TITLE 22. EXAMINING BOARDS

PART 5. STATE BOARD OF DENTAL EXAMINERS

CHAPTER 104. CONTINUING EDUCATION

22 TAC §104.6

The State Board of Dental Examiners (Board) proposes amended rule §104.6, concerning continuing education audits. The proposed amendment establishes how and when the board will conduct audits of continuing education.

Kelly Parker, Executive Director, has determined that for the first five-year period the proposed rules are in effect, there will not be any fiscal implications for state or local government as a result of enforcing or administering the amendments to the rule.

Kelly Parker has also determined that for the first five-year period the proposed rules are in effect, the public benefit anticipated as a result of administering this section will be to ensure licensees are completing their continuing education requirements. Ms. Parker has determined that for the first five-year period the proposed rules are in effect, costs to persons or small businesses will be minimal. There is no foreseeable impact on employment in any regional area where the rules are enforced or administered.

Comments on the proposed new rules may be submitted to Tyler Vance, General Counsel, 333 Guadalupe, Suite 3-800, Austin, Texas 78732, Fax (512) 475-0977, rulecomments@tsbde.texas.gov no later than 30 days from the date that the proposed rule is published in the Texas Register.

These new rules are proposed under Texas Occupations Code §254.001(a), which gives the Board authority to adopt rules necessary to perform its duties and ensure compliance with state laws relating to the practice of dentistry to protect the public health and safety.

No statutes are affected by these proposed new rules.

§104.6.Audits.

(a) All licensees are subject to audit by the State Board of Dental Examiners for purposes of ensuring compliance with the continuing education requirements as outlined in this chapter (Continuing Education) and any other rules.

(b) Board staff will randomly audit 5% of all licensees for compliance with the continuing education requirements as outlined in this chapter and other rules.

(c) Licensees who have been selected for a renewal-based audit will be notified at least 90 days prior to the expiration of their license. A licensee selected for audit may not renew their license until they have submitted proof of compliance with the continuing education requirements. Extensions may be granted at the discretion of the Executive Director only in extraordinary circumstances, such as demonstrated health issues that prevent a licensee from completing the audit requirements.

(d) Licensees may be selected at any time for a random audit of their compliance with the continuing education requirements outlined in this chapter and other rules.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on December 5, 2016.

TRD-201606158

Kelly Parker

Executive Director

State Board of Dental Examiners

Earliest possible date of adoption: January 15, 2017

For further information, please call: (512) 475-0977


CHAPTER 107. DENTAL BOARD PROCEDURES

SUBCHAPTER E. DATA REPORTING

22 TAC §107.400

The State Board of Dental Examiners (Board) proposes new Subchapter E, Data Reporting, and §107.400, concerning Collection and Reporting of Enforcement and Licensing Data. The proposed new rule identifies what kind of data will be gathered and how it will be published.

Kelly Parker, Executive Director, has determined that for the first five-year period the proposed rules are in effect, there will not be any fiscal implications for state or local government as a result of enforcing or administering the amendments to the rule.

Kelly Parker has also determined that for the first five-year period the proposed rules are in effect, the public benefit anticipated as a result of administering this section will be to shed light on complaints, investigations, and disciplinary actions taken by the Board. Ms. Parker has determined that for the first five-year period the proposed rules are in effect, costs to persons or small businesses will be minimal. There is no foreseeable impact on employment in any regional area where the rules are enforced or administered.

Comments on the proposed new rules may be submitted to Tyler Vance, General Counsel, 333 Guadalupe, Suite 3-800, Austin, Texas 78732, Fax (512) 475-0977, rulecomments@tsbde.texas.gov no later than 30 days from the date that the proposed rule is published in the Texas Register.

These new rules are proposed under Texas Occupations Code §254.001(a), which gives the Board authority to adopt rules necessary to perform its duties and ensure compliance with state laws relating to the practice of dentistry to protect the public health and safety.

No statutes are affected by these proposed new rules.

§107.400.Collection and Reporting of Enforcement and Licensing Data.

(a) All information related to an investigation is confidential, except that the agency shall provide information on a quarterly basis to the Board and the Anesthesia Committee of the Board, and to legislative offices upon request. This information shall consist of de-identified, case specific data reflecting information about jurisdictional, filed complaints involving sedation/anesthesia that were resolved during the reporting period, including, at a minimum, the following data points:

(1) Source of initial complaint -- public, other agency, self-report of death, self-report of hospitalization, or initiated by the Board.

(2) Information about licensee:

(A) Whether respondent is Medicaid provider;

(B) Respondent's highest sedation/anesthesia permit level;

(C) Whether respondent holds portability privileges; and

(D) Respondent's self-reported practice area.

(3) Information about patient:

(A) Patient ASA, as identified in respondent's dental records and/or determined by Dental Review Panel;

(B) Patient age -- 13 and under, between 13 and 18, between 19 and 75, and over 75;

(C) Location of the treatment investigated by the agency -- dental office, hospital, ASC, office of other practitioner;

(D) Level of sedation/anesthesia administered -- Local, Nitrous, I, II, III, IV (determined by Dental Review Panel);

(E) Sedation/anesthesia administrator -- respondent, other dentist, MD, CRNA (determined by Dental Review Panel); and

(F) Whether treatment investigated by the agency was paid by Medicaid.

(4) Information about investigation:

(A) Allegation categories identified in preliminary investigation;

(B) Disposition of official investigation -- Dismissed by Enforcement, Dismissed by Legal -- No Violation, Dismissed by Board Vote, Closed by Administrative Citation/Remedial Plan/Disciplinary Action; and

(C) If disposition is public action (Administrative Citation, Remedial Plan, or Disciplinary Action), the violations identified in the public action resolving the official investigation.

(b) In addition, the agency shall publish on its website aggregate data related to the preceding fiscal year for each type of license it issues. This aggregate data shall include, at a minimum, the following data points related to the preceding fiscal year:

(1) Number of licensees at the end of the fiscal year;

(2) Average number of days to issue a license;

(3) Total number of complaints against licensees received by the agency;

(4) Total number of jurisdictional complaints against licensees filed by the agency;

(5) The resolution of all cases resolved in the fiscal year:

(A) Nonjurisdictional;

(B) Jurisdictional, Not Filed;

(C) Dismissed by Agency;

(D) Dismissed by Board Vote;

(E) Closed by Administrative Citation;

(F) Closed by Remedial Plan;

(G) Warning;

(H) Reprimand;

(I) Probation;

(J) Suspension; and

(K) Revocation.

(6) For all jurisdictional, filed complaints resolved in the fiscal year, the allegation category of the complaints, as defined in §107.104;

(7) Number of cases that at the end of the fiscal year, have been filed with the agency for longer than one year;

(8) Average administrative penalty assessed through administrative citations issued in the fiscal year;

(9) Average administrative fine assessed through disciplinary actions taken in the fiscal year;

(10) Number of cases heard at Informal Settlement Conferences in the fiscal year;

(11) Number of cases resolved following Informal Settlement Conference, without referral to SOAH, in the fiscal year;

(12) Number of cases referred to SOAH in the fiscal year;

(13) Number of cases referred to SOAH and resolved following mediation, in the fiscal year;

(14) Number of cases returned to the Board for disposition on a default basis following referral to SOAH;

(15) Number of cases returned to the Board for consideration of a Proposal for Decision following a contested case hearing at SOAH;

(16) Number of cases resolved in the fiscal year that were appealed to District Court;

(17) Average number of days to investigate a complaint from complaint received to investigation completed, for all complaints received; and

(18) Average number of days to resolve a complaint from complaint received to final order issued, for all complaints received.

(c) In addition, the agency shall publish on its website aggregate data related to the preceding fiscal year that addresses adverse outcomes and complaints involving anesthesia. This aggregate data shall include, at a minimum, the following data points related to the preceding fiscal year:

(1) Number of jurisdictional, filed complaints involving mortality and morbidity. Morbidity is defined as life-threatening complications following a dental procedure or treatment;

(2) Total number of jurisdictional complaints against dentists related to the standard of care in anesthesia, by level of sedation/anesthesia permit held by the dentist, that were filed by the Board in the preceding fiscal year; and

(3) For all anesthesia-related jurisdictional, filed complaints identified in paragraph (2) of this subsection, the level of sedation/anesthesia permit held by the dentist, the anesthesia-related complication identified in the Board's investigation (if any), and the resolution of each complaint:

(A) Nonjurisdictional;

(B) Jurisdictional, Not Filed;

(C) Dismissed by Agency;

(D) Dismissed by Board Vote;

(E) Closed by Administrative Citation;

(F) Closed by Remedial Plan;

(G) Warning;

(H) Reprimand;

(I) Probation;

(J) Suspension; or

(K) Revocation.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on December 5, 2016.

TRD-201606157

Kelly Parker

Executive Director

State Board of Dental Examiners

Earliest possible date of adoption: January 15, 2017

For further information, please call: (512) 475-0977


CHAPTER 110. SEDATION AND ANESTHESIA

22 TAC §§110.1 - 110.6, 110.9, 110.11

The State Board of Dental Examiners (Board) proposes amended rules §110.1, concerning definitions; §110.2, concerning sedation/anesthesia permits; §110.3, concerning nitrous sedation; §110.4, concerning minimal sedation; §110.5, concerning moderate sedation; §110.6, concerning deep sedation; §110.9, concerning permit renewal; and new rule §110.11, concerning pediatric patients. The proposed rules establish new guidelines and permits for providing sedation and anesthesia.

Kelly Parker, Executive Director, has determined that for the first five-year period the proposed rules are in effect, there will not be any fiscal implications for state or local government as a result of enforcing or administering the amendments to the rule.

Ms. Parker has also determined that for the first five-year period the proposed rules are in effect, the public benefit anticipated as a result of administering these rules will be to ensure licensees are qualified and competent to sedate and anesthetize patients. Ms. Parker has determined that for the first five-year period the proposed rules are in effect, costs to persons or small businesses will be minimal. There is no foreseeable impact on employment in any regional area where the rules are enforced or administered.

Comments on the proposed rules may be submitted to Tyler Vance, General Counsel, 333 Guadalupe, Suite 3-800, Austin, Texas 78732, Fax (512) 475-0977, rulecomments@tsbde.texas.gov no later than January 31, 2017.

These amended and new rules are proposed under Texas Occupations Code §254.001(a), which gives the Board authority to adopt rules necessary to perform its duties and ensure compliance with state laws relating to the practice of dentistry to protect the health and safety of the public.

No statutes are affected by these proposal.

§110.1.Definitions.

Unless the context clearly indicates otherwise, the following words and terms shall have the following meaning when used in this chapter.

(1) Analgesia--the diminution or elimination of pain.

(2) Anxiolytic--a dangerous drug or controlled substance used to provide sedation and/or treat episodes of anxiety.

(3) [(2)] Behavioral management--the use of pharmacological or psychological techniques, singly or in combination, to modify behavior to a level that dental treatment can be performed effectively and efficiently.

(4) [(3)] Board/Agency--the Texas State Board of Dental Examiners, also known as the State Board of Dental Examiners, and, for brevity, the Dental Board, the Agency, or the Board.

(5) [(4)] Child/children--a patient under the age of thirteen (13) at the time of a dental treatment or procedure. [twelve (12) years of age or younger.]

(6) [(5)] Competent--displaying special skill or knowledge derived from training and experience.

(7) [(6)] Deep sedation--a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

(8) [(7)] Direct supervision--the dentist responsible for the sedation/general anesthesia procedure shall be physically present in the facility and shall be continuously aware of the patient's physical status and well-being.

(9) [(8)] Enteral--any technique of administration of sedation in which the agent is absorbed through the gastrointestinal (GI) tract or oral mucosa (i.e., oral, rectal, sublingual).

(10) [(9)] Facility--a [the] location where a permit holder practices dentistry and/or provides sedation/general anesthesia [anesthesia/sedation ] services.

(11) [(10)] Facility inspection--an on-site inspection to determine if a facility where the applicant proposes to provide anesthesia/sedation is supplied, equipped, staffed and maintained in a condition to support provision of anesthesia/sedation services that meet the minimum standard of care.

(12) [(11)] General anesthesia--a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

(13) [(12)] Immediately available--on-site in the facility and available for immediate use.

(14) [(13)] Incremental dosing--administration of multiple doses of a drug until a desired effect is reached, but not to exceed the maximum recommended dose (MRD).

(15) [(14)] Local anesthesia--the elimination of sensation, especially pain, in one part of the body by the topical application or regional injection of a drug.

(16) [(15)] Maximum recommended dose (applies to minimal sedation)--FDA maximum recommended dose (MRD) of a drug, as printed in FDA-approved labeling for unmonitored home use.

(17) [(16)] Minimal sedation--a minimally depressed level of consciousness, produced by a pharmacological method, which retains the patient's ability to independently and continuously maintain an airway and respond normally to tactile stimulation and verbal command. Although cognitive function and coordination may be modestly impaired, ventilatory and cardiovascular functions are unaffected. Medication administered for the purpose of minimal sedation shall not exceed the maximum doses recommended by the drug manufacturer. Nitrous oxide/oxygen may be used in combination with a single enteral drug in minimal sedation. During longer periods of minimal sedation in which the total amount of time of the procedures exceeds the effective duration of the sedative effect of the drug used, the supplemental dose of the sedative shall not exceed total safe dosage levels based on the effective half-life of the drug used. The total aggregate dose must not exceed one [and one-half times the] MRD on the day of treatment. The use of prescribed, previsit sedatives for children under the age of thirteen (13) [aged twelve (12) or younger] should be avoided due to the risk of unobserved respiratory obstruction during the transport by untrained individuals.

(18) [(17)] Moderate sedation--drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. A Level 2 permit is required for moderate sedation limited to enteral routes of administration. A Level 3 permit is required for moderate sedation including parenteral routes of administration. In accordance with this particular definition, the drugs or techniques used shall carry a margin of safety wide enough to render unintended loss of consciousness unlikely. Repeated dosing of an agent before the effects of previous dosing can be fully appreciated may result in a greater alteration of the state of consciousness than is the intent of the dentist. A patient whose only response is reflex withdrawal from a painful stimulus is not considered to be in a state of moderate sedation.

(19) [(18)] Parenteral--the administration of pharmacological agents intravenously, intraosseously, intramuscularly, subcutaneously, submucosally, intranasally, or transdermally.

(20) [(19)] Patient Physical Status Classification:

(A) ASA--American Society of Anesthesiologists

(B) ASA I--a normal health patient

(C) ASA II--a patient with mild systemic disease

(D) ASA III--a patient with severe systemic disease

(E) ASA IV--a patient with severe systemic disease that is a constant threat to life

(F) ASA V--a moribund patient who is not expected to survive without the operation

(G) ASA VI--a declared brain-dead patient whose organs are being removed for donor purposes

(H) E--emergency operation of any variety (used to modify ASA I - ASA VI).

(21) Pediatric patient--a patient who is under the age of 13 at the time of a dental treatment or procedure.

(22) [(20)] Portability--the ability of a permit holder to provide permitted anesthesia services in a location other than a facility or satellite facility.

(23) [(21)] Protective reflexes--includes the ability to swallow and cough effectively.

(24) [(22)] Satellite facility--an additional office or offices owned or operated by the permit holder, or owned or operated by a professional organization through which the permit holder practices dentistry, or a licensed hospital facility.

[(23) Supplemental dosing (applies to minimal sedation)--during minimal sedation, supplemental dosing is a single additional dose of the initial dose of the initial drug that may be necessary for prolonged procedures. The supplemental dose should not exceed one-half of the initial dose and should not be administered until the dentist has determined the clinical half-life of the initial dosing has passed. The aggregate dose must not exceed one and one-half times the MRD on the day of treatment.]

(25) [(24)] Time-oriented anesthesia record--documentation at appropriate time intervals of drugs, doses, and physiologic data obtained during patient monitoring. Physiologic data for moderate sedation, deep sedation and general anesthesia must be taken and recorded at required intervals unless patient cooperation interferes or prohibits compliance.

(26) [(25)] Titration (applies to moderate sedation)--administration of incremental doses of a drug until the desired effect is reached. Knowledge of each drug's time of onset, peak response and duration of action is essential to avoid over-sedation. When the intent is moderate sedation, one must know whether the previous dose has taken full effect before administering an additional drug increment.

§110.2.Sedation/General Anesthesia Permit.

(a) A dentist licensed under Chapter 101 of this title shall obtain a sedation/general [an] anesthesia permit for the following sedation/general anesthesia procedures used for the purpose of performing dentistry:

(1) Nitrous Oxide/Oxygen inhalation sedation;

(2) Level 1: Minimal sedation;

(3) Level 2: Moderate sedation limited to enteral routes of administration;

(4) Level 3: Moderate sedation which includes parenteral routes of administration; or

(5) Level 4: Deep sedation or general anesthesia.

(b) A dentist licensed to practice in Texas who desires to administer nitrous oxide/oxygen inhalation sedation or Level 1, Level 2, Level 3 or Level 4 sedation must obtain a permit from the State Board of Dental Examiners (Board). A sedation/general anesthesia permit is not required to administer Schedule II drugs prescribed for the purpose of pain control or post-operative care.

(1) A permit may be obtained by completing an application form approved by the Board.

(2) The application form must be filled out completely and appropriate fees paid.

(3) A dentist applying for a sedation/general anesthesia permit must meet the requirements of the highest permit level sought and all permit levels below the highest permit level sought.

(4) [(3)] Prior to issuance of a sedation/general anesthesia permit, the Board may require that the applicant undergo a facility inspection or further review of credentials. The Board may direct an Anesthesia Consultant, who has been appointed by the Board, to assist in this inspection or review. The applicant will be notified in writing if an inspection is required and provided with the name of an Anesthesia Consultant who will coordinate the inspection. The applicant must make arrangements for completion of the inspection within 180 days of the date the notice is mailed. An extension of no more than ninety (90) days may be granted if the designated Anesthesia Consultant requests one.

(5) [(4)] An applicant for a sedation/general anesthesia permit must be licensed by and should be in good standing with the Board. For purposes of this chapter "good standing" means that the dentist's license is not suspended, whether or not the suspension is probated. Applications from licensees who are not in good standing shall not be approved.

§110.3.Nitrous Oxide/Oxygen Inhalation Sedation.

(a) Initial Application for Nitrous Oxide/Oxygen Inhalation /Sedation. [Education and Professional Requirements. ] A dentist applying for a nitrous oxide/oxygen inhalation sedation permit shall demonstrate the following: [meet one of the following educational/professional criteria:]

(1) current certification in Basic Life Support (BLS) for Healthcare Providers; and

(2) [(1)] satisfactory completion of one of the following education programs:

(A) an American Dental Association (ADA) Commission on Dental Accreditation (CODA) approved or recognized pre-doctoral dental or postdoctoral dental training program that affords comprehensive training administering and managing nitrous oxide/oxygen inhalation sedation, commensurate with the ADA's Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students; or

(B) a comprehensive training program consistent with that described for nitrous oxide/oxygen inhalation sedation administration in the American Dental Association (ADA) Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students. This includes a minimum of fourteen (14) hours of training, including a clinical component of at least four hours of in-person clinical experience in the administration and management of nitrous oxide, during which competency in inhalation sedation technique is achieved. Acceptable courses include those obtained from academic programs of instruction recognized by the Commission on Dental Accreditation (CODA); or courses approved and recognized by the ADA Continuing Education Recognition Program (CERP); or courses approved and recognized by the Academy of General Dentistry (AGD) Program Approval for Continuing Education (PACE). [a comprehensive training program consistent with that described for nitrous oxide/oxygen inhalation sedation administration in the American Dental Association (ADA) Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students. This includes a minimum of fourteen (14) hours of training, including a clinical component, during which competency in inhalation sedation technique is achieved. Acceptable courses include those obtained from academic programs of instruction recognized by the ADA Commission on Dental Accreditation (CODA); or courses approved and recognized by the ADA Continuing Education Recognition Program (CERP); or courses approved and recognized by the Academy of General Dentistry (AGD) Program Approval for Continuing Education (PACE);]

[(2) satisfactory completion of an ADA/CODA approved or recognized pre-doctoral dental or postdoctoral dental training program which affords comprehensive training necessary to administer and manage nitrous oxide/oxygen inhalation sedation; or]

[(3) is a Texas licensed dentist, has a current Board-issued nitrous oxide/oxygen inhalation sedation permit, and has been using nitrous oxide/oxygen inhalation sedation in a competent manner immediately prior to the implementation of this chapter on June 1, 2011. Any dentist whose Board-issued nitrous oxide/oxygen inhalation sedation permit is active on June 1, 2011 shall automatically continue to hold this permit.]

(b) Maintenance of Permit. A dentist must comply with the requirements of rule 110.9 to qualify for annual renewal of a nitrous oxide/oxygen inhalation sedation permit.

(c) Administration of Nitrous Oxide/Oxygen Inhalation Sedation to Pediatric Patients. A dentist shall comply with all requirements regarding the treatment of pediatric patients, including those described in rule 110.11. Additionally, the dentist should observe the American Academy of Pediatrics/American Academy of Pediatric Dentists Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.

(d) Delegation and Supervision Requirements. A dentist performing nitrous oxide/oxygen inhalation sedation must maintain the minimum standard of care, including, but not limited to the requirements outlined in (e) below, and in addition, shall:

(1) maintain under continuous direct supervision auxiliary personnel who shall be capable of reasonably assisting in procedures, problems, and emergencies incident to the use of nitrous oxide/oxygen inhalation sedation;

(2) maintain current certification in Basic Life Support (BLS) for Healthcare Providers for the assistant staff by having them pass a course that includes a written examination and a hands-on demonstration of skills; and

(3) not supervise a Certified Registered Nurse Anesthetist (CRNA) any level of sedation unless the dentist holds a permit issued by the board for the level of sedation to be administered during the dental procedure being performed.

(e) Standard of Care and Clinical Requirements. A dentist must maintain the minimum standard of care in the administration of sedation/anesthesia in accordance with rule 108.7, including but not limited to the following requirements:

(1) Administration of Nitrous Oxide Following Anxiolysis or Analgesia. A dentist, who does not hold a Level 1 Minimal Sedation permit or higher, shall not administer nitrous oxide to a patient if the patient was treated with anxiolysis or analgesia administered by the dentist within the twelve hours prior to the dental treatment at which nitrous oxide will be administered.

(2) Patient Evaluation. Patients considered for nitrous oxide/oxygen inhalation sedation must be suitably evaluated prior to the start of any sedative procedure. In healthy or medically stable individuals (ASA I, II), this shall consist of a review of their current medical history and medication use. However, patients with significant medical considerations (ASA III, IV) require review of their current medical history and medication use, as well as documented verbal or written consultation with the patients' primary care physician or consulting medical specialist.

(3) Pre-Procedure Preparation and Informed Consent.

(A) The patient, parent, guardian, or care-giver must be advised of the risks associated with the delivery of nitrous oxide/oxygen inhalation sedation and must provide written, informed consent for the proposed sedation.

(B) The dentist shall determine that an adequate oxygen supply is available and evaluate equipment for proper operation and delivery of inhalation agents prior to use on each patient.

(C) Baseline vitals must be obtained in accordance with rules 108.7 and 108.8.

(4) Personnel and Equipment Requirements.

(A) In addition to the dentist, at least one member of the assistant staff should be present during the administration of nitrous oxide/oxygen inhalation sedation in nonemergency situations.

(B) The inhalation equipment must have a fail-safe system that is appropriately checked and calibrated. The equipment must also have either:

(i) a functioning device that prohibits the delivery of less than 30% oxygen; or

(ii) an appropriately calibrated and functioning in-line oxygen analyzer with audible alarm.

(C) If nitrous oxide and oxygen delivery equipment capable of delivering less than 30% oxygen is used, an in-line oxygen analyzer must be utilized.

(D) The equipment must have an appropriate nitrous oxide/oxygen scavenging system.

(E) The ability of the provider and/or the facility to deliver positive pressure oxygen must be maintained.

(5) Monitoring.

(A) The dentist must induce the nitrous oxide/oxygen inhalation sedation and must remain in the room with the patient during the maintenance of the sedation until pharmacologic and physiologic vital sign stability is established.

(B) After pharmacologic and physiologic vital sign stability has been established, the dentist may delegate the monitoring of the nitrous oxide/oxygen inhalation sedation to a dental auxiliary who has been certified to monitor the administration of nitrous oxide/oxygen inhalation sedation by the State Board of Dental Examiners.

(6) Documentation.

(A) Pre-operative baseline vitals must be documented.

(B) Individuals present during administration must be documented.

(C) Maximum concentration administered must be documented.

(D) The start and finish times of the inhalation agent must be documented.

(E) The dentist's record of the patient's treatment shall include all records created by or for the sedation provider.

(7) Recovery and Discharge.

(A) Recovery from nitrous oxide/oxygen inhalation sedation, when used alone, should be relatively quick, requiring only that the patient remain in an operatory chair as needed.

(B) Patients who have unusual reactions to nitrous oxide/oxygen inhalation sedation should be assisted and monitored either in an operatory chair or recovery room until stable for discharge.

(C) The dentist must determine that the patient is appropriately responsive prior to discharge. The dentist shall not leave the facility until the patient meets the criteria for discharge and is discharged from the facility.

(8) Emergency Management. Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. If a patient enters a deeper level of sedation than the dentist is qualified to provide, the dentist must stop the dental procedure until the patient returns to the intended level of sedation. The dentist is responsible for the sedative management, adequacy of the facility and staff, diagnosis and treatment of emergencies related to the administration of the nitrous oxide, and providing the equipment and protocols for patient rescue. A dentist must be able to rescue patients who enter a deeper state of sedation than intended. The dentist, personnel and facility must be prepared to treat emergencies that may arise from the administration of nitrous oxide/oxygen inhalation sedation.

[(b) Standard of Care Requirements. A dentist performing nitrous oxide/oxygen inhalation sedation shall maintain the minimum standard of care for anesthesia, and in addition shall:]

[(1) adhere to the clinical requirements as detailed in this section;]

[(2) maintain under continuous direct supervision auxiliary personnel who shall be capable of reasonably assisting in procedures, problems, and emergencies incident to the use of nitrous oxide/oxygen inhalation sedation;]

[(3) maintain current certification in Basic Life Support (BLS) for Healthcare Providers for the assistant staff by having them pass a course that includes a written examination and a hands-on demonstration of skills; and]

[(4) not supervise a Certified Registered Nurse Anesthetist (CRNA) performing a nitrous oxide/oxygen inhalation sedation procedure unless the dentist holds a permit issued by the Board for the sedation procedure being performed. This provision and similar provisions in subsequent sections address dentists and are not intended to address the scope of practice of persons licensed by any other agency.]

[(c) Clinical Requirements. A dentist must meet the following clinical requirements to utilize nitrous oxide/oxygen inhalation sedation:]

[(1) Patient Evaluation. Patients considered for nitrous oxide/oxygen inhalation sedation must be suitably evaluated prior to the start of any sedative procedure. In healthy or medically stable individuals (ASA I, II), this may consist of a review of their current medical history and medication use. However, patients with significant medical considerations (ASA III, IV) may require consultation with the patient's primary care physician or consulting medical specialist.]

[(2) Pre-Procedure Preparation and Informed Consent.]

[(A) The patient, parent, guardian, or care-giver must be advised of the risks associated with the delivery of nitrous oxide/oxygen inhalation sedation and must provide written, informed consent for the proposed sedation.]

[(B) The dentist shall determine that an adequate oxygen supply is available and evaluate equipment for proper operation and delivery of inhalation agents prior to use on each patient.]

[(C) Baseline vitals must be obtained in accordance with §108.7 and §108.8 of this title.]

[(3) Personnel and Equipment Requirements.]

[(A) In addition to the dentist, at least one member of the assistant staff should be present during the administration of nitrous oxide/oxygen inhalation sedation in nonemergency situations.]

[(B) The inhalation equipment must have a fail-safe system that is appropriately checked and calibrated. The equipment must also have either:]

[(i) a functioning device that prohibits the delivery of less than 30% oxygen; or]

[(ii) an appropriately calibrated and functioning in-line oxygen analyzer with audible alarm.]

[(C) If nitrous oxide and oxygen delivery equipment capable of delivering less than 30% oxygen is used, an in-line oxygen analyzer must be utilized.]

[(D) The equipment must have an appropriate nitrous oxide/oxygen scavenging system.]

[(E) The ability of the provider and/or the facility to deliver positive pressure oxygen must be maintained.]

[(4) Monitoring.]

[(A) The dentist must induce the nitrous oxide/oxygen inhalation sedation and must remain in the room with the patient during the maintenance of the sedation until pharmacologic and physiologic vital sign stability is established.]

[(B) After pharmacologic and physiologic vital sign stability has been established, the dentist may delegate the monitoring of the nitrous oxide/oxygen inhalation sedation to a dental auxiliary who has been certified to monitor the administration of nitrous oxide/oxygen inhalation sedation by the State Board of Dental Examiners.]

[(5) Documentation.]

[(A) Pre-operative baseline vitals must be documented.]

[(B) Individuals present during administration must be documented.]

[(C) Maximum concentration administered must be documented.]

[(D) The start and finish times of the inhalation agent must be documented.]

[(6) Recovery and Discharge.]

[(A) Recovery from nitrous oxide/oxygen inhalation sedation, when used alone, should be relatively quick, requiring only that the patient remain in an operatory chair as needed.]

[(B) Patients who have unusual reactions to nitrous oxide/oxygen inhalation sedation should be assisted and monitored either in an operatory chair or recovery room until stable for discharge.]

[(C) The dentist must determine that the patient is appropriately responsive prior to discharge. The dentist shall not leave the facility until the patient meets the criteria for discharge and is discharged from the facility.]

[(7) Emergency Management. Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. If a patient enters a deeper level of sedation than the dentist is qualified to provide, the dentist must stop the dental procedure until the patient returns to the intended level of sedation. The dentist is responsible for the sedative management, adequacy of the facility and staff, diagnosis and treatment of emergencies related to the administration of the nitrous oxide, and providing the equipment and protocols for patient rescue. A dentist must be able to rescue patients who enter a deeper state of sedation than intended. The dentist, personnel and facility must be prepared to treat emergencies that may arise from the administration of nitrous oxide/oxygen inhalation sedation.]

[(8) Management of Children. For children twelve (12) years of age and under, the dentist should observe the American Academy of Pediatrics/American Academy of Pediatric Dentists Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.]

(f) [(d)] A dentist who holds a nitrous oxide/oxygen inhalation sedation permit shall not intentionally administer minimal sedation, moderate sedation, deep sedation, or general anesthesia.

§110.4.Minimal Sedation - Level 1.

(a) Initial Application Requirements for Level 1 Minimal Sedation. [Education and Professional Requirements.] A dentist applying for a Level 1 Minimal Sedation permit shall demonstrate the following: [meet one of the following educational/professional criteria:]

(1) current certification in Basic Life Support (BLS) for Healthcare Providers; and

(2) satisfactory completion of one of the following education programs:

(A) an advanced education program accredited by the American Dental Association (ADA) Commission on Dental Accreditation (CODA) that affords comprehensive training in administering and managing minimal sedation, commensurate with the ADA's Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students; or

(B) a board-approved education program of at least sixteen (16) hours of didactic training and instruction in which competency in enteral and/or combined inhalation-enteral minimal sedation technique is demonstrated. A board-approved education program shall include, at a minimum, the following components: training in pharmacology; pre-procedure evaluation, patient selection, anatomy, and ASA classification; anesthesia technique and monitoring, equipment, and emergency preparedness, including running scenarios and management of complications; and managing special needs patients.

[(1) satisfactory completion of training to the level of competency in minimal sedation consistent with that prescribed in the American Dental Association (ADA) Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students, or a comprehensive training program in minimal sedation that satisfies the requirements described in the ADA Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students. This includes a minimum of sixteen (16) hours of didactic training and instruction in which competency in enteral and/or combined inhalation-enteral minimal sedation technique is demonstrated; or]

[(2) satisfactory completion of an advanced education program accredited by the ADA Commission on Dental Accreditation (CODA) that affords comprehensive training necessary to administer and manage minimal sedation, commensurate with the ADA's Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students; or]

[(3) is a Texas licensed dentist, has a current Board-issued enteral permit, and has been using minimal sedation in a competent manner immediately prior to the implementation of this chapter on June 1, 2011. Any Texas licensed dentist who was issued an enteral sedation permit before June 1, 2011 and whose enteral sedation permit was active on June 1, 2011 shall automatically have the permit reclassified as a Level 1 Minimal Sedation permit on June 1, 2011. A Texas licensed dentist whose permit is reclassified from an enteral sedation permit to a Level 1 Minimal Sedation permit on June 1, 2011 may continue to administer enteral sedation until January 1, 2013. On or before January 1, 2013, the dentist shall either provide proof that adequate education has been obtained by submitting an application for a Level 2 permit on or before that date, or shall comply with the requirements of a Level 1 permit after that date. A dentist shall always follow the standard of care and clinical requirements for the level of sedation he or she is performing.]

(b) Maintenance of Permit. A dentist must comply with the requirements of rule 110.9 to qualify for annual renewal of a Level 1 permit.

(c) Administration of Level 1 Sedation/Anesthesia to Pediatric Patients. A dentist shall comply with all requirements regarding the treatment of pediatric patients, including those described in rule 110.11. Additionally, the dentist should observe the American Academy of Pediatrics/American Academy of Pediatric Dentists Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.

(d) Delegation and Supervision Requirements. A dentist must maintain the minimum standard of care, including, but not limited to the requirements outlined in (e) below, and in addition, shall:

(1) maintain under continuous direct supervision auxiliary personnel who shall be capable of reasonably assisting in procedures, problems, and emergencies incident to the use of minimal sedation;

(2) maintain current certification in Basic Life Support (BLS) for Healthcare Providers for the assistant staff by having them pass a course that includes a written examination and a hands-on demonstration of skills; and

(3) not supervise a Certified Registered Nurse Anesthetist (CRNA) performing any level of sedation unless the dentist holds a permit issued by the board for the level of sedation to be administered during the dental procedure being performed.

(e) Standard of Care and Clinical Requirements. A dentist must maintain the minimum standard of care in the administration of sedation/anesthesia in accordance with rule 108.7, including, but not limited to the following requirements:

(1) Patient Evaluation. Patients considered for minimal sedation must be suitably evaluated prior to the start of any sedative procedure. In healthy or medically stable patients (ASA I, II), this shall consist of a review of the patients' current medical history and medication use. Patients with significant medical considerations (ASA III, IV) require review of the patients' current medical history and medication use, as well as documented verbal or written consultation with the patients' primary care physician or consulting medical specialist.

(2) Pre-Procedure Preparation and Informed Consent.

(A) The patient, parent, guardian, or care-giver must be advised regarding the procedure associated with the delivery of any sedative agents and must provide written, informed consent for the proposed sedation.

(B) The dentist shall determine that an adequate oxygen supply is available and evaluate equipment for proper operation and delivery of adequate oxygen under positive pressure.

(C) Baseline vital signs must be obtained in accordance with rules 108.7 and 108.8.

(D) A focused physical evaluation must be performed as deemed appropriate.

(E) Pre-procedure dietary restrictions must be considered based on the sedative technique prescribed.

(F) Pre-procedure verbal and written instructions must be given to the patient, parent, escort, guardian, or care-giver.

(3) Personnel and Equipment Requirements.

(A) In addition to the dentist, at least one additional person trained in Basic Life Support (BLS) for Healthcare Providers must be present.

(B) A positive-pressure oxygen delivery system suitable for the patient being treated must be immediately available.

(C) When inhalation equipment is used, it must have a fail-safe system that is appropriately checked and calibrated. The equipment must also have either:

(i) a functioning device that prohibits the delivery of less than 30% oxygen; or

(ii) an appropriately calibrated and functioning in-line oxygen analyzer with audible alarm.

(D) An appropriate scavenging system must be available if gases other than oxygen or air are used.

(4) Monitoring. The dentist administering the sedation must remain in the operatory room to monitor the patient until the patient meets the criteria for discharge to the recovery area. Once the patient meets the criteria for discharge to the recovery area, the dentist may delegate monitoring to a qualified dental auxiliary. Monitoring during the administration of sedation must include:

(A) Oxygenation.

(i) Color of mucosa, skin, or blood must be evaluated continually.

(ii) Oxygen saturation monitoring by pulse-oximetry should be used when a single drug minimal sedative is used. The additional use of nitrous oxide has a greater potential to increase the patient's level of sedation to moderate sedation, and a pulse oximeter must be used.

(B) Ventilation. The dentist (or appropriately qualified individual) must observe chest excursions and must verify respirations continually.

(C) Circulation. Blood pressure and heart rate should be evaluated preprocedurally, post-procedurally and intra-procedurally as necessary.

(5) Documentation.

(A) Documentation must be made in accordance with rules 108.7 and 108.8 of this title and must include the names and dosages of all drugs administered and the names of individuals present during administration of the drugs.

(B) A time-oriented sedation record may be considered for documentation of all monitoring parameters.

(C) Pulse oximetry, heart rate, respiratory rate, and blood pressure are the parameters which may be documented at appropriate intervals of no more than 10 minutes.

(D) The dentist's record of the patient's treatment shall include all records created by or for the sedation provider.

(6) Recovery and Discharge.

(A) Oxygen and suction equipment must be immediately available in the recovery area if a separate recovery area is utilized.

(B) The qualified dentist must monitor the patient during recovery until the patient is ready for discharge by the dentist. The dentist may delegate this task to an appropriately qualified dental auxiliary.

(C) The dentist must determine and document that the patient's level of consciousness, oxygenation, ventilation, and circulation are satisfactory prior to discharge. The dentist shall not leave the facility until the patient meets the criteria for discharge and is discharged from the facility.

(D) Post-procedure verbal and written instructions must be given to the patient, parent, escort, guardian, or care-giver. Post-procedure, patients should be accompanied by an adult caregiver for an appropriate period of recovery.

(7) Emergency Management. Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. If a patient enters a deeper level of sedation than the dentist is qualified to provide, the dentist must stop the dental procedure until the patient returns to the intended level of sedation. The dentist is responsible for the sedative management, adequacy of the facility and staff, diagnosis and treatment of emergencies related to the administration of minimal sedation, and providing the equipment and protocols for patient rescue. A dentist must be able to rescue patients who enter a deeper state of sedation than intended.

[(b) Standard of Care Requirements. A dentist performing minimal sedation shall maintain the minimum standard of care for anesthesia, and in addition shall:]

[(1) adhere to the clinical requirements as detailed in this section;]

[(2) maintain under continuous direct supervision auxiliary personnel who shall be capable of reasonably assisting in procedures, problems, and emergencies incident to the use of minimal sedation;]

[(3) maintain current certification in Basic Life Support (BLS) for Healthcare Providers for the assistant staff by having them pass a course that includes a written examination and a hands-on demonstration of skills; and]

[(4) not supervise a Certified Registered Nurse Anesthetist (CRNA) performing a minimal sedation procedure unless the dentist holds a permit issued by the Board for the sedation procedure being performed.]

[(c) Clinical Requirements. A dentist must meet the following clinical requirements for utilization of minimal sedation:]

[(1) Patient Evaluation. Patients considered for minimal sedation must be suitably evaluated prior to the start of any sedative procedure. In healthy or medically stable individuals (ASA I, II), this may consist of a review of their current medical history and medication use. However, patients with significant medical considerations (ASA III, IV) may require consultation with their primary care physician or consulting medical specialist.]

[(2) Pre-Procedure Preparation and Informed Consent.]

[(A) The patient, parent, guardian, or care-giver must be advised regarding the procedure associated with the delivery of any sedative agents and must provide written, informed consent for the proposed sedation.]

[(B) The dentist shall determine that an adequate oxygen supply is available and evaluate equipment for proper operation and delivery of adequate oxygen under positive pressure.]

[(C) Baseline vital signs must be obtained in accordance with §108.7 and §108.8 of this title.]

[(D) A focused physical evaluation must be performed as deemed appropriate.]

[(E) Pre-procedure dietary restrictions must be considered based on the sedative technique prescribed.]

[(F) Pre-procedure verbal and written instructions must be given to the patient, parent, escort, guardian, or care-giver.]

[(3) Personnel and Equipment Requirements.]

[(A) In addition to the dentist, at least one additional person trained in Basic Life Support (BLS) for Healthcare Providers must be present.]

[(B) A positive-pressure oxygen delivery system suitable for the patient being treated must be immediately available.]

[(C) When inhalation equipment is used, it must have a fail-safe system that is appropriately checked and calibrated. The equipment must also have either:]

[(i) a functioning device that prohibits the delivery of less than 30% oxygen; or]

[(ii) an appropriately calibrated and functioning in-line oxygen analyzer with audible alarm.]

[(D) An appropriate scavenging system must be available if gases other than oxygen or air are used.]

[(4) Monitoring. The dentist administering the sedation must remain in the operatory room to monitor the patient until the patient meets the criteria for discharge to the recovery area. Once the patient meets the criteria for discharge to the recovery area, the dentist may delegate monitoring to a qualified dental auxiliary. Monitoring during the administration of sedation must include:]

[(A) Oxygenation.]

[(i) Color of mucosa, skin, or blood must be evaluated continually.]

[(ii) Oxygen saturation monitoring by pulse-oximetry should be used when a single drug minimal sedative is used. The additional use of nitrous oxide has a greater potential to increase the patient's level of sedation to moderate sedation, and a pulse oximeter must be used.]

[(B) Ventilation. The dentist (or appropriately qualified individual) must observe chest excursions and must verify respirations continually.]

[(C) Circulation. Blood pressure and heart rate should be evaluated preprocedurally, post-procedurally and intra-procedurally as necessary.]

[(5) Documentation.]

[(A) Documentation must be made in accordance with §108.7 and §108.8 of this title and must include the names and dosages of all drugs administered and the names of individuals present during administration of the drugs.]

[(B) A time-oriented sedation record may be considered for documentation of all monitoring parameters.]

[(C) Pulse oximetry, heart rate, respiratory rate, and blood pressure are the parameters which may be documented at appropriate intervals of no more than 10 minutes.]

[(6) Recovery and Discharge.]

[(A) Oxygen and suction equipment must be immediately available in the recovery area if a separate recovery area is utilized.]

[(B) The qualified dentist must monitor the patient during recovery until the patient is ready for discharge by the dentist. The dentist may delegate this task to an appropriately qualified dental auxiliary.]

[(C) The dentist must determine and document that the patient's level of consciousness, oxygenation, ventilation, and circulation are satisfactory prior to discharge. The dentist shall not leave the facility until the patient meets the criteria for discharge and is discharged from the facility.]

[(D) Post-procedure verbal and written instructions must be given to the patient, parent, escort, guardian, or care-giver. Post-procedure, patients should be accompanied by an adult caregiver for an appropriate period of recovery.]

[(7) Emergency Management. Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. If a patient enters a deeper level of sedation than the dentist is qualified to provide, the dentist must stop the dental procedure until the patient returns to the intended level of sedation. The dentist is responsible for the sedative management, adequacy of the facility and staff, diagnosis and treatment of emergencies related to the administration of minimal sedation, and providing the equipment and protocols for patient rescue. A dentist must be able to rescue patients who enter a deeper state of sedation than intended.]

[(8) Management of Children. For children twelve (12) years of age and under, the dentist should observe the American Academy of Pediatrics/American Academy of Pediatric Dentists Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.]

(f) [(d)] A dentist who holds a minimal sedation permit shall not intentionally administer moderate sedation, deep sedation, or general anesthesia.

§110.5.Moderate Sedation - Levels 2 and 3.

(a) Initial Application Requirements for Level 2 Moderate Sedation (enteral). A dentist applying for a Level 2 Moderate Sedation Permit shall demonstrate the following: [Education and Professional Requirements.]

(1) current certification in Basic Life Support (BLS) for Healthcare Providers;

(2) current certification in Advanced Cardiac Life Support (ACLS); and

(3) satisfactory completion of one of the following education programs:

(A) an advanced education program accredited by the American Dental Association (ADA) Commission on Dental Accreditation (CODA) that affords comprehensive and appropriate training in administering and managing enteral moderate sedation, commensurate with the ADA's Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students; or

(B) completion of a board-approved education program that includes a minimum of sixty (60) hours of didactic training and instruction, and satisfactory management of at least twenty (20) case experiences in moderate sedation. These twenty (20) case experiences must include at least ten live clinical dental experiences managed by participants in groups of no larger than five (5). The remaining cases may include simulations and/or video presentations, but must include one experience in returning (rescuing) a patient from deep to moderate sedation. A board-approved education program shall include, at a minimum, the following components:

(i) Eight hours pharmacology;

(ii) 12 hours pre-procedure evaluation, patient selection, anatomy, and ASA classification;

(iii) Four hours anesthesia technique, monitoring, and equipment;

(iv) 12 hours inter-operative management and recognition of emergencies and complications;

(v) Six hours emergency preparedness, including running scenarios and management of complications; and

(vi) Four hours management of geriatric patients.

[(1) A dentist applying for a Level 2 Moderate Sedation permit (limited to enteral route of administration) must satisfy at least one of the following educational/professional criteria:]

[(A) satisfactory completion of a comprehensive training program consistent with that described for moderate enteral sedation in the American Dental Association (ADA) Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students. This includes a minimum of twenty-four (24) hours of instruction, plus management of at least ten (10) case experiences in enteral moderate sedation. These ten (10) case experiences must include at least three live clinical dental experiences managed by participants in groups of no larger than five (5). The remaining cases may include simulations and/or video presentations, but must include one experience in returning (rescuing) a patient from deep to moderate sedation; or]

[(B) satisfactory completion of an advanced education program accredited by the ADA Commission on Dental Accreditation (CODA) that affords comprehensive and appropriate training necessary to administer and manage enteral moderate sedation, commensurate with the ADA's Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students; or]

[(C) is a Texas licensed dentist who was issued an enteral sedation permit before June 1, 2011 and whose enteral sedation permit was active on June 1, 2011. Dentists in this category shall automatically have their permit reclassified as a Level 1 Minimal Sedation permit on June 1, 2011. A Texas licensed dentist whose permit is reclassified from an enteral sedation permit to a Level 1 Minimal Sedation permit on June 1, 2011 may continue to administer enteral sedation until January 1, 2013. On or before January 1, 2013, the dentist shall either provide proof that adequate education has been obtained by submitting an application for a Level 2 permit on or before that date, or shall comply with the requirements of a Level 1 permit after that date. A dentist shall always follow the standard of care and clinical requirements for the level of sedation he or she is performing.]

[(2) A dentist applying for a Level 3 Moderate Sedation permit (inclusive of parenteral routes of administration) must satisfy at least one of the following educational/professional criteria:]

[(A) satisfactory completion of a comprehensive training program consistent with that described for parenteral moderate sedation in the ADA Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students. This includes a minimum of sixty (60) hours of didactic training and instruction and satisfactory management of a minimum of twenty (20) dental patients, under supervision, using intravenous sedation; or]

[(B) satisfactory completion of an advanced education program accredited by the ADA/CODA that affords comprehensive and appropriate training necessary to administer and manage parenteral moderate sedation, commensurate with the ADA's Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students; or]

[(C) satisfactory completion of an internship or residency which included intravenous moderate sedation training equivalent to that defined in this subsection; or]

[(D) is a Texas licensed dentist who had a current parenteral sedation permit issued by the Board and has been using parenteral sedation in a competent manner immediately prior to the implementation of this chapter on June 1, 2011. A Texas licensed dentist whose Board-issued permit to perform parenteral sedation is active on June 1, 2011 shall automatically have the permit reclassified as a Level 3 Moderate Sedation (inclusive of parenteral routes of administration) permit.]

[(3) A dentist applying for a Level 2 or 3 Moderate Sedation permit must satisfy the following emergency management certification criteria:]

[(A) Licensees holding moderate sedation permits shall document:]

[(i) Current (as indicated by the provider), successful completion of Basic Life Support (BLS) for Healthcare Providers; AND]

[(ii) Current (as indicated by the provider), successful completion of an Advanced Cardiac Life Support (ACLS) course, OR current (as indicated by the provider), successful completion of a Pediatric Advanced Life Support (PALS) course.]

[(B) Licensees holding Level 2 or Level 3 Moderate Sedation permits who provide anesthesia services to children (age twelve (12) or younger) must document current, successful completion of a PALS course.]

(b) Initial Application Requirements for Level 3 Moderate Sedation (parenteral). A dentist applying for a Level 3 Moderate Sedation permit shall demonstrate the following:

(1) current certification in Basic Life Support (BLS) for Healthcare Providers;

(2) current certification in Advanced Cardiac Life Support (ACLS); and

(3) satisfactory completion of one of the following education programs:

(A) an advanced education program accredited by the ADA CODA that affords comprehensive and appropriate training in administering and managing parenteral moderate sedation, commensurate with the ADA's Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students; or

(B) an internship or residency that included intravenous moderate sedation training equivalent to that defined in this subsection; or

(C) a board-approved education program that includes a minimum of sixty (60) hours of didactic training and instruction and satisfactory management of a minimum of twenty (20) dental patients, under supervision, using intravenous sedation. A board-approved education program shall include, at a minimum, the following components:

(i) Eight hours pharmacology;

(ii) 12 hours pre-procedure evaluation, patient selection, anatomy, and ASA classification;

(iii) Four hours anesthesia technique, monitoring, and equipment;

(iv) 12 hours inter-operative management and recognition of emergencies and complications;

(v) Six hours emergency preparedness, including running scenarios and management of complications; and

(vi) Four hours management of geriatric patients.

(c) Maintenance of Permit. A dentist must comply with the requirements of rule 110.9 to qualify for annual renewal of a Level 2 or Level 3 sedation/anesthesia permit.

(d) Administration of Level 2 or Level 3 Sedation/Anesthesia to Pediatric Patients. A dentist shall comply with all requirements regarding the treatment of pediatric patients, including those described in rule 110.11. Additionally the dentist should observe the American Academy of Pediatrics/American Academy of Pediatric Dentists Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.

(e) Delegation and Supervision Requirements. A dentist must maintain the minimum standard of care, including, but not limited to the requirements outlined in (f) below, and in addition shall:

(1) maintain under continuous personal supervision auxiliary personnel who shall be capable of reasonably assisting in procedures, problems, and emergencies incident to the use of moderate sedation;

(2) maintain current certification in Basic Life Support (BLS) for Healthcare Providers for the assistant staff by having them pass a course that includes a written examination and a hands-on demonstration of skills; and

(3) not supervise a Certified Registered Nurse Anesthetist (CRNA) performing any level of sedation unless the dentist holds a permit issued by the board for the level of sedation to be administered during the dental procedure being performed.

(f) Standard of Care and Clinical Requirements. A dentist must maintain the minimum standard of care in the administration of sedation/anesthesia in accordance with rule 108.7, including but not limited to the following requirements:

(1) Patient Evaluation. Patients considered for moderate sedation must be suitably evaluated prior to the start of any sedative procedure. In healthy or medically stable individuals (ASA I, II) this shall consist of at least a review of the patient's current medical history and medication use. Patients with significant medical considerations (ASA III, IV) require review of their current medical history and medication use, as well as documented verbal or written consultation with the patients' primary care physician or consulting medical specialist.

(2) Pre-Procedure Preparation and Informed Consent.

(A) The patient, parent, guardian, or care-giver must be advised regarding the procedure associated with the delivery of any sedative agents and must provide written, informed consent for the proposed sedation. The informed consent must be specific to the procedure being performed and must specify that the risks related to the procedure include cardiac arrest, brain injury, and death.

(B) The dentist shall determine that an adequate oxygen supply is available and evaluate equipment for proper operation and delivery of adequate oxygen under positive pressure.

(C) Baseline vital signs must be obtained in accordance with rules 108.7 and 108.8 of this title.

(D) A focused physical evaluation must be performed as deemed appropriate.

(E) Pre-procedure dietary restrictions must be considered based on the sedative technique prescribed.

(F) Pre-procedure verbal or written instructions must be given to the patient, parent, escort, guardian, or care-giver.

(3) Personnel and Equipment Requirements.

(A) In addition to the dentist, at least one additional person trained in Basic Life Support (BLS) for Healthcare Providers must be present.

(B) A positive-pressure oxygen delivery system suitable for the patient being treated must be immediately available.

(C) When inhalation equipment is used, it must have a fail-safe system that is appropriately checked and calibrated. The equipment must also have either:

(i) a functioning device that prohibits the delivery of less than 30% oxygen; or

(ii) an appropriately calibrated and functioning in-line oxygen analyzer with audible alarm.

(D) An appropriate scavenging system must be available if gases other than oxygen or air are used.

(E) The equipment necessary to establish intravenous access must be available.

(4) Monitoring. The dentist administering moderate sedation must remain in the operatory room to monitor the patient continuously until the patient meets the criteria for recovery. When active treatment concludes and the patient recovers to a minimally sedated level, the dentist may delegate a qualified dental auxiliary to remain with the patient and continue to monitor the patient until he/she is discharged from the facility. The dentist must not leave the facility until the patient meets the criteria for discharge and is discharged from the facility. Monitoring must include:

(A) Consciousness. Level of consciousness (e.g., responsiveness to verbal command) must be continually assessed.

(B) Oxygenation.

(i) Color of mucosa, skin, or blood must be evaluated continually.

(ii) Oxygen saturation must be evaluated by pulse-oximetry continuously.

(C) Ventilation.

(i) Chest excursions must be continually observed.

(ii) Ventilation must be continually evaluated. This can be accomplished by auscultation of breath sounds, monitoring end-tidal CO2 or by verbal communication with the patient.

(D) Circulation.

(i) Blood pressure and heart rate must be continually evaluated.

(ii) Continuous EKG monitoring of patients sedated under moderate parenteral sedation is required.

(5) Documentation.

(A) Documentation must be made in accordance with §108.7 and §108.8 of this title.

(B) A written time-oriented anesthetic record must be maintained and must include the names and dosages of all drugs administered and the names of individuals present during administration of the drugs.

(C) Pulse-oximetry, heart rate, respiratory rate, and blood pressure must be continually monitored and documented at appropriate intervals of no more than ten (10) minutes.

(D) The dentist's record of the patient's treatment shall include all records created by or for the sedation provider.

(6) Recovery and Discharge.

(A) Oxygen and suction equipment must be immediately available if a separate recovery area is utilized.

(B) While the patient is in the recovery area, the dentist or qualified clinical staff must continually monitor the patient's blood pressure, heart rate, oxygenation, and level of consciousness.

(C) The dentist must determine and document that the patient's level of consciousness, oxygenation, ventilation, and circulation are satisfactory for discharge. The dentist shall not leave the facility until the patient meets the criteria for discharge and is discharged from the facility.

(D) Post-procedure verbal and written instructions must be given to the patient, parent, escort, guardian, or care-giver. Post-procedure, patients should be accompanied by an adult caregiver for an appropriate period of recovery.

(E) If a reversal agent is administered before discharge criteria have been met, the patient must be monitored until recovery is assured.

(7) Emergency Management.

(A) The dentist is responsible for the sedation management, adequacy of the facility and staff, diagnosis and treatment of emergencies associated with the administration of moderate sedation, and providing the equipment and protocols for patient rescue. This includes immediate access to pharmacologic antagonists and equipment for establishing a patent airway and providing positive pressure ventilation with oxygen.

(B) Advanced airway equipment and resuscitation medications must be available.

(C) A defibrillator must be available when patients are sedated under moderate sedation.

(D) Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. If a patient enters a deeper level of sedation than the dentist is qualified to provide, the dentist must stop the dental procedure until the patient returns to the intended level of sedation. The dentist administering moderate sedation must be able to recover patients who enter a deeper state of sedation than intended.

(g) A dentist who holds a moderate sedation permit shall not intentionally administer deep sedation or general anesthesia.

[(b) Standard of Care Requirements. A dentist must maintain the minimum standard of care as outlined in §108.7 of this title and in addition shall:]

[(1) adhere to the clinical requirements as detailed in this section;]

[(2) maintain under continuous personal supervision auxiliary personnel who shall be capable of reasonably assisting in procedures, problems, and emergencies incident to the use of moderate sedation;]

[(3) maintain current certification in Basic Life Support (BLS) for Healthcare Providers for the assistant staff by having them pass a course that includes a written examination and a hands-on demonstration of skills; and]

[(4) not supervise a Certified Registered Nurse Anesthetist (CRNA) performing a moderate sedation procedure unless the dentist holds a permit issued by the Board for the sedation procedure being performed.]

[(c) Clinical Requirements.]

[(1) Patient Evaluation. Patients considered for moderate sedation must be suitably evaluated prior to the start of any sedative procedure. In healthy or medically stable individuals (ASA I, II) this should consist of at least a review of the patient's current medical history and medication use. However, patients with significant medical considerations (ASA III, IV) may require consultation with their primary care physician or consulting medical specialist.]

[(2) Pre-Procedure Preparation and Informed Consent.]

[(A) The patient, parent, guardian, or care-giver must be advised regarding the procedure associated with the delivery of any sedative agents and must provide written, informed consent for the proposed sedation. The informed consent must be specific to the procedure being performed and must specify that the risks related to the procedure include cardiac arrest, brain injury, and death.]

[(B) The dentist shall determine that an adequate oxygen supply is available and evaluate equipment for proper operation and delivery of adequate oxygen under positive pressure.]

[(C) Baseline vital signs must be obtained in accordance with §108.7 and §108.8 of this title.]

[(D) A focused physical evaluation must be performed as deemed appropriate.]

[(E) Pre-procedure dietary restrictions must be considered based on the sedative technique prescribed.]

[(F) Pre-procedure verbal or written instructions must be given to the patient, parent, escort, guardian, or care-giver.]

[(3) Personnel and Equipment Requirements.]

[(A) In addition to the dentist, at least one additional person trained in Basic Life Support (BLS) for Healthcare Providers must be present.]

[(B) A positive-pressure oxygen delivery system suitable for the patient being treated must be immediately available.]

[(C) When inhalation equipment is used, it must have a fail-safe system that is appropriately checked and calibrated. The equipment must also have either:]

[(i) a functioning device that prohibits the delivery of less than 30% oxygen; or]

[(ii) an appropriately calibrated and functioning in-line oxygen analyzer with audible alarm.]

[(D) An appropriate scavenging system must be available if gases other than oxygen or air are used.]

[(E) The equipment necessary to establish intravenous access must be available.]

[(4) Monitoring. The dentist administering moderate sedation must remain in the operatory room to monitor the patient continuously until the patient meets the criteria for recovery. When active treatment concludes and the patient recovers to a minimally sedated level, the dentist may delegate a qualified dental auxiliary to remain with the patient and continue to monitor the patient until he/she is discharged from the facility. The dentist must not leave the facility until the patient meets the criteria for discharge and is discharged from the facility. Monitoring must include:]

[(A) Consciousness. Level of consciousness (e.g., responsiveness to verbal command) must be continually assessed.]

[(B) Oxygenation.]

[(i) Color of mucosa, skin, or blood must be evaluated continually.]

[(ii) Oxygen saturation must be evaluated by pulse-oximetry continuously.]

[(C) Ventilation.]

[(i) Chest excursions must be continually observed.]

[(ii) Ventilation must be continually evaluated. This can be accomplished by auscultation of breath sounds, monitoring end-tidal CO2 or by verbal communication with the patient.]

[(D) Circulation.]

[(i) Blood pressure and heart rate must be continually evaluated.]

[(ii) Continuous EKG monitoring of patients sedated under moderate parenteral sedation is required.]

[(5) Documentation.]

[(A) Documentation must be made in accordance with §108.7 and §108.8 of this title.]

[(B) A written time-oriented anesthetic record must be maintained and must include the names and dosages of all drugs administered and the names of individuals present during administration of the drugs.]

](C) Pulse-oximetry, heart rate, respiratory rate, and blood pressure must be continually monitored and documented at appropriate intervals of no more than ten (10) minutes.]

[(6) Recovery and Discharge.]

[(A) Oxygen and suction equipment must be immediately available if a separate recovery area is utilized.]

](B) While the patient is in the recovery area, the dentist or qualified clinical staff must continually monitor the patient's blood pressure, heart rate, oxygenation, and level of consciousness.]

[(C) The dentist must determine and document that the patient's level of consciousness, oxygenation, ventilation, and circulation are satisfactory for discharge. The dentist shall not leave the facility until the patient meets the criteria for discharge and is discharged from the facility.]

[(D) Post-procedure verbal and written instructions must be given to the patient, parent, escort, guardian, or care-giver. Post-procedure, patients should be accompanied by an adult caregiver for an appropriate period of recovery.]

[(E) If a reversal agent is administered before discharge criteria have been met, the patient must be monitored until recovery is assured.]

[(7) Emergency Management.]

[(A) The dentist is responsible for the sedation management, adequacy of the facility and staff, diagnosis and treatment of emergencies associated with the administration of moderate sedation, and providing the equipment and protocols for patient rescue. This includes immediate access to pharmacologic antagonists and equipment for establishing a patent airway and providing positive pressure ventilation with oxygen.]

[(B) Advanced airway equipment and resuscitation medications must be available.]

[(C) A defibrillator should be available when ASA I and II patients are sedated under moderate sedation. A defibrillator must be available when ASA III and IV patients are sedated under moderate sedation.]

[(D) Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. If a patient enters a deeper level of sedation than the dentist is qualified to provide, the dentist must stop the dental procedure until the patient returns to the intended level of sedation. The dentist administering moderate sedation must be able to recover patients who enter a deeper state of sedation than intended.]

[(8) Management of Children. For children twelve (12) years of age and under, the dentist should observe the American Academy of Pediatrics/American Academy of Pediatric Dentists Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.]

[(d) A dentist who holds a moderate sedation permit shall not intentionally administer deep sedation or general anesthesia.]

§110.6.Deep Sedation or General Anesthesia - Level 4.

(a) Initial Application Requirements for Level 4 Deep Sedation or General Anesthesia Permit. A Dentist applying for a Level 4 Deep Sedation or General Anesthesia permit shall demonstrate the following: [Education and Professional Requirements.]

(1) current certification in Basic Life Support (BLS) for Healthcare Providers;

(2) current certification in Advanced Cardiac Life Support (ACLS) or Pediatric Advanced Life Support (PALS) course; and

(3) satisfactory completion of an advanced education program accredited by the American Dental Association (ADA) Commission on Dental Accreditation (CODA) that affords comprehensive and appropriate training in administering and managing deep sedation or general anesthesia.

[(1) A dentist applying for a permit to administer deep sedation or general anesthesia must satisfy one of the following criteria:]

[(A) satisfactory completion of an advanced education program accredited by the American Dental Association (ADA) Commission on Dental Accreditation (CODA) that affords comprehensive and appropriate training necessary to administer and manage deep sedation or general anesthesia; or]

[(B) is a Texas licensed dentist who holds a current permit to administer deep sedation or general anesthesia issued by the Board and who has been using deep sedation or general anesthesia in a competent manner immediately prior to the implementation of this chapter on June 1, 2011. A Texas licensed dentist whose Board-issued permit to perform deep sedation or general anesthesia is active on June 1, 2011 shall automatically have the permit reclassified as a Level 4 Deep Sedation or General Anesthesia permit.]

[(2) A dentist applying for a permit to administer deep sedation or general anesthesia must satisfy the following emergency management certification criteria:]

[(A) Licensees holding deep sedation or general anesthesia permits shall document:]

[(i) Current (as indicated by the provider), successful completion of Basic Life Support (BLS) for Healthcare Providers; AND]

[(ii) Current (as indicated by the provider), successful completion of an Advanced Cardiac Life Support (ACLS) course, OR current (as indicated by the provider), successful completion of a Pediatric Advanced Life Support (PALS) course.]

[(B) Licensees holding deep sedation or general anesthesia permits who provide anesthesia services to children (age twelve (12) or younger) must document current, successful completion of a PALS course.]

(b) Maintenance of Permit. A dentist must comply with the requirements of rule 110.9 to qualify for annual renewal of a Level 4 sedation/general anesthesia permit.

(c) Administration of Level 4 Sedation/anesthesia to Pediatric Patients. A dentist shall comply with all requirements regarding the treatment of pediatric patients, including those described in rule 110.11. Additionally the dentist should observe the American Academy of Pediatrics/American Academy of Pediatric Dentists Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.

(d) Delegation and Supervision Requirements. A dentist must maintain the minimum standard of care, including, but not limited to the requirements outlined in (e) below, and in addition shall:

(1) maintain under continuous direct supervision a minimum of two qualified dental auxiliary personnel who shall be capable of reasonably assisting in procedures, problems, and emergencies incident to the use of deep sedation and/or general anesthesia;

(2) maintain current certification in Basic Life Support (BLS) for Healthcare Providers for the assistant staff by having them pass a course that includes a written examination and a hands-on demonstration of skills; and

(3) not supervise a Certified Registered Nurse Anesthetist (CRNA) performing any level of sedation unless the dentist holds a permit issued by the board for the level of sedation to be administered during the dental procedure being performed.

(e) Standard of Care and Clinical Requirements. A dentist must maintain the minimum standard of care in the administration of sedation/anesthesia in accordance with rule 108.7, including but not limited to the following requirements:

(1) Patient Evaluation. Patients considered for deep sedation or general anesthesia must be suitably evaluated prior to the start of any sedative procedure. In healthy or medically stable individuals (ASA I, II) this must consist of at least a review of their current medical history, medication use, and NPO status. Patients with significant medical considerations (ASA III, IV) require review of their current medical history, medication use, and NPO status, as well as documented verbal or written consultation with the patients' primary care physician or consulting medical specialist.

(2) Pre-Procedure Preparation and Informed Consent.

(A) The patient, parent, guardian, or care-giver must be advised regarding the procedure associated with the delivery of any sedative or anesthetic agents and must provide written, informed consent for the proposed deep sedation or general anesthesia procedure. The informed consent must be specific to the deep sedation and/or general anesthesia procedure being performed and must specify that the risks related to the procedure include cardiac arrest, brain injury, and death.

(B) The dentist shall determine that an adequate oxygen supply is available and evaluate equipment for proper operation and delivery of adequate oxygen under positive pressure.

(C) Baseline vital signs must be obtained in accordance with §108.7 and §108.8 of this title.

(D) A focused physical evaluation must be performed as deemed appropriate.

(E) Pre-procedure dietary restrictions must be considered based on the sedative/anesthetic technique prescribed.

(F) Pre-procedure verbal and written instructions must be given to the patient, parent, escort, guardian, or care-giver.

(G) An intravenous line, which is secured throughout the procedure, must be established except as provided in paragraph (7) of this subsection, regarding Special Situations and Special Needs Patients.

(3) Personnel and Equipment Requirements.

(A) Personnel. A minimum of three (3) individuals must be present during the procedure:

(i) a dentist who is qualified to administer the deep sedation or general anesthesia who is currently certified in ACLS; and

(ii) two additional individuals who hold current certification in Basic Life Support (BLS) for Healthcare Providers, one of which must be dedicated to assisting with patient monitoring.

(B) Equipment.

(i) A positive-pressure oxygen delivery system suitable for the patient being treated must be immediately available.

(ii) When inhalation equipment is used, it must have a fail-safe system that is appropriately checked and calibrated. The equipment must also have either:

(I) a functioning device that prohibits the delivery of less than 30% oxygen; or

(II) an appropriately calibrated and functioning in-line oxygen analyzer with audible alarm.

(iii) An appropriate scavenging system must be available if gases other than oxygen are used.

(iv) The equipment necessary to establish intravenous access must be available.

(v) Equipment and drugs necessary to provide advanced airway management and advanced cardiac life support must be immediately available.

(vi) If volatile anesthetic agents are utilized, an inspired agent analysis monitor and capnograph should be considered.

(vii) Emergency medications and a defibrillator must be immediately available.

(4) Monitoring. A qualified dentist administering deep sedation or general anesthesia must remain in the operatory room to monitor the patient continuously until the patient meets the criteria for discharge to the recovery area. The dentist must not leave the facility until the patient meets the criteria for discharge and is discharged from the facility. Monitoring must include:

(A) Oxygenation.

(i) Color of mucosa, skin, or blood must be continually evaluated.

(ii) Oxygenation saturation must be evaluated continuously by pulse oximetry.

(B) Ventilation.

(i) Intubated patient: End-tidal CO2 must be continuously monitored and evaluated.

(ii) Non-intubated patient: Breath sounds via auscultation and/or end-tidal CO2 must be continually monitored and evaluated.

(iii) Respiration rate must be continually monitored and evaluated.

(C) Circulation.

(i) Heart rate and rhythm via EKG and pulse rate via pulse oximetry must be evaluated throughout the procedure.

(ii) Blood pressure must be continually monitored.

(D) Temperature.

(i) A device capable of measuring body temperature must be readily available during the administration of deep sedation or general anesthesia.

(ii) The equipment to continuously monitor body temperature should be available and must be performed whenever triggering agents associated with malignant hyperthermia are administered.

(5) Documentation.

(A) Documentation must be made in accordance with §108.7 and §108.8 of this title and must include the names, times and dosages of all drugs administered and the names of individuals present during administration of the drugs.

(B) A written time-oriented anesthetic record must be maintained.

(C) Pulse oximetry and end-tidal CO2 measurements (if taken with an intubated patient), heart rate, respiratory rate, and blood pressure must be continually recorded at five (5) minute intervals.

(D) The dentist's record of the patient's treatment shall include all records created by or for the sedation provider.

(6) Recovery and Discharge.

(A) Oxygen and suction equipment must be immediately available if a separate recovery area is utilized.

(B) The dentist or clinical staff must continually monitor the patient's blood pressure, heart rate, oxygenation, and level of consciousness.

(C) The dentist must determine and document that the patient's level of consciousness, oxygenation, ventilation, and circulation are satisfactory prior to discharge. The dentist shall not leave the facility until the patient meets the criteria for discharge and is discharged from the facility.

(D) Post-procedure verbal and written instructions must be given to the patient, parent, escort, guardian, or care-giver. Post-procedure, patients should be accompanied by an adult caregiver for an appropriate period of recovery.

(7) Special Situations and Special Needs Patients. Because many dental patients undergoing deep sedation or general anesthesia are mentally and/or physically challenged, it is not always possible to have a comprehensive physical examination or appropriate laboratory tests prior to administering care. When these situations occur, the dentist responsible for administering the deep sedation or general anesthesia shall document the reasons preventing the pre-procedure management.

(8) Emergency Management.

(A) The dentist is responsible for the sedation management, adequacy of the facility and staff, diagnosis and treatment of emergencies associated with the administration of deep sedation or general anesthesia, and providing the equipment and protocols for patient rescue. This includes immediate access to pharmacologic antagonists and equipment for establishing a patent airway and providing positive pressure ventilation with oxygen.

(B) Advanced airway equipment, emergency medications and a defibrillator must be immediately available.

(C) Appropriate pharmacologic agents must be immediately available if known triggering agents of malignant hyperthermia are part of the anesthesia plan.

[(b) Standard of Care Requirements. A dentist must maintain the minimum standard of care for the administration of anesthesia as outlined in §108.7 of this title and in addition shall:]

[(1) adhere to the clinical requirements as detailed in this section;]

[(2) maintain under continuous direct supervision a minimum of two qualified dental auxiliary personnel who shall be capable of reasonably assisting in procedures, problems, and emergencies incident to the use of deep sedation and/or general anesthesia;]

[(3) maintain current certification in Basic Life Support (BLS) for Healthcare Providers for the assistant staff by having them pass a course that includes a written examination and a hands-on demonstration of skills; and]

[(4) not supervise a Certified Registered Nurse Anesthetist (CRNA) performing a deep sedation/general anesthesia procedure unless the dentist holds a permit issued by the Board for the sedation procedure being performed.]

[(c) Clinical Requirements.]

[(1) Patient Evaluation. Patients considered for deep sedation or general anesthesia must be suitably evaluated prior to the start of any sedative procedure. In healthy or medically stable individuals (ASA I, II) this must consist of at least a review of their current medical history, medication use, and NPO status. However, patients with significant medical considerations (ASA III, IV) may require consultation with their primary care physician or consulting medical specialist.]

[(2) Pre-Procedure Preparation and Informed Consent.]

[(A) The patient, parent, guardian, or care-giver must be advised regarding the procedure associated with the delivery of any sedative or anesthetic agents and must provide written, informed consent for the proposed deep sedation or general anesthesia procedure. The informed consent must be specific to the deep sedation and/or general anesthesia procedure being performed and must specify that the risks related to the procedure include cardiac arrest, brain injury, and death.]

[(B) The dentist shall determine that an adequate oxygen supply is available and evaluate equipment for proper operation and delivery of adequate oxygen under positive pressure.]

[(C) Baseline vital signs must be obtained in accordance with §108.7 and §108.8 of this title.]

[(D) A focused physical evaluation must be performed as deemed appropriate.]

[(E) Pre-procedure dietary restrictions must be considered based on the sedative/anesthetic technique prescribed.]

[(F) Pre-procedure verbal and written instructions must be given to the patient, parent, escort, guardian, or care-giver.]

[(G) An intravenous line, which is secured throughout the procedure, must be established except as provided in paragraph (7) of this subsection, regarding Pediatric and Special Needs Patients.]

[(3) Personnel and Equipment Requirements.]

[(A) Personnel. A minimum of three (3) individuals must be present during the procedure:]

[(i) a dentist who is qualified to administer the deep sedation or general anesthesia who is currently certified in ACLS and/or PALS; and]

[(ii) two additional individuals who have current certification of successfully completing a course in Basic Life Support (BLS) for Healthcare Providers, one of which must be dedicated to assisting with patient monitoring.]

[(B) Equipment.]

[(i) A positive-pressure oxygen delivery system suitable for the patient being treated must be immediately available.]

[(ii) When inhalation equipment is used, it must have a fail-safe system that is appropriately checked and calibrated. The equipment must also have either:]

[(I) a functioning device that prohibits the delivery of less than 30% oxygen; or]

[(II) an appropriately calibrated and functioning in-line oxygen analyzer with audible alarm.]

[(iii) An appropriate scavenging system must be available if gases other than oxygen are used.]

[(iv) The equipment necessary to establish intravenous access must be available.]

[(v) Equipment and drugs necessary to provide advanced airway management and advanced cardiac life support must be immediately available.]

[(vi) If volatile anesthetic agents are utilized, an inspired agent analysis monitor and capnograph should be considered.]

[(vii) Emergency medications and a defibrillator must be immediately available.]

[(4) Monitoring. A qualified dentist administering deep sedation or general anesthesia must remain in the operatory room to monitor the patient continuously until the patient meets the criteria for discharge to the recovery area. The dentist must not leave the facility until the patient meets the criteria for discharge and is discharged from the facility. Monitoring must include:]

[(A) Oxygenation.]

[(i) Color of mucosa, skin, or blood must be continually evaluated.]

[(ii) Oxygenation saturation must be evaluated continuously by pulse oximetry.]

[(B) Ventilation.]

[(i) Intubated patient: End-tidal CO2 must be continuously monitored and evaluated.]

[(ii) Non-intubated patient: Breath sounds via auscultation and/or end-tidal CO2 must be continually monitored and evaluated.]

[(iii) Respiration rate must be continually monitored and evaluated.]

[(C) Circulation.]

[(i) Heart rate and rhythm via EKG and pulse rate via pulse oximetry must be evaluated throughout the procedure.]

[(ii) Blood pressure must be continually monitored.]

[(D) Temperature.]

[(i) A device capable of measuring body temperature must be readily available during the administration of deep sedation or general anesthesia.]

[(ii) The equipment to continuously monitor body temperature should be available and must be performed whenever triggering agents associated with malignant hyperthermia are administered.]

[(5) Documentation.]

[(A) Documentation must be made in accordance with §108.7 and §108.8 of this title and must include the names, times and dosages of all drugs administered and the names of individuals present during administration of the drugs.]

[(B) A written time-oriented anesthetic record must be maintained.]

[(C) Pulse oximetry and end-tidal CO2 measurements (if taken with an intubated patient), heart rate, respiratory rate, and blood pressure must be continually recorded at five (5) minute intervals.]

[(6) Recovery and Discharge.]

[(A) Oxygen and suction equipment must be immediately available if a separate recovery area is utilized.]

[(B) The dentist or clinical staff must continually monitor the patient's blood pressure, heart rate, oxygenation, and level of consciousness.]

[(C) The dentist must determine and document that the patient's level of consciousness, oxygenation, ventilation, and circulation are satisfactory prior to discharge. The dentist shall not leave the facility until the patient meets the criteria for discharge and is discharged from the facility.]

[(D) Post-procedure verbal and written instructions must be given to the patient, parent, escort, guardian, or care-giver. Post-procedure, patients should be accompanied by an adult caregiver for an appropriate period of recovery.]

[(7) Special Situations.]

[(A) Special Needs Patients. Because many dental patients undergoing deep sedation or general anesthesia are mentally and/or physically challenged, it is not always possible to have a comprehensive physical examination or appropriate laboratory tests prior to administering care. When these situations occur, the dentist responsible for administering the deep sedation or general anesthesia shall document the reasons preventing the pre-procedure management.]

[(B) Management of Children. For children twelve (12) years of age and under, the dentist should observe the American Academy of Pediatrics/American Academy of Pediatric Dentists Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.]

[(8) Emergency Management.]

[(A) The dentist is responsible for the sedation management, adequacy of the facility and staff, diagnosis and treatment of emergencies associated with the administration of deep sedation or general anesthesia, and providing the equipment and protocols for patient rescue. This includes immediate access to pharmacologic antagonists and equipment for establishing a patent airway and providing positive pressure ventilation with oxygen.]

[(B) Advanced airway equipment, emergency medications and a defibrillator must be immediately available.]

[(C) Appropriate pharmacologic agents must be immediately available if known triggering agents of malignant hyperthermia are part of the anesthesia plan.]

§110.9.Sedation/General Anesthesia Permit Renewal.

(a) The Board shall renew a sedation/general anesthesia [an anesthesia/sedation] permit annually if required fees are paid and the required emergency management training and continuing education requirements are satisfied. The Board shall consider disciplinary history in Texas and in other jurisdictions in its review of a sedation/general anesthesia permit renewal application. The Board shall not renew a sedation/general anesthesia [an anesthesia/sedation] permit if, after notice and opportunity for hearing, the Board finds the permit holder has provided, or is likely to provide, sedation/general anesthesia [anesthesia/sedation ] services in a manner that does not meet the minimum standard of care. If a hearing is held, the Board shall consider factors including patient complaints, morbidity, mortality, and anesthesia consultant recommendations.

(b) Fees. Annual dental license renewal certificates shall include the annual permit renewal, except as provided for in this section. The licensee shall be assessed an annual renewal fee in accordance with the fee schedule in Chapter 102 of this title.

(c) Emergency Management Training. To renew a sedation/general anesthesia permit, a dentist shall demonstrate maintenance of competency in emergency management. Specifically, a dentist must provide proof of the emergency management certification required of the dentist's highest sedation/general anesthesia permit level, as follows:

(1) Nitrous Oxide/Oxygen Inhalation Sedation and Level 1 Minimal Sedation - current certification in Basic Life Support (BLS).

(2) Levels 2 and 3: Moderate Sedation - current certification in BLS and current certification in Advanced Cardiac Life Support (ACLS). A dentist who obtained pediatric privileges by meeting the requirements of rule 110.11(b)(1), may meet this requirement by maintaining current certification in BLS and current certification in Pediatric Advanced Life Support (PALS).

(3) Level 4: Deep Sedation/General Anesthesia - current certification in BLS and current certification in ACLS. A dentist who obtained pediatric privileges by meeting the requirements of rule 110.11(b)(1), may meet this requirement by maintaining current certification in BLS and current certification in Pediatric Advanced Life Support (PALS).

(d) Continuing Education. In addition to the continuing education required for renewal of dental licensure, a dentist seeking to renew a minimal sedation, moderate sedation, or deep sedation/general anesthesia permit must submit proof of completion of additional continuing education to maintain a sedation/anesthesia permit. A dentist shall, at a minimum, complete the following hours of continuing education every two years on the administration of or medical emergencies associated with the permitted level of sedation:

(1) Level 1: Minimal Sedation - twelve (12) hours, including eight hours of sedation/general anesthesia emergency preparedness training

(2) Levels 2 and 3: Moderate Sedation - twelve (12) hours, including eight hours of sedation/general anesthesia emergency preparedness training

(3) Level 4: Deep Sedation/General Anesthesia - sixteen (16) hours, including eight hours of sedation/general anesthesia emergency preparedness training.

(e) The emergency management training and continuing education requirements required by this rule shall be in addition to any additional continuing education required to maintain dental licensure. ACLS, BLS, and Pediatric Advanced Life Support (PALS) courses may not be used to fulfill continuing education required for renewal of dental licensure or renewal of a sedation/anesthesia permit under this section.

(f) A licensee's emergency management and continuing education is subject to audit in Board investigation and as described in rule 104.5.

(g) Continuing education courses must meet the provider endorsement requirements of rule 104.2.

[(c) Continuing Education.]

[(1) In conjunction with the annual renewal of a dental license, a dentist seeking to renew a minimal sedation, moderate sedation, or deep sedation/general anesthesia permit must submit proof of completion of the following hours of continuing education every two years on the administration of or medical emergencies associated with the permitted level of sedation:]

[(A) Level 1: Minimal Sedation - six (6) hours]

[(B) Levels 2 and 3: Moderate Sedation - eight (8) hours]

[(C) Level 4: Deep Sedation/General Anesthesia - twelve (12) hours]

[(2) The continuing education requirements under this section shall be in addition to any additional courses required for licensure. Advanced Cardiac Life Support (ACLS) course and Pediatric Advanced Life Support (PALS) course may not be used to fulfill the continuing education requirement for renewal of the permit under this section.]

[(3) Continuing education courses must meet the provider endorsement requirements of §104.2 of this title.]

§110.11.Sedation/General Anesthesia of Pediatric Patients.

(a) Pediatric patients include all patients under the age of thirteen (13) at the time of a dental treatment or procedure.

(b) Initial Requirement for Pediatric Sedation/General Anesthesia Privileges. A dentist may obtain pediatric privileges on a Level 1, Level 2, Level 3, or Level 4 sedation/general anesthesia permit by demonstrating compliance with one of the following requirements at the time the dentist renews or seeks a sedation/general anesthesia permit:

(1) completion of an advanced education program accredited by the Commission on Dental Accreditation that provided didactic and clinical education in pediatric sedation/general anesthesia;

(2) successful administration of sedation/general anesthesia to at least 20 (twenty) pediatric patients, in the six months preceding the date of initial application for a sedation/general anesthesia permit with pediatric privileges or the date of renewal application for a sedation/general anesthesia permit with initial application for pediatric privileges; or

(3) completion of an in-person board-approved education program of at least 24 (twenty-four) hours of training in pediatric sedation/general anesthesia. The board-approved education program shall include, at a minimum, the following 21 (twenty-one) hours of training:

(A) A minimum of three hours of training in pharmacology;

(B) A minimum of three hours of training in pre-procedure evaluation, patient selection, anatomy, and ASA classification;

(C) A minimum of six hours of training in sedation/general anesthesia technique, monitoring, and equipment;

(D) A minimum of six hours of training in emergency preparedness, including running scenarios and management of complications; and

(E) A minimum of three hours of training in treating special needs pediatric patients.

(c) For the time period from September 1, 2017, through a dentist's next sedation/general anesthesia permit renewal occurring prior to September 1, 2018, a dentist may sedate pediatric patients pursuant to the dentist's underlying sedation/general anesthesia permit without demonstrating to the agency compliance with (b) above.

(d) If a dentist does not demonstrate compliance with (b) above at the time of the sedation/general anesthesia permit renewal occurring between September 1, 2017, and August 31, 2018, the dentist does not hold pediatric sedation privileges and may no longer sedate pediatric patients, as of the date of the dentist's sedation/general anesthesia permit renewal.

(e) A dentist may seek pediatric sedation privileges at any time by completing an application and demonstrating compliance with (b) above and any other requirements.

(f) Continuing Education Requirements for Pediatric Sedation/General Anesthesia Privileges. In addition to continuing education required by other rules, a dentist who administers Level 1, 2, 3, or 4 sedation/general anesthesia to a pediatric patient must complete a minimum of eight hours of continuing education in pediatric sedation/general anesthesia every two years. This continuing education is in addition to continuing education required for license renewal, renewal of sedation/anesthesia permits, or any other continuing education requirement. BLS, ACLS, or PALS do not satisfy the continuing education requirement for renewal of sedation/general anesthesia permits under this section. A dentist must submit proof of compliance at the time of permit renewal.

(g) The initial training requirements in subsection (b) and the continuing education requirements in subsection (f) are subject to audit by the agency.

(h) Emergency Preparedness. In addition to the requirements of emergency preparedness in other sections of these rules, a dentist administering sedation/general anesthesia to a pediatric patient must be prepared to rescue a child from a deeper level of sedation than intended, and comply with the following requirements:

(1) A dentist administering sedation to a pediatric patient must maintain current certification in Pediatric Advanced Life Support (PALS). A dentist delegating the administration of sedation to a pediatric patient must maintain current certification in PALS or Advanced Cardiac Life Support (ACLS). A dentist must submit proof of compliance at the time of permit renewal.

(2) A dentist administering sedation to a pediatric patient or delegating the administration of sedation to a pediatric patient must maintain a protocol for immediate access to back-up emergency services, including, for nonhospital facilities a protocol for the immediate activation of the EMS system for life-threatening complications. The practitioners must be prepared to provide initial rescue for life-threatening complications.

(3) A dentist administering sedation to a pediatric patient or delegating the administration of sedation to a pediatric patient must ensure that an emergency cart or kit is immediately accessible and contains the necessary age- and size-appropriate equipment and emergency drugs to resuscitate a non-breathing and unconscious child. The contents of the kit must allow for the provision of continuous life support while the pediatric patient is being transported to a medical/dental facility or to another area within the facility. All equipment and drugs must be checked and maintained on a scheduled basis.

(A) An emergency cart or kit accompanying a pediatric sedation at Level 1 or 2 must include, at a minimum, the following components: oral and nasal airways, bag-valve-mask device, laryngeal mask airways or other superglottic devices, face masks, blood pressure cuffs; and

(B) An emergency cart or kit accompanying a pediatric sedation at Level 3 or 4 must include, at a minimum, the following components: oral and nasal airways, bag-valve-mask device, laryngeal mask airways or other superglottic devices, laryngoscope blades, tracheal tubes, face masks, blood pressure cuffs, and intravenous catheters.

(i) Pediatric Standard of Care and Monitoring.

(1) Nitrous oxide shall not be administered to a pediatric patient at a concentration of greater than 50% unless the person administering the nitrous oxide holds a Level 2 or higher sedation/general anesthesia permit and meets all other requirements of this rule.

(2) Monitoring of a pediatric patient undergoing minimal sedation must include the use of pulse oximetry and precordial stethoscope.

(3) Monitoring of a pediatric patient undergoing moderate sedation must include the use of pulse oximetry, electrocardiography, and either capnography or a precordial/pretracheal stethoscope.

(4) Monitoring of a pediatric patient undergoing deep sedation/general anesthesia must include the use of pulse oximetry, electrocardiography, capnography and a precordial/pretracheal stethoscope.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on December 5, 2016.

TRD-201606155

Kelly Parker

Executive Director

State Board of Dental Examiners

Earliest possible date of adoption: January 15, 2017

For further information, please call: (512) 475-0977


PART 21. TEXAS STATE BOARD OF EXAMINERS OF PSYCHOLOGISTS

CHAPTER 469. COMPLAINTS AND ENFORCEMENT

22 TAC §469.13

The Texas State Board of Examiners of Psychologists proposed a repeal to §469.13, Non-Compliance with Professional Development Requirements. The proposed repeal reflects a shift in policy away from treating the failure to report compliance with the Board's professional development requirements as a rule violation that should result in discipline. The Board's intent behind this proposed change, together with the proposed change to Board rule 471.1, is to treat compliance with the professional development requirements as a prerequisite for renewing a license. This proposed change is also intended to ease the burden on enforcement staff by eliminating the need to open a CE complaint every time a licensee fails to indicate compliance with Board rule 461.11 when renewing his or her license.

Darrel D. Spinks, Executive Director, has determined that for the first five-year period the proposed repeal will be in effect, there will be no fiscal implications for state or local governments as a result of enforcing or administering the rule.

Mr. Spinks has also determined that for each year of the first five years the rule is in effect, the public benefit anticipated as a result of enforcing the rule will be to help the Board protect the public. There will be no economic costs to persons required to comply with this rule. There will be no effect on small businesses or local economies.

Comments on the proposed repeal may be submitted to Brenda Skiff, Texas State Board of Examiners of Psychologists, 333 Guadalupe, Ste 2-450, Austin, Texas 78701, within 30 days of publication of this proposal in the Texas Register. Comments may also be submitted via fax to (512) 305-7701, or via email to brenda@tsbep.texas.gov.

The repeal is proposed under Texas Occupations Code, Title 3, Subtitle I, Chapter 501, which provides the Texas State Board of Examiners of Psychologists with the authority to make all rules, not inconsistent with the Constitution and Laws of this State, which are reasonably necessary for the proper performance of its duties and regulations of proceedings before it.

No other code, articles or statutes are affected by this proposal.

§469.13.Non-Compliance with Professional Development Requirements.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on December 5, 2016.

TRD-201606137

Darrel D. Spinks

Executive Director

Texas State Board of Examiners of Psychologists

Earliest possible date of adoption: January 15, 2017

For further information, please call: (512) 305-7706


CHAPTER 471. RENEWALS

22 TAC §471.1

The Texas State Board of Examiners of Psychologists proposed repeal to §471.1, Notification of Renewal. The repeal, together with the newly proposed version of the rule, reflects a shift in policy toward recognizing compliance with Board rule §461.11 as a condition of renewal, rather than noncompliance serving as a basis for disciplinary action. The Board's intent behind this proposed change is to treat compliance with the professional development requirements as a prerequisite for renewing a license, and thereby reduce the need to open complaints against those licensees who fail to report their professional development hours when renewing their license.

Darrel D. Spinks, Executive Director, has determined that for the first five-year period the proposed repeal will be in effect, there will be no fiscal implications for state or local governments as a result of enforcing or administering the rule.

Mr. Spinks has also determined that for each year of the first five years the rule is in effect, the public benefit anticipated as a result of enforcing the rule will be to help the Board protect the public. There will be no economic costs to persons required to comply with this rule. There will be no effect on small businesses or local economies.

Comments on the proposed repeal may be submitted to Brenda Skiff, Texas State Board of Examiners of Psychologists, 333 Guadalupe, Ste 2-450, Austin, Texas 78701, within 30 days of publication of this proposal in the Texas Register. Comments may also be submitted via fax to (512) 305-7701, or via email to brenda@tsbep.texas.gov.

The repeal is proposed under Texas Occupations Code, Title 3, Subtitle I, Chapter 501, which provides the Texas State Board of Examiners of Psychologists with the authority to make all rules, not inconsistent with the Constitution and Laws of this State, which are reasonably necessary for the proper performance of its duties and regulations of proceedings before it.

No other code, articles or statutes are affected by this section.

§471.1.Notification of Renewal.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on December 5, 2016.

TRD-201606138

Darrel D. Spinks

Executive Director

Texas State Board of Examiners of Psychologists

Earliest possible date of adoption: January 15, 2017

For further information, please call: (512) 305-7706


22 TAC §471.1

The Texas State Board of Examiners of Psychologists propose new rule §471.1, Renewal of a License. The new rule reflects a shift in policy toward recognizing compliance with Board rule §461.11 as a condition of renewal, rather than noncompliance serving as a basis for disciplinary action. The Board's intent behind this proposed change is to treat compliance with the professional development requirements as a prerequisite for renewing a license, and thereby reduce the need to open complaints against those licensees who fail to report their professional development hours when renewing their license.

Darrel D. Spinks, Executive Director, has determined that for the first five-year period the proposed new rule will be in effect, there will be no fiscal implications for state or local governments as a result of enforcing or administering the rule.

Mr. Spinks has also determined that for each year of the first five years the rule is in effect, the public benefit anticipated as a result of enforcing the rule will be to help the Board protect the public. There will be no economic costs to persons required to comply with this rule. There will be no effect on small businesses or local economies.

Comments on the proposed new rule may be submitted to Brenda Skiff, Texas State Board of Examiners of Psychologists, 333 Guadalupe, Ste 2-450, Austin, Texas 78701, within 30 days of publication of this proposal in the Texas Register. Comments may also be submitted via fax to (512) 305-7701, or via email to brenda@tsbep.texas.gov.

The new rule is proposed under Texas Occupations Code, Title 3, Subtitle I, Chapter 501, which provides the Texas State Board of Examiners of Psychologists with the authority to make all rules, not inconsistent with the Constitution and Laws of this State, which are reasonably necessary for the proper performance of its duties and regulations of proceedings before it.

No other code, articles or statutes are affected by this section.

§471.1.Renewal of a License.

(a) All licenses issued by the Board shall be subject to annual renewal.

(b) Annual renewals are due on the last day of the license holder's birth month.

(c) Licensees must pay all applicable renewal and late fees, indicate compliance with the professional development requirements set out in Board rule §461.11 of this title (relating to Professional Development), and comply with any other requirements set out in agency renewal forms as a prerequisite for renewal of a license. A license may not be renewed until a licensee has complied with the requirements of this rule.

(d) A licensee who falsely reports compliance with Board rule §461.11 of this title on his or her renewal form or who practices with a license renewed under false pretenses will be subject to disciplinary action.

(e) Each year licensees will be sent notification of their approaching renewal date at least 30 days before the last day of their birth month. This notification will be sent to the licensee's address of record via first class mail. Responsibility for renewing a license rests exclusively with the licensee, and the failure of the licensee to receive the reminder notification from the Board shall not operate to excuse a licensee's failure to timely renew a license. Licensees who do not timely renew their license will be sent a second notice informing them that their license has become delinquent. The second notice will be sent to the licensee's address of record via certified or register mail. Failure of a licensee to receive the second notification shall not operate to excuse the failure to timely renew a license or any unlawful practice with a delinquent license.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on December 5, 2016.

TRD-201606139

Darrel D. Spinks

Executive Director

Texas State Board of Examiners of Psychologists

Earliest possible date of adoption: January 15, 2017

For further information, please call: (512) 305-7706


PART 24. TEXAS BOARD OF VETERINARY MEDICAL EXAMINERS

CHAPTER 571. LICENSING

SUBCHAPTER A. GENERAL

22 TAC §571.1

The Texas Board of Veterinary Medical Examiners (Board) proposes amendments to §571.1, concerning Definitions.

Overview

There are two parts to the proposed amendments. The first amendment is a clerical change, which replaces the term "jurisprudence examination" with "Jurisprudence Examination."

The second of the proposed amendments supplements the definition of "renewal year" to clarify that the first regular license issued to a person is valid for at least one full year, which is the Board's current practice. Effective January 1, 2016, the Board transitioned from a calendar year renewal cycle to a renewal cycle based upon each licensee's birth month. However, the definition for "renewal year" did not clearly identify the length of the first renewal year for newly issued licenses. New licenses should be valid for at least one year, regardless of the length of time between licensure and the licensee's birth month. The purpose of amendment is to clarify the Board's current practice and to ensure that new licensees have at least a full year period before they are required to renew their license and pay the associated renewal fees.

Fiscal Note

Rudy Calderon, Interim Executive Director, has determined that for each year of the first five years that the rule is in effect, there are no anticipated increases or reductions in costs to the state and local governments as a result of enforcing or administering the rule.

Mr. Calderon has also determined that for each year of the first five years that the rule is in effect, there will be a minimal anticipated impact on revenue to state government as a result of enforcing or administering the rule. The exact duration of a newly issued license will vary based on the date of issuance and the licensee's birth month. Thus, some new licenses will remain valid for longer than others before the licensee must pay a renewal fee. However, the renewal year period for each subsequent renewal and all existing license renewals will be unchanged by the proposed amendment.

Public Benefit and Cost Note

Mr. Calderon has also determined that for each year of the first five years the rule is in effect, the anticipated public benefit will be that the first renewal year period is clearly defined and that new licensees have at least a full year period before they are required to renew their license and pay the associated renewal fees. There are no anticipated economic costs to persons required to comply with the rule.

Local Employment Impact Statement

Mr. Calderon has determined that the amendments to the rule will have no impact on local employment or a local economy. Thus, the board is not required to prepare a local employment impact statement pursuant to Government Code §2001.022.

Economic Impact Statement and Regulatory Flexibility Analysis

Mr. Calderon has determined that there are no anticipated adverse economic effects on small business or micro-businesses. Thus, the Board is not required to prepare an economic impact statement or a regulatory flexibility analysis pursuant to Government Code §2006.002.

Takings Impact Assessment

Mr. Calderon has determined that there are no private real property interests affected by the proposed amendments. Thus, the board is not required to prepare a takings impact assessment pursuant to Government Code §2007.043.

Request for Public Comments

The Texas Board of Veterinary Medical Examiners invites comments on the proposed amendment to the rule from any member of the public or interested person. A written statement should be mailed or delivered to Loris Jones, Texas Board of Veterinary Medical Examiners, 333 Guadalupe, Ste. 3-810, Austin, Texas 78701-3942, by facsimile (FAX) to (512) 305-7574, or by e-mail to vet.board@tbvme.state.tx.us. Comments will be accepted for 30 days following publication in the Texas Register. Comments must be received within 30 days after publication of this proposal in order to be considered.

Statutory Authority

The amendment is proposed under the authority of the Veterinary Licensing Act, Texas Occupations Code, §801.151(a), which states that the Board may adopt rules necessary to administer the chapter; and §801.301(b) which states that the board by rule may adopt a system under which licenses expire on various dates during the year.

No other statutes, articles, or codes are affected by the proposal.

§571.1.Definitions.

The following words and terms, when used in the Veterinary Licensing Act (Chapter 801, Texas Occupations Code) or the Rules of the Board (Texas Administrative Code, Title 22, Part 24, Chapters 571 - 577) shall have the following meaning:

(1) Board--the Texas Board of Veterinary Medical Examiners.

(2) EDPE--Equine Dental Provider Jurisprudence Examination.

(3) Locally derived scaled score--the equivalent of the criterion referenced passing point for the national examination or the NAVLE.

(4) Name on license--licenses will be issued to successful applicants in the name of the individual as it appears on the birth certificate, court order, marriage license, or documentation of naturalization.

(5) National Board of Veterinary Medical Examiners (NBVME)--the organization responsible for producing, administering and scoring the NAVLE.

(6) National examination--the examination in existence and effective prior to the inauguration date of the NAVLE and which consists of the national board examination (NBE) and the clinical competency test (CCT).

(7) North American Veterinary Licensing Examination (NAVLE)--the examination which replaced the national examination in the year 2000.

(8) Passing Score--an examination score of at least 75 percent on the national examination and NAVLE, which is based on a locally derived scaled score; an examination score of at least 75 percent on the VTNE, which is based on a locally derived scaled score; an examination score of at least 85 percent on the SBE, the LVTE, or the EDPE. The examination score on the SBE, LVTE, or the EDPE is valid for one year past the date of the examination.

(9) SBE--State Board Examination.

(10) School or college of veterinary medicine--a school or college of veterinary medicine that is approved by the Board and accredited by the Council on Education of the American Veterinary Medical Association (AVMA). Applicants who are graduates of a school or college of veterinary medicine not accredited by the Council on Education of the AVMA are eligible provided that the applicant presents satisfactory proof to the Board that the applicant is a graduate of a school or college of veterinary medicine and possesses an Educational Commission for Foreign Veterinary Graduates (ECFVG) certificate or a Program for Assessment of Veterinary Education Equivalence (PAVE) certificate.

(11) VTNE--Veterinary Technician National Examination.

(12) LVTE--Licensed Veterinary Technician Jurisprudence Examination [jurisprudence examination].

(13) Veterinary Technician Program--a program of education for veterinary technicians accredited by AVMA.

(14) Renewal year--the year between the first day of the month after a licensee's birth month and the last day of the licensee's birth month in the following year. The first regular license is valid from the date of issuance until the last day of the applicant's birth month, with a duration of at least one year.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on December 5, 2016.

TRD-201606161

Loris Jones

Executive Assistant

Texas Board of Veterinary Medical Examiners

Earliest possible date of adoption: January 15, 2017

For further information, please call: (512) 305-7563


22 TAC §571.15

The Texas Board of Veterinary Medical Examiners (Board) proposes amendments to §571.15, concerning Temporary Veterinary Licenses.

Overview

The purpose of the amendment is to ease the burden on applicants for temporary veterinary licenses by removing some of the requirements for receiving a temporary veterinary license, and by reducing the amount of documentation required to be submitted with an application for a temporary veterinary license. Simplifying the application process for a temporary veterinary license would allow more opportunities for out-of-state practitioners to travel to Texas to attend or teach certain practical continuing education courses, or to perform highly specialized procedures.

The amendment would remove the requirement that applicants attain a score of at least 75% on the pertinent national licensing examination. The amendment would remove the requirement that an applicant provide proof of a current active license in good standing in another state, jurisdiction, or foreign country with substantially equivalent licensing requirements. However, applicants would still be required to possess such a license.

The amendment would remove the requirement that an applicant provide proof of having earned a minimum of 17 hours of continuing education within 12 months preceding their application. The amendment would also remove the requirement that an applicant provide the following documents: a letter of good standing from each jurisdiction in which the applicant is or has been licensed; a certified copy of the applicant's veterinary school transcript; a certified copy of the applicant's birth certificate; a certified report verifying that the applicant passed the NAVLE; and official verification of board certification if the applicant is certified by a nationally recognized veterinary specialty board.

Applicants for temporary veterinary licenses would still be required to attest to the accuracy of the information submitted with their applications Submission of false or inaccurate information would be subject to prosecution under Texas Penal Code §37.10, which prohibits knowingly making a false entry in a governmental record, and subject to disciplinary action under Veterinary Licensing Act, Texas Occupations Code, §801.402(2). These amendments were recommended in the Board's Sunset Advisory Commission Staff Report.

Fiscal Note

Rudy Calderon, Interim Executive Director, has determined that for each year of the first five years that the rule is in effect, there are no anticipated increases in costs to the state and local governments as a result of enforcing or administering the rule. Mr. Calderon has determined that there will be a slight reduction in cost to the state government as a result of enforcing or administering the rule, as it would reduce the time and resources used by Board staff to process temporary veterinary license applications. Mr. Calderon has determined that there will be no reduction in cost to local governments as a result of enforcing or administering this rule. Mr. Calderon has determined that there is a potential slight increase in revenue to state government as a result of enforcing or administering the rule. A less burdensome application process may encourage more applicants for temporary licensure, thus increasing the fees received for issuing temporary veterinary licenses.

Public Benefit and Cost Note

Mr. Calderon has determined that for each year of the first five years the rule is in effect, the anticipated public benefit will be to ease the burden on applicants for temporary veterinary licenses, and thus create more opportunities for out-of-state practitioners to travel to Texas to attend or teach certain practical continuing education courses, or to perform highly specialized procedures. There are no anticipated economic costs to persons required to comply with the rule.

Local Employment Impact Statement

Mr. Calderon has determined that the amendments to the rule will have no impact on local employment or a local economy. Thus, the board is not required to prepare a local employment impact statement pursuant to Government Code §2001.022.

Economic Impact Statement and Regulatory Flexibility Analysis

Mr. Calderon has determined that there are no anticipated adverse economic effects on small business or micro-businesses. Thus, the Board is not required to prepare an economic impact statement or a regulatory flexibility analysis pursuant to Government Code §2006.002.

Takings Impact Assessment

Mr. Calderon has determined that there are no private real property interests affected by the proposed amendments. Thus, the board is not required to prepare a takings impact assessment pursuant to Government Code §2007.043.

Request for Public Comments

The Texas Board of Veterinary Medical Examiners invites comments on the proposed amendment to the rule from any member of the public or interested person. A written statement should be mailed or delivered to Loris Jones, Texas Board of Veterinary Medical Examiners, 333 Guadalupe, Ste. 3-810, Austin, Texas 78701-3942, by facsimile (FAX) to (512) 305-7574, or by e-mail to vet.board@tbvme.state.tx.us. Comments will be accepted for 30 days following publication in the Texas Register. Comments must be received within 30 days after publication of this proposal in order to be considered.

Statutory Authority

The amendments are proposed under the authority of the Veterinary Licensing Act, Texas Occupations Code, §801.151(a), which states that the Board may adopt rules necessary to administer the chapter, and §801.258, which states that the board by rule may provide for the issuance of a temporary license to practice veterinary medicine to an applicant who: (1) is licensed in good standing as a veterinarian in another state or foreign country; (2) meets the eligibility requirements under §801.252(1) and (2); and (3) is not subject to denial of a license or to disciplinary action for a ground listed in §801.402.

No other statutes, articles or codes are affected by the proposal.

§571.15.Temporary Veterinary License.

(a) The board may issue a temporary veterinary license to an applicant who:

(1) is at the age of majority; and

(2) is a graduate of a school or college of veterinary medicine that is approved by the Board and accredited by the Council on Education of the American Veterinary Medical Association (AVMA); or

(3) is a graduate of a school or college of veterinary medicine not accredited by the Council on Education of the AVMA and presents satisfactory proof to the Board that the applicant is a graduate of a school or college of veterinary medicine and possesses an Educational Commission for Foreign Veterinary Graduates (ECFVG) Certificate or a Program for Assessment of Veterinary Education Equivalence (PAVE) Certificate. The Board may refuse to issue a license to an applicant who meets the qualification criteria but is otherwise disqualified as provided in the Texas Occupations Code, §801.401; and

[(4) has attained a passing score of at least 75% on:]

[(A) The NAVLE if an applicant sits for that examination subsequent to its inauguration date; or]

[(B) The national examinations referred to as the NBE (National Board Examination) and the CCT (Clinical Competency Test) required prior to the inauguration date of the NAVLE; and]

(4) [(5)] has [presents proof of] a current active license in good standing in another state or jurisdiction of the United States or foreign country that has licensing requirements substantially equivalent to the requirements of the Veterinary Licensing Act, Texas Occupations Code Chapter 801; and

(5) [(6)] at the time of application, is not subject to final or pending disciplinary action in any foreign country, state or jurisdiction in which the applicant is now licensed or has ever held a license; and

(6) [(7)] presents proof of having earned a minimum of 17 hours of acceptable continuing education related to veterinary medicine or general scientific subjects within 12 months preceding application for temporary license.

(b) The applicant who earns the temporary veterinary license must be under general supervision of a Texas licensed veterinarian who possesses an active, current license in the state of Texas.

(c) The applicant for a temporary veterinary license shall submit to the Board a complete application in the form designated by the Board including any required application fee in an amount set by the Board and contained in §577.15 of this title (relating to Fee Schedule), as well as notification of board certification if the applicant is certified by a nationally recognized veterinary specialty board, if applicable. [with the supporting required documentation as set out in subsection (a) of this section, as well as:]

[(1) A letter of good standing not older than six months from each jurisdiction in which the applicant is currently actively licensed or has been previously licensed;]

[(2) a certified copy of the applicant's veterinary school transcript including a graduation date;]

[(3) a certified copy of the applicant's birth certificate;]

[(4) a certified report from the official reporting service verifying that the applicant passed the national examination or the NAVLE, subject to a petition by the applicant for an exception to this requirement in accordance with §571.5(c) of this title (relating to Qualifications for Veterinary License);]

[(5) official verification of board certification if applicant is certified by a nationally recognized veterinary specialty board, if applicable; and]

[(6) an application fee in an amount set by the Board and contained in §577.15 of this title (relating to Fee Schedule).]

(d) The temporary veterinary license application [and all supporting documentation] must be received in the board office PRIOR to being issued a temporary veterinary license. A temporary veterinary license will only be issued once the applicant's file is complete and the [ALL] required [, supporting documentation and] fee has been received. The Board's Executive Director will issue a temporary veterinary license to an applicant following [verification of the requirements set out in subsections (a) - (c) of this section, and] receipt of the complete application [documents] and required fee [required].

(e) The temporary veterinary license is valid only for a specific patient, client, continuing education course, or task per issuance. A temporary veterinary license granted under this section is valid for 30 days from the date of original issue, per temporary veterinary license issued. The temporary veterinary license should be available for review at the place of practice for the period the applicant is in Texas under the temporary veterinary license.

(f) The temporary veterinary license is not renewable nor can it be reissued. The applicant must cease and desist the practice of veterinary medicine the day after the expiration of the temporary veterinary license. Continued practice of veterinary medicine without the valid, temporary veterinary license is a violation of current laws and rules and is viewed as the practice of veterinary medicine without a license. Disciplinary action can be taken and includes, but is not limited to, the refusal of the Board to issue a second temporary veterinary license, for which the applicant may otherwise be eligible, and possibly the issuance of a future, regular license.

(g) An applicant may request a second temporary veterinary license within the same calendar year, provided no more than two temporary veterinary licenses are issued per applicant. After the second temporary veterinary license, if the applicant wishes to continue to practice in the State of Texas, he/she must seek regular licensing and must be eligible for such regular license as set out in current laws and rules governing the issuance of a regular license in the State of Texas.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on December 5, 2016.

TRD-201606164

Loris Jones

Executive Assistant

Texas Board of Veterinary Medical Examiners

Earliest possible date of adoption: January 15, 2017

For further information, please call: (512) 305-7563


CHAPTER 573. RULES OF PROFESSIONAL CONDUCT

SUBCHAPTER F. RECORDS KEEPING

22 TAC §573.51

The Texas Board of Veterinary Medical Examiners (Board) proposes amendments to §573.51, concerning Rabies Control.

Overview

This amendment would reflect the existing requirement that a veterinarian administering a rabies vaccination include the veterinarian's license number and practice address in each official rabies vaccination certificate. The purpose of the amendment is to conform the Board's rules to the existing requirements of 25 TAC §169.29, relating to Vaccination Requirements, adopted by the Department of State Health Services. This amendment is proposed in response to a petition for rulemaking.

Fiscal Note

Rudy Calderon, Interim Executive Director, has determined that for each year of the first five years that the rule is in effect, there are no anticipated increases or reductions in costs to the state and local governments as a result of enforcing or administering the rule. Mr. Calderon has determined that there is no anticipated impact on revenue to the state and local government as a result of enforcing or administering the rule.

Public Benefit and Cost Note

Mr. Calderon has determined that for each year of the first five years the rule is in effect, the anticipated public benefit will be that the Board's rule correctly reflects the existing requirements of 25 TAC §169.29, and clarifies those requirements for licensees. There are no anticipated economic costs to persons required to comply with the rule.

Local Employment Impact Statement

Mr. Calderon has determined that the amendments to the rule will have no impact on local employment or a local economy. Thus, the board is not required to prepare a local employment impact statement pursuant to Government Code §2001.022.

Economic Impact Statement and Regulatory Flexibility Analysis

Mr. Calderon has further determined that there are no anticipated adverse economic effects on small business or micro-businesses. Thus, the Board is not required to prepare an economic impact statement or a regulatory flexibility analysis pursuant to Government Code §2006.002.

Takings Impact Assessment

Mr. Calderon has determined that there are no private real property interests affected by the proposed amendments. Thus, the board is not required to prepare a takings impact assessment pursuant to Government Code §2007.043.

Request for Public Comments

The Texas Board of Veterinary Medical Examiners invites comments on the proposed amendment to the rule from any member of the public or interested person. A written statement should be mailed or delivered to Loris Jones, Texas Board of Veterinary Medical Examiners, 333 Guadalupe, Ste. 3-810, Austin, Texas 78701-3942, by facsimile (FAX) to (512) 305-7574, or by e-mail to vet.board@tbvme.state.tx.us. Comments will be accepted for 30 days following publication in the Texas Register. Comments must be received within 30 days after publication of this proposal in order to be considered.

Statutory Authority

The amendments are proposed under the authority of the Veterinary Licensing Act, Texas Occupations Code, §801.151(a), which states that the Board may adopt rules necessary to administer the chapter, and §801.151(c)(1), which states that the Board shall adopt rules to protect the public.

No other statutes, articles or codes are affected by the proposal.

§573.51.Rabies Control.

(a) Only the vaccinating veterinarian shall issue official rabies vaccination certificates. Each certificate shall contain the information required by 25 TAC §169.29 (relating to Vaccination Requirement) adopted by the Department of State Health Services, including:

(1) owner's name, address and telephone number;

(2) animal identification species, sex (including neutered if applicable), approximate age (three months to 12 months, 12 months or older), size (pounds), predominant breed, and colors;

(3) vaccine used product name, manufacturer, and serial number;

(4) date vaccinated;

(5) date vaccination expires (re-vaccination due date);

(6) rabies tag number if a tag is issued; and

(7) veterinarian's license number and practice address; and

(8) [(7)] veterinarian's signature, or electronic signature, or signature stamp and license number, in accordance with §573.10 of this title (relating to Supervision of Non-Licensed Persons).

(b) Each veterinarian that issues a rabies vaccination certificate, or the veterinary practice where the certificate was issued, shall retain a readily retrievable copy of the certificate for a period of not less than five years from the date of issuance.

(c) A veterinarian having knowledge of an animal bite to a human shall immediately report the incident to the local health authority. A veterinarian preparing an animal's body for rabies diagnosis shall comply with all requirements of 25 TAC §169.33 (relating to Submission of Specimens for Laboratory Examination) adopted by the Department of State Health Services.

(d) A veterinarian who ceases the practice of veterinary medicine shall deliver to the local health authority all duplicate rabies vaccination certificates issued by the veterinarian within the preceding five-year period. A veterinarian who sells or leases his or her practice to another veterinarian may transfer duplicate rabies certificates with the records of the practice which are transferred to a new owner.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on December 5, 2016.

TRD-201606166

Loris Jones

Executive Assistant

Texas Board of Veterinary Medical Examiners

Earliest possible date of adoption: January 15, 2017

For further information, please call: (512) 305-7563


SUBCHAPTER G. OTHER PROVISIONS

22 TAC §573.64

The Texas Board of Veterinary Medical Examiners (Board) proposes amendments to §573.64, concerning Continuing Education Requirements.

Overview

Effective January 1, 2016, the Board transitioned from a calendar year renewal cycle to a renewal cycle based upon each licensee's birth month. The purpose of this amendment is to reflect this transition by replacing the term "calendar year" with "renewal year." The proposed amendment would also amend the deadline for licensees to request a hardship extension. Under the previous system, licensees were required to request a hardship extension by no later than December 15th. Under the proposed amendment, licensees would be able to request a hardship extension up to the 15th day of the month three months prior to the last day of the licensee's birth month. This amendment allows licensees the same approximate amount of time to request a hardship exemption as they were allowed under the previous renewal system.

Fiscal Note

Rudy Calderon, Interim Executive Director, has determined that for each year of the first five years that the rule is in effect, there are no anticipated increases or reductions in costs to the state and local governments as a result of enforcing or administering the rule. Mr. Calderon has determined that there is no anticipated impact on revenue to the state and local government as a result of enforcing or administering the rule.

Public Benefit and Cost Note

Mr. Calderon has determined that for each year of the first five years the rule is in effect, the anticipated public benefit will be that the Board's rule reflects the transition to a birth month renewal system and provides clarity for licensees regarding the deadline to request a hardship exemption. There are no anticipated economic costs to persons required to comply with the rule.

Local Employment Impact Statement

Mr. Calderon has determined that there are no anticipated adverse economic effects on small business or micro-businesses. Thus, the Board is not required to prepare an economic impact statement or a regulatory flexibility analysis pursuant to Government Code §2006.002.

Takings Impact Assessment

Mr. Calderon has determined that there are no private real property interests affected by the proposed amendments. Thus, the board is not required to prepare a takings impact assessment pursuant to Government Code §2007.043.

Request for Public Comments

The Texas Board of Veterinary Medical Examiners invites comments on the proposed amendment to the rule from any member of the public or interested person. A written statement should be mailed or delivered to Loris Jones, Texas Board of Veterinary Medical Examiners, 333 Guadalupe, Ste. 3-810, Austin, Texas 78701-3942, by facsimile (FAX) to (512) 305-7574, or by e-mail to vet.board@tbvme.state.tx.us. Comments will be accepted for 30 days following publication in the Texas Register. Comments must be received within 30 days after publication of this proposal in order to be considered.

Statutory Authority

The amendments are proposed under the authority of the Veterinary Licensing Act, Texas Occupations Code, §801.151(a), which states that the Board may adopt rules necessary to administer the chapter; and §801.301(b), which states that the board by rule may adopt a system under which licenses expire on various dates during the year.

No other statutes, articles or codes are affected by the proposal.

§573.64.Continuing Education Requirements.

(a) Required Continuing Education Hours.

(1) Licensed Veterinarians. Seventeen (17) hours of acceptable continuing education shall be required annually for renewal of all types of Texas veterinary licenses, except as provided in subsection (b) of this section. Veterinary licensees who successfully complete the Texas State Board Licensing Examination shall receive credit for 17 continuing education hours for their first renewal [the calendar] year following licensure [in which they were examined and licensed].

(2) Licensed Equine Dental Providers. Six (6) hours of acceptable continuing education shall be required annually for renewal of Texas equine dental provider licenses.

(3) Licensed Veterinary Technicians. Ten (10) hours of acceptable continuing education shall be required annually for renewal of Texas veterinary technician licenses.

(4) A licensee shall earn the required hours of acceptable continuing education during the renewal [calendar] year immediately preceding the licensee's application for license renewal. Should a licensee earn acceptable continuing education hours during the year in excess of the required hours, the licensee may carry over and apply the excess hours to the requirement for the next renewal year. Licensees may carry over excess hours to the following renewal year only, and may not carry over more hours than the licensee is required to earn in a renewal [calendar] year.

(5) Hardship extensions may be granted by appeal to the Executive Director of the Board. The executive director shall only consider requests for a hardship extension from licensees who were prevented from completing the required continuing education hours due to circumstances beyond the licensee's control. A hardship extension generally will not be allowed due to financial hardship or lack of time due to a busy professional or personal schedule. Requests for a hardship extension must be received in writing and in the Board offices by no later than the 15th day of the month three (3) months prior to the last day of the licensee's birth month [December 15]. Should such extension be granted, twice the number of hours of continuing education required for a standard annual license renewal shall be obtained in the two-year period of time that includes the year of insufficiency and the year of extension. Licensees receiving a hardship extension shall maintain records of the continuing education obtained and shall file copies of these records with the Board by attaching the records to the license renewal application submitted following the extension year, or by sending them to the Board separately if the licensee submits his or her renewal application electronically (on-line).

(6) A military service member, as defined in Chapter 55, §55.001, of the Texas Occupations Code, has up to two years to complete the required continuing education requirements for each renewal year.

(7) Except as provided in subsection (a)(1) of this section, continuing education hours obtained prior to licensure in Texas may not be applied toward the required number of continuing education hours.

(b) Exemption from Continuing Education Requirements for Veterinary Licensees. A veterinary licensee is not required to obtain or report continuing education hours, provided that the veterinary licensee submits to the Board sufficient proof that during the preceding year the veterinary licensee was:

(1) in retired status;

(2) a veterinary intern or resident; or

(3) out-of-country on charitable, military, or special government assignments for at least nine (9) months in a year; or

(4) on inactive status. Veterinary licensees on inactive status may voluntarily acquire continuing education for purposes of reinstating his/her license to regular status.

(c) Make up Hours. The Board may require a licensee who does not complete the required hours of continuing education to make up the missed hours in later years. Hours required to be made up in a later year are in addition to the continuing education hours required to be completed in that year.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on December 5, 2016.

TRD-201606168

Loris Jones

Executive Assistant

Texas Board of Veterinary Medical Examiners

Earliest possible date of adoption: January 15, 2017

For further information, please call: (512) 305-7563