandates one-hour of safe opioid prescribing training once every three years. States may have additional required training. Documentation of training should be on file prior to the initiation of controlled medication prescriptive authority. Additional information can be found in the IHSC APP Orientation and Credentialing - Controlled Medication Prescribing Folder.

____ / ____ (Initials of APP/physician) - Date of safe opioid prescribing training: ___________

Initiation of treatment with controlled medications: IHSC APPs are authorized to initiate treatment with controlled medications. The APP must document appropriate justification for the use of controlled medications in the diagnosis and treatment plan. The treatment plan must be routed for subsequent review by the collaborating physician through the electronic health record (EHR).

Continuity of care / new intake: IHSC APPs are authorized to initiate controlled medications for purposes of continuity of care. The APP should substantiate prior treatment with controlled medications by obtaining and reviewing relevant patient medical records. The treatment plan must be routed for subsequent review by the collaborating physician through the EHR.

Written prescriptions: All prescriptions for controlled medications must be entered into the EHR and printed to create a written hard copy. The written prescription must be signed (wet-ink signature) by the APP and routed to the pharmacist. When the APP is not on-site, the APP must wet-ink sign the hard copy and fax or mail it to the pharmacist for dispensing.

Verbal Orders: IHSC APPs may initiate verbal orders for controlled medications when the APP is off-site, during after-hours, for continuity of care, and for emergencies, when delay may lead to suffering, injury, or death to the patient. All verbal orders must be documented in the EHR. Verbal orders must be limited to the amount and duration needed to treat the patient until the APP is able to issue a prescription that follows the process for controlled prescriptions. Verbal orders must follow guidance in the IHSC Pharmaceutical Services Directive 09-02, located here: IHSC POLICY.

Detoxification and Withdrawal: IHSC APPs are authorized to initiate treatment for detoxification and withdrawal in accordance with guidance in the IHSC Clinical Guidelines and IHSC document 03-13, Detainees with Substance Dependence and Abuse, located here: IHSC POLICY. All detoxifications are done under the supervision of a physician.

Renewal or Refills: The controlled medication prescription, including refills, may not exceed 90 days without authorization from the collaborating physician. The authorization for renewal must be obtained and documented through the EHR.

APPs are not authorized to initiate treatment with involuntary psychotropic medications.

https://sp.ice.dhs.gov/sites/ihsc/csu/MLPDocuments/Forms/AllItems.aspx?RootFolder=%2Fsites%2Fihsc%2Fcsu%2FMLPDocuments%2FORIENTATION%20and%20CREDENTIALING%20%2D%20IHSC%20ADVANCED%20PRACTICE%20PROVIDERS%2DFY2019%2FControlled%20Medication%20Prescribing&FolderCTID=0x01200099EFC67983C8B440909D50B4A470247A&View=%7BEC9EA4D7%2D2A62%2D42B3%2DA7FE%2DA5D02559F762%7D https://sp.ice.dhs.gov/sites/ihsc/csu/MLPDocuments/Forms/AllItems.aspx?RootFolder=%2Fsites%2Fihsc%2Fcsu%2FMLPDocuments%2FORIENTATION%20and%20CREDENTIALING%20%2D%20IHSC%20ADVANCED%20PRACTICE%20PROVIDERS%2DFY2019%2FControlled%20Medication%20Prescribing&FolderCTID=0x01200099EFC67983C8B440909D50B4A470247A&View=%7BEC9EA4D7%2D2A62%2D42B3%2DA7FE%2DA5D02559F762%7D

Name of APP: ___________________________________________________________ IHSC Form 910 FEB2019

CONTROLLED MEDICATION PRESCRIPTIVE AUTHORITY (continued)

Additional requirements per the collaborating physician:

____/ ___ (Initials- APP/physician) This prescriptive authority agreement (circle) WILL or WILL NOT include authority to order and prescribe controlled medications for ICE detainees within IHSC.

Collaborating physician statement: I hereby acknowledge my review and approval of the contents of this collaborative practice and prescriptive authority agreement. I have the certification and licensure as indicated in this document and have no knowledge of any pending adverse actions against my license.

Physician Signature / Printed Name Date

APP statement: I hereby acknowledge that I have no known reason to prohibit my ability to perform the duties outlined in this collaborative practice and prescriptive authority agreement. I have the education, certification, and licensure as indicated in this document and have no knowledge of any pending adverse actions against my license.

Advanced Practice Provider Signature / Printed Name Date

Additional or alternate collaborating physician:

Physician name:

Physician clinical practice area:

Physician state / territory of license:

Physician license number / expiration:

DEA license number / expiration:

Collaborating physician statement: I hereby acknowledge my review and approval of the contents of this collaborative practice and prescriptive authority agreement. I have the certification and licensure as indicated in this document and have no knowledge of any pending adverse actions against my license.

Physician Signature / Printed Name Date

APP statement: I hereby acknowledge that I have no known reason to prohibit my ability to perform the duties outlined in this collaborative practice and prescriptive authority agreement. I have the education, certification, and licensure as indicated in this document and have no knowledge of any pending adverse actions against my license.

Advanced Practice Provider Signature / Printed Name Date

Name of APP: ___________________________________________________________ IHSC Form 910 FEB2019

Additional or alternate collaborating physician:

Physician name:

Physician clinical practice area:

Physician state / territory of license:

Physician license number / expiration:

DEA license number / expiration:

Collaborating physician statement: I hereby acknowledge my review and approval of the contents of this collaborative practice and prescriptive authority agreement. I have the certification and licensure as indicated in this document and have no knowledge of any pending adverse actions against my license.

Physician Signature / Printed Name Date

APP statement: I hereby acknowledge that I have no known reason to prohibit my ability to perform the duties outlined in this collaborative practice and prescriptive authority agreement. I have the education, certification, and licensure as indicated in this document and have no knowledge of any pending adverse actions against my license.

Advanced Practice Provider Signature / Printed Name Date

Physician clinical practice area:

Physician state / territory of license:

Physician license number / expiration:

DEA license number / expiration:

Collaborating physician statement: I hereby acknowledge my review and approval of the contents of this collaborative practice and prescriptive authority agreement. I have the certification and licensure as indicated in this document and have no knowledge of any pending adverse actions against my license.

Physician Signature / Printed Name Date education, certification, and licensure as indicated in this document and have no knowledge of any pending adverse actions against my license.

Advanced Practice Provider Signature / Printed Name Date

Name of APP: ___________________________________________________________ IHSC Form 910 FEB2019

Physician clinical practice area:

Physician state / territory of license:

Physician license number / expiration:

DEA license number / expiration:

Collaborating physician statement: I hereby acknowledge my review and approval of the contents of this collaborative practice and prescriptive authority agreement. I have the certification and licensure as indicated in this document and have no knowledge of any pending adverse actions against my license.

Physician Signature / Printed Name Date education, certification, and licensure as indicated in this document and have no knowledge of any pending adverse actions against my license.

Advanced Practice Provider Signature / Printed Name Date

Physician clinical practice area:

Physician state / territory of license:

Physician license number / expiration:

DEA license number / expiration:

Collaborating physician statement: I hereby acknowledge my review and approval of the contents of this collaborative practice and prescriptive authority agreement. I have the certification and licensure as indicated in this document and have no knowledge of any pending adverse actions against my license.

Physician Signature / Printed Name Date education, certification, and licensure as indicated in this document and have no knowledge of any pending adverse actions against my license.

Advanced Practice Provider Signature / Printed Name Date