244 CMR 4.00 — Advanced practice registered nursing

244 CMR: BOARD OF REGISTRATION IN NURSING 244 CMR 4.00:ADVANCED PRACTICE REGISTERED NURSING Section

244 CMR 4.00 Advanced practice registered nursing

4.01 Purpose

4.01: Purpose

4.02 Definitions

4.02: Definitions

4.03 Clinical Categories of Advanced Practice Registered Nurses

4.03: Clinical Categories of Advanced Practice Registered Nurses

4.04 Prohibition of Practice without Authorization and Rules Governing Advertising and Personal

4.04: Prohibition of Practice without Authorization and Rules Governing Advertising and Personal Identification

4.05 Eligibility Requirements for Advanced Practice Registered Nurse (APRN) Authorization

4.05: Eligibility Requirements for Advanced Practice Registered Nurse (APRN) Authorization

4.06 Responsibility, Accountability and Scope of Practice for Advanced Practice Registered Nurses

4.06: Responsibility, Accountability and Scope of Practice for Advanced Practice Registered Nurses

4.07 Advanced Practice Registered Nurse Eligible to Engage in Prescriptive Practice

4.07: Advanced Practice Registered Nurse Eligible to Engage in Prescriptive Practice

4.08 Authorization to Practice as an Advance Practice Registered Nurse in More than One Clinical

4.08: Authorization to Practice as an Advance Practice Registered Nurse in More than One Clinical Category

4.09 Malpractice Insurance

4.09: Malpractice Insurance

4.01 Purpose

4.01: Purpose The purpose of 244 CMR 4.00 is to establish the conditions under which the Registered Nurse (RN) licensed by the Board of Registration in Nursing may be authorized to practice as an Advanced Practice Registered Nurse (APRN). 244 CMR 4.00 also establishes principles regarding clinical category, scope, collaboration, supervision, and accountability to which Advanced Practice Registered Nurses (APRNs) are subject.

4.02 Definitions

4.02: Definitions Definitions for terms used in 244 CMR 4.00 and throughout 244 CMR are set forth in 244 CMR 10.00: Definitions.

4.03 Clinical Categories of Advanced Practice Registered Nurses

4.03: Clinical Categories of Advanced Practice Registered Nurses (1) Board recognized APRN clinical categories and abbreviations include: (a) Certified Registered Nurse Anesthetist (CRNA); (b) Certified Nurse Midwife (CNM); (c) Certified Nurse Practitioner (CNP); (d) Clinical Nurse Specialist (CNS); and (2) Psychiatric Nurse Mental Health Clinical Specialist (PNMHCS). This category corresponds to M.G.L. c. 94C, §§ 1, 7 and 9 and M.G.L. c. 112, §§ 80E, and includes the advanced practice registered nurse clinical category Psychiatric Clinical Nurse Specialist (PCNS).

4.04 Prohibition of Practice without Authorization and Rules Governing Advertising and Personal

4.04: Prohibition of Practice without Authorization and Rules Governing Advertising and Personal Identification No person shall announce or represent to the public that such person is an APRN or use the name of any APRN clinical category unless such person has complied with the requirements for and received Board authorization to practice as an APRN in accordance with 244 CMR 4.00.

4.05 Eligibility Requirements for Advanced Practice Registered Nurse (APRN) Authorization

4.05: Eligibility Requirements for Advanced Practice Registered Nurse (APRN) Authorization (1) Certified Registered Nurse Anesthetist (CRNA). (a) To be eligible for initial Board authorization to practice as a CRNA, an applicant must provide proof satisfactory to the Board of the following:

Valid Massachusetts RN licensure in good standing;
Good moral character as required by M.G.L. c. 112, § 74, and as established by Board policy; (Mass. Register #1451 9/3/21)

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4.05: continued

3. Compliance with the following academic requirements:

Graduation from a graduate degree program that:
is designed to prepare the RN for practice as a CRNA; and

ii. holds accreditation from a Board recognized national accrediting organization

for academic programs; and

b. Successful completion of, at minimum, core content at the graduate level

in advanced assessment, advanced pathophysiology and advanced pharmaco-

therapeutics.

4. Current CRNA certification granted by a Board Recognized APRN Certifying

Organization;

5. Payment of the required fees as established by the Executive Office of Administration

and Finance, unless waived pursuant to M.G.L. c. 112, § 1B;

6. An attestation, signed under the pains and penalties of perjury, that the applicant

participates in, or has applied to participate in, MassHealth as either a provider of

services or as a non-billing provider for the purpose of ordering and referring services

covered under MassHealth; and

7. If engaging in prescriptive practice, completion of training required pursuant to

M.G.L. c. 94C, § 18(e).

(b) To be eligible for renewal of the Board's authorization to practice as a CRNA, the

CRNA must provide proof satisfactory to the Board of the following:

Valid Massachusetts RN licensure in good standing;
Good moral character as required at MGL c. 112, § 74, and as established by Board policy;
Current CRNA certification granted by a Board Recognized APRN Certifying Organization;
Payment of the required fees as established by the Executive Office of Administration and Finance; and
If engaging in prescriptive practice, completion of training required pursuant to M.G.L. c. 94C, § 18(e). (c) Nurses who obtained initial Board authorization to practice as a CRNA prior to August 1, 2014 may renew their authorization in accordance with the provisions of 244 CMR 4.05(1)(b), even if they do not meet requirements for initial authorization to practice as a CRNA set forth in 244 CMR 4.05(1)(a) or 4.05(1)(d). (d) Initial Authorization of CRNA by Reciprocity. To be eligible for reciprocal Board authorization to practice as a CRNA from another jurisdiction, an applicant must provide proof satisfactory to the Board of the following:
Valid Massachusetts RN licensure in good standing;
Good moral character as required by M.G.L. c. 112, § 74, and as established by Board policy;
Compliance with the following academic requirements:
1. Graduation from a graduate degree program that:
2. is designed to prepare the RN for practice as a CRNA; and
ii. holds accreditation from a Board recognized national accrediting organization for academic programs; or b. Satisfactory completion of a formal education program in addition to academic nursing preparation which meets the standards of a Board recognized national accrediting organization for academic programs and which has as its objective the preparation of nurses to perform as a CRNA; and c. Successful completion of, at minimum, core content at the graduate level in advanced assessment, advanced pathophysiology and advanced pharmaco- therapeutics.
Current license or authorization as a CRNA in another state, the District of Columbia, or a U.S. Territory in good standing;
Current CRNA certification granted by a Board Recognized APRN Certifying Organization; 6.Payment of the required fees as established by the Executive Office of Administration and Finance, unless waived pursuant to M.G.L. c. 112, § 1B.;

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4.05: continued 7. An attestation, signed under the pains and penalties of perjury, that the applicant participates in, or has applied to participate in, MassHealth as either a provider of services or as a non-billing provider for the purpose of ordering and referring services covered under MassHealth; and 8. If engaging in prescriptive practice, completion of training required pursuant to M.G.L. c. 94C, § 18(e). (e) The Board may revoke, suspend, or refuse to renew its authorization permitting an RN to practice as a CRNA or otherwise discipline the authorization and/or the RN license if it determines, after an adjudicatory hearing conducted in accordance with M.G.L. c. 30A, that the person fails to meet any regulation requirement. In addition, the Board may impose discipline for any of the reasons set forth in M.G.L. c. 112, §§ 61 and 74. (2) Certified Nurse Midwife (CNM). (a) To be eligible for initial Board authorization to practice as a CNM, an applicant must provide proof satisfactory to the Board of the following:

Valid Massachusetts RN licensure in good standing;
Good moral character as required by M.G.L. c. 112, § 74, and as established by Board policy;
Compliance with the following academic requirements:
1. Graduation from a graduate degree program that:
2. is designed to prepare the RN for practice as a CNM;
ii. holds accreditation from a Board recognized national accrediting organization for academic programs; and b. Successful completion of, at minimum, core content at the graduate level in advanced assessment, advanced pathophysiology and advanced pharmaco- therapeutics.
Current CNM certification granted by a Board Recognized APRN Certifying Organization; 5.Payment of the required fees as established by the Executive Office of Administration and Finance, unless waived pursuant to M.G.L. c. 112, § 1B;
An attestation, signed under the pains and penalties of perjury, that the applicant participates in, or has applied to participate in, MassHealth as either a provider of services or as a non-billing provider for the purpose of ordering and referring services covered under MassHealth; and
If engaging in prescriptive practice, completion of training required pursuant to M.G.L. c. 94C, § 18(e). (b) To be eligible for renewal of the Board's authorization to practice as a CNM, an applicant must provide proof satisfactory to the Board of the following:
Valid Massachusetts RN licensure in good standing;
Good moral character as required at MGL c. 112, § 74, and as established by Board policy;
Current CNM certification granted by a Board Recognized APRN Certifying Organization;
Payment of the required fees as established by the Executive Office of Administration and Finance; and
If engaging in prescriptive practice, completion of training required pursuant to M.G.L. c. 94C, § 18(e). (c) Nurses who obtained initial Board authorized practice as a CNM prior to August 1, 2014 may renew their authorization in accordance with the provisions of 244 CMR 4.05(2)(b), even if they do not meet the requirements for initial authorization to practice as a CNM set fourth in 244 CMR 4.05(2)(a) or 4.05(2)(d). (d) Initial Authorization of CNM by Reciprocity. To be eligible for reciprocal Board authorization to practice as a CNM from another jurisdiction, an applicant must provide proof satisfactory to the Board of the following:
Valid Massachusetts RN licensure in good standing;
Good moral character as required by M.G.L. c. 112, § 74, and as established by Board policy;

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4.05: continued

3. Compliance with the following academic requirements:

Graduation from a graduate degree program that:
is designed to prepare the RN for practice as a CNM; and

ii. holds accreditation from a Board recognized national accrediting organization

for academic programs; or

b. Satisfactory completion of a formal educational program in addition to academic

nursing preparation which meets the standards of a Board recognized national

accrediting organization for academic programs and which has as its objective the

preparation of nurses to practice as a CNM; and

c. Successful completion of, at minimum, core content at the graduate level in

advanced assessment, advanced pathophysiology and advanced pharmaco-

therapeutics.

4. Current license or authorization as a CNM in another state, the District of Columbia,

or a U.S. Territory in good standing;

5. Current CNM certification granted by a Board Recognized APRN Certifying

Organization;

6. Payment of the required fees as established by the Executive Office of Administration

and Finance, unless waived pursuant to M.G.L. c. 112, § 1B;

7. An attestation, signed under the pains and penalties of perjury, that the applicant

participates in, or has applied to participate in, MassHealth as either a provider of

services or as a non-billing provider for the purpose of ordering and referring services

covered under MassHealth; and

8. If engaging in prescriptive practice, completion of training required pursuant to

M.G.L. c. 94C, § 18(e).

(e) The Board may revoke, suspend, or refuse to renew its authorization permitting an RN

to practice as a CNM or otherwise discipline the authorization and/or the RN license if it

determines, after an adjudicatory hearing conducted in accordance with M.G.L. c. 30A, that

the person fails to meet any regulation requirement. In addition, the Board may impose

discipline for any of the reasons set forth in M.G.L. c. 112, §§ 61 and 74.

(3) Certified Nurse Practitioner (CNP).

(a) To be eligible for initial Board authorization to practice as a CNP, an applicant must

provide proof satisfactory to the Board of the following:

Valid Massachusetts RN licensure in good standing;
Good moral character as required by M.G.L. c. 112, § 74, and as established by Board policy;
Compliance with the following academic requirements:
1. Graduation from a graduate degree program that:
2. is designed to prepare the RN for practice as a CNP; and
ii. holds accreditation from a Board recognized national accrediting organization for academic programs; and b. Successful completion of, at minimum, core content at the graduate level in advanced assessment, advanced pathophysiology and advanced pharmacotherapeutics.
Current CNP certification granted by a Board Recognized APRN Certifying Organization;
Payment of the required fees as established by the Executive Office of Administration and Finance, unless waived pursuant to M.G.L. c. 112, § 1B;
An attestation, signed under the pains and penalties of perjury, that the applicant participates in, or has applied to participate in, MassHealth as either a provider of services or as a non-billing provider for the purpose of ordering and referring services covered under MassHealth; and
If engaging in prescriptive practice, completion of training required pursuant to M.G.L. c. 94C, § 18(e). (b) To be eligible for renewal of the Board's authorization to practice as a CNP, the CNP must provide proof satisfactory to the Board of the following:
Valid Massachusetts RN licensure in good standing;
Good moral character as required at M.G.L. c. 112, § 74, and as established by Board policy;

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4.05: continued 3. Current CNP certification granted by a Board Recognized APRN Certifying Organization; 4. Payment of the required fees as established by the Executive Office of Administration and Finance; and 5. If engaging in prescriptive practice, completion of training required pursuant to M.G.L. c. 94C, § 18(e). (c) Nurses who obtained initial Board authorized practice as a CNP prior to August 1, 2014 may renew their authorization in accordance with the provisions of 244 CMR 4.05(3)(b), even if they do not meet requirements for initial authorization to practice as a CNP set forth in 244 CMR 4.05(3)(a) or 4.05(3)(d). (d) Initial Authorization of CNP by Reciprocity. To be eligible for reciprocal Board authorization to practice as a CNP from another jurisdiction, an applicant must provide proof satisfactory to the Board of the following:

Valid Massachusetts RN licensure in good standing;
Good moral character as required by M.G.L. c. 112, § 74, and as established by Board policy;
Compliance with the following academic requirements:
1. Graduation from a graduate degree program that:
2. is designed to prepare the RN for practice as a CNP; and
ii. holds accreditation from a Board recognized national accrediting organization for academic programs; or b. Satisfactory completion of a formal educational program in addition to academic nursing preparation which meets the standards of a Board recognized national accrediting organization for academic programs and which has as its objective the preparation of professional nurses to practice as a CNP; and c. Successful completion of, at minimum, core content at the graduate level in advanced assessment, advanced pathophysiology and advanced pharmacotherapeutics.
Current license or authorization as a CNP in another state, the District of Columbia, or a U.S. Territory in good standing;
Current CNP certification granted by a Board Recognized APRN Certifying Organization;
Payment of the required fees as established by the Executive Office of Administration and Finance, unless waived pursuant to M.G.L. c. 112, § 1B; 7.An attestation, signed under the pains and penalties of perjury, that the applicant participates in, or has applied to participate in, MassHealth as either a provider of services or as a non-billing provider for the purpose of ordering and referring services covered under MassHealth; and 8.If engaging in prescriptive practice, completion of training required pursuant to M.G.L. c. 94C, § 18(e). (e) The Board may revoke, suspend, or refuse to renew its authorization permitting a RN to practice as a CNP or otherwise discipline the authorization and/or the RN license if it determines, after an adjudicatory hearing conducted in accordance with M.G.L. c. 30A, that the person fails to meet any regulation requirement. In addition, the Board may impose discipline for any of the reasons set forth in M.G.L. c. 112, §§ 61 and 74. (4) Psychiatric Nurse Mental Health Clinical Specialist (PNMHCS). (a) To be eligible for initial Board authorization to practice as a PNMHCS, an applicant must provide proof satisfactory to the Board of the following:
Valid Massachusetts RN licensure in good standing;
Good moral character as required by M.G.L. c. 112, § 74, and as established by Board policy; 3.Compliance with the following academic requirements:
1. Graduation from a graduate degree program that:
2. is designed to prepare the RN for practice as a PNMHCS; and
ii. holds accreditation from a Board recognized national accrediting organization for academic programs; and b. Successful completion of, at minimum, core content at the graduate level in advanced assessment, advanced pathophysiology and advanced pharmacotherapeutics.

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4.05 continued

4.05: continued 4. Current PNMHCS certification granted by a Board Recognized APRN Certifying Organization; 5. Payment of the required fees as established by the Executive Office of Administration and Finance, unless waived pursuant to M.G.L. c. 112, § 1B; 6. An attestation, signed under the pains and penalties of perjury, that the applicant participates in, or has applied to participate in, MassHealth as either a provider of services or as a non-billing provider for the purpose of ordering and referring services covered under MassHealth; and 7. If engaging in prescriptive practice, completion of training required pursuant to M.G.L. c. 94C, § 18(e). (b) To be eligible for renewal of the Board's authorization to practice as a PNMHCS, an applicant must provide proof satisfactory to the Board of the following:

Valid Massachusetts RN licensure in good standing;
Good moral character as required at M.G.L. c. 112, § 74, and as established by Board policy;
Current PNMHCS certification granted by a Board Recognized APRN Certifying Organization;
Payment of the required fees as established by the Executive Office of Administration and Finance; and
If engaging in prescriptive practice, completion of training required pursuant to M.G.L. c. 94C, § 18(e). (c) Nurses who obtained initial Board authorized practice as a PNMHCS prior to August 1, 2014 may renew their authorization in accordance with the provisions of 244 CMR 4.05(4)(b), even if they do not meet requirements for initial authorization to practice as a PCNS set forth in 244 CMR 4.05(4)(a) or 4.05(4)(d). (d) Initial Authorization of PNMHCS by Reciprocity. To be eligible for reciprocal Board authorization to practice as a PNMHCS from another jurisdiction, an applicant must provide proof satisfactory to the Board of the following:
Valid Massachusetts RN licensure in good standing;
Good moral character as required by M.G.L. c. 112, § 74, and as established by Board policy;
Compliance with the following academic requirements:
1. Graduation from a graduate degree program that:
2. is designed to prepare the RN for practice as a PNMHCS; and
ii. holds accreditation from a Board recognized national accrediting organization for academic programs; or b. Satisfactory completion of a formal educational program in addition to academic nursing preparation which meets the standards of a Board recognized national accrediting organization for academic programs and which has as its objective the preparation of nurses to practice as PNMHCS; and c. Successful completion of, at minimum, core content at the graduate level in advanced assessment, advanced pathophysiology and advanced pharmacotherapeutics.
Current license or authorization as a PNMHCS in another state, the District of Columbia, or a U.S. Territory in good standing;
Current PNMHCS certification granted by a Board Recognized APRN Certifying Organization;
Payment of the required fees as established by the Executive Office of Administration and Finance, unless waived pursuant to M.G.L. c. 112, § 1B;
An attestation, signed under the pains and penalties of perjury, that the applicant participates in, or has applied to participate in, MassHealth as either a provider of services or as a non-billing provider for the purpose of ordering and referring services covered under MassHealth; and
If engaging in prescriptive practice, completion of training required pursuant to M.G.L. c. 94C, § 18(e). (e) The Board may revoke, suspend, or refuse to renew its authorization permitting a RN to practice as a PNMHCS or otherwise discipline the authorization and/or the RN license if it determines, after an adjudicatory hearing conducted in accordance with M.G.L. c. 30A, that the person fails to meet any regulation requirement. In addition, the Board may impose discipline for any of the reasons set forth in M.G.L. c. 112, §§ 61 and 74.

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4.05 continued

4.05: continued (5) Clinical Nurse Specialist (CNS). (a) To be eligible for initial Board authorization to practice as a CNS, an applicant must provide proof satisfactory to the Board of the following:

Valid Massachusetts RN licensure in good standing;
Good moral character as required by M.G.L. c. 112, § 74, and as established by Board policy;
Compliance with the following academic requirements:
1. Graduation from a graduate degree program that:
2. is designed to prepare the RN for practice as a CNS; and
ii. holds accreditation from a Board recognized national accrediting organization for academic programs; b. Successful completion of, at minimum, core content at the graduate level in advanced assessment, advanced pathophysiology and advanced pharmacotherapeutics; and c. Current CNS certification granted by a Board Recognized APRN Certifying Organization;
Payment of the required fees as established by the Executive Office of Administration and Finance, unless waived pursuant to M.G.L. c. 112, § 1B;
An attestation, signed under the pains and penalties of perjury, that the applicant participates in, or has applied to participate in, MassHealth as either a provider of services or as a non-billing provider for the purpose of ordering and referring services covered under MassHealth; and
Effective until December 31, 2016, the Board will accept current CNS certification granted by a Board-recognized certifying organization as equivalent to 244 CMR 4.05(5)(a)3b. The CNS who is authorized by the Board on the basis of this equivalent competency will be eligible to renew his or her authorization under 244 CMR 4.05(5)(b). (b) To be eligible for renewal of the Board's authorization to practice as a CNS, an applicant must provide proof satisfactory to the Board of the following:
Valid Massachusetts RN licensure in good standing;
Good moral character as required at M.G.L. c. 112, § 74, and as established by Board policy;
Current CNS certification granted by a Board Recognized APRN Certifying Organization; and
Payment of the required fees as established by the Executive Office of Administration and Finance, unless waived pursuant to M.G.L. c. 112, § 1B. (c) Initial Authorization of CNS by Reciprocity. To be eligible for reciprocal Board authorization to practice as a CNS from another jurisdiction, an applicant must provide proof satisfactory to the Board of the following:
Valid Massachusetts RN licensure in good standing;
Good moral character as required by M.G.L. c. 112, § 74, and as established by Board policy;
Compliance with the following academic requirements:
1. Graduation from a graduate degree program that:
2. is designed to prepare the RN for practice as a CNS ; and
ii. holds accreditation from a Board recognized national accrediting organization for academic programs; and b. Successful completion of, at minimum, core content at the graduate level in advanced assessment, advanced pathophysiology and advanced pharmacotherapeutics;
Current license or authorization as a CNS in another state, the District of Columbia, or a U.S. Territory in good standing;
Current CNS certification granted by a Board Recognized APRN Certifying Organization;
Payment of the required fees as established by the Executive Office of Administration and Finance, unless waived pursuant to M.G.L. c. 112, § 1B; and
An attestation, signed under the pains and penalties of perjury, that the applicant participates in, or has applied to participate in, MassHealth as either a provider of services or as a non-billing provider for the purpose of ordering and referring services covered under MassHealth.

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4.05 continued

4.05: continued 8. Effective until December 31, 2016, the Board will accept current CNS certification granted by a Board-recognized certifying organization as equivalent to 244 CMR 4.05(5)(c)3b. The CNS who is authorized by the Board on the basis of this equivalent competency will be eligible to renew his or her authorization under 244 CMR 4.05(5)(b). (d) The Board may revoke, suspend, or refuse to renew its authorization permitting a RN to practice as a CNS or otherwise discipline the authorization and/or the RN license if it determines, after an adjudicatory hearing conducted in accordance with M.G.L. c. 30A, that the person fails to meet any regulation requirement. In addition, the Board may impose discipline for any of the reasons set forth in M.G.L. c. 112, §§ 61 and 74.

4.06 Responsibility, Accountability and Scope of Practice for Advanced Practice Registered Nurses

4.06: Responsibility, Accountability and Scope of Practice for Advanced Practice Registered Nurses Each APRN is responsible and accountable for their nursing judgments, actions, and competency. (1) Certified Registered Nurse Anesthetist (CRNA). (a) A CRNA will only practice in the clinical category(s) for which the CRNA has attained and maintained certification. A CRNA may attain additional competencies within their category(s) consistent with the scope and standards of CRNA practice. It is the responsibility of each CRNA to maintain records of competency-based training and submit evidence to the Board upon request. (b) The scope of CRNA practice is reflective of standards for the provision of healthcare services in diverse settings for for individuals across the lifespan, whose health status may range from healthy through all recognized levels of acuity, including persons with immediate, severe, or life-threatening illness or injury, including anesthesia care and anesthesia-related care, acute and chronic pain management, palliative care, emergency care, critical care, resuscitative and sedation services. In order to issue prescriptions, the CRNA must register with the Department of Public Health's Drug Control Program pursuant to M.G.L. c. 94C, and 105 CMR 700.00: Implementation of M.G.L. c. 94C, as well as with the U.S. Drug Enforcement Agency (DEA), if applicable. (c) A CRNA who does not register for prescriptive authority administers anesthesia pursuant to the signed order of a registered prescriber. Such CRNA may select anesthetic agents based upon protocols that are mutually developed with a registered prescriber responsible for the perioperative care of a patient, as appropriate for the practice setting. (d) Pursuant to M.G.L. c. 112, § 80H, the administration of anesthesia by a CRNA directly to a patient does not require a prescription. (2) Certified Nurse Midwife (CNM). (a) A CNM will only practice in the clinical category(s) for which the CNM has attained and maintained certification. A CNM may attain additional competencies within their category(s) consistent with the scope and standards of CNM practice. It is the responsibility of each CNM to maintain records of competency-based training and submit evidence to the Board upon request. (b) The scope of CNM practice is reflective of the standards established by a Board recognized national organization for midwifery practice for the provision of primary health care services in diverse settings to individuals throughout the lifespan, including gynecologic care, abortion for pregnancy less than 24 weeks, family planning services, preconception care, prenatal and postpartum care, childbirth, care of the newborn and treatment of the partner of their clients for sexually transmitted disease, transgender care, sexual health and reproductive health for which the CNM has been educationally prepared and for which competency has been established and maintained. A CNM practices within a healthcare system and develops clinical relationships with obstetrician-gynecologists. (3) Certified Nurse Practitioner (CNP). (a) A CNP will only practice in the clinical category(s) for which the CNP has attained and maintained certification. A CNP may attain additional competencies within their category(s) consistent with the scope and standards of CNP practice. It is the responsibility of each CNP to maintain records of competency-based training and submit evidence to the Board upon request.

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4.06 continued

4.06: continued (b) The scope of CNP practice is reflective of standards for the provision of health care services in diverse settings to individuals throughout the lifespan, including health promotion, disease prevention, health education, abortion for pregnancy less than 24 weeks, counseling and making referrals to other members of the health care team, as well as the diagnosis and management of acute and chronic illness and disease. (c) Pursuant to M.G.L. c. 112, § 80I, when a law or rule requires a signature, certification, stamp, verification, affidavit or endorsement by a physician, when relating to physical or mental health, that requirement may be fulfilled by a CNP, provided that the signature, certification, stamp, verification, affidavit, or endorsement is consistent with established scope of practice standards and does not expand the scope of practice of the CNP. (d) Pursuant to St. 2012, c. 369 and M.G.L. c. 112, § 80I, CNPs with independent practice authority, and CNPs under supervised practice pursuant to mutually agreed upon guidelines between the CNP and Qualified Healthcare Professional, as defined in 244 CMR 4.07, supervising the CNP's prescriptive practice, are authorized to issue written certifications of marijuana for medical use. (4) Psychiatric Nurse Mental Health Clinical Specialist (PNMHCS). (a) A PNMHCS will only practice in the clinical category(s) for which the PNMHCS has attained and maintained certification. A PNMHCS may attain additional competencies within their category(s) consistent with the scope and standards of PNMHCS practice. It is the responsibility of each PNMHCS to maintain records of competency-based training and submit evidence to the Board upon request. (b) The scope of PNMHCS practice is reflective of standards for the provision of psychiatric health care services in diverse settings to individuals throughout the lifespan, including health promotion, disease prevention, health education, counseling and making referrals to other members of the health care team, as well as the diagnosis and management of acute and chronic psychiatric illness and psychiatric disease. (5) Clinical Nurse Specialist (CNS). (a) A CNS will only practice in the clinical category(s) for which the CNS has attained and maintained certification. A CNS may attain additional competencies within their category(s) consistent with the scope and standards of CNS practice. It is the responsibility of each CNS to maintain records of competency-based training and submit evidence to the Board upon request. (b) The scope of CNS practice is reflective of standards for the integration of an advanced level of direct and indirect nursing care beyond the scope of RN practice. In addition to the provision of assistance to other nurses and health professionals in establishing and meeting health goals of individuals and groups, a CNS may provide health care services in diverse settings to individuals throughout the lifespan, including health promotion, disease prevention, health education, counseling and making referrals to other members of the health care team, as well as the diagnosis and management of illness and disease.

4.07 Advanced Practice Registered Nurses Eligible to Engage in Prescriptive Practice

4.07: Advanced Practice Registered Nurses Eligible to Engage in Prescriptive Practice (1) Purpose. The purpose of 244 CMR 4.07 is to establish, pursuant to M.G.L. c. 112, §§ 80B, 80C, 80E, 80G and 80H, regulations governing the practice of those APRNs who are registered prescribers. The following APRNs are eligible to register with the Department of Public Health pursuant to M.G.L. c. 94C and the U.S. Drug Enforcement Administration to engage in prescriptive practice. (a) A Certified Nurse Midwife authorized to practice within a healthcare system as a nurse midwife by the Board pursuant to M.G.L. c. 112, §§ 80B, 80C and 80G, and 244 CMR 4.00. (b) A Certified Nurse Practitioner authorized to practice as a nurse practitioner by the Board pursuant to M.G.L. c. 112, §§ 80B and 80E, and 244 CMR 4.00. (c) A Psychiatric Clinical Nurse Specialist authorized to practice as a psychiatric nurse mental health clinical specialist by the Board pursuant to M.G.L. c. 112, §§ 80B and 80E, and 244 CMR 4.00.

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4.07 continued

4.07: continued (d) A Certified Registered Nurse Anesthetist authorized to practice as a nurse anesthetist by the Board pursuant to M.G.L. c. 112, §§ 80B and 80H, and 244 CMR 4.00. For purposes of 244 CMR 4.07, a Qualified Healthcare Professional means a person who meets the following criteria:

a physician who: a. holds an unrestricted full license issued by the Board of Registration in Medicine (BORIM) that is in good standing; b. is Board-certified in a specialty area appropriately related to the APRN's area of practice, or has hospital admitting privileges in a specialty area appropriately related to the APRN's area of practice; and c. holds a valid controlled substances registration issued by the U.S. Drug Enforcement Administration, or the Department of Public Health, or both.
a CRNA, CNP or PNMHCS who holds:
1. a valid Registered Nurse license in good standing issued by the Board; and
2. advanced practice authorization issued by the Board that it is in the same clinical
category as the person being supervised or advanced practice authorization in an area appropriately related to the practice of the person being supervised; and
a controlled substance registration issued by the U.S. Drug Enforcement Administration, or the Department of Public Health, or both, for a minimum of one year; and
either: a. a combination of supervised practice for a minimum of two years plus independent practice authority for a minimum of one year; or b. three years of independent practice authority. (2) Prescriptive Practice. CNMs may engage in prescriptive practice as authorized pursuant to M.G.L. c. 94C, § 7(g) and M.G.L. c. 112, §§ 80C and 80G. CRNAs, CNPs or PNMHCSs may engage in prescriptive practice as authorized pursuant to M.G.L. c. 94C, § 7 and M.G.L. c. 112, §§ 80B, 80E and 80H. (a) CRNAs, CNPs or PNMHCSs with a minimum of two years of supervised practice may engage in prescriptive practice without supervision upon submission of an attestation to the Board that the CRNA, CNP or PNMHCS has completed a minimum of two years of supervised practice by a Qualified Healthcare Professional. (b) If applying for authorization in Massachusetts by reciprocity, the CRNA, CNP or PNMHCS may engage in prescriptive practice without supervision upon the submission of an attestation to the Board that the CRNA, CNP or PNMHCS has practiced independently or with supervision as a CRNA, CNP or PNMHCS in a jurisdiction other than Massachusetts for a minimum of two years. (c) CRNAs, CNPs or PNMHCSs with less than two years of supervised practice experience, or its equivalent, may engage in prescriptive practice with supervision by a Qualified Healthcare Professional. CRNAs, CNPs or PNMHCSs with less than two years supervised practice will develop mutually agreed upon guidelines with the Qualified Healthcare Professional which will:
identify the supervising Qualified Healthcare Professional, including a mechanism for ongoing supervision by another Qualified Healthcare Professional, including but not limited to, duration and scope of the supervision ;
describe circumstances in which Qualified Healthcare Professional consultation or referral is required;
CRNA guidelines do not need to be signed. CNP and PNMHCS guidelines shall be signed. The guidelines will be kept on file in the workplace; and
conform to M.G.L. c. 94C, the regulations of the Department of Public Health at 105 CMR 700.000: Implementation of M.G.L. c. 94C, 105 CMR 721.000: Standards for Prescription Format and Security in Massachusetts, M.G.L. c. 112, §§ 80B, 80E, 80H and 80I, and 244 CMR 4.00. The Board may request at any time an opportunity to review the APRN prescriptive practice guidelines. Failure to provide guidelines to the Board is a basis for and may result in disciplinary action. The Board may require changes in the guidelines if it determines that they do not comply with 244 CMR 4.00 and accepted standards of nursing practice.

244 CMR: BOARD OF REGISTRATION IN NURSING

4.06 continued

4.06: continued (3) Prescribing Hydrocodone-only Extended Release Medication. Prior to prescribing a hydrocodone-only extended release medication that is not in an abuse deterrent form, a licensee must: (a) Thoroughly assess the patient, including an evaluation of the patient's risk factors, substance abuse history, presenting condition(s), current medication(s) and a check of the online Prescription Monitoring Program; (b) Discuss the risks and benefits of the medication with the patient; (c) Enter into a Pain Management Treatment Agreement with the patient that shall appropriately address drug screening, pill counts, safe storage and disposal and other requirements based on the patient's diagnoses, treatment plan, and risk assessment; (d) Supply a Letter of Medical Necessity as required by the Board of Registration in Pharmacy that includes the patient's diagnoses and treatment plan, verifies that other pain management treatments have failed, indicates that a risk assessment was performed and that the licensee and the patient have entered into a Pain Management Treatment Agreement; and (e) Document 244 CMR 4.07(3)(a) through (d) in the patient's medical record. The purpose of 244 CMR 4.07(3) is to enhance the public health and welfare by promoting optimum therapeutic outcomes, avoiding patient injury and eliminating medication errors. Nothing in 244 CMR 4.07(3) shall alter the standard of care a licensee must use when prescribing any Schedule II, III or IV controlled substance. (4) Self-prescribing and Prescribing for Family Members. An APRN authorized to prescribe medication is prohibited from prescribing drugs in Schedules II, III, and IV for personal use. Except in an emergency, such APRN is prohibited from prescribing Schedule II drugs to a member of his or her immediate family, including spouse or equivalent, a parent, a child, sibling, parent-in-law, son/daughter-in-law, brother/sister-in-law, step- parent, step-child, step sibling and any other relative residing in the same household. (5) At the time of initial application for Massachusetts Controlled Substance Registration and subsequently during each APRN authorization renewal period the APRN must comply with all state and federal requirements for continuing education. All continuing education offerings must be consistent with Board requirements at 244 CMR 5.00: Continuing Education.

4.08 Authorization to Practice as an Advance Practice Registered Nurse in More than One Clinical

4.08: Authorization to Practice as an Advance Practice Registered Nurse in More than One Clinical Category An RN authorized by the Board to practice in an APRN clinical category may be authorized in additional APRN clinical categories in accordance with the requirements for authorization established for each clinical category. A RN authorized in more than one category must comply with the requirements for initial and renewal Board authorization to practice as an APRN for each clinical category, including payment of all initial and renewal fees established by the Executive Office of Administration and Finance for each APRN clinical category in which the RN is authorized.

4.09 Malpractice Insurance

4.09: Malpractice Insurance An APRN with direct patient care responsibilities must obtain and maintain professional malpractice liability insurance with coverage of at least $100,000.00 per claim, with a minimum annual aggregate of not less than $300,000.00. (1) Upon request by the Board at any time, the APRN will provide proof of coverage satisfactory to the Board based upon the above criteria.

244 CMR: BOARD OF REGISTRATION IN NURSING

4.09 continued

4.09: continued (2) These requirements do not apply to APRNs whose practice in Massachusetts is limited to professional services rendered at or on behalf of federal, state, county or municipal health care facilities. REGULATORY AUTHORITY 244 CMR 4.00:M.G.L. c. 13, § 14; M.G.L. c. 94C; M.G.L. c. 112, §§ 80B, 80C, 80E, 80G, 80H and 80I; St. 2012, c. 369;

244 CMR 4.00 — Advanced practice registered nursing