Section A: Legal basis of Nurse Anesthesia Practice in California
A1. Scope of Practice Guidelines for California Certified Registered Nurse Anesthetists.
A2. CRNA Scope of Practice Memorandum, Mayer Brown 09/23/2014
A3. Nursing Practice Act, California Business and Professions Code, Section 2725 to Section 2727.5
A4. Nurse Anesthetist Act, California Business and Professions Code, Section 2825 to Section 2833.6
A5. California Attorney General opinion number 83-1007 issued April 5, 1984 concluded that it is within the scope of practice of a certified registered nurse anesthetist to administer general or regional anesthesia.
A6. Board of Registered Nursing Opinions and Correspondence
A6.1 (11/15/1985) Copy of motion adopting legal opinion that the practice of registered nursing includes the ordering of laboratory tests, the results of which may be used in performing nursing functions.
A6.2 (4/14/1986) CRNAs may perform the pre and post anesthesia evaluation, authorize the release of the patient from the PACU and may implement emergency procedures
A6.3 (9/12/1988) CRNAs may authorize the discharge of a patient from outpatient surgery or an ambulatory care surgery center. CRNAs are independent practitioners and do not require supervision by a physician.
A6.4 (11/11/1988) CRNAs may administer anesthesia ordered by a physician, dentist or podiatrist. Anesthesia services include regional or local anesthesia by injection and general anesthesia. May initiate orders to RNs, may perform a preanesthesia and post anesthesia evaluation
A6.5 (July 1990) CRNA is responsible for selecting and administering the anesthetic agent, monitoring the patient’s response thereto, and selecting and administering drugs required to maintain the patient’s stability during the operative period.
A6.6 (1/15/1992) It is within the scope of practice of the CRNA to provide pain management services and emergency procedures both inside and outside the operating room suite.
A6.7 (2/18/1993) CRNAs are responsible for their own professional conduct and may be held liable for those professional acts. CRNAs practice under his or her license and not that of a physician.
A6.8 (9/16/1994) there is nothing in the statute that would preclude a CRNA from providing anesthesia services in Level I, II, or III trauma centers.
A6.9 (7/11/2002) Letter to the California Department of Health Services; “It is the position of the Board of Registered Nursing that physician supervision is not required for certified registered nurse anesthetist practice.”
A6.10 (11/20/2002) California Department of Health Services letter to Board of Registered Nursing stating that the Department defers to the Board of Registered Nursing concerning the scope of practice of nurse anesthetists.
A6.11 (11/20/2009) California Department of Health Services letter to California Society of Anesthesiologists stating that the Department defers to the Board of Registered Nursing concerning the scope of practice of nurse anesthetists.
A6.12 (1/24/2003) Letter to the California Society of Anesthesiologists stating that the BRN has determined that CRNAs may administer all types of anesthesia for surgery performed by podiatrists.
A6.13 (11/23/2004) Letter to Department of Health Services “The BRN has long held that CRNAs are licensed independent practitioners and do not require the supervision of a surgeon or anesthesiologist”.
A6.14 (1/20/2005) Letter to Harold Bressler, General Counsel, Joint Commission on Accreditation of Healthcare Organizations stating that California CRNAs do not require supervision.
A6.15 (2/4/2005) Letter from DHS to BRN in part states that CRNAs are considered licensed independent practitioners under state law.
Section B: California Administrative Code, Title 22
B1. Title 22, Section 70231 to 70239, Anesthesia Services.
B2. Title 22, Section 70223 Surgical Services, see part (d) for the anesthesia requirements for the surgical section.
B3. Title 22 Regulatory Package R-34-85, December 22, 1986, changes eliminated the physician CRNA supervision requirement and restrictions on CRNAs administering regional anesthesia.
B4. Title 22 Regulatory Package R 41-91, April 15, 1993, changes eliminated the requirement that only a physician may perform the pre-anesthesia evaluation and authorize the discharge of the patient from the PACU or the outpatient section. The wording changes permit CRNAs to perform those functions.
Section C: Centers for Medicare & Medicaid Services (CMS): California Supervision Exemption (“Opt-Out”), Conditions of Participation (CoP) for Hospitals, Conditions for Coverage (CfC) for Ambulatory Surgery Centers, and Updates
C1. CMS Spotlight: Opt-Out of Federal CRNA Supervision Requirement
C1.a. Letter from Governor Schwarzenegger to CMS opting California out of the Medicare supervision requirement for anesthesia services provided by a certified registered nurse anesthetist.
C1.b. CSA-CMA Lawsuit: Superior Court, Original Filing (Feb. 2, 2010)
C1.c. CSA-CMA Lawsuit: Summary Judgment Granted in Favor of Governor + CANA (Sept. 28, 2010)
C1.d. CSA-CMA Lawsuit: Appeal filed against the opt-out (Jan. 31, 2011)
C1.e. CSA-CMA Lawsuit: Appellate Court FINAL Judgment in Favor of Governor + CANA (March 15, 2012)
C1.f. CSA-CMA-Lawsuit: CA Supreme Court Review Denied – IV. DISPOSITION, pp 10 (June 13, 2012)
C1.g. California Opt-Out: FAQs Information Sheet (July, 2013)
C1.h. CMS Spotlight: Opt-Out of Federal CRNA Supervision Requirement
C2. Medicare Conditions of Participation for Hospitals and Survey Guidelines, section 482.52: Anesthesia Services.
C3. Medicare Conditions for Coverage for Ambulatory Surgical Centers and Survey Guidelines, section 416.42: Surgical service and section 416.52: Patient admission, assessment and discharge.
C4. CRNA Medicare payment policies and anesthesia claims modifiers.
C5. CMS Update: Anesthesia Teaching Rules (Nov. 20, 2009)
C6. CMS Update on OB Pain Management and Sedation Services (Feb. 5, 2010)
C7. CMS Update on CRNA Chronic Pain Management (Nov. 1, 2012)
C8. CMS Part B QZ Modifier for Claims may only be used by CRNAs; Medical Direction is Required for Anesthesiologist Assistants (AA)s (May 30, 2013)
Section D: The Joint Commission Standards
D1. Anesthesia Standards for Hospitals
D2. The Joint Commission letter to AANA outlining the process of The Joint Commission survey procedure for determining licensed independent practitioner status for CRNAs (November 12, 2003).
D3. The Joint Commission General Counsel letter to CANA attorney Patrick Shannon stating that CA CRNAs are eligible to be credentialed as licensed independent practitioners (November 12, 2004).
D4. The Joint Commission General Counsel letter to CANA attorney Phillip Recht providing the definition of licensed independent practitioner and the process to determine licensed independent practitioner status (April 7, 1989).
Section E: California Outpatient Surgery Center Laws
Section F: California Dental Anesthesia Laws and Regulations
Section G: Podiatry
G1. Memo from the attorney for the Department of Consumer Affairs concluding that nurse anesthetists may provide the full range of their services in an inpatient or outpatient setting for surgery performed by a podiatrist (9/2/1988).
G2. Letter from the Board of Registered Nursing stating that CRNAs may administer all types of anesthesia as ordered by a podiatrist (1/24/2003).
G3. Letter from the Board of Podiatric Medicine to California Society of Anesthesiologist stating that the restrictions on podiatrists administering anesthesia does not apply to the type of anesthesia a podiatrist may order (2/10/2003).
Section H: Education and Practice Standards
H1. Education Standards of the Council on Accreditation of Nurse Anesthesia Education Programs
H2. Scope of Nurse Anesthesia Practice, American Association of Nurse Anesthetists
H3. Standards for Nurse Anesthesia Practice, American Association of Nurse Anesthetist
H4. Guidelines for Core Clinical Privileges, Certified Registered Nurse Anesthetists, American Association of Nurse Anesthetists
H5. CANA AANA-standards for office based anesthesia practice
H6. CANA AANA-postanesthesia care standards for the CRNA
Section I: Drug Enforcement Administration (DEA) Rules – CRNA Registration Exemption
I1. Title 21 CFR §1301.22 Exemption of agents and employees; affiliated practitioners
I2. Federal Register Vol 57 (No. 146) 33466 – “DEA neither requires nor encourages registration for Mid-Level Practitioners (MLPs) acting as agents of other registrants” in order to “dispense controlled substances in the course of professional practice as a primary health care provider.” (July 29, 1992)
I3. DEA: AANA Legal Briefs, Blumenreich (Oct., 1993)
Section J: Resources
J1. American Association of Nurse Anesthetists at http://www.aana.com – go to Resources on the home page. The site contains practice documents, legal briefs and publications.
J2. California Codes (laws) and legislation information http://www.leginfo.ca.gov
J4. California Board of Registered Nursing http://www.rn.ca.gov
J5. Dental Board of California http://www.dbc.ca.gov
J6. Centers for Medicare and Medicaid (CMS) – contains links to reimbursement, regulations and manuals concerning Medicare http://www.cms.hhs.gov
J7. Studies commissioned by non-CRNA groups
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