On June 13, 2018, Connecticut Governor Dannel P. Malloy signed into law Public Act No. 18-168 “An Act Concerning the Department of Public Health’s Recommendations Regarding Various Revisions to the Public Health Statutes” (PA 18-168). This legislation makes a number of changes to state laws concerning public health and the responsibilities of the Department of Public Health (DPH), including laws affecting advanced practice registered nurses (APRNs), advance directives, the scope of practice for podiatry, respiratory care, reportable events at nursing homes, and the supervision of physician assistants. Below is a summary of certain key provisions within the law, along with their respective effective dates, but please note that PA 18-168 contains a number of additional changes not described in this article that affect entities and individuals regulated by DPH.
Supervision of Physician Assistants – Effective July 1, 2018
PA 18-168 repeals the current limit on the number of physician assistants a physician can supervise at one time. Currently, under Conn. Gen. Stat. § 20-12c(b), a physician may act as a supervising physician for up to six full-time physician assistants (or the part-time equivalent thereof), as medically appropriate under the circumstances, as long as the supervision is “active and direct.” This legislation removes the one physician to six physician assistants supervision limitation, and will allow a supervising physician to supervise as many physician assistants as is medically appropriate under the circumstances, provided that the supervision is “active and direct.”
Advanced Practice Registered Nurses and Advance Directives – Effective October 1, 2018
PA 18-168 revises Connecticut laws concerning advance directives to allow APRNs to occupy an equivalent role to that occupied by physicians under current law, for purposes of advance directives. Under Connecticut’s advance directives laws, an APRN is defined as a Connecticut-licensed APRN whom a patient has selected and who exercises primary responsibility for the treatment and care of the patient.
Conn. Gen. Stat. § 19a-575 currently sets forth a template document that can be executed by an individual over the age of 18 to provide instructions concerning the withholding or withdrawal of life support systems in certain circumstances. Currently, the template form contemplates the advanced directive being relied upon if the individual is incapacitated and cannot direct his or her physician as to his or her own medical care. This legislation provides that the advanced directive may be relied upon if the individual cannot direct his or her selected physician or APRN as to his or her own medical care, and that an individual’s APRN or attending physician may determine that the individual has a terminal condition. Notably, Conn. Gen. Stat. § 19a-575 and Conn. Gen. Stat. § 19a-575a (discussed below) were also amended during this legislative session by a separate bill – Public Act No. 18-11 – to add a section to allow pregnant individuals to provide specific instructions concerning life support based on the status of the fetus.
This legislation makes a similar change to add APRNs to Conn. Gen. Stat. § 19a-575a, which sets forth a template document for an individual (18 years of age or older) to express his or her health care instructions, appoint a health care representative, designate a conservator, and document an anatomical gift. This legislation allows an individual’s APRN, in addition to his or her attending physician, to rely on the advance directive, to render an opinion that the individual has a terminal condition and to determine that the individual is incapacitated. This legislation also provides that an APRN may serve as one of the two mandatory witnesses to the execution of the appointment of a health care representative by an individual residing in a facility operated or licensed by the Department of Mental Health and Addiction Services or the Department of Developmental Services; current law allows a physician or licensed clinical psychologist with specialized training applicable to the facility’s residents to serve as one of the two mandatory witnesses.
This legislation also adds references to APRNs to Conn. Gen. Stat. § 19a-577. That statute currently allows an individual (18 years of age or older) to appoint a health care representative to make decisions on his or her behalf in accordance with his or her stated wishes or best interests when the individual’s attending physician determines that the individual is unable to understand and appreciate the nature and consequence of health care decisions and to reach and communicate an informed decision regarding treatment. PA 18-168 allows an APRN or a physician to determine when an individual’s health care representative can begin making decisions. Currently, a living will or appointment of a health care representative only becomes operative when the document is provided to the attending physician and the declarant is determined by the attending physician to be incapacitated (which determination must be disclosed, in writing, upon request of the health care representative). This legislation provides that an APRN, or an individual’s attending physician, may receive a living will or appointment of a health care representative and may make a determination of incapacity regarding the declarant.
Finally, this legislation provides that an APRN may not act as both a health care representative for an individual and as the individual’s attending APRN, which echoes a current statutory prohibition on a physician acting as an individual’s health care presentative and as their attending physician.
Podiatry Scope of Practice – Effective October 1, 2018
PA 18-168 expands the statutory scope of practice for podiatrists in Connecticut by broadening the definition of “podiatric medicine” under Conn. Gen. Stat. § 20-50 to include the diagnosis and treatment of the ankle as well as the foot. This legislation also provides that “podiatric medicine” includes local manifestations of systemic diseases as they appear on the ankle (as well as on the foot).
Under current law, licensed podiatrists must obtain a permit from DPH before independently engaging in surgical treatment of the ankle. This legislation removes the permit requirement and instead requires a podiatrist to provide documentation of the following to DPH in order to independently provide surgical treatment of the ankle:
(1) the podiatrist graduated on or after June 1, 2006 from a three-year residency program in podiatric medicine and surgery that was accredited by the Council on Podiatric Medical Education (or its successor) at the time the individual graduated, and the podiatrist is board certified or qualified in reconstructive rearfoot ankle surgery by the American Board of Foot and Ankle Surgery (or its successor);
(2) the podiatrist graduated before June 1, 2006 from a residency program in podiatric medicine and surgery that spanned at least two years and was accredited at the time the individual graduated, and the podiatrist is board certified or qualified in reconstructive rearfoot ankle surgery by the American Board of Foot and Ankle Surgery (or its successor).
Notably, this legislation also stipulates that all podiatrists holding DPH-issued permits as of October 1, 2018, will be considered to have met the applicable documentation requirements. In lieu of the permit requirement under current law, this legislation requires DPH to implement a system under which podiatrists can submit the required documentation and grants access to credentialing boards and the public to review such documents.
PA 18-168 also expands the definition of “surgical treatment of the ankle” that a licensed podiatrist may perform under Conn. Gen. Stat. § 20-54. Currently, “surgical treatment of the ankle” is defined in the negative as not including “the performance of total ankle replacements or the treatment of tibial pilon fractures.” This legislation revises that definition to provide examples of what constitutes “surgical treatment of the ankle,” including “all soft tissue and osseous procedures, including ankle fracture fixation, ankle fusion, ankle arthroscopy, insertion or removal of external fixation pins into or from the tibial diaphysis at or below the level of the myotendinous junction of the triceps surae and insertion and removal of retrograde tibiotalocalcaneal intramedullary rods and locking screws up to the level of the myotendinous junction of the triceps surea.” Additionally, PA 18-168 specifically prohibits podiatrists from performing surgical treatment of complications within the tibial diaphysis related to the use of external fixation pins.
Event Reporting by Nursing Homes – Effective July 1, 2018
PA 18-168 requires DPH to develop a system for nursing homes to electronically notify DPH of a “reportable event” by January 1, 2019. Starting on January 1, 2019, this legislation requires nursing homes to notify DPH electronically of reportable events using the newly-developed DPH system. For purposes of this legislation, a “reportable event” is defined as an “event occurring at a nursing home that is deemed by [DPH] to require the immediate notification of [DPH].” This definition gives DPH significant latitude to establish a definition (and thus threshold for reporting) of reportable events at nursing homes.
Connecticut Freedom of Information Act and DPH Investigations – Effective October 1, 2018
Currently, records obtained by DPH in connection with any investigation of a health care facility are not subject to the Connecticut Freedom of Information Act (Conn. Gen. Stat. § 1-210) for a period of six months after initiation of an investigation, or until the investigation is terminated. PA 18-168 makes a clarifying change to that law to expressly state that patient medical records and personnel records received by DPH during the course of such an investigation are not subject to disclosure at any time under Connecticut’s Freedom of Information Act.
DPH Inspections and Plans of Correction – Effective October 1, 2018
Currently, DPH is permitted to inspect licensed health care institutions in Connecticut to determine compliance with state law and regulations. Upon a finding of noncompliance, DPH issues a notice of such noncompliance to the institution, and the institution is then required to submit a plan of correction addressing the noncompliance within ten days. PA 18-168 clarifies that the deadline for submitting a plan of correction is ten business days.
Respiratory Care Practitioners – Effective October 1, 2018 (except as noted below)
This legislation expands the statutory scope of practice of respiratory care practitioners in Connecticut by expanding the definition of “respiratory care” under Conn. Gen. Stat. § 20-162n(2) as follows:
- PA 18-168 adds, as an example of physiological monitoring of cardiopulmonary systems, the percutaneous insertion and monitoring and maintenance of arterial catheters and the monitoring and maintenance of other cardiovascular indwelling catheters, including central venous and pulmonary artery catheters;
- PA 18-168 adds the following new activities as within the definition of respiratory care:
- the insertion of intravenous and intraosseous catheters in appropriately identified health care settings, including medical evacuation and transport vehicles, outpatient bronchoscopy facilities and long-term care and rehabilitation facilities, provided the respiratory care practitioner has completed a competency-based training and education program in the insertion and maintenance of such catheters;
- the insertion of nasogastric tubes, including such tubes used for the purpose of sensing diaphragmatic movements;
- the monitoring and maintenance of all forms of extracorporeal life support, including, but not limited to, extracorporeal membrane oxygenation and extracorporeal carbon dioxide removal in appropriately identified health care settings – including, adult, pediatric and neonatal intensive care units – provided the respiratory care practitioner meets specific statutory requirements for performing such extracorporeal life support, including without limitation completion of examination and resulting registration as a respiratory therapist by the National Board for Respiratory Care , clinical expertise in neonatal, pediatric or adult critical care, and completion of education and training as an extracorporeal membrane oxygenation specialist.
Finally, as of January 1, 2019, PA 18-168 increases the minimum continuing education requirement for respiratory care practitioner license renewals from six to 10 hours during the preceding registration period, and adds the requirement that at least five hours of the continuing education must be spent on real-time education with opportunities for live interaction, including, but not limited to, in-person conferences or real-time webinars.