81_FR_33256 81 FR 33155 - Advanced Practice Registered Nurses

81 FR 33155 - Advanced Practice Registered Nurses

DEPARTMENT OF VETERANS AFFAIRS

Federal Register Volume 81, Issue 101 (May 25, 2016)

Page Range33155-33160
FR Document2016-12338

The Department of Veterans Affairs (VA) is proposing to amend its medical regulations to permit full practice authority of all VA advanced practice registered nurses (APRNs) when they are acting within the scope of their VA employment. This rulemaking would increase veterans' access to VA health care by expanding the pool of qualified health care professionals who are authorized to provide primary health care and other related health care services to the full extent of their education, training, and certification, without the clinical supervision of physicians. This rule would permit VA to use its health care resources more effectively and in a manner that is consistent with the role of APRNs in the non-VA health care sector, while maintaining the patient-centered, safe, high-quality health care that veterans receive from VA. The proposed rulemaking would establish additional professional qualifications an individual must possess to be appointed as an APRN within VA. The proposed rulemaking would subdivide APRN's into four separate categories that include certified nurse practitioner, certified registered nurse anesthetist, clinical nurse specialist, and certified nurse-midwife. The proposed rulemaking would also provide the criteria under which VA may grant full practice authority to an APRN, and define the scope of full practice authority for each category of APRN. VA intends that the services to be provided by an APRN in one of the four APRN roles would be consistent with the nursing profession's standards of practice for such roles.

Federal Register, Volume 81 Issue 101 (Wednesday, May 25, 2016)
[Federal Register Volume 81, Number 101 (Wednesday, May 25, 2016)]
[Proposed Rules]
[Pages 33155-33160]
From the Federal Register Online  [www.thefederalregister.org]
[FR Doc No: 2016-12338]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 17

RIN 2900-AP44


Advanced Practice Registered Nurses

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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SUMMARY: The Department of Veterans Affairs (VA) is proposing to amend 
its medical regulations to permit full practice authority of all VA 
advanced practice registered nurses (APRNs) when they are acting within 
the scope of their VA employment. This rulemaking would increase 
veterans' access to VA health care by expanding the pool of qualified 
health care professionals who are authorized to provide primary health 
care and other related health care services to the full extent of their 
education, training, and certification, without the clinical 
supervision of physicians. This rule would permit VA to use its health 
care resources more effectively and in a manner that is consistent with 
the role of APRNs in the non-VA health care sector, while maintaining 
the patient-centered, safe, high-quality health care that veterans 
receive from VA. The proposed rulemaking would establish additional 
professional qualifications an individual must possess to be appointed 
as an APRN within VA. The proposed rulemaking would subdivide APRN's 
into four separate categories that include certified nurse 
practitioner, certified registered nurse anesthetist, clinical nurse 
specialist, and certified nurse-midwife. The proposed rulemaking would 
also provide the criteria under which VA may grant full practice 
authority to an APRN, and define the scope of full practice authority 
for each category of APRN. VA intends that the services to be provided 
by an APRN in one of the four APRN roles would be consistent with the 
nursing profession's standards of practice for such roles.

DATES: Comments must be received by VA on or before July 25, 2016.

ADDRESSES: Written comments may be submitted: Through http://www.Regulations.gov; by mail or hand-delivery to Director, Regulations 
Management (02REG), Department of Veterans Affairs, 810 Vermont Avenue 
NW., Room 1068, Washington, DC 20420; by fax to (202) 273-9026. 
Comments should indicate that they are submitted in response to ``RIN 
2900-AP44-Advanced Practice Registered Nurses.'' Copies of comments 
received will be available for public inspection in the Office of 
Regulation Policy and Management, Room 1068, between the hours of 8 
a.m. and 4:30 p.m., Monday through Friday (except holidays). Call (202) 
461-4902 for an appointment. (This is not a toll-free number.) In 
addition, during the comment period, comments may be viewed online 
through the Federal Docket Management System (FDMS) at http://www.Regulations.gov.

FOR FURTHER INFORMATION CONTACT: Dr. Penny Kaye Jensen, Liaison for 
National APRN Practice, 810 Vermont Ave. NW., Washington, DC 20420; 
(202) 461-6700. (This is not a toll-free number.)

SUPPLEMENTARY INFORMATION: Section 7301 of title 38 United States Code 
(U.S.C.) establishes the Veterans Health Administration (VHA) within 
VA, and establishes that its primary function is to ``provide a 
complete medical and hospital service for the medical care and 
treatment of veterans, as provided in this title and in regulations 
prescribed by the Secretary pursuant to this title.'' 38 U.S.C. 
7301(b). In carrying out this function, VHA has an obligation to ensure 
that patient care is appropriate and safe and its health care 
practitioners meet or exceed generally-accepted professional standards 
for patient care. The Secretary is responsible for the proper execution 
and administration of all laws administered by the Department and for 
the control, direction, and management of the Department, to include 
agency personnel and management matters. See 38 U.S.C. 303. To enable 
the Secretary to direct, control and manage VA, Congress authorized the 
Secretary ``to prescribe all rules and regulations which are necessary 
or appropriate to carry out the laws administered by the Department and 
are consistent with those laws.'' 38 U.S.C. 501(a). The Under Secretary 
for Health is directly responsible to the Secretary for the operation 
of VHA (38 U.S.C. 305(b)). Unless specifically otherwise provided, the 
Under Secretary for Health, as the head of VHA, is authorized to 
``prescribe all regulations necessary to the administration of the 
Veterans Health Administration,'' subject to the approval of the 
Secretary. 38 U.S.C. 7304. To allow VA to carry out its medical care 
mission, Congress also established a comprehensive personnel system for 
certain medical employees in VHA, independent of the civil service 
rules. See Chapters 73 and 74 of title 38, U.S.C. The Secretary was 
granted express statutory authority to establish the qualifications for 
VA's healthcare practitioners, determine the hours and conditions of 
employment, take disciplinary action against employees, and otherwise 
regulate the professional activities of those individuals. 38 U.S.C. 
7401-7464. As an integrated Federal health care system with the 
responsibility to provide comprehensive care under 38 U.S.C. 7301, it 
is essential that VHA wisely manage its resources and fully utilize the 
skills of its health care providers to the full extent of their 
education, training, and certification. By permitting APRNs throughout 
the VHA system a way to achieve full practice authority in order to 
provide advanced nursing services to the full extent of their 
professional competence, VHA would further its statutory mandate to 
provide quality health care to our nation's veterans. This proposed 
regulatory change to nursing policy would permit APRNs to practice to 
the full extent of their education, training and certification, without 
the clinical supervision or mandatory collaboration of physicians. 
Standardization of APRN full practice authority, without regard for 
individual State practice regulations, would help to ensure a 
consistent continuum of health care across VHA by decreasing the 
variability in APRN practice that currently exists across VHA as a 
result of disparate State practice regulations. As of March 7, 2016 
CRNAs have full practice authority in 17 states, while CNPs have full 
practice authority in almost 50% of the nation, which includes 21 
states and the District of Columbia.
    It would also aid in fully maximizing VHA APRN staff capabilities, 
which would increase VA's capacity to provide timely, efficient, and 
effective primary care services, as well as other services. This would 
increase veteran access to needed VA health care, particularly in 
medically-underserved areas, as well as decrease the amount of time 
veterans spend waiting for patient appointments. In addition, 
standardizing APRN practice authority would enable veterans, their 
families, and caregivers to understand more readily the health care 
services that VA APRNs are authorized to provide. This preemptive rule 
would increase access to care and reduce the wait times for VA 
appointments utilizing the current workforce already in place.

[[Page 33156]]

    To ensure that VA would have available highly qualified medical 
personnel, Congress mandated the basic qualifications for certain 
health care positions, including registered nurses. Sections 7401 
through 7464 of title 38, U.S.C., grant VA authority to regulate the 
professional activities of such personnel. To be eligible for 
appointment as a VA employee in a health care position covered by 
section 7402(b) (other than Director), of title 38, U.S.C., a person 
must, among other requirements, be licensed, registered or certified to 
practice their profession in a State. The standards prescribed in 
section 7402(b) establish only the basic qualifications necessary 
``[t]o be eligible for appointment'' and do not limit the Secretary or 
Under Secretary for Health from establishing other qualifications for 
appointment, or additional rules governing such personnel. In 
particular, 38 U.S.C. 7403(a)(1) provides that appointments under 
Chapter 74 ``may be made only after qualifications have been 
established in accordance with regulations prescribed by the Secretary, 
without regard to civil-service requirements.'' In addition, 38 U.S.C. 
7421(a) directs that, ``[n]otwithstanding any law, Executive order, or 
regulation, the Secretary shall prescribe by regulation the hours and 
conditions of employment and leaves of absence of employees appointed 
under any provision of [chapter 74] [in the specifically numerated 
positions] in the Veterans Health Administration'' (including 
registered nurses). As the head of VHA, the Under Secretary for Health 
has the duty to ``prescribe all regulations necessary to the 
administration of the Veterans Health Administration,'' subject to 
approval by the Secretary. 38 U.S.C. 7304; see also 38 U.S.C. 501. 
Pursuant to this authority, the Under Secretary for Health is 
authorized to establish the qualifications and clinical practice 
standards of VHA's nursing personnel and to otherwise regulate their 
professional conduct.
    To continue to provide high quality health care to veterans, VA is 
proposing to amend its regulations to allow APRNs to practice to the 
full extent of their education, training, and certification, regardless 
of individual State restrictions that limit such full practice 
authority, except for applicable State restrictions on the authority to 
prescribe and administer controlled substances, when such APRNs are 
acting within the scope of their VA employment. The proposed rule would 
use the term ``full practice authority'' to refer to the APRN's 
authority to provide advanced nursing services without the clinical 
oversight of a physician when that APRN is working within the scope of 
their VA employment. Such full practice authority would be granted by 
VA upon demonstrating that the established regulatory criteria are met. 
In addition, full practice authority would be granted appropriate to 
the clinical service setting.
    This proposed rule is consistent with the recommendation of the 
Institute of Medicine (IOM) of the National Academy of Sciences to 
remove scope-of-practice barriers. Specifically, the 2010 IOM report, 
``The Future of Nursing: Leading Change Advancing Health,'' (IOM 
Report) available at http://iom.nationalacademies.org/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx, recommended 
that ``[a]dvanced practice registered nurses (APRNs) should be able to 
practice to the full extent of their education and training.'' Id. at 
9. More generally, the report stated that ``[r]estrictions on scope of 
practice and professional tensions have undermined the nursing 
profession's ability to provide and improve both general and advanced 
care'' and asserted that ``[p]roducing a health care system that 
delivers the right care--quality care that is patient centered, 
accessible, evidence based, and sustainable--at the right time will 
require transforming the work environment, scope of practice, 
education, and numbers and composition of America's nurses.'' Id. at 
26. In addition, the proposed rule is consistent with the National 
Council of State Boards of Nursing (NCSBN) Consensus Model, as 
discussed in more detail later in this rulemaking. Significantly, many 
States already permit full practice authority of APRNs or are in the 
process of doing so. Under the proposed rulemaking, APRNs would not be 
authorized to replace or act as physicians or to provide any health 
care services that are beyond their clinical education, training, and 
national certification. The proposed rule would limit an APRN's full 
practice authority to practice within the scope of their VA employment, 
and any APRN practice outside of VA employment would remain subject to 
applicable State laws, in the same manner as any other licensed VA 
practitioner in their private practice.
    In this rulemaking, VA is proposing to exercise Federal preemption 
of State nursing licensure laws to the extent such State laws conflict 
with the full practice authority granted to VA APRNs while acting 
within the scope of their VA employment. Preemption would be the 
minimum necessary action for VA to allow APRNs full practice authority. 
It would be impractical for VA to lobby to each State that does not 
allow full practice authority to APRNs to change their laws regarding 
full practice authority. This process would be costly and time 
consuming for VA and would not guarantee the desired result of full 
practice authority to all APRNs.

Section-by-Section Analysis of the Proposed Rule

17.415 Full Practice Authority for Advanced Practice Registered Nurses

    The general qualifications for a person to be appointed as a VA 
nurse are found in 38 U.S.C. 7402(b)(3), which requires that a person 
must have successfully completed a full course of nursing in a 
recognized school of nursing, as well as be registered as a graduate 
nurse in a State. VA interprets ``a recognized school of nursing'' to 
mean a school of professional nursing approved by the appropriate State 
agency and accredited by the National League for Nursing Accrediting 
Commission (NLNAC) or the Commission on Collegiate Nursing Education 
(CCNE); the completion of coursework equivalent to a nursing degree in 
a MSN Bridge Program that qualifies for professional nursing 
registration; or a foreign school of professional nursing that enables 
the graduate to obtain current, full, active and unrestricted 
registration. VA Handbook 5005/27, Part II, Appendix G6, paragraph 2, 
Section B.a(2). VA interprets ``registered as a graduate nurse in a 
state'' to mean a current, full, active and unrestricted licensure, 
registration or certification as a graduate professional nurse in a 
State, Territory, or Commonwealth (i.e., Puerto Rico) of the U.S. or in 
the District of Columbia (hereinafter ``licensure''). Id. Pursuant to 
the authorities in 38 U.S.C. 7401 through 7464 and VA's rulemaking 
authorities at 38 U.S.C. 501 and 7304, VA is proposing a new Sec.  
17.415(a), which would define additional qualifications a registered 
nurse must possess to be appointed to one of four (4) APRN roles, i.e., 
Certified Nurse practitioner (CNP), Certified Registered Nurse 
Anesthetist (CRNA), Clinical Nurse Specialist (CNS), or Certified 
Nurse-Midwife (CNM). The proposed rule would require an advanced 
practice registered nurse to have successfully completed a nationally-
accredited, graduate-level educational program that prepares the 
advanced practice registered nurse in one of the four APRN roles; and 
to possess, and maintain, national certification and State licensure in 
that APRN role. These additional

[[Page 33157]]

qualifications are derived from criteria set forth in the IOM Report, 
and the National Council of State Boards of Nursing Consensus Model for 
APRN Regulation: Licensure, Accreditation, Certification & Education) 
Regulation, July 2008 (the APRN Consensus Model), which VA finds to be 
the criteria most widely accepted by State boards of nursing and the 
nursing community as necessary to practice as an APRN. Under the 
proposed rule, APRNs who meet these additional qualifications may be 
granted full practice authority within VA in one of the four recognized 
APRN roles.
    Proposed Sec.  17.415(a)(1) would require an APRN to have 
successfully completed an accredited graduate-level educational program 
in one of the four distinct APRN roles. The Consensus Model defines 
these roles as CNP, CRNA, CNS, and CNM. These APRN roles are widely 
known and accepted by State boards of nursing and the nursing 
community. VA currently does not employ CNMs; however, the proposed 
rule includes CNMs in the event that VA has the need to hire CNMs in 
the future.
    Proposed Sec.  17.415(a)(2) would require an APRN to have passed a 
national certification examination that measures the APRN's knowledge, 
skills and experience demonstrated by the achievement of standards 
identified by the profession in one of the four APRN roles established 
in proposed Sec.  17.415(a)(1). Public and private sector health care 
employers, State boards of nursing, and the nursing community rely on 
national certification through an examination process as the standard, 
which conveys adequate APRN knowledge, and VA's regulation would adopt 
the same standard.
    Proposed Sec.  17.415(a)(3) would require an APRN to possess a 
license from a State licensing board in one of the four recognized APRN 
roles. Proposed Sec.  17.415(a)(4) would require an APRN to maintain 
both the national certification and licensure required in proposed 
paragraphs (a)(2) and (3) of Sec.  17.415.
    In total, proposed paragraphs (a)(1) through (4) of Sec.  17.415 
would establish qualifications for employment within VA as a CNP, CRNA, 
CNS and CNM. These qualifications would ensure that VA APRNs possess 
and maintain the education, knowledge, national certification and State 
licensure necessary for VA employment in one of the four recognized 
APRN roles. APRNs who meet these qualifications would be granted full 
practice authority within VA in one of the four recognized APRN roles.
    Proposed Sec.  17.415(b) would define ``full practice authority'' 
to mean that an APRN working within the scope of VA employment would be 
authorized to provide the services described in proposed Sec.  
17.415(d), without the clinical oversight of a physician, regardless of 
State or local law restrictions on that authority. Further, any APRN 
practice established outside VA employment would be subject to 
applicable State law, in the same manner as private practice by any 
other licensed VA provider.
    Proposed Sec.  17.415(c) would establish the criteria by which VA 
may grant full practice authority to an APRN. Proposed paragraph 
(c)(1), would require a VA medical facility to verify that the APRN 
meets the requirements established in proposed Sec.  17.415(a). 
Proposed paragraph (c)(2) would require VA to confirm that the APRN has 
demonstrated the knowledge and skills necessary to provide the services 
described in proposed Sec.  17.415(d) without the clinical oversight of 
a physician, and is thus qualified to be privileged for such scope of 
practice. Proposed Sec.  17.415(c)(1) and (2) together would clarify 
that the VA processes for credentialing and privileging of licensed 
independent health care providers would apply to VA APRNs with full 
practice authority. VA anticipates that the granting of full-practice 
authority under proposed Sec.  17.415(c) would be implemented through 
formal VHA guidance issuances.
    Proposed Sec.  17.415(d)(1) would describe the role-specific 
services that a VA APRN would be authorized to perform under their full 
practice authority. This authority would be without regard to state 
licensure restrictions, except as provided in proposed paragraph 
(d)(2), which would defer to State licensure restrictions on a VA 
APRN's authority to prescribe, or administer controlled substances. We 
emphasize that full practice authority for an APRN in this rulemaking 
would apply only to services provided by an APRN when working within 
the scope of their VA employment, as required by proposed Sec.  
17.415(b). Additionally, all full practice authority of APRNs in 
proposed Sec.  17.415(d)(1) would be under approved privileges by, and 
within the available resources of, a VA medical facility, as required 
by proposed Sec.  17.415(c). VA intends that the services to be 
provided by an APRN in one of the four APRN roles would be consistent 
with the nursing profession's standards of practice for such roles.
    In proposed Sec.  17.415(d)(1)(i), a CNP would have full practice 
authority to provide the following services: Comprehensive histories, 
physical examinations and other health assessment and screening 
activities; diagnose, treat, and manage patients with acute and chronic 
illnesses and diseases; order, perform, supervise, and interpret 
laboratory and imaging studies; prescribe medication and durable 
medical equipment and; make appropriate referrals for patients and 
families; and aid in health promotion, disease prevention, health 
education, and counseling as well as the diagnosis and management of 
acute and chronic diseases.
    In proposed Sec.  17.415(d)(1)(ii), a CRNA would have full practice 
authority to provide a patient's anesthesia care and anesthesia related 
care, to include planning and initiating anesthetic techniques 
(general, regional, local) and sedation, providing post-anesthesia 
evaluation and discharge; ordering and evaluating diagnostic tests; 
requesting consultations; performing point-of-care testing; and 
responding to emergency situations for airway management.
    In proposed Sec.  17.415(d)(1)(iii), a CNS would have full practice 
authority to provide diagnosis and treatment of health or illness 
states, disease management, health promotion, and prevention of illness 
and risk behaviors among individuals, families, groups, and communities 
within their scope of practice.
    Lastly, in proposed Sec.  17.415(d)(1)(iv), a CNM would have full 
practice authority to provide a full range of primary health care 
services to women veterans, including gynecologic care, family planning 
service, preconception care (care that women veterans receive before 
becoming pregnant, including reducing the risk of birth defects and 
other problems such as the treatment of diabetes and high blood 
pressure), prenatal and postpartum care, childbirth, and care of a 
newborn. We note that the pregnancy and delivery services described 
above, as well as the newborn care services, would be subject to the 
limitations established in 38 CFR 17.38(a)(1)(xiii) and (xiv), 
respectively. We also note that authorized CNM services would include 
treating the partner of the female patient for sexually transmitted 
infection and reproductive health, if the partner is enrolled in the VA 
healthcare system or not required to enroll to receive VA services. We 
would include the services of a CNM in this rulemaking in anticipation 
that VA would hire CNMs at a future date to improve access to health 
care for the increasing number of female veterans.
    Proposed Sec.  17.415(d)(2) would expressly limit full practice 
authority.

[[Page 33158]]

Congress has specifically required reliance on a specific State law 
under the Controlled Substance Act (CSA). Specifically, proposed Sec.  
17.415(a)(2) would provide that full practice authority within VA is 
subject to State licensure law with regard to the authority of an APRN 
to prescribe, or administer controlled substances, and to any other 
limitations on the provision of VA care set forth in applicable Federal 
law and policy. Regarding the full practice authority limitations for 
controlled substances, the CSA, 21 U.S.C. 801 et seq., and implementing 
regulations in 21 CFR part 1300, make State licensure authority to 
prescribe, or administer controlled substances a prerequisite for 
authority under the CSA to prescribe, or administer controlled 
substances. See 21 U.S.C. 802(21) (providing that a practitioner must 
be ``licensed, registered, or otherwise permitted, by the United States 
or the jurisdiction in which he practices or does research, to 
distribute, conduct research with respect to, administer, or use in 
teaching or chemical analysis, a controlled substance in the course of 
professional practice or research.''); See also 21 CFR 1306.03(a) 
(stating that a prescription for a controlled substance may be issued 
only by an individual practitioner who is: (1) Authorized to prescribe 
controlled substances by the jurisdiction in which he is licensed to 
practice his profession and (2) either registered or exempted from 
registration pursuant to Sec. Sec.  1301.22(c) and 1301.23.). Proposed 
Sec.  17.415(d)(2) also would make the full practice authority of an 
APRN subject to any other limitations on the provision of VA care set 
forth in Federal law or policy.
    Proposed Sec.  17.415(e) would expressly state the intended 
preemptive effect of proposed Sec.  17.415, to ensure it is clear that 
conflicting State and local laws related to the practice of APRNs would 
have no force or effect when such APRNs are working within the scope of 
their VA employment. In circumstances where there is a conflict between 
Federal and State Law, Federal law prevails in accordance with Article 
VI, clause 2, of the U.S. Constitution (Supremacy Clause). It is a 
well-established principle of constitutional law that Federal law is 
supreme, and States may not regulate or control the lawful actions of 
the Federal Government, absent Congressional consent. Therefore, where 
there is conflict between State law and Federal law with regard to full 
practice authority of APRNs working within the scope of their federal 
VA employment, this regulation would control. Accordingly, State 
disciplinary actions that would penalize, or otherwise interfere with, 
an APRN's full practice authority in the performance of their official 
VA duties, would likewise be effectively preempted. However, where 
there is no conflict between this regulation and State law, the State 
would retain authority to impose State regulations on its APRN 
licensees and take disciplinary action for any violations. We emphasize 
that this preemptive effect would only pertain to APRNs when they are 
acting within the scope of their federal VA employment; this rule would 
not have any effect on individual State efforts to either permit or 
restrict full practice authority for APRNs who are not working within a 
VA scope of employment.
    The Indian Health Service already grants full practice authority to 
APRNs. See Part 4, Chapter 3, Section 11, ``Advanced Practice Nurses,'' 
Indian Health Manual. In the Military Health System, the Services 
employ APRNs, which includes Nurse Midwives, Nurse Practitioners, and 
Nurse Anesthetists, in independent practice without oversight from 
physicians. They are privileged in their roles as APRNs and can adjust 
their scope practice (level of care) through privileging as granted by 
a committee of physicians and the military treatment facility 
commander. Nurse Practitioners specifically have an assigned group of 
patients for which they are responsible. Therefore, we do not 
anticipate that the proposed changes in this rulemaking would be 
completely novel or unexpected to the general public or other Federal 
entities that provide health care services to beneficiaries.

Executive Order 13132, Federalism

    Section 4 of Executive Order 13132 (titled ``Federalism'') requires 
an agency that is publishing a regulation that preempts State law to 
follow certain procedures. Section 4(b) of the Executive Order requires 
agencies to ``construe any authorization in the statute for the 
issuance of regulations as authorizing preemption of State law by 
rulemaking only when the exercise of State authority directly conflicts 
with the exercise of Federal authority under the Federal statute or 
there is clear evidence to conclude that the Congress intended the 
agency to have the authority to preempt State law.'' Section 4(d) of 
the Executive Order requires that when an agency proposes to act 
through rulemaking to preempt State law, ``the agency shall consult, to 
the extent practicable, with appropriate State and local officials in 
an effort to avoid such a conflict.'' Section 4(e) of the Executive 
Order requires that when an agency proposes to act through rulemaking 
to preempt State law, ``the agency shall provide all affected State and 
local officials notice and an opportunity for appropriate participation 
in the proceedings.''
    Section 6(c) of Executive Order 13132 states that ``no agency shall 
promulgate any regulation that has federalism implications and that 
preempts State law, unless the agency, prior to the formal promulgation 
of the regulation, (1) consulted with State and local officials early 
in the process of developing the proposed regulation; (2) in a 
separately identified portion of the preamble to the regulation as it 
is to be issued in the Federal Register, provides to the Director of 
the Office of Management and Budget a federalism summary impact 
statement, which consists of a description of the extent of the 
agency's prior consultation with State and local officials, a summary 
of the nature of their concerns and the agency's position supporting 
the need to issue the regulation, and a statement of the extent to 
which the concerns of State and local officials have been met; and (3) 
makes available to the Director of the Office of Management and Budget 
any written communications submitted to the agency by State and local 
officials.''
    Because this regulation would address preemption of certain State 
laws, VA conducted prior consultation with State officials in 
compliance with Executive Order 13132. VA sent a letter to the National 
Council of State Boards of Nursing to state VA's intent to allow full 
practice authority to VA APRNs and for the National Council of State 
Boards of Nursing to notify every State Board of Nursing of VA's intent 
and to seek feedback from such Boards of Nursing.
    In addition, VA solicited comments and input from State Boards of 
Nursing, through their representative national organization, the 
National Council of State Boards of Nursing (NCSBN). In response to its 
request for comments, VA received correspondence from the Executive 
Director and other relevant staff members within NCSBN, which agreed 
with VA's position that this rulemaking properly identifies the areas 
in VA regulations that preempt State laws and regulations. VA received 
no other comments from the NCSBN on this rulemaking. In response to 
VA's outreach to NCSBN, VA received numerous calls and correspondence 
from State and local officials in support of this proposed rule. Such 
State and local officials included State Senators from Georgia and 
Illinois, State Representatives from Florida, Ohio,

[[Page 33159]]

Vermont, North Carolina, Georgia, and Illinois, County Commissioners 
from Nevada, Ohio, and North Carolina, and the State Comptroller and 
Secretary of State from Illinois, to name a few.
    VA additionally engaged other relevant external groups on the 
proposed changes in this rulemaking, including the American Association 
of Nurse Anesthetists, American Association of Nurse Practitioners, 
American College of Surgeons, American Academy of Family Practice 
Physicians, American Society of Anesthesiologists, American Medical 
Association, Association of American Medical Colleges, The Joint 
Commission-Office of Accreditation and Certification, American 
Association of Retired Persons, American Legion, Blinded Veterans 
Association, Vietnam Veterans of America, American Women Veterans, 
Disabled American Veterans, Paralyzed Veterans of America, Veterans of 
Foreign Wars. VA also engaged the Senate and House Veterans Affairs 
Committees and the Senate and House Armed Services Committees.
    Many external stakeholders expressed general support for VA's 
positions taken in this proposed rule, particularly with respect to 
full practice authority of APRNs in primary health care. However, we 
also received comments opposing full practice authority for CRNAs when 
providing anesthetics. To aid in VA's full consideration to this issue, 
VA encourages any comments regarding the proposed full practice 
authority. In this way, VA will be providing all affected State and 
local officials notice and an opportunity for appropriate participation 
in the proceedings.
    VA's promulgation of this regulation complies with the requirements 
of Executive Order 13132 by (1) in the absence of explicit preemption 
in the authorizing statute, identifying where the exercise of State 
authority conflicts with the exercise of Federal authority under 
Federal statute; (2) limiting the preemption to only those areas where 
we find existence a conflict; (3) restricting the regulatory preemption 
to the minimum level necessary to achieve the objectives of the 
statute; (4) consulting with the State Boards of Nursing and other 
relevant external parties as indicated above; and (5) providing 
opportunity for comment through this rulemaking.

Effect of Rulemaking

    Title 38 of the Code of Federal Regulations, as proposed to be 
revised by this rulemaking, will represent VA's implementation of its 
legal authority on this subject. Other than future amendments to this 
regulation or governing statutes, no contrary guidance or procedures 
would be authorized. All existing or subsequent VA guidance must be 
read to conform with this rulemaking if possible or, if not possible, 
such guidance will be superseded by this rulemaking.

Paperwork Reduction Act

    This proposed rule contains no provisions constituting a collection 
of information under the Paperwork Reduction Act of 1995 (44 U.S.C. 
3501-3521).

Regulatory Flexibility Act

    The Secretary hereby certifies that this proposed rule would not 
have a significant economic impact on a substantial number of small 
entities as they are defined in the Regulatory Flexibility Act, 5 
U.S.C. 601-612. This proposed rule would directly affect only 
individuals and would not directly affect small entities. Therefore, 
pursuant to 5 U.S.C. 605(b), this amendment would be exempt from the 
initial and final regulatory flexibility analysis requirements of 5 
U.S.C. 603 and 604.

Executive Orders 12866 and 13563

    Executive Orders 12866 and 13563 direct agencies to assess the 
costs and benefits of available regulatory alternatives and, when 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects, and other advantages; distributive impacts; 
and equity). Executive Order 13563 (Improving Regulation and Regulatory 
Review) emphasizes the importance of quantifying both costs and 
benefits, reducing costs, harmonizing rules, and promoting flexibility. 
Executive Order 12866 (Regulatory Planning and Review) defines a 
``significant regulatory action,'' which requires review by OMB, as 
``any regulatory action that is likely to result in a rule that may: 
(1) Have an annual effect on the economy of $100 million or more or 
adversely affect in a material way the economy, a sector of the 
economy, productivity, competition, jobs, the environment, public 
health or safety, or State, local, or tribal governments or 
communities; (2) Create a serious inconsistency or otherwise interfere 
with an action taken or planned by another agency; (3) Materially alter 
the budgetary impact of entitlements, grants, user fees, or loan 
programs or the rights and obligations of recipients thereof; or (4) 
Raise novel legal or policy issues arising out of legal mandates, the 
President's priorities, or the principles set forth in this Executive 
Order.''
    The economic, interagency, budgetary, legal, and policy 
implications of this proposed rule have been examined, and it has been 
determined to be a significant regulatory action under Executive Order 
12866. VA's impact analysis can be found as a supporting document at 
http://www.regulations.gov, usually within 48 hours after the 
rulemaking document is published. Additionally, a copy of the 
rulemaking and its impact analysis are available on VA's Web site at 
http://www.va.gov/orpm/, by following the link for ``VA Regulations 
Published From FY 2004 Through Fiscal Year to Date.''

Unfunded Mandates

    The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 
1532, that agencies prepare an assessment of anticipated costs and 
benefits before issuing any rule that may result in the expenditure by 
State, local, and tribal governments, in the aggregate, or by the 
private sector, of $100 million or more (adjusted annually for 
inflation) in any one year. This proposed rule would have no such 
effect on State, local, and tribal governments, or on the private 
sector.

Catalog of Federal Domestic Assistance

    The Catalog of Federal Domestic Assistance numbers and titles for 
the programs affected by this document are: 64.007, Blind 
Rehabilitation Centers; 64.008, Veterans Domiciliary Care; 64.009, 
Veterans Medical Care Benefits; 64.010, Veterans Nursing Home Care; 
64.011, Veterans Dental Care; 64.012, Veterans Prescription Service; 
64.013, Veterans Prosthetic Appliances; 64.014, Veterans State 
Domiciliary Care; 64.015, Veterans State Nursing Home Care; 64.018, 
Sharing Specialized Medical Resources; 64.019, Veterans Rehabilitation 
Alcohol and Drug Dependence; 64.022, Veterans Home Based Primary Care; 
and 64.024, VA Homeless Providers Grant and Per Diem Program.

Signing Authority

    The Secretary of Veterans Affairs, or designee, approved this 
document and authorized the undersigned to sign and submit the document 
to the Office of the Federal Register for publication electronically as 
an official document of the Department of Veterans Affairs. Robert L. 
Nabors II, Chief of Staff, Department of Veterans Affairs, approved 
this document on January 6, 2016.

[[Page 33160]]

List of Subjects in 38 CFR Part 17

    Administrative practice and procedure, Alcohol abuse, Alcoholism, 
Claims, Day care, Dental health, Drug abuse, Foreign relations, 
Government contracts, Grant programs--health, Grant programs--veterans, 
Health care, Health facilities, Health professions, Health records, 
Homeless, Medical and dental schools, Medical devices, Medical 
research, Mental health programs, Nursing homes, Philippines, Reporting 
and recordkeeping requirements, Scholarships and fellowships, Travel 
and transportation expenses, Veterans.

    Dated: May 20, 2016.
Michael Shores,
Acting Director, Office of Regulation Policy & Management, Office of 
Secretary, Department of Veterans Affairs.
    For the reasons set forth in the preamble, we propose to amend 38 
CFR part 17 as follows:

PART 17--MEDICAL

0
1. The authority citation for part 17 continues to read as follows:

    Authority:  38 U.S.C. 501, and as noted in specific sections.

0
2. Amend part 17 by adding an undesignated center heading and Sec.  
17.415 immediately after Sec.  17.410 to read as follows:

Nursing Services


Sec.  17.415  Full practice authority for advanced practice registered 
nurses.

    (a) Advanced practice registered nurse (APRN). For purposes of this 
section, an advanced practice registered nurse (APRN) is an individual 
who:
    (1) Has completed a nationally-accredited, graduate-level 
educational program that prepares them for one of the four APRN roles 
of Certified Nurse Practitioner (CNP), Certified Registered Nurse 
Anesthetist (CRNA), Clinical Nurse Specialist (CNS), or Certified 
Nurse-Midwife (CNM);
    (2) Has passed a national certification examination that measures 
knowledge in one of the APRN roles described in paragraph (a)(1) of 
this section;
    (3) Has obtained a license from a State licensing board in one of 
four recognized APRN roles described in paragraph (a)(1) of this 
section; and
    (4) Maintains certification and licensure as required by paragraphs 
(a)(2) and (3) of this section.
    (b) Full practice authority. For purposes of this section, full 
practice authority means the authority of an APRN to provide services 
described in paragraph (d) of this section without the clinical 
oversight of a physician, regardless of State or local law 
restrictions, when that APRN is working within the scope of their VA 
employment.
    (c) Granting of full practice authority. VA may grant full practice 
authority to an APRN subject to the following:
    (1) Verification that the APRN meets the requirements established 
in paragraph (a) of this section; and
    (2) Determination that the APRN has demonstrated the knowledge and 
skills necessary to provide the services described in paragraph (d) of 
this section without the clinical oversight of a physician, and is thus 
qualified to be privileged for such scope of practice.
    (d) Services provided by an APRN with full practice authority. (1) 
Subject to the limitations established in paragraph (d)(2) of this 
section, the full practice authority for each of the four APRN roles 
includes, but is not limited to, providing the following services:
    (i) A CNP has full practice authority to:
    (A) Take comprehensive histories, provide physical examinations and 
other health assessment and screening activities, diagnose, treat, and 
manage patients with acute and chronic illnesses and diseases;
    (B) Order, perform, supervise, and interpret laboratory and imaging 
studies;
    (C) Prescribe medication and durable medical equipment;
    (D) Make appropriate referrals for patients and families, and 
request consultations;
    (E) Aid in health promotion, disease prevention, health education, 
and counseling as well as the diagnosis and management of acute and 
chronic diseases.
    (ii) A CRNA has full practice authority to:
    (A) Plan and initiate anesthetic techniques (general, regional, 
local) and sedation;
    (B) Provide post-anesthesia evaluation and discharge;
    (C) Order and evaluate diagnostic tests;
    (D) Request consultations;
    (D) Perform point-of-care testing; and
    (E) Respond to emergency situations for airway management.
    (iii) A CNS has full practice authority to provide diagnosis and 
treatment of health or illness states, disease management, health 
promotion, and prevention of illness and risk behaviors among 
individuals, families, groups, and communities within their scope of 
practice.
    (iv) A CNM has full practice authority to provide a range of 
primary health care services to women, including gynecologic care, 
family planning services, preconception care (care that women veterans 
receive before becoming pregnant, including reducing the risk of birth 
defects and other problems such as the treatment of diabetes and high 
blood pressure), prenatal and postpartum care, childbirth, and care of 
a newborn, and treating the partner of their female patients for 
sexually transmitted disease and reproductive health, if the partner is 
also enrolled in the VA healthcare system or is not required to enroll.
    (2) The full practice authority of an APRN is subject to the 
limitations imposed by the Controlled Substances Act, 21 U.S.C. 801 et 
seq., and that APRN's State licensure on the authority to prescribe, or 
administer controlled substances, as well as any other limitations on 
the provision of VA care set forth in applicable Federal law and 
policy.
    (e) Preemption of State and local law. To achieve important Federal 
interests, including but not limited to the ability to provide the same 
comprehensive care to veterans in all States under 38 U.S.C. 7301, this 
section preempts conflicting State and local laws relating to the 
practice of APRNs when such APRNs are working within the scope of their 
VA employment. Any State or local law, or regulation pursuant to such 
law, is without any force or effect on, and State or local governments 
have no legal authority to enforce them in relation to this section or 
decisions made by VA under this section.

(Authority: 38 U.S.C. 7301, 7304, 7402, and 7403)


[FR Doc. 2016-12338 Filed 5-24-16; 8:45 am]
 BILLING CODE 8320-01-P



                                                                         Federal Register / Vol. 81, No. 101 / Wednesday, May 25, 2016 / Proposed Rules                                         33155

                                               *      *      *       *      *                           delivery to Director, Regulations                     also established a comprehensive
                                                 Dated: May 19, 2016.                                   Management (02REG), Department of                     personnel system for certain medical
                                               Jacqueline C. Charlesworth,
                                                                                                        Veterans Affairs, 810 Vermont Avenue                  employees in VHA, independent of the
                                                                                                        NW., Room 1068, Washington, DC                        civil service rules. See Chapters 73 and
                                               General Counsel and Associate Register of
                                               Copyrights.
                                                                                                        20420; by fax to (202) 273–9026.                      74 of title 38, U.S.C. The Secretary was
                                                                                                        Comments should indicate that they are                granted express statutory authority to
                                               [FR Doc. 2016–12227 Filed 5–24–16; 8:45 am]
                                                                                                        submitted in response to ‘‘RIN 2900–                  establish the qualifications for VA’s
                                               BILLING CODE 1410–30–P
                                                                                                        AP44-Advanced Practice Registered                     healthcare practitioners, determine the
                                                                                                        Nurses.’’ Copies of comments received                 hours and conditions of employment,
                                                                                                        will be available for public inspection in            take disciplinary action against
                                               DEPARTMENT OF VETERANS                                   the Office of Regulation Policy and                   employees, and otherwise regulate the
                                               AFFAIRS                                                  Management, Room 1068, between the                    professional activities of those
                                                                                                        hours of 8 a.m. and 4:30 p.m., Monday                 individuals. 38 U.S.C. 7401–7464. As an
                                               38 CFR Part 17                                           through Friday (except holidays). Call                integrated Federal health care system
                                               RIN 2900–AP44                                            (202) 461–4902 for an appointment.                    with the responsibility to provide
                                                                                                        (This is not a toll-free number.) In                  comprehensive care under 38 U.S.C.
                                               Advanced Practice Registered Nurses                      addition, during the comment period,                  7301, it is essential that VHA wisely
                                               AGENCY:     Department of Veterans Affairs.              comments may be viewed online                         manage its resources and fully utilize
                                                                                                        through the Federal Docket Management                 the skills of its health care providers to
                                               ACTION:    Proposed rule.
                                                                                                        System (FDMS) at http://                              the full extent of their education,
                                               SUMMARY:    The Department of Veterans                   www.Regulations.gov.                                  training, and certification. By permitting
                                               Affairs (VA) is proposing to amend its                   FOR FURTHER INFORMATION CONTACT: Dr.                  APRNs throughout the VHA system a
                                               medical regulations to permit full                       Penny Kaye Jensen, Liaison for National               way to achieve full practice authority in
                                               practice authority of all VA advanced                    APRN Practice, 810 Vermont Ave. NW.,                  order to provide advanced nursing
                                               practice registered nurses (APRNs)                       Washington, DC 20420; (202) 461–6700.                 services to the full extent of their
                                               when they are acting within the scope                    (This is not a toll-free number.)                     professional competence, VHA would
                                               of their VA employment. This                             SUPPLEMENTARY INFORMATION: Section                    further its statutory mandate to provide
                                               rulemaking would increase veterans’                      7301 of title 38 United States Code                   quality health care to our nation’s
                                               access to VA health care by expanding                    (U.S.C.) establishes the Veterans Health              veterans. This proposed regulatory
                                               the pool of qualified health care                        Administration (VHA) within VA, and                   change to nursing policy would permit
                                               professionals who are authorized to                      establishes that its primary function is              APRNs to practice to the full extent of
                                               provide primary health care and other                    to ‘‘provide a complete medical and                   their education, training and
                                               related health care services to the full                 hospital service for the medical care and             certification, without the clinical
                                               extent of their education, training, and                 treatment of veterans, as provided in                 supervision or mandatory collaboration
                                               certification, without the clinical                      this title and in regulations prescribed              of physicians. Standardization of APRN
                                               supervision of physicians. This rule                     by the Secretary pursuant to this title.’’            full practice authority, without regard
                                               would permit VA to use its health care                   38 U.S.C. 7301(b). In carrying out this               for individual State practice regulations,
                                               resources more effectively and in a                      function, VHA has an obligation to                    would help to ensure a consistent
                                               manner that is consistent with the role                  ensure that patient care is appropriate               continuum of health care across VHA by
                                               of APRNs in the non-VA health care                       and safe and its health care practitioners            decreasing the variability in APRN
                                               sector, while maintaining the patient-                   meet or exceed generally-accepted                     practice that currently exists across
                                               centered, safe, high-quality health care                 professional standards for patient care.              VHA as a result of disparate State
                                               that veterans receive from VA. The                       The Secretary is responsible for the                  practice regulations. As of March 7,
                                               proposed rulemaking would establish                      proper execution and administration of                2016 CRNAs have full practice authority
                                               additional professional qualifications an                all laws administered by the Department               in 17 states, while CNPs have full
                                               individual must possess to be appointed                  and for the control, direction, and                   practice authority in almost 50% of the
                                               as an APRN within VA. The proposed                       management of the Department, to                      nation, which includes 21 states and the
                                               rulemaking would subdivide APRN’s                        include agency personnel and                          District of Columbia.
                                               into four separate categories that                       management matters. See 38 U.S.C. 303.                   It would also aid in fully maximizing
                                               include certified nurse practitioner,                    To enable the Secretary to direct,                    VHA APRN staff capabilities, which
                                               certified registered nurse anesthetist,                  control and manage VA, Congress                       would increase VA’s capacity to provide
                                               clinical nurse specialist, and certified                 authorized the Secretary ‘‘to prescribe               timely, efficient, and effective primary
                                               nurse-midwife. The proposed                              all rules and regulations which are                   care services, as well as other services.
                                               rulemaking would also provide the                        necessary or appropriate to carry out the             This would increase veteran access to
                                               criteria under which VA may grant full                   laws administered by the Department                   needed VA health care, particularly in
                                               practice authority to an APRN, and                       and are consistent with those laws.’’ 38              medically-underserved areas, as well as
                                               define the scope of full practice                        U.S.C. 501(a). The Under Secretary for                decrease the amount of time veterans
                                               authority for each category of APRN. VA                  Health is directly responsible to the                 spend waiting for patient appointments.
                                               intends that the services to be provided                 Secretary for the operation of VHA (38                In addition, standardizing APRN
                                               by an APRN in one of the four APRN                       U.S.C. 305(b)). Unless specifically                   practice authority would enable
                                               roles would be consistent with the                       otherwise provided, the Under Secretary               veterans, their families, and caregivers
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                                               nursing profession’s standards of                        for Health, as the head of VHA, is                    to understand more readily the health
                                               practice for such roles.                                 authorized to ‘‘prescribe all regulations             care services that VA APRNs are
                                               DATES: Comments must be received by                      necessary to the administration of the                authorized to provide. This preemptive
                                               VA on or before July 25, 2016.                           Veterans Health Administration,’’                     rule would increase access to care and
                                               ADDRESSES: Written comments may be                       subject to the approval of the Secretary.             reduce the wait times for VA
                                               submitted: Through http://                               38 U.S.C. 7304. To allow VA to carry                  appointments utilizing the current
                                               www.Regulations.gov; by mail or hand-                    out its medical care mission, Congress                workforce already in place.


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                                               33156                 Federal Register / Vol. 81, No. 101 / Wednesday, May 25, 2016 / Proposed Rules

                                                  To ensure that VA would have                         nursing services without the clinical                 the minimum necessary action for VA to
                                               available highly qualified medical                      oversight of a physician when that                    allow APRNs full practice authority. It
                                               personnel, Congress mandated the basic                  APRN is working within the scope of                   would be impractical for VA to lobby to
                                               qualifications for certain health care                  their VA employment. Such full                        each State that does not allow full
                                               positions, including registered nurses.                 practice authority would be granted by                practice authority to APRNs to change
                                               Sections 7401 through 7464 of title 38,                 VA upon demonstrating that the                        their laws regarding full practice
                                               U.S.C., grant VA authority to regulate                  established regulatory criteria are met.              authority. This process would be costly
                                               the professional activities of such                     In addition, full practice authority                  and time consuming for VA and would
                                               personnel. To be eligible for                           would be granted appropriate to the                   not guarantee the desired result of full
                                               appointment as a VA employee in a                       clinical service setting.                             practice authority to all APRNs.
                                               health care position covered by section                    This proposed rule is consistent with
                                                                                                       the recommendation of the Institute of                Section-by-Section Analysis of the
                                               7402(b) (other than Director), of title 38,                                                                   Proposed Rule
                                               U.S.C., a person must, among other                      Medicine (IOM) of the National
                                               requirements, be licensed, registered or                Academy of Sciences to remove scope-                  17.415 Full Practice Authority for
                                               certified to practice their profession in               of-practice barriers. Specifically, the               Advanced Practice Registered Nurses
                                               a State. The standards prescribed in                    2010 IOM report, ‘‘The Future of                        The general qualifications for a person
                                               section 7402(b) establish only the basic                Nursing: Leading Change Advancing                     to be appointed as a VA nurse are found
                                               qualifications necessary ‘‘[t]o be eligible             Health,’’ (IOM Report) available at                   in 38 U.S.C. 7402(b)(3), which requires
                                               for appointment’’ and do not limit the                  http://iom.nationalacademies.org/                     that a person must have successfully
                                               Secretary or Under Secretary for Health                 Reports/2010/The-Future-of-Nursing-
                                                                                                                                                             completed a full course of nursing in a
                                               from establishing other qualifications                  Leading-Change-Advancing-
                                                                                                                                                             recognized school of nursing, as well as
                                               for appointment, or additional rules                    Health.aspx, recommended that
                                                                                                                                                             be registered as a graduate nurse in a
                                               governing such personnel. In particular,                ‘‘[a]dvanced practice registered nurses
                                                                                                                                                             State. VA interprets ‘‘a recognized
                                               38 U.S.C. 7403(a)(1) provides that                      (APRNs) should be able to practice to
                                                                                                                                                             school of nursing’’ to mean a school of
                                               appointments under Chapter 74 ‘‘may                     the full extent of their education and
                                                                                                                                                             professional nursing approved by the
                                               be made only after qualifications have                  training.’’ Id. at 9. More generally, the
                                                                                                                                                             appropriate State agency and accredited
                                               been established in accordance with                     report stated that ‘‘[r]estrictions on
                                                                                                                                                             by the National League for Nursing
                                               regulations prescribed by the Secretary,                scope of practice and professional
                                                                                                                                                             Accrediting Commission (NLNAC) or
                                               without regard to civil-service                         tensions have undermined the nursing
                                                                                                       profession’s ability to provide and                   the Commission on Collegiate Nursing
                                               requirements.’’ In addition, 38 U.S.C.                                                                        Education (CCNE); the completion of
                                               7421(a) directs that, ‘‘[n]otwithstanding               improve both general and advanced
                                                                                                       care’’ and asserted that ‘‘[p]roducing a              coursework equivalent to a nursing
                                               any law, Executive order, or regulation,                                                                      degree in a MSN Bridge Program that
                                               the Secretary shall prescribe by                        health care system that delivers the right
                                                                                                       care—quality care that is patient                     qualifies for professional nursing
                                               regulation the hours and conditions of                                                                        registration; or a foreign school of
                                               employment and leaves of absence of                     centered, accessible, evidence based,
                                                                                                       and sustainable—at the right time will                professional nursing that enables the
                                               employees appointed under any                                                                                 graduate to obtain current, full, active
                                               provision of [chapter 74] [in the                       require transforming the work
                                                                                                       environment, scope of practice,                       and unrestricted registration. VA
                                               specifically numerated positions] in the                                                                      Handbook 5005/27, Part II, Appendix
                                                                                                       education, and numbers and
                                               Veterans Health Administration’’                                                                              G6, paragraph 2, Section B.a(2). VA
                                                                                                       composition of America’s nurses.’’ Id. at
                                               (including registered nurses). As the                                                                         interprets ‘‘registered as a graduate
                                                                                                       26. In addition, the proposed rule is
                                               head of VHA, the Under Secretary for                                                                          nurse in a state’’ to mean a current, full,
                                                                                                       consistent with the National Council of
                                               Health has the duty to ‘‘prescribe all                                                                        active and unrestricted licensure,
                                                                                                       State Boards of Nursing (NCSBN)
                                               regulations necessary to the                                                                                  registration or certification as a graduate
                                                                                                       Consensus Model, as discussed in more
                                               administration of the Veterans Health                                                                         professional nurse in a State, Territory,
                                                                                                       detail later in this rulemaking.
                                               Administration,’’ subject to approval by                                                                      or Commonwealth (i.e., Puerto Rico) of
                                                                                                       Significantly, many States already
                                               the Secretary. 38 U.S.C. 7304; see also                                                                       the U.S. or in the District of Columbia
                                                                                                       permit full practice authority of APRNs
                                               38 U.S.C. 501. Pursuant to this                                                                               (hereinafter ‘‘licensure’’). Id. Pursuant to
                                                                                                       or are in the process of doing so. Under
                                               authority, the Under Secretary for                      the proposed rulemaking, APRNs would                  the authorities in 38 U.S.C. 7401
                                               Health is authorized to establish the                   not be authorized to replace or act as                through 7464 and VA’s rulemaking
                                               qualifications and clinical practice                    physicians or to provide any health care              authorities at 38 U.S.C. 501 and 7304,
                                               standards of VHA’s nursing personnel                    services that are beyond their clinical               VA is proposing a new § 17.415(a),
                                               and to otherwise regulate their                         education, training, and national                     which would define additional
                                               professional conduct.                                   certification. The proposed rule would                qualifications a registered nurse must
                                                  To continue to provide high quality                  limit an APRN’s full practice authority               possess to be appointed to one of four
                                               health care to veterans, VA is proposing                to practice within the scope of their VA              (4) APRN roles, i.e., Certified Nurse
                                               to amend its regulations to allow APRNs                 employment, and any APRN practice                     practitioner (CNP), Certified Registered
                                               to practice to the full extent of their                 outside of VA employment would                        Nurse Anesthetist (CRNA), Clinical
                                               education, training, and certification,                 remain subject to applicable State laws,              Nurse Specialist (CNS), or Certified
                                               regardless of individual State                          in the same manner as any other                       Nurse-Midwife (CNM). The proposed
                                               restrictions that limit such full practice              licensed VA practitioner in their private             rule would require an advanced practice
                                               authority, except for applicable State                                                                        registered nurse to have successfully
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                                                                                                       practice.
                                               restrictions on the authority to prescribe                 In this rulemaking, VA is proposing to             completed a nationally-accredited,
                                               and administer controlled substances,                   exercise Federal preemption of State                  graduate-level educational program that
                                               when such APRNs are acting within the                   nursing licensure laws to the extent                  prepares the advanced practice
                                               scope of their VA employment. The                       such State laws conflict with the full                registered nurse in one of the four APRN
                                               proposed rule would use the term ‘‘full                 practice authority granted to VA APRNs                roles; and to possess, and maintain,
                                               practice authority’’ to refer to the                    while acting within the scope of their                national certification and State licensure
                                               APRN’s authority to provide advanced                    VA employment. Preemption would be                    in that APRN role. These additional


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                                                                     Federal Register / Vol. 81, No. 101 / Wednesday, May 25, 2016 / Proposed Rules                                            33157

                                               qualifications are derived from criteria                   Proposed § 17.415(b) would define                  Comprehensive histories, physical
                                               set forth in the IOM Report, and the                    ‘‘full practice authority’’ to mean that an           examinations and other health
                                               National Council of State Boards of                     APRN working within the scope of VA                   assessment and screening activities;
                                               Nursing Consensus Model for APRN                        employment would be authorized to                     diagnose, treat, and manage patients
                                               Regulation: Licensure, Accreditation,                   provide the services described in                     with acute and chronic illnesses and
                                               Certification & Education) Regulation,                  proposed § 17.415(d), without the                     diseases; order, perform, supervise, and
                                               July 2008 (the APRN Consensus Model),                   clinical oversight of a physician,                    interpret laboratory and imaging
                                               which VA finds to be the criteria most                  regardless of State or local law                      studies; prescribe medication and
                                               widely accepted by State boards of                      restrictions on that authority. Further,              durable medical equipment and; make
                                               nursing and the nursing community as                    any APRN practice established outside                 appropriate referrals for patients and
                                               necessary to practice as an APRN.                       VA employment would be subject to                     families; and aid in health promotion,
                                               Under the proposed rule, APRNs who                      applicable State law, in the same                     disease prevention, health education,
                                               meet these additional qualifications may                manner as private practice by any other               and counseling as well as the diagnosis
                                               be granted full practice authority within               licensed VA provider.                                 and management of acute and chronic
                                               VA in one of the four recognized APRN                      Proposed § 17.415(c) would establish               diseases.
                                               roles.                                                  the criteria by which VA may grant full                  In proposed § 17.415(d)(1)(ii), a CRNA
                                                 Proposed § 17.415(a)(1) would require                 practice authority to an APRN. Proposed               would have full practice authority to
                                               an APRN to have successfully                            paragraph (c)(1), would require a VA                  provide a patient’s anesthesia care and
                                               completed an accredited graduate-level                  medical facility to verify that the APRN              anesthesia related care, to include
                                               educational program in one of the four                  meets the requirements established in                 planning and initiating anesthetic
                                               distinct APRN roles. The Consensus                      proposed § 17.415(a). Proposed                        techniques (general, regional, local) and
                                               Model defines these roles as CNP,                       paragraph (c)(2) would require VA to                  sedation, providing post-anesthesia
                                               CRNA, CNS, and CNM. These APRN                          confirm that the APRN has                             evaluation and discharge; ordering and
                                               roles are widely known and accepted by                  demonstrated the knowledge and skills                 evaluating diagnostic tests; requesting
                                               State boards of nursing and the nursing                 necessary to provide the services                     consultations; performing point-of-care
                                               community. VA currently does not                        described in proposed § 17.415(d)                     testing; and responding to emergency
                                               employ CNMs; however, the proposed                      without the clinical oversight of a                   situations for airway management.
                                                                                                       physician, and is thus qualified to be                   In proposed § 17.415(d)(1)(iii), a CNS
                                               rule includes CNMs in the event that
                                                                                                       privileged for such scope of practice.                would have full practice authority to
                                               VA has the need to hire CNMs in the
                                                                                                       Proposed § 17.415(c)(1) and (2) together              provide diagnosis and treatment of
                                               future.
                                                                                                       would clarify that the VA processes for               health or illness states, disease
                                                 Proposed § 17.415(a)(2) would require                                                                       management, health promotion, and
                                                                                                       credentialing and privileging of licensed
                                               an APRN to have passed a national                                                                             prevention of illness and risk behaviors
                                                                                                       independent health care providers
                                               certification examination that measures                                                                       among individuals, families, groups,
                                                                                                       would apply to VA APRNs with full
                                               the APRN’s knowledge, skills and                                                                              and communities within their scope of
                                                                                                       practice authority. VA anticipates that
                                               experience demonstrated by the                                                                                practice.
                                                                                                       the granting of full-practice authority
                                               achievement of standards identified by                                                                           Lastly, in proposed § 17.415(d)(1)(iv),
                                                                                                       under proposed § 17.415(c) would be
                                               the profession in one of the four APRN                                                                        a CNM would have full practice
                                                                                                       implemented through formal VHA
                                               roles established in proposed                           guidance issuances.                                   authority to provide a full range of
                                               § 17.415(a)(1). Public and private sector                  Proposed § 17.415(d)(1) would                      primary health care services to women
                                               health care employers, State boards of                  describe the role-specific services that a            veterans, including gynecologic care,
                                               nursing, and the nursing community                      VA APRN would be authorized to                        family planning service, preconception
                                               rely on national certification through an               perform under their full practice                     care (care that women veterans receive
                                               examination process as the standard,                    authority. This authority would be                    before becoming pregnant, including
                                               which conveys adequate APRN                             without regard to state licensure                     reducing the risk of birth defects and
                                               knowledge, and VA’s regulation would                    restrictions, except as provided in                   other problems such as the treatment of
                                               adopt the same standard.                                proposed paragraph (d)(2), which would                diabetes and high blood pressure),
                                                 Proposed § 17.415(a)(3) would require                 defer to State licensure restrictions on a            prenatal and postpartum care,
                                               an APRN to possess a license from a                     VA APRN’s authority to prescribe, or                  childbirth, and care of a newborn. We
                                               State licensing board in one of the four                administer controlled substances. We                  note that the pregnancy and delivery
                                               recognized APRN roles. Proposed                         emphasize that full practice authority                services described above, as well as the
                                               § 17.415(a)(4) would require an APRN to                 for an APRN in this rulemaking would                  newborn care services, would be subject
                                               maintain both the national certification                apply only to services provided by an                 to the limitations established in 38 CFR
                                               and licensure required in proposed                      APRN when working within the scope                    17.38(a)(1)(xiii) and (xiv), respectively.
                                               paragraphs (a)(2) and (3) of § 17.415.                  of their VA employment, as required by                We also note that authorized CNM
                                                 In total, proposed paragraphs (a)(1)                  proposed § 17.415(b). Additionally, all               services would include treating the
                                               through (4) of § 17.415 would establish                 full practice authority of APRNs in                   partner of the female patient for
                                               qualifications for employment within                    proposed § 17.415(d)(1) would be under                sexually transmitted infection and
                                               VA as a CNP, CRNA, CNS and CNM.                         approved privileges by, and within the                reproductive health, if the partner is
                                               These qualifications would ensure that                  available resources of, a VA medical                  enrolled in the VA healthcare system or
                                               VA APRNs possess and maintain the                       facility, as required by proposed                     not required to enroll to receive VA
                                               education, knowledge, national                          § 17.415(c). VA intends that the services             services. We would include the services
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                                               certification and State licensure                       to be provided by an APRN in one of the               of a CNM in this rulemaking in
                                               necessary for VA employment in one of                   four APRN roles would be consistent                   anticipation that VA would hire CNMs
                                               the four recognized APRN roles. APRNs                   with the nursing profession’s standards               at a future date to improve access to
                                               who meet these qualifications would be                  of practice for such roles.                           health care for the increasing number of
                                               granted full practice authority within                     In proposed § 17.415(d)(1)(i), a CNP               female veterans.
                                               VA in one of the four recognized APRN                   would have full practice authority to                    Proposed § 17.415(d)(2) would
                                               roles.                                                  provide the following services:                       expressly limit full practice authority.


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                                               33158                 Federal Register / Vol. 81, No. 101 / Wednesday, May 25, 2016 / Proposed Rules

                                               Congress has specifically required                      Accordingly, State disciplinary actions               Order requires that when an agency
                                               reliance on a specific State law under                  that would penalize, or otherwise                     proposes to act through rulemaking to
                                               the Controlled Substance Act (CSA).                     interfere with, an APRN’s full practice               preempt State law, ‘‘the agency shall
                                               Specifically, proposed § 17.415(a)(2)                   authority in the performance of their                 provide all affected State and local
                                               would provide that full practice                        official VA duties, would likewise be                 officials notice and an opportunity for
                                               authority within VA is subject to State                 effectively preempted. However, where                 appropriate participation in the
                                               licensure law with regard to the                        there is no conflict between this                     proceedings.’’
                                               authority of an APRN to prescribe, or                   regulation and State law, the State                      Section 6(c) of Executive Order 13132
                                               administer controlled substances, and to                would retain authority to impose State                states that ‘‘no agency shall promulgate
                                               any other limitations on the provision of               regulations on its APRN licensees and                 any regulation that has federalism
                                               VA care set forth in applicable Federal                 take disciplinary action for any                      implications and that preempts State
                                               law and policy. Regarding the full                      violations. We emphasize that this                    law, unless the agency, prior to the
                                               practice authority limitations for                      preemptive effect would only pertain to               formal promulgation of the regulation,
                                               controlled substances, the CSA, 21                      APRNs when they are acting within the                 (1) consulted with State and local
                                               U.S.C. 801 et seq., and implementing                    scope of their federal VA employment;                 officials early in the process of
                                               regulations in 21 CFR part 1300, make                   this rule would not have any effect on                developing the proposed regulation; (2)
                                               State licensure authority to prescribe, or              individual State efforts to either permit             in a separately identified portion of the
                                               administer controlled substances a                      or restrict full practice authority for               preamble to the regulation as it is to be
                                               prerequisite for authority under the CSA                APRNs who are not working within a                    issued in the Federal Register, provides
                                               to prescribe, or administer controlled                  VA scope of employment.                               to the Director of the Office of
                                               substances. See 21 U.S.C. 802(21)                          The Indian Health Service already                  Management and Budget a federalism
                                               (providing that a practitioner must be                  grants full practice authority to APRNs.              summary impact statement, which
                                               ‘‘licensed, registered, or otherwise                    See Part 4, Chapter 3, Section 11,                    consists of a description of the extent of
                                               permitted, by the United States or the                  ‘‘Advanced Practice Nurses,’’ Indian                  the agency’s prior consultation with
                                               jurisdiction in which he practices or                   Health Manual. In the Military Health                 State and local officials, a summary of
                                               does research, to distribute, conduct                   System, the Services employ APRNs,                    the nature of their concerns and the
                                               research with respect to, administer, or                which includes Nurse Midwives, Nurse                  agency’s position supporting the need to
                                               use in teaching or chemical analysis, a                 Practitioners, and Nurse Anesthetists, in             issue the regulation, and a statement of
                                               controlled substance in the course of                   independent practice without oversight                the extent to which the concerns of
                                               professional practice or research.’’); See              from physicians. They are privileged in               State and local officials have been met;
                                               also 21 CFR 1306.03(a) (stating that a                  their roles as APRNs and can adjust                   and (3) makes available to the Director
                                               prescription for a controlled substance                 their scope practice (level of care)                  of the Office of Management and Budget
                                               may be issued only by an individual                     through privileging as granted by a                   any written communications submitted
                                               practitioner who is: (1) Authorized to                  committee of physicians and the                       to the agency by State and local
                                               prescribe controlled substances by the                  military treatment facility commander.                officials.’’
                                                                                                       Nurse Practitioners specifically have an                 Because this regulation would address
                                               jurisdiction in which he is licensed to
                                                                                                       assigned group of patients for which                  preemption of certain State laws, VA
                                               practice his profession and (2) either
                                                                                                       they are responsible. Therefore, we do                conducted prior consultation with State
                                               registered or exempted from registration
                                                                                                       not anticipate that the proposed changes              officials in compliance with Executive
                                               pursuant to §§ 1301.22(c) and 1301.23.).
                                                                                                       in this rulemaking would be completely                Order 13132. VA sent a letter to the
                                               Proposed § 17.415(d)(2) also would
                                                                                                       novel or unexpected to the general                    National Council of State Boards of
                                               make the full practice authority of an                                                                        Nursing to state VA’s intent to allow full
                                                                                                       public or other Federal entities that
                                               APRN subject to any other limitations                                                                         practice authority to VA APRNs and for
                                                                                                       provide health care services to
                                               on the provision of VA care set forth in                                                                      the National Council of State Boards of
                                                                                                       beneficiaries.
                                               Federal law or policy.                                                                                        Nursing to notify every State Board of
                                                  Proposed § 17.415(e) would expressly                 Executive Order 13132, Federalism                     Nursing of VA’s intent and to seek
                                               state the intended preemptive effect of                    Section 4 of Executive Order 13132                 feedback from such Boards of Nursing.
                                               proposed § 17.415, to ensure it is clear                (titled ‘‘Federalism’’) requires an agency               In addition, VA solicited comments
                                               that conflicting State and local laws                   that is publishing a regulation that                  and input from State Boards of Nursing,
                                               related to the practice of APRNs would                  preempts State law to follow certain                  through their representative national
                                               have no force or effect when such                       procedures. Section 4(b) of the                       organization, the National Council of
                                               APRNs are working within the scope of                   Executive Order requires agencies to                  State Boards of Nursing (NCSBN). In
                                               their VA employment. In circumstances                   ‘‘construe any authorization in the                   response to its request for comments,
                                               where there is a conflict between                       statute for the issuance of regulations as            VA received correspondence from the
                                               Federal and State Law, Federal law                      authorizing preemption of State law by                Executive Director and other relevant
                                               prevails in accordance with Article VI,                 rulemaking only when the exercise of                  staff members within NCSBN, which
                                               clause 2, of the U.S. Constitution                      State authority directly conflicts with               agreed with VA’s position that this
                                               (Supremacy Clause). It is a well-                       the exercise of Federal authority under               rulemaking properly identifies the areas
                                               established principle of constitutional                 the Federal statute or there is clear                 in VA regulations that preempt State
                                               law that Federal law is supreme, and                    evidence to conclude that the Congress                laws and regulations. VA received no
                                               States may not regulate or control the                  intended the agency to have the                       other comments from the NCSBN on
                                               lawful actions of the Federal                           authority to preempt State law.’’ Section             this rulemaking. In response to VA’s
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                                               Government, absent Congressional                        4(d) of the Executive Order requires that             outreach to NCSBN, VA received
                                               consent. Therefore, where there is                      when an agency proposes to act through                numerous calls and correspondence
                                               conflict between State law and Federal                  rulemaking to preempt State law, ‘‘the                from State and local officials in support
                                               law with regard to full practice                        agency shall consult, to the extent                   of this proposed rule. Such State and
                                               authority of APRNs working within the                   practicable, with appropriate State and               local officials included State Senators
                                               scope of their federal VA employment,                   local officials in an effort to avoid such            from Georgia and Illinois, State
                                               this regulation would control.                          a conflict.’’ Section 4(e) of the Executive           Representatives from Florida, Ohio,


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                                                                     Federal Register / Vol. 81, No. 101 / Wednesday, May 25, 2016 / Proposed Rules                                           33159

                                               Vermont, North Carolina, Georgia, and                   amendments to this regulation or                      President’s priorities, or the principles
                                               Illinois, County Commissioners from                     governing statutes, no contrary guidance              set forth in this Executive Order.’’
                                               Nevada, Ohio, and North Carolina, and                   or procedures would be authorized. All                   The economic, interagency,
                                               the State Comptroller and Secretary of                  existing or subsequent VA guidance                    budgetary, legal, and policy
                                               State from Illinois, to name a few.                     must be read to conform with this                     implications of this proposed rule have
                                                  VA additionally engaged other                        rulemaking if possible or, if not                     been examined, and it has been
                                               relevant external groups on the                         possible, such guidance will be                       determined to be a significant regulatory
                                               proposed changes in this rulemaking,                    superseded by this rulemaking.                        action under Executive Order 12866.
                                               including the American Association of                                                                         VA’s impact analysis can be found as a
                                               Nurse Anesthetists, American                            Paperwork Reduction Act
                                                                                                                                                             supporting document at http://
                                               Association of Nurse Practitioners,                       This proposed rule contains no                      www.regulations.gov, usually within 48
                                               American College of Surgeons,                           provisions constituting a collection of               hours after the rulemaking document is
                                               American Academy of Family Practice                     information under the Paperwork                       published. Additionally, a copy of the
                                               Physicians, American Society of                         Reduction Act of 1995 (44 U.S.C. 3501–                rulemaking and its impact analysis are
                                               Anesthesiologists, American Medical                     3521).                                                available on VA’s Web site at http://
                                               Association, Association of American                    Regulatory Flexibility Act                            www.va.gov/orpm/, by following the
                                               Medical Colleges, The Joint                                                                                   link for ‘‘VA Regulations Published
                                               Commission-Office of Accreditation and                     The Secretary hereby certifies that
                                                                                                       this proposed rule would not have a                   From FY 2004 Through Fiscal Year to
                                               Certification, American Association of                                                                        Date.’’
                                               Retired Persons, American Legion,                       significant economic impact on a
                                               Blinded Veterans Association, Vietnam                   substantial number of small entities as               Unfunded Mandates
                                               Veterans of America, American Women                     they are defined in the Regulatory
                                                                                                       Flexibility Act, 5 U.S.C. 601–612. This                  The Unfunded Mandates Reform Act
                                               Veterans, Disabled American Veterans,                                                                         of 1995 requires, at 2 U.S.C. 1532, that
                                               Paralyzed Veterans of America, Veterans                 proposed rule would directly affect only
                                                                                                       individuals and would not directly                    agencies prepare an assessment of
                                               of Foreign Wars. VA also engaged the
                                                                                                       affect small entities. Therefore, pursuant            anticipated costs and benefits before
                                               Senate and House Veterans Affairs
                                                                                                       to 5 U.S.C. 605(b), this amendment                    issuing any rule that may result in the
                                               Committees and the Senate and House
                                                                                                       would be exempt from the initial and                  expenditure by State, local, and tribal
                                               Armed Services Committees.
                                                  Many external stakeholders expressed                 final regulatory flexibility analysis                 governments, in the aggregate, or by the
                                               general support for VA’s positions taken                requirements of 5 U.S.C. 603 and 604.                 private sector, of $100 million or more
                                               in this proposed rule, particularly with                                                                      (adjusted annually for inflation) in any
                                                                                                       Executive Orders 12866 and 13563                      one year. This proposed rule would
                                               respect to full practice authority of
                                               APRNs in primary health care.                              Executive Orders 12866 and 13563                   have no such effect on State, local, and
                                               However, we also received comments                      direct agencies to assess the costs and               tribal governments, or on the private
                                               opposing full practice authority for                    benefits of available regulatory                      sector.
                                               CRNAs when providing anesthetics. To                    alternatives and, when regulation is
                                                                                                                                                             Catalog of Federal Domestic Assistance
                                               aid in VA’s full consideration to this                  necessary, to select regulatory
                                               issue, VA encourages any comments                       approaches that maximize net benefits                   The Catalog of Federal Domestic
                                               regarding the proposed full practice                    (including potential economic,                        Assistance numbers and titles for the
                                               authority. In this way, VA will be                      environmental, public health and safety               programs affected by this document are:
                                               providing all affected State and local                  effects, and other advantages;                        64.007, Blind Rehabilitation Centers;
                                               officials notice and an opportunity for                 distributive impacts; and equity).                    64.008, Veterans Domiciliary Care;
                                               appropriate participation in the                        Executive Order 13563 (Improving                      64.009, Veterans Medical Care Benefits;
                                               proceedings.                                            Regulation and Regulatory Review)                     64.010, Veterans Nursing Home Care;
                                                  VA’s promulgation of this regulation                 emphasizes the importance of                          64.011, Veterans Dental Care; 64.012,
                                               complies with the requirements of                       quantifying both costs and benefits,                  Veterans Prescription Service; 64.013,
                                               Executive Order 13132 by (1) in the                     reducing costs, harmonizing rules, and                Veterans Prosthetic Appliances; 64.014,
                                               absence of explicit preemption in the                   promoting flexibility. Executive Order                Veterans State Domiciliary Care; 64.015,
                                               authorizing statute, identifying where                  12866 (Regulatory Planning and                        Veterans State Nursing Home Care;
                                               the exercise of State authority conflicts               Review) defines a ‘‘significant                       64.018, Sharing Specialized Medical
                                               with the exercise of Federal authority                  regulatory action,’’ which requires                   Resources; 64.019, Veterans
                                               under Federal statute; (2) limiting the                 review by OMB, as ‘‘any regulatory                    Rehabilitation Alcohol and Drug
                                               preemption to only those areas where                    action that is likely to result in a rule             Dependence; 64.022, Veterans Home
                                               we find existence a conflict; (3)                       that may: (1) Have an annual effect on                Based Primary Care; and 64.024, VA
                                               restricting the regulatory preemption to                the economy of $100 million or more or                Homeless Providers Grant and Per Diem
                                               the minimum level necessary to achieve                  adversely affect in a material way the                Program.
                                               the objectives of the statute; (4)                      economy, a sector of the economy,
                                                                                                                                                             Signing Authority
                                               consulting with the State Boards of                     productivity, competition, jobs, the
                                               Nursing and other relevant external                     environment, public health or safety, or                The Secretary of Veterans Affairs, or
                                               parties as indicated above; and (5)                     State, local, or tribal governments or                designee, approved this document and
                                               providing opportunity for comment                       communities; (2) Create a serious                     authorized the undersigned to sign and
                                                                                                       inconsistency or otherwise interfere                  submit the document to the Office of the
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                                               through this rulemaking.
                                                                                                       with an action taken or planned by                    Federal Register for publication
                                               Effect of Rulemaking                                    another agency; (3) Materially alter the              electronically as an official document of
                                                 Title 38 of the Code of Federal                       budgetary impact of entitlements,                     the Department of Veterans Affairs.
                                               Regulations, as proposed to be revised                  grants, user fees, or loan programs or the            Robert L. Nabors II, Chief of Staff,
                                               by this rulemaking, will represent VA’s                 rights and obligations of recipients                  Department of Veterans Affairs,
                                               implementation of its legal authority on                thereof; or (4) Raise novel legal or policy           approved this document on January 6,
                                               this subject. Other than future                         issues arising out of legal mandates, the             2016.


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                                               33160                 Federal Register / Vol. 81, No. 101 / Wednesday, May 25, 2016 / Proposed Rules

                                               List of Subjects in 38 CFR Part 17           clinical oversight of a physician,                               care services to women, including
                                                  Administrative practice and               regardless of State or local law                                 gynecologic care, family planning
                                               procedure, Alcohol abuse, Alcoholism,        restrictions, when that APRN is working                          services, preconception care (care that
                                               Claims, Day care, Dental health, Drug        within the scope of their VA                                     women veterans receive before
                                               abuse, Foreign relations, Government         employment.                                                      becoming pregnant, including reducing
                                                                                               (c) Granting of full practice authority.                      the risk of birth defects and other
                                               contracts, Grant programs—health,
                                                                                            VA may grant full practice authority to                          problems such as the treatment of
                                               Grant programs—veterans, Health care,
                                                                                            an APRN subject to the following:                                diabetes and high blood pressure),
                                               Health facilities, Health professions,
                                                                                               (1) Verification that the APRN meets                          prenatal and postpartum care,
                                               Health records, Homeless, Medical and
                                                                                            the requirements established in                                  childbirth, and care of a newborn, and
                                               dental schools, Medical devices,
                                                                                            paragraph (a) of this section; and                               treating the partner of their female
                                               Medical research, Mental health                 (2) Determination that the APRN has
                                               programs, Nursing homes, Philippines,                                                                         patients for sexually transmitted disease
                                                                                            demonstrated the knowledge and skills                            and reproductive health, if the partner
                                               Reporting and recordkeeping                  necessary to provide the services
                                               requirements, Scholarships and                                                                                is also enrolled in the VA healthcare
                                                                                            described in paragraph (d) of this                               system or is not required to enroll.
                                               fellowships, Travel and transportation       section without the clinical oversight of
                                               expenses, Veterans.                                                                                              (2) The full practice authority of an
                                                                                            a physician, and is thus qualified to be                         APRN is subject to the limitations
                                                  Dated: May 20, 2016.                      privileged for such scope of practice.                           imposed by the Controlled Substances
                                               Michael Shores,                                 (d) Services provided by an APRN                              Act, 21 U.S.C. 801 et seq., and that
                                               Acting Director, Office of Regulation Policy with full practice authority. (1) Subject                        APRN’s State licensure on the authority
                                               & Management, Office of Secretary,           to the limitations established in                                to prescribe, or administer controlled
                                               Department of Veterans Affairs.              paragraph (d)(2) of this section, the full                       substances, as well as any other
                                                  For the reasons set forth in the          practice authority for each of the four                          limitations on the provision of VA care
                                               preamble, we propose to amend 38 CFR APRN roles includes, but is not limited                                  set forth in applicable Federal law and
                                               part 17 as follows:                          to, providing the following services:                            policy.
                                                                                               (i) A CNP has full practice authority                            (e) Preemption of State and local law.
                                               PART 17—MEDICAL                              to:                                                              To achieve important Federal interests,
                                                                                               (A) Take comprehensive histories,                             including but not limited to the ability
                                               ■ 1. The authority citation for part 17      provide physical examinations and
                                               continues to read as follows:                                                                                 to provide the same comprehensive care
                                                                                            other health assessment and screening                            to veterans in all States under 38 U.S.C.
                                                  Authority: 38 U.S.C. 501, and as noted in activities, diagnose, treat, and manage                          7301, this section preempts conflicting
                                               specific sections.                           patients with acute and chronic                                  State and local laws relating to the
                                               ■ 2. Amend part 17 by adding an              illnesses and diseases;                                          practice of APRNs when such APRNs
                                               undesignated center heading and                 (B) Order, perform, supervise, and                            are working within the scope of their
                                               § 17.415 immediately after § 17.410 to       interpret laboratory and imaging                                 VA employment. Any State or local law,
                                               read as follows:                             studies;                                                         or regulation pursuant to such law, is
                                                                                               (C) Prescribe medication and durable                          without any force or effect on, and State
                                               Nursing Services                             medical equipment;                                               or local governments have no legal
                                                                                               (D) Make appropriate referrals for                            authority to enforce them in relation to
                                               § 17.415 Full practice authority for
                                               advanced practice registered nurses.
                                                                                            patients   and families, and request                             this section or decisions made by VA
                                                                                            consultations;                                                   under this section.
                                                  (a) Advanced practice registered nurse       (E) Aid in health promotion, disease
                                               (APRN). For purposes of this section, an prevention, health education, and                                    (Authority: 38 U.S.C. 7301, 7304, 7402, and
                                               advanced practice registered nurse           counseling as well as the diagnosis and                          7403)
                                               (APRN) is an individual who:                 management of acute and chronic                                  [FR Doc. 2016–12338 Filed 5–24–16; 8:45 am]
                                                  (1) Has completed a nationally-           diseases.                                                        BILLING CODE 8320–01–P
                                               accredited, graduate-level educational          (ii) A CRNA has full practice
                                               program that prepares them for one of        authority to:
                                               the four APRN roles of Certified Nurse          (A) Plan and initiate anesthetic                              ENVIRONMENTAL PROTECTION
                                               Practitioner (CNP), Certified Registered     techniques (general, regional, local) and                        AGENCY
                                               Nurse Anesthetist (CRNA), Clinical           sedation;
                                               Nurse Specialist (CNS), or Certified            (B) Provide post-anesthesia evaluation                        40 CFR Part 52
                                               Nurse-Midwife (CNM);                         and discharge;
                                                  (2) Has passed a national certification                                                                    [EPA–R01–OAR–2014–0364; A–1–FRL–
                                                                                               (C) Order and evaluate diagnostic
                                               examination that measures knowledge                                                                           9936–62–Region 1]
                                                                                            tests;
                                               in one of the APRN roles described in           (D) Request consultations;                                    Air Plan Approval; Connecticut; Sulfur
                                               paragraph (a)(1) of this section;               (D) Perform point-of-care testing; and                        Content of Fuel Oil Burned in
                                                  (3) Has obtained a license from a State      (E) Respond to emergency situations                           Stationary Sources
                                               licensing board in one of four               for airway management.
                                               recognized APRN roles described in              (iii) A CNS has full practice authority                       AGENCY:  Environmental Protection
                                               paragraph (a)(1) of this section; and        to provide diagnosis and treatment of                            Agency (EPA).
                                                  (4) Maintains certification and           health or illness states, disease
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                                                                                                                                                             ACTION: Proposed rule.
                                               licensure as required by paragraphs          management, health promotion, and
                                               (a)(2) and (3) of this section.              prevention of illness and risk behaviors                         SUMMARY:  The Environmental Protection
                                                  (b) Full practice authority. For          among individuals, families, groups,                             Agency (EPA) is proposing to approve a
                                               purposes of this section, full practice      and communities within their scope of                            State Implementation Plan (SIP)
                                               authority means the authority of an          practice.                                                        revision submitted by the State of
                                               APRN to provide services described in           (iv) A CNM has full practice authority                        Connecticut on April 22, 2014, with
                                               paragraph (d) of this section without the to provide a range of primary health                                supplemental submittals on June 18,


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Document Created: 2018-02-07 15:03:42
Document Modified: 2018-02-07 15:03:42
CategoryRegulatory Information
CollectionFederal Register
sudoc ClassAE 2.7:
GS 4.107:
AE 2.106:
PublisherOffice of the Federal Register, National Archives and Records Administration
SectionProposed Rules
ActionProposed rule.
DatesComments must be received by VA on or before July 25, 2016.
ContactDr. Penny Kaye Jensen, Liaison for National APRN Practice, 810 Vermont Ave. NW., Washington, DC 20420; (202) 461-6700. (This is not a toll-free number.)
FR Citation81 FR 33155 
RIN Number2900-AP44
CFR AssociatedAdministrative Practice and Procedure; Alcohol Abuse; Alcoholism; Claims; Day Care; Dental Health; Drug Abuse; Foreign Relations; Government Contracts; Grant Programs-Health; Grant Programs-Veterans; Health Care; Health Facilities; Health Professions; Health Records; Homeless; Medical and Dental Schools; Medical Devices; Medical Research; Mental Health Programs; Nursing Homes; Philippines; Reporting and Recordkeeping Requirements; Scholarships and Fellowships; Travel and Transportation Expenses and Veterans

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