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APRN WRITTEN PROTOCOLS / GUIDELINES AUDIT
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The law requires the South Carolina Board of Nursing to conduct a random audit of approved APRN written protocols/ guidelines at least biennially.  

APRN Written Protocols and/ or Guidelines Audit FAQ

Q. Why was I chosen for the APRN Protocols and/ or Guidelines audit?
The names for the audit were selected randomly by computer.

Q. What authority does the Board have to perform the audit of APRN Protocols and/ or Guidelines?
The Nurse Practice Act Chapter 33 Sections §40-33-34 (D)(2) and §40-33-34(H)(3) require the Board to conduct a random audit of approved written protocols and/ or guidelines at least biennially.

The South Carolina State Board of Nursing (SC BON) Nurse Practice Act Section Sections §40-33-34(D)(2) and §40-33-34(H)(3) stipulate that the original protocol(s) and/ or guideline(s) and any amendments must be reviewed at least annually, dated and signed by the nurse and physician and made available within seventy-two hours of request.

Q. How many APRNs are selected for the audit?
The South Carolina Board of Nursing (SC BON) has directed that a total of 5% of the APRN credentials be randomly selected for the audit of written guidelines and/or protocols.  All audit response packets submitted to the SC BON from each nurse will be carefully reviewed for compliance with requirements.

Q. How many times can an APRN be selected for the audit?

There is no limit to the number of times an APRN could be selected for audit.   If a nurse has an active APRN credential, then he/she is eligible for audit selection.

Q. May I send my audit response documents by fax or email to the Board office?
Documents sent by fax /or email will not be accepted.  Mail all documentation together in one (1) envelope.  Do NOT mail items separately.  Audit response packets must arrive at the Board no later than the due date provided in the audit notification letter.

Q. What address do I mail my audit response packet and how can I ensure it arrives at the SC BON by the deadline?
Mail the full and complete audit response packet to:


South Carolina Board of Nursing
PO Box 12367.
Columbia SC 29211


Due to the large volume of documents which arrive daily, the SC BON Board staff will not be able to provide confirmation of receipt of the audit packet.  However, each audited nurse will be sent an email notification regarding the outcome of his/ her audit. To ensure the nurse receives this important message, please be sure to provide an updated e-mail address or alternate method of contact to the Board.

 

If the nurse wishes to have confirmation of the day/ date their audit response packet arrives at the the SCBON office, the packet may be mailed at the licensee’s expense to the SC BON using an overnight or 2nd day delivery service that provides the nurse with a tracking number that he/ she can utilize to monitor delivery with the shipping provider.  Documents in this case should be mailed to:


South Carolina Board of Nursing
110 Centerview Drive
Columbia, SC 29210

Remember – Determination of compliance (or non-compliance) with the SC BON requirements will be based on the first and initial audit response packet received by the Board; therefore, it is imperative for each nurse to read and provide the requirements of the Nurse Practice Act Chapter 33 Sections §40-33-34 (D) and §40-33-34(H).


Faxed and/or emailed documents will not be accepted.  Mail all documentation together in one (1) envelope.  Do NOT mail items separately.  Audit response packets must arrive at the Board no later than the due date provided in the audit notification letter.


Q.  When did the Board send out notification of audit to the APRNs selected this year?
General information regarding the upcoming audit was provided via e-blast to all licensees holding an active APRN credential in January 2015.

Individual nurses selected for the audit will receive written notification/ instructions to their address of record as reported to the Board.

Q. What is the penalty for not submitting a complete audit response packet – OR – if my audit response packet does not arrive at the SC BON by the deadline?
An audited nurse who is unable to provide valid documentation demonstrating proof of the required written protocols and/ or guidelines will be considered non-compliant with the audit and may be issued disciplinary action, including invalidation of his/ her APRN credential.

Q. What documentation do I mail to the SC BON in my response packet?

A. For APRN Written Protocols


(D)(1) Delegated medical acts performed by a nurse practitioner, certified nurse-midwife, or clinical nurse specialist must be performed pursuant to an approved written protocol between the nurse and the physician and must include, but is not limited to:

(a) this general information:

(i) name, address, and South Carolina license number of the nurse;

(ii) name, address, and South Carolina license number of the physician;
(iii) nature of practice and practice locations of the nurse and physician;

(iv) date the protocol was developed and dates the protocol was reviewed and amended;

(v) description of how consultation with the physician is provided and provision for backup consultation in the physician's absence;

(b) this information for delegated medical acts:

(i) the medical conditions for which therapies may be initiated, continued, or modified;

(ii) the treatments that may be initiated, continued, or modified;

(iii) the drug therapies that may be prescribed;

(iv) situations that require direct evaluation by or referral to the physician.

(2) The original protocol and any amendments to the protocol must be reviewed at least annually, dated and signed by the nurse and physician, and made available to the Board for review within seventy-two hours of request. Failure to produce protocols upon request of the Board is considered misconduct and subjects the licensee to disciplinary action. A random audit of approved written protocols must be conducted by the Board at least biennially.


B. For CRNA Written Guidelines


(H)(1) Nothing in this section may be construed to require a CRNA to obtain prescriptive authority to deliver anesthesia care.

(2) A CRNA shall practice pursuant to approved written guidelines developed with the supervising licensed physician or dentist or by the medical staff within the facility where practice privileges have been granted and must include, but are not limited to:

(a) the following general information:

(i) name, address, and South Carolina license number of the registered nurse;

(ii) name, address, and South Carolina license number of the supervising physician, dentist, or the physician director of anesthesia services or the medical director of the facility;

(iii) dates the guidelines were developed, and dates the guidelines were reviewed and amended;

(iv) physical address of the primary practice and any additional practice sites;

(b) these requirements for providing anesthesia services:

(i) documentation of clinical privileges in the institutions where anesthesia services are provided, if applicable;

(ii) copy of job description;

(iii) policies and procedures that outline the pre-anesthesia evaluation, induction, intra-operative maintenance, and emergence from anesthesia.

(3) The original and any amendments to the approved written guidelines must be reviewed at least annually, dated and signed by the CRNA and physician or dentist, and must be made available to the Board for review within seventy-two hours of request. Failure to produce the guidelines is considered misconduct and subjects the licensee to disciplinary action. A random audit of approved written guidelines must be conducted by the Board at least biennially.

 

Q. What if I have had an address change of which I failed to notify the SC BON and I’m worried that I was chosen for the audit?
Section 40-33-38 (c) requires that a licensee notify the Board in writing within 15 days of any change of address.
Failure to notify the Board of a current mailing address will not absolve the licensee from the audit requirement, and may result in adverse action.


All actively licensed nurses are required to maintain current contact information on file with the SC BON.  Verifying and updating a personal mailing address and/or email address is fast and easy online through the SC BON home page under Online Services and is available to all nurses 24/7 free of charge.


If a nurse has recently moved or changed his or her email address and is concerned that he/she may have been selected for the audit and would not receive notification, the nurse should:


1.    Immediately go to the Board website under Online Services and update his/ her nursing file with the most current mailing address and email address.

2.    E-mail NurseBoard@llr.sc.gov and request the SC BON Board staff check the licensure file to determine whether the licensee has been selected for the APRN written protocols and/ or guidelines audit.  If the file indicates the nurse was selected for audit of his/ her written protocols and/ or guidelines, then he/she must mail a full and complete audit response packet to the SC BON for arrival at the Board office no later than the due date stipulated in the audit notice;

3.    Read/ review the full FAQ list prior to submitting the audit response packet to the SC BON for review.

 

Information from the April 2015 Issue of the SC Nurse pages 17-18

 

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