Collaborating in California

This outlines the key requirements for NPs and PAs collaborating in California.

State Regulations for Nurse Practitioners

What Is the State Practice Environment for NPs in California?

In which category does the state fall: NP independent practice, transition to independence, or collaboration required?

California is officially a Restricted Practice state, but also offers “transition to independence.”

Within the context of NP autonomy, “transition to independence” refers to the process through which nurse practitioners gain increased professional independence and take on more roles in patient care. This transition involves a progression from a more supervised or collaborative practice to a greater degree of self-directed decision-making and responsibility.

California has two stages APRNs must complete to achieve full independent practice, each require certification from the board:

1. “103” APRN: APRN must practice in a group setting without collaborative agreement; requires 4,600 hours or 3 full-time years of qualifying experience (completed in California within 5 years prior to the APRN’s application for 103 certification).
2. “104” APRN: APRN can practice outside group setting; requires 3 years of experience as a certified 103 APRN

Delegation Authority & Process

Is an agreement required?

Yes, a written agreement called “standardized procedures”.

What form of agreement is required and what are the requirements for the substance of the agreement?

No state form is required. Requirements for substance of agreement are as follows. The agreement must:

1. Be in writing, dated and signed by the organized health care system personnel authorized to approve it.
2. Specify which standardized procedure functions registered nurses may perform and under what circumstances.
3. State any specific requirements which are to be followed by registered nurses in performing particular standardized procedure functions.
4. Specify any experience, training, and/or education requirements for performance of standardized procedure functions.
5. Establish a method for initial and continuing evaluation of the competence of those registered nurses authorized to perform standardized procedure functions.
6. Provide for a method of maintaining a written record of those persons authorized to perform standardized procedure functions.
7. Specify the scope of supervision required for performance of standardized procedure functions, for example, immediate supervision by a physician.
8. Set forth any specialized circumstances under which the registered nurse is to immediately communicate with a patient's physician concerning the patient's condition.
9. State the limitations on settings, if any, in which standardized procedure functions may be performed.
10. Specify patient record keeping requirements.
11. Provide for a method of periodic review of the standardized procedures.

Where must the agreement be stored?

There are no restrictions.

Does the agreement need to be filed with the state?

No, it is not required.

Are there requirements to file the agreement after the initial filing (e.g., for updates or on a specified frequency)?

There are no restrictions.

Who must sign the agreement?

A personnel member of the “Organized Health Care System” authorized to sign and approve the agreement must sign.

"Organized Health Care System" means a health facility which is not licensed pursuant to Chapter 2 (commencing with Section 1250), Division 2 of the Health and Safety Code and includes, but is not limited to, clinics, home health agencies, physicians' offices and public or community health services.

How often must the agreement be reviewed/reauthorized?

There are no restrictions.

What are the required qualifications for the collaborating provider (licensure, same scope, active practice in state, etc.)?

The collaborating provider sust be a physician, surgeon or podiatrist.

What are the required qualifications for the NP?

The NP must be certified as a Nurse Practitioner by the BRN. View this link (California Board of Registered Nursing) for further details.

Is an alternate collaborating physician required?

No, an alternate collaborating physician is not required.

Collaboration Requirements

Are there ratios/limits on the number of NPs that a collaborator may supervise or enter into collaboration agreements?

1:4 furnishing NPs (i.e. prescribing) at one time.

Is there an express requirement to review a certain number/percentage of charts?

There are no restrictions.

Is there a requirement to meet and, if so, how often and how?

There are no restrictions.

Are there proximity requirements (e.g., between the NP/collaborator or practice site)?

There are no restrictions.

Are there location-specific requirements (e.g., that collaborator must go to practice site at some frequency)?

There are no restrictions.

Is remote supervision allowed/are there limitations on remote supervision?

Remote supervision is permitted, provided the supervising physician is available “by telephonic contact at the time of patient examination by the NP.”

Physician & NP Filing Requirements

Outside of filing the collaboration agreement, must the physician and/or NP file any separate forms (e.g., notice of delegation of prescriptive authority, notice of collaboration, notice to PDMP, etc.)?

NOTE: timing/frequency should be noted because the state may have requirements for initial filing and/or filing for updates, terminations, etc.

There are no requirements.

Prescription Requirements & Controlled Substance Prescribing

What are the prescription requirements?

The standardized procedure or protocol covering the furnishing of drugs or devices shall specify which nurse practitioners may furnish or order drugs or devices, which drugs or devices may be furnished or ordered, under what circumstances, the extent of physician and surgeon supervision, the method of periodic review of the nurse practitioner’s competence, including peer review, and review of the provisions of the standardized procedure.

What are the requirements for controlled substance prescribing?

For Schedule II controlled substance protocols, the provision for furnishing Schedule II controlled substances shall address the diagnosis of the illness, injury, or condition for which the Schedule II controlled substance is to be furnished.

Sources

State Regulations for Physician Assistants

General

• Is the supervising physician responsible for PA’s patients?
  • Yes. The supervising physician has continuing responsibility to follow the progress of the patient and to ensure that the PA does not function autonomously. The supervising physician shall be responsible for all medical services provided by a PA under his or her supervision.

  Delegation Authority/Process

  • Is an agreement required?
    • Yes. It is called a "Practice Agreement" or "Delegation of Services Agreement".
    • A Delegation of Services Agreement:
      • Shall be signed and dated by the physician assistant and each supervising physician.
      • May be signed by more than one supervising physician only if the same medical services have been delegated by each supervising physician.
      • Shall establish transport and back-up procedures for the immediate care of patients who are in need of emergency care beyond the PA's scope of practice for such times when a supervising physician is not on the premises.
      • Shall set forth the types of medical services a physician assistant is authorized to perform.
      • Shall establish guidelines for adequate supervision of the PA, including, but not limited to, appropriate communication, availability, consultations, and referrals between a physician and surgeon and the PA in the provision of medical services, which includes one or more of the following:
        • Examination of the patient by a supervising physician the same day as care is given by the PA.
        • Countersignature and dating of all medical records written by the PA within thirty (30) days that the care was given by the PA.
        • Adopt protocols to govern the performance of a PA for some or all tasks. The minimum content for a protocol governing diagnosis and management as referred to in this section shall include the presence or absence of symptoms, signs, and other data necessary to establish a diagnosis or assessment, any appropriate tests or studies to order, drugs to recommend to the patient, and education to be given the patient. For protocols governing procedures, the protocol shall state the information to be given to the patient, the nature of the consent to be obtained from the patient, the preparation and technique of the procedure, and the follow-up care. Protocols shall be developed by the physician, adopted from, or referenced to, texts or other sources. Protocols shall be signed and dated by the supervising physician and the PA. The supervising physician shall review, countersign, and date a minimum of 5% sample of medical records of patients treated by the PA functioning under these protocols within thirty (30) days. The physician shall select for review those cases which by diagnosis, problem, treatment or procedure represent, in his or her judgment, the most significant risk to the patient.
        • Other mechanisms approved in advance by the board.
        • No requirement.
        • No, unless requested by the PA Board.
        • No requirement.
        • The PA and each supervising physician.
        • No requirement.

        Qualifications

        • What are the qualifications for the supervising physician?
          • A licensed physician and surgeon who is not subject to a disciplinary condition imposed by the Medical Board of California or by the Osteopathic Medical Board of California prohibiting that supervision or prohibiting the employment of a PA.
          • The supervising physician may delegate to a PA only those tasks and procedures consistent with the supervising physician's specialty or usual and customary practice and with the patient's health and condition
          • Not required.

          Collaboration Requirements

          • Are there ratios/limits on the number of PAs that a supervising physician may supervise?
            • 1 physician may supervise up to 4 PAs, except in certain emergency situations.
            • One suggested way to set forth proper supervision of a PA is through protocols (see above). The supervising physician shall review, countersign, and date a minimum of 5% sample of medical records of patients treated by the PA functioning under these protocols within thirty (30) days. The physician shall select for review those cases which by diagnosis, problem, treatment or procedure represent, in his or her judgment, the most significant risk to the patient.
            • No requirement. However, the supervising physician must observe or review evidence of the PA’s performance of all tasks and procedures until assured of competency.
            • Is there a requirement to meet and, if so, how often and how?
            • No requirement. However, the supervising physician must observe or review evidence of the PA’s performance of all tasks and procedures to be delegated to the PA until assured of competency.
            • Are there proximity requirements? (e.g., between the PA/physician or practice site)
              • No requirement.
              • No requirement.
              • Remote supervision is allowed. The supervising physician must be available in person or by electronic communication at all times when the PA is caring for patients.
              • Each time a PA provides care for a patient and enters his or her name, signature, initials, or computer code on a patient's record, chart or written order, the PA shall also record in the medical record for that episode of care the supervising physician who is responsible for the patient. When a PA transmits an oral order, he or she shall also state the name of the supervising physician responsible for the patient. If the electronic medical record software used by the PA is designed to, and actually does, enter the name of the supervising physician for each episode of care into the patient's medical record, such automatic entry shall be sufficient for compliance with this recordkeeping requirement. This is not a state filing requirement, but must be recorded.
              • PAs engaged in providing medical services shall provide notification to each patient of the fact that the licensee is licensed and regulated by the PA board. The notification shall include the following statement and information:

              NOTIFICATION TO CONSUMERS

              Physician assistants are licensed and regulated by the Physician Assistant Board

              • The notification shall be provided by one of the following methods:
                • (1) Prominently posting the notification in an area visible to patients on the premises where the licensee provides the licensed services, in which case the notice shall be in at least 48-point type in Arial font.
                • (2) Including the notification in a written statement, signed and dated by the patient or the patient's representative and retained in that patient's medical records, stating the patient understands the PA is licensed and regulated by the board.
                • (3) Including the notification in a statement on letterhead, discharge instructions, or other document given to a patient or the patient's representative, where the notice is placed immediately above the signature line for the patient in at least 14-point type.
                • What are the prescription requirements?
                  • The supervising physician must be identified on any order or prescription. (whether electronic, written, or oral).
                  • The PA may furnish or order only those Schedule II through Schedule V controlled substances under the California Uniform Controlled Substances Act that have been agreed upon in the practice agreement. PA may furnish or order Schedule II or III controlled substances in accordance with the practice agreement or a patient-specific order approved by the treating or supervising physician and surgeon. In order to be eligible to prescribe, the PA must take an approved pharmacology course and obtain a DEA certificate.

                  Sources for Reference:

                  • 16 CCR 1399.540
                  • 16 CCR 1399.545
                  • 16 CCR 1399.546
                  • 16 CCR 1399.547
                  • 16 CCR 1399.610
                  • Cal Bus & Prof Code § 3501
                  • Cal Bus & Prof Code § 3502.3
                  • Cal Bus & Prof Code § 3502.1
                  • Cal Bus & Prof Code § 3516