Starting September 1st, 2013, the Texas Peer Assistance Program for Nurses (TPAPN) will significantly increase the length of their standard monitoring contracts. Previously an RN or LVN participant could expect to sign a two-year participation agreement while an Advanced Practice Nurse or CRNA would be asked to participate for three years. RN/LVN's and APN/CRNA's will now need to participate for three and five years, respectively. The new change applies to both nurses who enter TPAPN with or without an accompanying Board Order.
This policy change is probably meant to bring TPAPN more in line with the monitoring programs used by other Texas healthcare licensing agencies. For example, the Professional Recovery Network, which serves as the official peer assistance program for the Texas Pharmacy, Dental, and Veterinary Boards normally asks its participants to sign a five-year agreement. The Texas Physician Health Program also frequently makes use of a five-year agreement, although this can be much longer depending on the case.
While it is understandable why the Texas Board of Nursing would want to increase the standard timeframe for TPAPN participation, I have concerns as to how effective this change will be without corresponding reform of the TPAPN process. My firm has represented hundreds of nurses who have participated in TPAPN both with and without a corresponding Board Order. Many of these nurses have ended up in TPAPN even though they do not have a qualifying substance abuse, chemical dependency, or mental health issue. Usually this is due to the nurse believing they have no other option to retain their license and/or avoid action by the Board. This is oftentimes incorrect and our firm has helped numerous nurses achieve a better result.
This being said, for many nurses participation in TPAPN is a good option. TPAPN does provide a level of structure and direction which can be helpful to someone who is new to sobriety and just learning the tools necessary to remain abstinent. Ideally, this should be accompanied by a supportive and non-punitive atmosphere designed to assist this process. TPAPN's goal is, and should be, assisting nurses to become and stay sober while monitoring this process through objective indicators such as drug and alcohol screening and regular reports from employers and medical/mental health providers. Unfortunately, it has been my experience that many of TPAPN's rules and policies are counterproductive to these goals, lead to unnecessary referrals to the Board, and discourage potential participants from enrolling in the program.
Flaws with TPAPN include its policy of refusing to allow a participant to work until they have been cleared by an evaluator and passed a drug and alcohol screen. While sometimes this makes sense, oftentimes it does not as the nurse is already sober and may have been so for some time. This requirement frequently results in the nurse losing their job which significantly undermines their ability to successfully participate both from a sobriety, financial, and mental health standpoint.TPAPN also prohibits its participants from taking any medication that is potentially abusable even if it is medically indicated, validly prescribed, and completely unrelated to the reason for their participation. For example, a nurse who enrolls in TPAPN due to a history of alcohol abuse but who also has a longstanding and well documented chronic pain syndrome will be asked to discontinue all narcotics. A nurse may also be forced to discontinue psychiatric medications even though these are medically indicated and beneficial. This rule automatically disqualifies a whole range of potential participants who would otherwise be good candidates and can make compliance for existing participants extremely difficult.
This policy also causes significant hardship for participants who develop a new medical condition while enrolled in TPAPN. As an example, a previous client of the firm was discharged from TPAPN after repeatedly testing positive for narcotics. The reason for the positive tests were the client's periodic trips to the Emergency Room when he would pass a kidney stone and be given a short-term prescription to treat the accompanying severe pain. Each time the reason and prescription for the medication were clearly documented and not in dispute; However, in each instance the nurse was pulled away from work by TPAPN, often for more than a week, until he could provide a negative urine screen. He was further warned repeated instances could result in him being ejected or asked to restart the program. Not surprisingly, this is eventually exactly what occurred.
I see no reason why the above scenario should occur. It makes no sense from a sobriety perspective, is cruel to the participant, and places an unnecessary burden on the Nursing Board who is then forced to take on the case. Both the Professional Recovery Network and Physician Health Program allow participants to receive potentially addictive medication so long as it is medically indicated and documentation is promptly provided. In appropriate cases, they may require a consult with an addictionologist or other qualified professional to assess and monitor the need for such medication, but the decision is left to medical professionals, not a blanket policy.
A reform of TPAPN's policies and process to allow greater discretion on a case-by-case basis would greatly improve the program's effectiveness and success rate. It should emulate the more flexible approaches of its fellow monitoring programs in Texas, particularly as it starts to model the length of their participation agreements. Absent some of these reforms, I foresee the expanded participation window only compounding existing problems and increasing the number of nurses who fail to complete their agreements.As emphasized repeatedly throughout this blog, a nurse who has been referred to TPAPN, or who is being referred to the Board by TPAPN, should contact an attorney for a consult. Many nurses aren't aware there may be alternative options or, in the event of a Board referral, the best way to defend themselves and minimize any impact on their ability to practice. An experienced Texas Board of Nursing attorney should be able to discuss these issues and help you decide if it makes sense to retain a lawyer to defend your interests.
Important Update for Texas Nurses on a Board Order: Texas Board of Nursing Starts Screening for EtG and EtS
During the last month my firm has experienced an influx of calls from nurses who have tested positive for alcohol while on an Order with the Texas Board of Nursing. The consequences of testing positive for a prohibited substance, including alcohol, while under a Board Order can be quite severe. This includes an automatic temporary suspension of the nurse's license and a high likelihood that this suspension will be continued until the nurse has subsequently obtained twelve consecutive months of sobriety verified by additional random drug and alcohol testing. Moreover, from a legal perspective it is very difficult to mount an effective defense in the face of a positive test and avoid these harsh consequences.
The reason for the sudden increase in nurses testing positive for alcohol appears to be the Texas Board of Nursing's new decision to include testing for ethyl glucuronide (EtS) and ethly sulfate (EtS) in their screening panel. Previously, the screening company used by the Texas Board of Nursing only tested for ethanol, however, the Board recently signed a contract with a new vendor that includes both EtG and EtS screening in their panel. This is crucial as the sensitivity and detection window of EtG and EtS testing is much higher than a traditional urine ethanol screen.
Ethanol, or alcohol, is the primary intoxicating ingredient in alcoholic beverages. Accordingly, a person who has ingested alcohol will only test positive for ethanol as long as the alcohol remains in their system. Once it has been fully metabolized by the liver, the person will no longer test positive. Given this is a relatively quick process ethanol testing will generally only provide a 10-12 hour window in which to detect if a person has ingested alcohol. If the person has only had one or two drinks, the detection window is even shorter.
In contrast, EtG and EtS testing can detect even light alcohol use over a period of several days. Additionally, these tests, and the low cut-off levels used by the Board, are highly sensitive to even a small amount of alcohol ingetsion. It is also well documented that inadvertent, casual exposure to alcohol in the environment can cause a person to test positive. Sources of incidental exposure to alcohol that can cause positive results include:
- hand sanitizers containing alcohol;
- foods containing trace amounts of alcohol;
- non-alcoholic beers such as O'Doul's;
- colognes and perfumes;
- sustained exposure to gasoline and other chemical agents containing alcohol;
- mouthwashes containing alcohol such as Listerine and Scope;
- over-the-counter medications containing alcohol;
- certain natural and herbal medications.
I am unaware whether the Board has provided nurses testing pursuant to a Board Order with information concerning this new testing panel. Ideally, nurses should also be provided with a list of different substances which can inadvertently cause a positive result. For many years, nurses in the Texas Peer Assistance Program for Nurses been given this information prior to their enrollment in testing and hopefully the Board is doing or will soon be doing the same. This is also the standard of practice for the Texas Physician Health Program and the Professional Recovery Network.
Texas nurses testing through the Board need to be made aware that they are now being tested for EtG and EtS and receive education on how to avoid an inadvertent positive. Whether a nurse who has already tested positive can mount a legal defense is largely dependent on their test level and whether they were positive for both EtG and EtS. A low positive can be an indication of only inadvertent exposure to alcohol while a test that is positive for EtG but negative for EtS strongly suggests either a contaminated sample or the spontaneous production of ethyl glucuronide in the specimen container. In District Court actions, my firm has previously successfully challenged on these bases two automatic suspension orders entered against physicians by the Texas Medical Board.
If you have tested positive for EtG or EtS, it is prudent to contact an attorney with Board experience immediately to explore your legal options. The Board is likely to move quickly to temporarily suspend your license and time is of the essence. Even if a suspension is inevitable, oftentimes an attorney can be useful in negotiating a subsequent Order with the Board that minimizes the amount of time the nurse will be unable to practice.
When confronted with allegations of drug diversion or intemperate use, an employer will frequently present a nurse with a choice: either accept a referral into TPAPN or face a report to the Texas Board of Nursing. For a nurse who actually suffers from a substance abuse or chemical dependency diagnosis, acceptance of a referral toTPAPN may be a wise first step towards recovery. Nurses who do not believe they are an appropriate candidate for TPAPN, however, may want to give pause prior to pursuing that route as the restrictions and conditions imposed on a participant are onerous and will affect, sometimes drastically, their ability to continue practicing in their present capacity.
This is doubly so for Advanced Practice Nurses such as Certified Nurse Anesthetists and Nurse Practitioners. At a minimum both CRNA’s and Nurse Practitioner’s will be precluded from practicing in their respective fields for one year. Moreover, the TPAPN participation term for Advanced Practice Nurses is three years instead of the two years applicable to regular RNs and LVNs. A CRNA or Nurse Practitioner’s enrollment in TPAPN is also clearly reportable to provider networks, malpractice insurers, hospitals, and other credentialing agencies and can affect their ability to successfully enter into agreements with these entities for years to come.
A CRNA or NP who has been referred to TPAPN, or the Board of Nursing, should know there are other potential options available and I strongly advise them to speak with an attorney well versed in representation before both TPAPN and the Texas Board of Nursing prior to making a final decision. At the outset, it may be possible for you and your attorney to refute or dispel the allegations underlying the TPAPN or Board referral. Even if this is not possible, a CRNA, Nurse Practitioner, or any other nurse is not eligible to participate in TPAPN or be placed on an equivalent Board Order unless they have a diagnosis of substance abuse or chemical dependency. Depending on the allegation and the nurse’s history of use or abuse of mind-altering substances, they might not carry such a diagnosis.
Some cases may even be eligible to be resolved through a referral to the Extended Evaluation Program (EEP), a sub-program operated by TPAPN which is meant to apply to nurses who may have some history indicating an issue with drugs or alcohol but who do not carry a DSM-IV diagnosis of substance abuse or chemical dependency. A nurse in EEP is only required to verify their sobriety through one year of negative random drug screening. It does not involve any restrictions on their scope of practice or, in the case of Nurse Practitioner’s, their prescribing authority. Moreover, a nurse’s participation in EEP is confidential, not a part of the public record, and is not disclosable on credentialing and other similar applications. Furthermore, participation in EEP is not considered to be discipline under the Nursing Practice Act.
A CRNA or Nurse Practitioner who is being asked to enroll in TPAPN and who thinks this is not an appropriate route should explore their options prior to making a decision which will dramatically affect their ability to practice as an APN. The unfortunate truth is that many nurses are in TPAPN when they shouldn’t be, likely because they felt they had no other choice. Even more tragically, it is often these nurses who have the most problem complying with their participation agreement as an individual who is in a treatment program but who don’t belong there is more likely to not give sufficient attention to remaining in compliance. Completing 90 Alcoholic’s Anonymous meetings in 90 days is hard enough for someone who genuinely belongs in and can benefit from AA. It is especially difficult for someone who does not. If you are in such a situation, I emphatically suggest that you talk to an attorney and weigh your options prior to making a final decision.
Recent Amendments to the Nursing Practice Act and the Subsequent Granting of Power to the Texas Board of Nursing
The statutory amendments to the Texas Nursing Practice Act as proposed by House Bill 3961 came into effect on September 1, 2009. The Amendments were largely suggested by the Texas Board of Nursing’s executive staff and attorneys in an effort to circumvent difficulties they were experiencing prosecuting disciplinary and licensure cases involving the nursing practice of Registered Nurses (RN’s), Licensed Vocational Nurses (LVN’s) and Advanced Practice Nurses (APN’s) such as CRNA’s or Clinical Nurse Specialists (CNS).
The lawyers and staff of the Texas Board of Nursing (TBON) proposed these legislative changes to the Nursing Practice Act in response to challenges they were encountering when experienced administrative law and professional license defense attorneys opposed the abuses and tactics that Nursing Board Staff employed in license investigation(s) and contested case hearings.
While it is unclear how Staff of the Board will try to utilize its new regulatory authority the House Research Organization Bill Analysis does help to explain the bill and does confer what the legislature interpreted the provisions / amendments to mean. The changes also require the Board to adopt rules relating to the practice and procedure surrounding its new ability to request / require forensic psychological evaluations and the questionable polygraph report. This procedure is to be accomplished through a probable cause hearing at the State Office of Administrative Hearings (SOAH) and will be the topic of an independent and subsequent blog article.
The changes that will affect the way that license defense / disciplinary cases are handled involve Board Staff’s ability to request and potentially order a chemical dependency analysis or forensic psychological evaluation of a nurse. The Nursing Practice Act now also mandates that the Board utilize its Temporary Suspension Authority when a nurse tests positive for drugs or alcohol while under a Board Order or while participating in the activities of the Texas Peer Assistance Program for Nurses (TPAPN). The statute also requires the Temporary Suspension of a Nurse who is deemed non-compliant with TPAPN. This is especially troubling (as it has been my experience in handling over 500 nursing license defense cases) that oftentimes a nurse ends up in TPAPN due to routine practices by Nursing Board Staff despite the fact that the nurse is neither appropriate nor eligible for TPAPN per TPAPN’s own standards. Oftentimes TPAPN deems a person non-compliant for a cause that does not relate to drugs or alcohol such as the inability to find employment or disqualification to an ongoing medical condition. Unfortunately these nurses may find themselves temporarily suspended without good cause.
Fortunately the new statute appears to require the agency to demonstrate that probable cause exists that the nurse through their continued practice would pose an imminent danger or threat to the public health & welfare.
While reading the House Bill Analysis it is clear that Board Staff lobbied the legislature and attempted to legitimize its use of polygraph tests as a tool in the forensic psychological evaluations. Nurses however should take note that this tactic is still illegal and inappropriate under Texas Case Law and the Supreme Court’s rulings on the admissibility of polygraph test results in a Court of Law.
Any Nurse who falls prey to Staff of the Texas Board of Nursing’s new use of its authority with respect to mandated psychological evaluations or a temporary suspension should contact an experienced administrative law and professional license defense attorney immediately. The Statutes changes clearly allow for defense and rights relevant to these changes and it is best to assert them before Staff of the Board and its lawyers gain an unfair advantage a nurses license / ability to practice.
Recently I have been the attorney of record in nursing license defense matters against the Texas Board of Nursing for a number of registered nurses and licensed vocational nurses (RN & LVN Practice) in cases where a low level EtG test is in issue despite clear indications that these test results are inadequate proof of deliberate consumption of ethyl alcohol (ETOH). Thus the formal charge by the BON is unsupported by adequate admissible evidence and should not be the basis for the discipline of the nursing license / registration. In most of these cases a favorable result is anticipated for the nurse, but not without a long and arduous fight against the staff and lawyers of the Texas Board of Nursing.
Generally the cases arise in one of two ways:
- The Texas Peer Assistance Program for Nurses (TPAPN) is monitoring someone’s nursing practice pursuant to a Board Directive or Agreed Order and as such any low level test per TPAPN policy is considered a violation and is per se grounds for dismissal from TPAPN. This is also cause for a new report to the Texas Board of Nursing and Staff’s allegations / Formal Charges that the Nurse’s conduct is “unprofessional”;
- The Texas Board of Nursing has disciplined the license of a Nurse who is now under an Agreed Order and monitored by staff of the Board’s compliance and enforcement division (Carolyn Hudson for LVN Practice and Diane Burell for RN and APN practice).
In either case my law firm has seen low level tests where the result is less than 1000 ng/ml being used as an attempted basis for the unwarranted discipline of a nursing license by the attorneys and executive director of the Texas Board of Nursing in spite of clear advisory warnings that the test is in-and-of-itself flawed. Despite clear evidentiary problems staff of the Texas Board of Nursing still attempts to impose new disciplinary action against the nurse and their nursing license that generally involves either a voluntary surrender or an order of enforced suspension. This is especially egregious, as in most of the cases that the lawyers in my law firm have reviewed there is no indication that the nurse has actually violated their agreed order or the Texas Nursing Practice Act.
In a recent case I am the attorney for a Nurse (RN) who admitted truthfully on her license renewal form that she had attended treatment for alcohol use and dependency (Substance Abuse). There were no practice issues alleged and a long history of quality nursing care provided. The Nurse was ordered to TPAPN under a Board Order and she had been compliant in TPAPN for almost two (2) years -22 months to be exact.
The client then threw off a low lying result for EtG which was under 500 ng/ml. Nevertheless TPAPN deemed her non-compliant and reported her to the Texas Board of Nursing for further prosecution and licensure discipline. Staff of the Board is now attempting to revoke her license even though she has never been charged or deemed to have committed a nursing practice error and there is no evidence that she has been anything but sober.
SAMSHA (the Substance Abuse and Mental Health Services Administration) has posted an advisory warning that the EtG lacks proven reliability and should not be used as the basis for regulatory action on its own. Despite this fact, staff of the Texas Board of Nursing continues to harass and punish nurses who do not hire an experienced attorney to defend themselves in a license defense matter involving allegations / violations of the Nursing Practice Act. The punishment is executed in the form of an Agreed Order of Surrender or Enforced Suspension until the nurse goes through unnecessary treatment again and demonstrates one-year of objective and verifiable proof of sobriety / abstinence. Any nurse with a vested interest in thier license owes it to themselves to call an experienced attorney so they may better understand and properly assert their rights.
In cases involving possible alcohol/controlled substance abuse or mental health issues, the Texas Board of Nursing frequently asks nurses to submit to a forensic psychological evaluation and polygraph examination. This standard letter also contains a list of pre-approved evaluators and polygraph examiners. Any nurse who receives such a request should immediately stop and call an attorney with experience practicing before the Texas Board of Nursing.
The psychologists and psychiatrists referenced on this pre-approved list are there solely because they have a history of providing one-sided reports supporting whatever disciplinary measures the Board is considering imposing on your license. During the past decade I have represented approximately one thousand nurses before the Texas Board of Nursing. Throughout this period I have never seen an evaluation performed by a professional on the pre-approved list that is favorable to the nurse. This includes individuals whose entire history involves one or two DWIs or misdemeanor marijuana charges from two or more decades ago.
The bulk of these questionable evaluations are performed by two forensic psychologists in Richardson Texas. When reading an evaluation by one of these evaluators, I am frequently shocked by the vast leap between the verifiable facts in a given case, the results from the relevant forensic tests (such as the SASSI), and the final recommendations of the Board evaluators. Regardless of whether or not it is objectively justified, this recommendation is typically for revocation, referral to TPAPN, or the imposition of a long period of Board monitoring.
For example, one recent case involved a nurse with a ten-year old deferred adjudication involving possession of methamphetamines. Despite ten intervening years of incident-free nursing practice, my client’s successful completion of five years of community supervision (including the provision of five years of clean drug screens), and no other evidence of a problem, one of the above-referenced doctors wrote an evaluation finding that the nurse was an addict, unfit to practice nursing, and that the Board should seek to revoke her license. At this point the nurse felt the situation was so hopeless she had already sent started voluntarily surrendering to the Board; however, thanks to a last minute call to my office, I was able to rescind her surrender and ultimately have her case dismissed without any disciplinary action.
I have previously blogged about the Board’s use of polygraph examinations on this site which I urge you to read. The bottom line is that despite being scientifically invalid and clearly inadmissible in court, the Board continues to request polygraph exams. This is presumably so that their pre-approved evaluators can then use the questionable results to claim that a nurse was lying or overly defensive during the examination. Yet, even in the rare instance where the nurse obtains a clean polygraph, the forensic psychologist’s evaluation is invariably still negative.
Any nurse who receives a request from the Board that they should submit to a forensic evaluation and polygraph exam should immediately contact an attorney with experience before the Texas Board of Nursing. You need to know your rights including the ability to refuse the polygraph exam and request an evaluator not on the pre-approved list. By seeing one of the Board’s evaluators and polygraph examiners you place your nursing license at significant risk. A negative report will have to be rebutted, likely through a second evaluation by a neutral and better credentialed evaluator. Even then there is still a disfavorable evaluation out there raising an issue as to your fitness to practice.
I sincerely urge you to contact a lawyer prior to simply acceding to the request. More is at stake than you might think and you shouldn’t go ahead without some advice from someone other than the agency who holds authority over your license.
As most Texas nurses are now aware, the Texas Board of Nursing has for several years been performing criminal background checks as part of the renewal process. Each year a certain number of nurses who are up for renewal are required to submit fingerprints for an FBI background check. Those persons who lack any criminal history or who have previously disclosed that history to the Board need not worry. However, any licensees who do have an undisclosed criminal matter, even a minor one, should be concerned as the Board will likely use that record as an excuse to open an investigation and vigorously probe for any history or other indications that they feel indicates the person may lack fitness to practice nursing. Perhaps the most frustrating part of the Board’s policy is that they will apply the same searching examination no matter how old or miniscule the criminal record.
As an example, I recently served as the attorney for the spouse of a former client, who is also a nurse. His issue was that he recently received a letter from a Board investigator stating that a twenty year old arrest for misdemeanor possession of marijuana had popped up during his renewal background check and that they were opening an investigation based on it. The charge was so old that my client didn’t even remember it which is also the reason he had not disclosed it the Board. The arrest in fact is so old that it predates his entrance into nursing school. Furthermore, the fact that only an arrest showed up indicates that the local prosecutor likely decided that the matter was so minor that it did not warrant prosecution. Yet, the Board’s desire to pursue this old charge meant that he had to contact me and I dutifully sent a not so nice letter to the Board telling them to back off.
Essentially the Board is wasting state tax dollars and subjecting veteran nurses to searching and oftentimes humiliating investigations on the basis of decades-old minor criminal offenses which likely committed before the person was even licensed. This goes well beyond any investigatory/disciplinary mandate extended by the state legislature when they granted the Board the authority to perform extensive background checks as part of the renewal process.
The Texas Board of Nursing’s functions do include the screening of new and current licensees for the kind of criminal record which could indicate that they lack fitness to practice nursing. However, this authority does not extend to investigations and possible disciplinary action based on minor offenses committed one or two decades ago with years of uninterrupted, problem-free practice in the interim. All this does is waste Board funding and misdirect their limited resources away from pursuing licensees with genuine and ongoing issues that raise real questions about their safe practice.
It is unfortunate that it often takes the hiring of an attorney to convince the Board to retreat from this type of baseless investigation since they should never occur in the first place. It has been my experience as an attorney in many of these cases that the Board is essentially using the old offense as an excuse to sift into the nurse’s record and try and find anything which can then be added on as firmer grounds for disciplinary action. For example, the nurse will frequently be asked to submit to a polygraph examination and post-test forensic evaluation. As I have discussed elsewhere in my blog the Board has no authority to request this and the nurse is full within their rights to simply refuse. The problem is the nurse is never informed of this right of refusal as submission to test is presented as a mandatory matter-of-course. Following this the Board will habitually make an inappropriate referral to TPAPN based on the original criminal matter and whatever admissions or suspicious responses result from the polygraph and interview. Again the foundation for all of this can be nothing more than a decades old DWI or possession charge.
Any nurse facing such a situation should consider hiring an attorney with experience representing clients before the Texas Board of Nursing. Unless they face a lawyer who knows what is and is not within their authority, the Board will likely try to initiate their own minor inquisition into your work and life history.
According to the Texas Board of Nursing’s Administrative Rules any nurse who has a diagnosis of chemical dependency or who otherwise has a history of abuse of controlled substances must demonstrate through “objective, verifiable evidence” that they have been sober for the past twelve months before they can be allowed to continue practicing licensed nursing. Title 22 Texas Administrative Code § 213.29 and the Board’s “Eligibility and Disciplinary Sanctions for Nurses with Substance Abuse, Misuse, Substance Dependency, or other Substance Use Disorder.” Normally, a nurse will establish that they have been sober throughout the past year by offering up AA logs, negative drug screens, an expert evaluation by an addiction specialist, and testimony from support group members, coworkers, and other intimate acquaintances. The idea is that with the evidence in hand, the Nursing Board will be able to verify the nurse’s sobriety date and see if this meets the twelve-month threshold.
Regrettably, it has been my recent experience serving as an attorney for such nurses that the Texas Board of Nursing is all too eager to brush aside such offers of proof and race to a full administrative hearing where they seek, contrary to their own rules and policy guidelines, a one-year suspension of the nurse’s license. In the cases I have been involved with, Texas Nursing Board Staff have repeatedly argued that a one year “timeout” is the appropriate sanction. Their idea is that during this year long timeout period, the licensee can work on their recovery and accumulate verifiable evidence of their sobriety. The problem is that the Board maintains that this timeout applies whether or not the nurse all ready has twelve months of verifiable sobriety. This is an incorrect statement of the law and is grossly unfair and unnecessary for nurses who have already been sober for a year or longer.
Another problem with the Board trial strategy in this area is that in the lead up time to a full SOAH hearing, they typically refuse to accept a chemically dependent nurse’s evidence of their sobriety date. In line with this any Agreed Order offered by the Board to settle the case fails to include a finding of fact setting forth the licensee’s date of sobriety. Inclusion of the sobriety date is absolutely crucial. This is the finding the nurse needs so that they can trace back twelve months of continuous sobriety. Otherwise when they later seek to lift any bar to their ability to actively practice nursing, the whole issue of when is their initial date of sobriety will have to be litigated all over again. The Board of Nursing will once again reject the nurse’s evidence of sobriety as insufficient and force the licensee to once again hire an attorney and take the matter all the way through to the State Office of Administrative Hearings.
Given the Texas Board of Nursing’s intransigence on this point, a nurse’s only real option is to pursue their case all the way to SOAH the first time around. This is the only way to have a finding of fact issued, in this case by an Administrative Law Judge, establishing their date of sobriety so that they will have a concrete point from which to trace their one-year of sobriety. This is a waste of taxpayer money and needlessly creates stress and drains the finances of the nurse. Simply put, the Board needs to follow their own administrative rules and policies.
As an attorney I usually advise my clients in this situation not to accept an Agreed Order that does not contain a sobriety date. Fighting the Board all the way through SOAH may be more expensive in the short run than simply signing the agreement, however, in the long run they will probably need to hire an attorney when they later attempt to reactive their license or lift any bar preventing them from practicing as a nurse. This is because they still need to establish their sobriety date so that they can demonstrate twelve months free from any chemical substances. Furthermore, if they decide to challenge the Board now, their current license will remain active and they will be able to continue working as a nurse while the disciplinary process runs its course. Because of the Board’s refusal to accept a sobriety date, by the time this process has run its course, the nurse may have already accumulated a full year of sobriety and therefore not suffer any down time.
I strongly recommend that any nurse’s facing this scenario contact an attorney with experience in administrative law and representing clients before the Texas Board of Nursing. They will be able to help you accumulate the evidence needed to demonstrate twelve months of continuous sobriety and be able to discuss with you the best options for protecting your license.
The Texas Peer Assistance Program for Nurses (TPAPN) has a long history of helping Texas nurses suffering from chemical dependency regain control over their lives and keep their license in the process. Nurses referred to TPAPN are able to confidentially undergo treatment and later return to nursing practice. Texas nurses should be aware of two new changes regarding the TPAPN program, one positive and one negative. For a description of TPAPN please see my law firm's web site or blog post from July 2007 entitled "What is TPAPN"
On the positive front, the TPAPN program has developed a new category of treatment named the Extended Evaluation Participation (EEP). To be eligible for the EEP program, the nurse must be involved in an isolated drug incident with no other history of substance abuse and, after professional evaluation, be found to have a low probability of chemical dependency. Participants are subject to one year of drug screening, with a minimum of 18 screens, and are allowed to continue work without any restrictions during this period. If there are no positive screens at the end of the year, the nurse is discharged from the program and their participation and the initial incident remain confidential. Yet, if there is a positive screen or the nurse fails to adhere to the screening program, the participant will be referred to the Texas Board of Nurse Examiners. This new category of treatment program should prove beneficial to the class of nurses who become involved in an isolated incident involving a chemical substance, maybe even inadvertently, and also are not actively abusing that substance and show a low risk of doing so in the future.
Unfortunately, this step in the right direction is undermined by a change in the confidentiality provisions of the standard TPAPN treatment program. Traditionally, nurses whose practice was impaired by substance abuse or mental illness could be either referred by a third party or self-referred directly to TPAPN without the involvement of the Board of Nurse Examiners. Under the new regime, however, the Board must be notified of any referral that involves a practice violation, such as diverting medication or practicing while impaired.
While it is understandable that the Nursing Board would want to be apprised of instances of impaired practice, I fear this change could have an overall negative impact on Texas nursing. Nurses suffering from mental illness or a chemical dependency will likely be more reluctant to self-refer to TPAPN once they know that the Nursing Board and their license will be involved. This may lead to more nurses putting off seeking help until their situation and the potential well-being of their patients become much worse. The old confidentiality provision was specifically, and wisely I think, designed to promote self-referrals to treatment. Now, nurses will have to be more careful in deciding whether to report. Unless they qualify for the new Extended Evaluation Program, the threat to their license will be much more serious.
Recently I have had a flurry of cases where Texas nurses are accused of violating their Agreed Board Orders or their Texas Peer Assistance Program for Nurses (TPAPN) contracts due to positive Ethylglucuronide (EtG) tests in the 300 to 500 ng/ml range. In each case the Nurse denied consuming alcohol and corroborating evidence suggested they were sober; nevertheless, TPAPN expelled them from participation and a subsequent BNE investigation ensued against their nursing license.
This is clearly contrary to the admissibility of EtG testing in Court or as valid scientific evidence for the Board of Nurse Examiners to consider regarding these individuals knowing or intentional use of ethyl alcohol (ETOH). Please see my blog post: “What is EtG”. Moreover, it is a clear abuse of the power of both TPAPN and the BNE as they have decided their interpretations and determinations regarding EtG testing validity and use are superior to that of the Courts, SAMSHA and the scientific community at large.
Properly utilized, EtG testing can be an excellent screening tool to confront someone about a positive test. Oftentimes the initial confrontation will yield to an admission of a return to active drinking. However, when denied and all circumstances suggest that sobriety is in tact the EtG test in this range is insufficient in and of itself to prove alcohol consumption.
The BNE, however, is actively pursuing these cases in an effort to exact a surrender or active suspension of each nurse’s license. Moreover, one Client came to me after they had submitted to Board Staff’s request to undergo a forensic psychological evaluation and polygraph test. Although the test(s) yielded abstinence, Board Staff maintains other evidence developed during the psychological testing yielded information which shows the individual is otherwise unfit to possess a license to practice professional nursing in the State of Texas. The result –Formal Charges.
The bottom line is nurses who have been subjected to a BNE or TPAPN test for EtG and have tested positive should contact an attorney immediately for advice. Statements made to TPAPN or a Board investigator will be used by Board Staff against the licensee to pursue misconduct. Moreover, the inevitable request for a polygraph test is forthcoming and should be suitably denied. Please see my post titled - "The Polygraph Test: Just Say No to the BNE".
Established under Chapter 467 of the Health and Safety Code, TPAPN is a state-approved peer assistance program for Texas nurses. Operated by the Texas Nurses Association, TPAPN offers licensed nurses who are impaired by chemical dependency or mental illness an opportunity to undergo treatment and to safely return back to nursing practice -all under the protection of confidentiality.Available to Licensed Vocational and Registered Nurses who are diagnosed with substance abuse, chemical dependency, anxiety disorders, major depression, bipolar disorder, schizophrenia or schizoaffective disorder, program participation is an alternative to being reported to the Board of Nurse Examiners. A nurse suffering or who thinks they may be afflicted with one of the above diagnoses can either self-report or be referred to TPAPN by their employer. Completely voluntary, the program allows a nurse who has entered TPAPN to decline to participate or withdraw at any time. However, failure to adequately fulfill the TPAPN contract may result in a report being generated to the Texas Board of Nurse Examiners.
The self-proclaimed goal of the program is to provide an effective channel for recovery from chemical dependency and/or mental illness and effective re-integration back into nursing practice, thus protecting the public and providing incentives for professional accountability. Once in TPAPN, the nurse is assigned a case manager with extensive academic and clinical expertise in chemical dependency and psychiatric nursing. The program also includes advocates, LVN and RN volunteers who are there to support nurses throughout the program. Advocates create another layer of support for when a nurse’s case manager is not available.
The TPAPN program combines the roles of overseeing appropriate treatment, continuing care, self-help groups, practice restrictions, drug screens and monthly/quarterly reporting to ensure that nurses honor their TPAPN agreements. When a nurse self-reports or is referred to TPAPN, the program staff will make an initial assessment as to eligibility. During the first 90 days after treatment, program participants must attend daily self-help meetings such as those conducted by AA or NA and afterwards continue to attend at least four meetings per week. Nurses participating due to mental illness must follow the recommendations of their mental health professionals. Once the nurse is ready to return to work they must receive authorization by their case manager and will be subject to temporary practice restrictions. These restrictions include a requirement to be supervised by another nurse, being barred from access to controlled medications during the first six months of work, shifts limited to a maximum of twelve hours, no overtime, on-call, or night-shift assignments, and not accepting employment with temporary staffing agencies. Program participants must also both abstain from all alcohol and abusable drugs/medications and agree to provide random drug screens. The program runs for a minimum of two years.
Program staff must report to the nurse’s employer as well as the Board if the participant is non-compliant, has a positive drug screen, withdraws from the program, or moves out of state. If the nurse is a self-referral, the TPAPN staff will report the nurse to the Board only if they determine that the participant may pose an immediate threat to themselves or others.
The primary legal benefit of TPAPN is that participation is confidential and successful completion serves as an alternative to being reported to the Texas Board of Nurse Examiners and possible disciplinary action taken against the nurse’s license. The greater advantage of TPAPN participation, however, is the advocacy and assistance it offers to help guide impaired nurses back into control over their lives and the effective practice of their profession.