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Sometimes a Cigar Is Just a Cigar
Legal Matters
John R. Clark, JD, MBA, NREMT-P, FP-C,CCP-C, CFC, CMTE
Sometimes a Cigar Is Just a Cigar We mix and match crewmembers all the time. The most common crew configuration in the United States is a registered nurse/paramedic (RN/paramedic) team, while others use RN/RN. Some programs mix it up a little with physician (MD)/RN, RN/registered respiratory therapist (RRT), or RN/nurse practitioner (NP) teams. The crew composition needs to fit the needs of the program, but there will be variations. An RN/paramedic configuration today may be an RN/RN tomorrow if the paramedic is called off and the only person who can fill the shift is an RN. Similarly, a program may substitute 1 crewmember for another to accommodate a specialty team. Additionally, there may be formal or informal times when an MD is on board. In most areas, the statutory schema has flexed to accommodate helicopter emergency medical services (HEMS) into the already existing emergency medical services (EMS) rules, placing a focal point on some level of prehospital licensure or certification with a carve out for nursing practice, most commonly in the interfacility transfer role. As a practical concern, crew mix is driven by a defined scope of practice, appropriate credentialing, and the necessary education and experience matched to the level of care dictated by the mission profile. On another level, crew mix is determined by the regulatory requirements of a given area. For example, in some states, administration of patients with paralysis is outside of the nursing but within the paramedic scope of practice. This creates an issue for the HEMS team that traditionally used a model wherein the paramedic secured the airway while the nurse pushed the drugs. Now the roles are reversed. Another example common in many states is when the requirement “prehospital air ambulances are required to have a minimum of 1 paramedic”1 creates a situation in which, unless all of the nurses are dual credentialed as RN/paramedic, you would never have 2 nurses flying together, which may mean that the aircraft is out of service for that shift. Theoretically, this example results in a situation in which 2 paramedics could fly together and meet the letter of the law but may not meet the expectation of the program’s level of care. “Sometimes a cigar is just a cigar,” as Sigmund Freud is often quoted, but more to the point is Rudyard Kipling’s musing that “A woman is only a woman, but a good cigar is a smoke.” People see things differently, and crew configuration as understood by the program may be interpreted differently by the public, the customer, and the regulator. What does the referring facility expect when requesting an air ambulance? What does the family expect? What do the regulators demand? November-December 2012
Practicing at a Level Below Licensure There is not 1 consistent national standard for nursing practice. Each state has some variation of its own Nursing Practice Act, and only 24 states are part of the compact state nurse licensure (NLC) that allows a nurse with a permanent residency in an NLC state to have multi-state nursing license and to be eligible to work in other states that make up the compact states. Paramedic practice is even more fragmented, with each state having its own set of rules about paramedic licensure or certification. Even “The Nation’s EMS Certification” provided by the National Registry of Emergency Medical Technicians (NREMT) falls short of a uniform standard, with only 45 states using the NREMT at any level of certification. Certification by the NREMT does not authorize practice, which can be done only by the state in which the paramedic practices, so having a registry card is not enough to practice. A question worth consideration is that if someone is dual credentialed as an RN/paramedic but, in her flight job, she flies as a paramedic, is there any liability if the RN scope is of greater breadth? Looked at another way, what if a paramedic is working overtime at a fire station and fills a firefighter slot on an engine company that does not carry advanced life support (ALS) equipment on the engine? This is sometimes compounded by a fire engine with “Paramedic” emblazoned on the side that does not always have ALS staffing. Does “RN” or “paramedic” have any legally binding connotation when used to advertise a person’s role? To explore this question, we need to see how various states approach the same issue. Reading the state statute for Wisconsin, nurses who practice at a level below that of their licensure are expected to function according to the position description for which they are employed.2 For example, a licensed practical nurse who is employed as a home health care aide or certified nursing assistant should not exceed the scope of the duties of that position, although the RN will have education and training beyond what the position requires. When an RN volunteers as an emergency medical technician (EMT) for his community ambulance service, he should limit his practice to the job description and not act beyond the EMT scope of practice. However, according to the Wisconsin Nursing Practice Act, 2 if the nurse voluntarily acts beyond the scope of the position description, the nurse may be held to the highest standard of care for which she is licensed. Wisconsin’s approach is very altruistic, but in reality, people who practice at a level below that of licensure may also be held accountable to a higher standard of care if they knew or should have known, based on their education, training, or licensure, that the failure to act would cause harm to a 267
patient, unless the employer has clearly prohibited them from taking any action. Although the nursing board recognizes that it may be difficult for an RN or licensed practical nurse to practice at a level below that of licensure, education, and training, they have acknowledged that nurses may choose, for a variety of personal reasons, to accept such a position. The Wisconsin Board of Nursing2 provides the following caveats to anyone taking this path: 1. Obtain a thorough understanding of the position, including a clear description of the position and responsibilities, preferably in writing. 2. Clarify the limits of the position and what protocol to follow when a situation occurs that may require the nurse to make a referral to another health care provider. 3. Identify the risk that the nurse may be held to a higher standard of care if he or she exceeds the duties and responsibilities of the job description or inappropriately performs a nursing procedure. North Carolina suggests that licensed nurses may accept and work in a position for which they have the training and that is within their scope of practice.3 But similar to Wisconsin, they warn that if the nurses do function in a lesser role, they are required to act prudently based on their educational preparation and would be held to that standard. Essentially, it is okay to work below your level of licensure if you are willing to accept all of the risk of your full licensure. The Maine statute4 suggests that a licensed person who agrees to be employed in a position that requires less knowledge and skill than that for which they are prepared may find several problems in that they may be expected to perform at the level for which they have been prepared, even though they are classified at a lesser level. They also will be held to the standard expected of the higher licensure level if legal problems occur in that health care facility, no matter what the job classification.4 So to read between the lines in the Maine statute, you are fine to work below your level of licensure until something bad happens. Then you will be held accountable to the RN standard of care. This statute places that licensed nurse in potential legal jeopardy. Although my survey of state statutes is not exhaustive, the EMS rules are not as detailed in outlining issues in which a paramedic functions in a lesser role. Some of this is because the issue is unchallenged, because paramedic scope is often left to a “local option” with both online and offline medical control guiding practice. I have personal knowledge of a scenario in a northern Virginia county in which a citizen filed a complaint because providers with “paramedic” clearly displayed on their uniform provided only basic life support (BLS) care and waited for a medic unit to arrive until initiating ALS care. The resolution was to require ALS equipment on any piece of apparatus that was staffed by a paramedic. Looking beyond the concept of practicing below the level of licensure, consider implications created by regulations regarding how air ambulances are staffed in a variety of states. 268
Required Staffing for Air Ambulances In Florida, all prehospital air ambulances are required to have a minimum of 1 paramedic, whereas interfacility air ambulance staffing is based on patient condition as determined by the medical director.5 If an HEMS service works in conjunction with another EMS (eg, county 911), the air ambulance service must meet all of the provisions of the air ambulance section in addition to separate BLS and ALS requirements unique to air ambulance operations as is required by department rules. Therefore, under the Florida statute, a single paramedic crew can respond to scene calls. However, if operating in an interfacility-transfer capacity, an RN can be used in place of an EMT or paramedic if, first, the RN holds a current advanced cardiac life support (ACLS) card; the physician in charge has granted permission for such a transfer, has designated the level of service required for such transfer, and has deemed the patient to be in a condition appropriate to this type of ambulance staffing; and the RN operates within the scope of the Nursing Practice Act.6 In Kentucky,7 rotor-wing air ambulance services operating an ALS aircraft shall ensure that it is minimally staffed by a pilot and 2 attendants that meet 1 of the following staffing configurations: 1. A Kentucky-licensed paramedic and RN authorized to practice in the state of Kentucky pursuant to KRS Chapter 314. 2. An RN and an RN, both of whom are authorized to practice in the state of Kentucky pursuant to KRS Chapter 314. 3. A physician authorized to practice in the state of Kentucky pursuant to KRS Chapter 311 and an RN authorized to practice in the state of Kentucky pursuant to KRS Chapter 314. Additionally, each attendant must have ACLS, BLS, Pediatric ALS, Prehospital Trauma Life Support or International Trauma Life Support or Transport Nurse Advanced Trauma Course, and Neonatal Resuscitation Program. Additionally, all aircraft providing ALS care that are licensed and based in Kentucky shall have a Kentucky licensed paramedic on board all aircraft that respond to scene flights. A variance from the paramedic requirement for all other flights is permitted if the patient care requires a specialized caregiver and that substitution is approved by the medical director or designee. All aircraft responding to flights originating in Kentucky shall be licensed in Kentucky. They do make an allowance for aircraft licensed in Kentucky but based in contiguous states, in that they may use the staffing requirements of the state in which they are located if a minimum for scene flights shall be an RN/paramedic, RN/RN, or MD/RN configuration.7 Rule §157.12 of the Texas Administrative Code, Title 25 for Rotor-wing Air Ambulance Operations, requires 2 Texas licensed/certified personnel on board the helicopter when in service. For scene calls, at least 1 person must be a paramedic, Air Medical Journal 31:6
and for interfacility transports, at least 1 person can be a certified or licensed paramedic, RN, or MD. For both scene and interfacility transports, the second person may be a certified or licensed paramedic, RN, or an MD. Texas will waive license/certification if personnel are employed by providers in New Mexico, Oklahoma, Arkansas, and Louisiana who respond in Texas and are licensed in their respective state.8 Under the Texas fixed-wing rules,9 the crew mix is a little more relaxed in that really anything goes. Staffing must have at least 1 licensed or certified paramedic, RN, or MD on board an air ambulance to perform patient care duties with as long as staffing is appropriate to patient care needs. Unlike the more restrictive rotor-wing rules, fixed-wing operators based in another state do not need Texas certification/licensure but must be certified/licensed in their respective state. Fixed-wing crews need to document training specific to the fixed-wing transport environment consistent with the Department of Transportation Air Medical Crew–National Standard Curriculum or equivalent. The briefest of crew configuration mentioned is from the New Hampshire EMS statute that outlines the crew mix requirement as, at a minimum, 1 nationally registered EMTBasic, EMT-Intermediate, or EMT-Paramedic.10
7. 202 Kentucky Administrative Regulations (KAR) 7:510. 8. Texas Administrative Code, Title 25 Health Services, Part 1, § 157, Emergency Medical Care, Subchapter B, EMS Provider Licenses. 9. Texas Administrative Code, Title 25 Health Services, Part 1, §157.13 Fixed-Wing Air Ambulance Operations. 10. New Hampshire Department of Safety. Administrative Rules; Rule Number Saf-C 5902.07(j)(2), Emergency Medical Care Provider Requirements.
John R. Clark, JD, MBA, NREMT-P, FP-C, CCP-C, CFC, CMTE, is a member of the board of directors for the Board for Critical Care Transport Paramedic Certification and legal advisor and member of the board of directors for the International Association of Flight and Critical Care Paramedics. Editor’s Note: While the information in this article deals with legal issues, it does not constitute legal advice. If you have specific questions related to this topic, you are encouraged to consult an attorney who can investigate the particular circumstances of your individual situation. If you have an issue you would like to see addressed in a future issue of AMJ, please contact the author at [email protected] to suggest a topic. 1067-991X/$36.00 Copyright 2012 Air Medical Journal Associates http://dx.doi.org/10.1016/j.amj.2012.08.004
Conclusion There is much variation among states in how practice is defined, but it is reasonable to suggest that if you practice below your level of licensure and education, laws in every state are consistent in holding you accountable to your highest level of training. Even if the statute is mute on the actual issue, a jury would likely find reason to convict you if you had a duty to do something and could have done something because you were trained to do so but opted not to. Basically, anything you were taught is the standard to which you will be held if you are working in a position in which you technically do less. As far as the crew configuration questions, know your state statute relative to air ambulances and act accordingly. Keeping the aircraft in service seems like the right thing to do, but if the state statute clearly dictates that a paramedic is always required for a scene flight but you respond with 2 nurses and something goes wrong, this failure to follow the statute will be another item that you must prepare to defend and may be held against you. Staffing with the proper people in the proper roles will help you avoid risk.
References 1. 2012 Florida Statutes, Title XXIX, Public Health Chapter 401, Medical Telecommunications and Transport 401.25. 2. 2011 Wisconsin Code Chapter 441. Board of Nursing. 3. North Carolina Nursing Practice Act. § 90-171.19. 4. Maine Law Regulating the Practice of Nursing (32 M.R.S.A. Chapter 31). 5. Reference Section 401.25, Florida Statutes, Section 401.251, Florida Statutes, & Sections 64E-2.003; 64J-1.004; & 64J-1.005, Florida Administrative Code. 6. Title XXXII, Regulation of Professions and Occupations, Chapter 464, Part I, Nursing Practice Act.
November-December 2012
269
John R. Clark, JD, MBA, NREMT-P, FP-C,CCP-C, CFC, CMTE
Sometimes a Cigar Is Just a Cigar We mix and match crewmembers all the time. The most common crew configuration in the United States is a registered nurse/paramedic (RN/paramedic) team, while others use RN/RN. Some programs mix it up a little with physician (MD)/RN, RN/registered respiratory therapist (RRT), or RN/nurse practitioner (NP) teams. The crew composition needs to fit the needs of the program, but there will be variations. An RN/paramedic configuration today may be an RN/RN tomorrow if the paramedic is called off and the only person who can fill the shift is an RN. Similarly, a program may substitute 1 crewmember for another to accommodate a specialty team. Additionally, there may be formal or informal times when an MD is on board. In most areas, the statutory schema has flexed to accommodate helicopter emergency medical services (HEMS) into the already existing emergency medical services (EMS) rules, placing a focal point on some level of prehospital licensure or certification with a carve out for nursing practice, most commonly in the interfacility transfer role. As a practical concern, crew mix is driven by a defined scope of practice, appropriate credentialing, and the necessary education and experience matched to the level of care dictated by the mission profile. On another level, crew mix is determined by the regulatory requirements of a given area. For example, in some states, administration of patients with paralysis is outside of the nursing but within the paramedic scope of practice. This creates an issue for the HEMS team that traditionally used a model wherein the paramedic secured the airway while the nurse pushed the drugs. Now the roles are reversed. Another example common in many states is when the requirement “prehospital air ambulances are required to have a minimum of 1 paramedic”1 creates a situation in which, unless all of the nurses are dual credentialed as RN/paramedic, you would never have 2 nurses flying together, which may mean that the aircraft is out of service for that shift. Theoretically, this example results in a situation in which 2 paramedics could fly together and meet the letter of the law but may not meet the expectation of the program’s level of care. “Sometimes a cigar is just a cigar,” as Sigmund Freud is often quoted, but more to the point is Rudyard Kipling’s musing that “A woman is only a woman, but a good cigar is a smoke.” People see things differently, and crew configuration as understood by the program may be interpreted differently by the public, the customer, and the regulator. What does the referring facility expect when requesting an air ambulance? What does the family expect? What do the regulators demand? November-December 2012
Practicing at a Level Below Licensure There is not 1 consistent national standard for nursing practice. Each state has some variation of its own Nursing Practice Act, and only 24 states are part of the compact state nurse licensure (NLC) that allows a nurse with a permanent residency in an NLC state to have multi-state nursing license and to be eligible to work in other states that make up the compact states. Paramedic practice is even more fragmented, with each state having its own set of rules about paramedic licensure or certification. Even “The Nation’s EMS Certification” provided by the National Registry of Emergency Medical Technicians (NREMT) falls short of a uniform standard, with only 45 states using the NREMT at any level of certification. Certification by the NREMT does not authorize practice, which can be done only by the state in which the paramedic practices, so having a registry card is not enough to practice. A question worth consideration is that if someone is dual credentialed as an RN/paramedic but, in her flight job, she flies as a paramedic, is there any liability if the RN scope is of greater breadth? Looked at another way, what if a paramedic is working overtime at a fire station and fills a firefighter slot on an engine company that does not carry advanced life support (ALS) equipment on the engine? This is sometimes compounded by a fire engine with “Paramedic” emblazoned on the side that does not always have ALS staffing. Does “RN” or “paramedic” have any legally binding connotation when used to advertise a person’s role? To explore this question, we need to see how various states approach the same issue. Reading the state statute for Wisconsin, nurses who practice at a level below that of their licensure are expected to function according to the position description for which they are employed.2 For example, a licensed practical nurse who is employed as a home health care aide or certified nursing assistant should not exceed the scope of the duties of that position, although the RN will have education and training beyond what the position requires. When an RN volunteers as an emergency medical technician (EMT) for his community ambulance service, he should limit his practice to the job description and not act beyond the EMT scope of practice. However, according to the Wisconsin Nursing Practice Act, 2 if the nurse voluntarily acts beyond the scope of the position description, the nurse may be held to the highest standard of care for which she is licensed. Wisconsin’s approach is very altruistic, but in reality, people who practice at a level below that of licensure may also be held accountable to a higher standard of care if they knew or should have known, based on their education, training, or licensure, that the failure to act would cause harm to a 267
patient, unless the employer has clearly prohibited them from taking any action. Although the nursing board recognizes that it may be difficult for an RN or licensed practical nurse to practice at a level below that of licensure, education, and training, they have acknowledged that nurses may choose, for a variety of personal reasons, to accept such a position. The Wisconsin Board of Nursing2 provides the following caveats to anyone taking this path: 1. Obtain a thorough understanding of the position, including a clear description of the position and responsibilities, preferably in writing. 2. Clarify the limits of the position and what protocol to follow when a situation occurs that may require the nurse to make a referral to another health care provider. 3. Identify the risk that the nurse may be held to a higher standard of care if he or she exceeds the duties and responsibilities of the job description or inappropriately performs a nursing procedure. North Carolina suggests that licensed nurses may accept and work in a position for which they have the training and that is within their scope of practice.3 But similar to Wisconsin, they warn that if the nurses do function in a lesser role, they are required to act prudently based on their educational preparation and would be held to that standard. Essentially, it is okay to work below your level of licensure if you are willing to accept all of the risk of your full licensure. The Maine statute4 suggests that a licensed person who agrees to be employed in a position that requires less knowledge and skill than that for which they are prepared may find several problems in that they may be expected to perform at the level for which they have been prepared, even though they are classified at a lesser level. They also will be held to the standard expected of the higher licensure level if legal problems occur in that health care facility, no matter what the job classification.4 So to read between the lines in the Maine statute, you are fine to work below your level of licensure until something bad happens. Then you will be held accountable to the RN standard of care. This statute places that licensed nurse in potential legal jeopardy. Although my survey of state statutes is not exhaustive, the EMS rules are not as detailed in outlining issues in which a paramedic functions in a lesser role. Some of this is because the issue is unchallenged, because paramedic scope is often left to a “local option” with both online and offline medical control guiding practice. I have personal knowledge of a scenario in a northern Virginia county in which a citizen filed a complaint because providers with “paramedic” clearly displayed on their uniform provided only basic life support (BLS) care and waited for a medic unit to arrive until initiating ALS care. The resolution was to require ALS equipment on any piece of apparatus that was staffed by a paramedic. Looking beyond the concept of practicing below the level of licensure, consider implications created by regulations regarding how air ambulances are staffed in a variety of states. 268
Required Staffing for Air Ambulances In Florida, all prehospital air ambulances are required to have a minimum of 1 paramedic, whereas interfacility air ambulance staffing is based on patient condition as determined by the medical director.5 If an HEMS service works in conjunction with another EMS (eg, county 911), the air ambulance service must meet all of the provisions of the air ambulance section in addition to separate BLS and ALS requirements unique to air ambulance operations as is required by department rules. Therefore, under the Florida statute, a single paramedic crew can respond to scene calls. However, if operating in an interfacility-transfer capacity, an RN can be used in place of an EMT or paramedic if, first, the RN holds a current advanced cardiac life support (ACLS) card; the physician in charge has granted permission for such a transfer, has designated the level of service required for such transfer, and has deemed the patient to be in a condition appropriate to this type of ambulance staffing; and the RN operates within the scope of the Nursing Practice Act.6 In Kentucky,7 rotor-wing air ambulance services operating an ALS aircraft shall ensure that it is minimally staffed by a pilot and 2 attendants that meet 1 of the following staffing configurations: 1. A Kentucky-licensed paramedic and RN authorized to practice in the state of Kentucky pursuant to KRS Chapter 314. 2. An RN and an RN, both of whom are authorized to practice in the state of Kentucky pursuant to KRS Chapter 314. 3. A physician authorized to practice in the state of Kentucky pursuant to KRS Chapter 311 and an RN authorized to practice in the state of Kentucky pursuant to KRS Chapter 314. Additionally, each attendant must have ACLS, BLS, Pediatric ALS, Prehospital Trauma Life Support or International Trauma Life Support or Transport Nurse Advanced Trauma Course, and Neonatal Resuscitation Program. Additionally, all aircraft providing ALS care that are licensed and based in Kentucky shall have a Kentucky licensed paramedic on board all aircraft that respond to scene flights. A variance from the paramedic requirement for all other flights is permitted if the patient care requires a specialized caregiver and that substitution is approved by the medical director or designee. All aircraft responding to flights originating in Kentucky shall be licensed in Kentucky. They do make an allowance for aircraft licensed in Kentucky but based in contiguous states, in that they may use the staffing requirements of the state in which they are located if a minimum for scene flights shall be an RN/paramedic, RN/RN, or MD/RN configuration.7 Rule §157.12 of the Texas Administrative Code, Title 25 for Rotor-wing Air Ambulance Operations, requires 2 Texas licensed/certified personnel on board the helicopter when in service. For scene calls, at least 1 person must be a paramedic, Air Medical Journal 31:6
and for interfacility transports, at least 1 person can be a certified or licensed paramedic, RN, or MD. For both scene and interfacility transports, the second person may be a certified or licensed paramedic, RN, or an MD. Texas will waive license/certification if personnel are employed by providers in New Mexico, Oklahoma, Arkansas, and Louisiana who respond in Texas and are licensed in their respective state.8 Under the Texas fixed-wing rules,9 the crew mix is a little more relaxed in that really anything goes. Staffing must have at least 1 licensed or certified paramedic, RN, or MD on board an air ambulance to perform patient care duties with as long as staffing is appropriate to patient care needs. Unlike the more restrictive rotor-wing rules, fixed-wing operators based in another state do not need Texas certification/licensure but must be certified/licensed in their respective state. Fixed-wing crews need to document training specific to the fixed-wing transport environment consistent with the Department of Transportation Air Medical Crew–National Standard Curriculum or equivalent. The briefest of crew configuration mentioned is from the New Hampshire EMS statute that outlines the crew mix requirement as, at a minimum, 1 nationally registered EMTBasic, EMT-Intermediate, or EMT-Paramedic.10
7. 202 Kentucky Administrative Regulations (KAR) 7:510. 8. Texas Administrative Code, Title 25 Health Services, Part 1, § 157, Emergency Medical Care, Subchapter B, EMS Provider Licenses. 9. Texas Administrative Code, Title 25 Health Services, Part 1, §157.13 Fixed-Wing Air Ambulance Operations. 10. New Hampshire Department of Safety. Administrative Rules; Rule Number Saf-C 5902.07(j)(2), Emergency Medical Care Provider Requirements.
John R. Clark, JD, MBA, NREMT-P, FP-C, CCP-C, CFC, CMTE, is a member of the board of directors for the Board for Critical Care Transport Paramedic Certification and legal advisor and member of the board of directors for the International Association of Flight and Critical Care Paramedics. Editor’s Note: While the information in this article deals with legal issues, it does not constitute legal advice. If you have specific questions related to this topic, you are encouraged to consult an attorney who can investigate the particular circumstances of your individual situation. If you have an issue you would like to see addressed in a future issue of AMJ, please contact the author at [email protected] to suggest a topic. 1067-991X/$36.00 Copyright 2012 Air Medical Journal Associates http://dx.doi.org/10.1016/j.amj.2012.08.004
Conclusion There is much variation among states in how practice is defined, but it is reasonable to suggest that if you practice below your level of licensure and education, laws in every state are consistent in holding you accountable to your highest level of training. Even if the statute is mute on the actual issue, a jury would likely find reason to convict you if you had a duty to do something and could have done something because you were trained to do so but opted not to. Basically, anything you were taught is the standard to which you will be held if you are working in a position in which you technically do less. As far as the crew configuration questions, know your state statute relative to air ambulances and act accordingly. Keeping the aircraft in service seems like the right thing to do, but if the state statute clearly dictates that a paramedic is always required for a scene flight but you respond with 2 nurses and something goes wrong, this failure to follow the statute will be another item that you must prepare to defend and may be held against you. Staffing with the proper people in the proper roles will help you avoid risk.
References 1. 2012 Florida Statutes, Title XXIX, Public Health Chapter 401, Medical Telecommunications and Transport 401.25. 2. 2011 Wisconsin Code Chapter 441. Board of Nursing. 3. North Carolina Nursing Practice Act. § 90-171.19. 4. Maine Law Regulating the Practice of Nursing (32 M.R.S.A. Chapter 31). 5. Reference Section 401.25, Florida Statutes, Section 401.251, Florida Statutes, & Sections 64E-2.003; 64J-1.004; & 64J-1.005, Florida Administrative Code. 6. Title XXXII, Regulation of Professions and Occupations, Chapter 464, Part I, Nursing Practice Act.
November-December 2012
269