TITLE 22. EXAMINING BOARDS

PART 5. STATE BOARD OF DENTAL EXAMINERS

CHAPTER 100. GENERAL PROVISIONS

22 TAC §100.12

The State Board of Dental Examiners (Board) proposes amendments to §100.12 concerning the Advisory Committee on Dental Anesthesia. The rule amendment provides for staggered terms of the Committee members.

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

Ms. Parker has also determined that for the first five-year period the proposed amendment is in effect, the public benefit anticipated as a result of establishing staggered terms is to establish the committee in accordance with the law. Ms. Parker has determined that for the first five-year period the proposed rule is 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 proposal may be submitted to Tyler Vance, General Counsel, 333 Guadalupe, Suite 3-800, Austin, Texas 78732, Fax (512) 475-0977, rulecomments@tsbde.texas.gov.

The amendments 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 proposal.

§100.12.Advisory Committee on Dental Anesthesia.

(a) Pursuant to §258.202 of the Texas Occupations Code, the board establishes an advisory committee: the Advisory Committee on Dental Anesthesia.

(b) Purpose. The purpose of the advisory committee is to analyze and report on de-identified data and associated trends concerning anesthesia-related deaths or incidents. The data and information provided by the agency to the advisory committee is confidential. The recommendations and findings reported by the advisory committee to the board are public information and published on the board’s Internet website.

(c) Compilation of Information by Agency. The agency shall identify investigations and provide confidential, de-identified information regarding the investigations to the advisory committee as described below:

(1) By September 30 of each year, the agency shall identify official investigations in which the preliminary investigation was initiated after September 1, 2016, and the official investigation was resolved by the board in the preceding fiscal year, which involve anesthesia-related deaths or incidents. A death shall be considered anesthesia-related if the dental treatment involved the administration of an anesthetic or sedative agent in the dental office, including local anesthesia, and a death occurred. An incident shall be considered anesthesia-related if the dental treatment involved the administration of an anesthetic or sedative agent in a dental office, including local anesthesia, and the Dental Review Panel identified a complication associated with the administration of the anesthetic or sedative agent.

(2) By November 30 of each year, the agency shall compile confidential, de-identified information on each investigation identified under paragraph (1) of this subsection, including, but not limited to, the following information:

(A) Information about respondent:

(i) Whether respondent is a Medicaid provider;

(ii) Respondent’s highest sedation/anesthesia permit level;

(iii) Whether respondent reported providing anesthesia services in more than one location on the licensee’s application or latest renewal;

(iv) Respondent’s self-reported practice area; and

(v) Whether the investigation was initiated as the result of a complaint submitted by a patient or member of the public, as a self-report to the agency required by Board Rule 108.6, or both.

(B) Information about patient:

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

(ii) Patient age -- under the age of 13, 13 and over but under 18, 18 and over but under 75, and 75 and over;

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

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

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

(vi) Whether treatment investigated by the agency was paid by Medicaid; and

(C) The Dental Review Panel report designated as the final report by the Dental Review Panel.

(3) By November 30 of each year, the agency shall provide the information identified under paragraph (2) of this subsection to the members of the advisory committee.

(4) On request of the advisory committee, the agency may provide confidential, de-identified investigative files to the advisory committee in addition to the information provided under paragraph (2) of this subsection. Pursuant to §258.505 of the Texas Occupations Code, the advisory committee may conduct a closed meeting to review confidential investigative files provided to the advisory committee under this paragraph.

(d) Analysis of Information by Advisory Committee. The advisory committee shall analyze the information compiled under subsection (c)(2) to identify any trends and submit a report to the board as described below:

(1) By June 30 of each year, the advisory committee shall submit a written report to the board of the advisory committee’s findings and any recommendations for changes to the board rules or the Dental Practice Act.

(2) The advisory committee’s annual report shall be posted on the Board’s Internet website.

(e) Membership and Term Length. The advisory committee consists of six members appointed by the board to serve staggered two-year terms. The Board’s presiding officer will draw lots to determine which of the three initial members will serve a one-year term and which three will serve a two-year term, all of which begin on December 1, 2017. Thereafter, all appointments will be for two years from the date of appointment. [beginning on December 1 of each odd-numbered year.] Members, including the advisory committee chair, may serve no more than three consecutive two-year terms as members of the advisory committee. An advisory committee chair may serve no more than four consecutive one-year terms as advisory committee chair. The advisory committee must include a licensed Texas physician anesthesiologist and five licensed Texas dentists. The five licensed Texas dentists must include at least one dentist who holds a level 1 sedation/anesthesia permit and no higher permit, at least one dentist who holds a level 2 sedation/anesthesia permit and no higher permit, at least one dentist who holds a level 3 sedation/anesthesia permit and no higher permit, and at least one dentist who holds a level 4 sedation/anesthesia permit. In addition, the five dentist members of the advisory committee shall include one general dentist. The remaining four dentist members shall be dentists who are university-trained in their respective practice areas, with applicants’ education and experience verified during the application process. These four dentist members shall include one university-trained dentist to represent each of the following practice areas:

(1) dental anesthesiology;

(2) oral and maxillofacial surgery;

(3) pediatric dentistry; and

(4) periodontics.

(f) Qualification for Membership. A person cannot be appointed as a member unless he or she holds a Texas dental or medical license that he or she has maintained in good standing for at least the five years preceding application for membership on the advisory committee. A license is in good standing if it is not expired, currently subject to a probated suspension, or currently subject to an enforced suspension.

(g) Board Member Membership on Advisory Committee. In accordance with §258.202(c) of the Texas Occupations Code, a currently serving board member cannot be appointed to the advisory committee. A former board member cannot be appointed to the advisory committee prior to the second anniversary of the expiration or termination of the board member’s service on the board.

(h) Application, Nomination, and Confirmation Process. Pursuant to §258.203 of the Texas Occupations Code, the board establishes the following process for the application, nomination, and confirmation of members of the advisory committee.

(1) Application for Membership. The application for the initial appointments will be published on the board’s internet website by October 1, 2017,and the application period will close on October 15, 2017. Thereafter [By October 1 of each odd-numbered year], the agency shall publish an application for advisory committee membership on the board’s Internet website three months prior to the expiration of an appointment or as soon as possible following the resignation or removal of a member. The application period shall close two weeks after the application has been published. [on October 15 of each odd-numbered year.]

(2) Nomination of Advisory Committee Members. By November 1, 2017, the presiding officer of the board shall review all initial applications and nominate applicants for membership on the advisory committee. Thereafter, nominations will be made within two weeks of the closure of the application period. [By November 1 of each odd-numbered year, the presiding officer of the board shall review all applications and nominate six applicants for membership on the advisory committee.] The applicants nominated by the presiding officer shall represent the same self-reported practice area as the member they may replace. [membership described by subsection (e) of this section.]

(3) Confirmation of Advisory Committee Members. By December 1, 2017, [of each odd-numbered year,] the board shall vote by ballot in a public meeting to confirm or reject each of the presiding officer’s initial nominees for membership on the advisory committee. Thereafter, the board shall vote for nominees at the first regularly scheduled board meeting that follows the nominations. Confirmation of a nominee requires the affirmative vote of an absolute majority of the entire membership of the board if the board is comprised of more than six, but fewer than eleven members, or if the board is comprised of more than eleven members. Confirmation of a nominee requires the affirmative vote of at least seven members of the board if the board is comprised of eleven members.

(4) Rejection of Nomination by Board. If one of the presiding officer’s nominations for membership on the advisory committee is rejected by the board, the presiding officer shall nominate another applicant to membership on the advisory committee, subject to confirmation by the board, as described in paragraph (3) of this subsection. The subsequent nominee shall represent the same self-reported practice area as the original nominee.

(5) Appointment of Advisory Committee Members. The appointment of an advisory committee member commences on the date the board confirms the presiding officer’s appointment of the advisory committee member.

(i) Designation of Advisory Committee Chair. Each year the presiding officer of the board shall designate one of the advisory committee members appointed by the board to serve a one-year term as chair of the advisory committee.

(1) This paragraph applies if the board is comprised of more than six, but fewer than eleven members, or if the board is comprised of more than eleven members. The board shall confirm the presiding officer’s designation by affirmative vote of an absolute majority of the entire membership of the board. If the presiding officer’s designation is unconfirmed by such an affirmative vote, the presiding officer shall designate another member of the advisory committee as the chair of the advisory committee, subject to an affirmative vote of an absolute majority of the entire membership of the board.

(2) This paragraph applies if the board is comprised of eleven members. The board shall confirm the presiding officer’s designation by affirmative vote of at least seven members of the board. If the presiding officer’s designation is unconfirmed by such an affirmative vote, the presiding officer shall designate another member of the advisory committee as the chair of the advisory committee, subject to an affirmative vote of at least seven members of the board.

(j) Resignation, Removal, and Replacement of Advisory Committee Members. If an advisory committee member resigns or is removed from the advisory committee prior to the expiration of his or her term, the advisory committee member shall be replaced with another member that represents the self-reported practice area of the former advisory committee member. The application period shall re-open for a period of no more than 30 days. The agency shall publish the application for advisory committee membership on the board’s Internet website, specifying the self-reported practice area to be replaced by a new member of the advisory committee. The presiding officer shall nominate the replacement member of the advisory committee at the next public meeting of the board, and the board shall confirm or reject the nomination as described in subsection (h) of this section.

(k) Confidential Information. The members of the advisory committee shall execute confidentiality agreements related to their membership on the advisory committee. Violation of the confidentiality agreement is grounds for immediate removal from the advisory committee and may subject the member of the advisory committee to investigation and disciplinary proceedings for dishonorable conduct pursuant to Board Rule 108.9.

(l) Communication with Other Parties. Members of the advisory committee shall not engage in private communications with non-advisory committee members about the subject matter of the advisory committee or its work, except that members of the advisory committee may communicate with agency staff to facilitate the completion of tasks required by this rule.

(m) Reimbursement. The advisory committee may be reimbursed for expenses in accordance with §2110.004 of the Texas Government Code.

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 October 19, 2017.

TRD-201704209

Kelly Parker

Executive Director

State Board of Dental Examiners

Earliest possible date of adoption: December 3, 2017

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


PART 9. TEXAS MEDICAL BOARD

CHAPTER 160. MEDICAL PHYSICISTS

22 TAC §160.7, §160.10

The Texas Medical Board (Board) proposes amendments to §160.7, concerning Qualifications for Licensure and §160.10, concerning Training Licensure.

The amendments to §160.7, amend the rule by deleting a reference to a foreign educational credentialing service that is no longer in operation and adding language authorizing international credit evaluations from credential evaluation organizations approved by the American Board of Radiology. The amendment also removes language regarding a master or doctorate degree that was unnecessary and covered by another section of the rule.

The amendments to §160.10, amend the rule by eliminating the term "training license" and substituting the term "temporary license" to be consistent with language in the Medical Physicist Act. The amendments increase the number of temporary license which an applicant may granted from four to twelve, with the proviso that after the seventh renewal the Board shall perform an evaluation to determine if an applicant is making progress in a medical physicist training program. The amendment also eliminates the term "renewal," because that term was inaccurate as temporary license are not renewed, but rather each license requires a new application. The amendment further adds language authorizing the executive director, at the executive director's discretion, to approve a supervisor of temporary licensees to supervise more than two temporary licensees. Finally, the amendment adds language allowing a supervisor at a CAMPEP approved medical physics training program to supervise more than two temporary licensees without requesting executive director approval.

Scott Freshour, General Counsel for the Board, has determined that for each year of the first five years the sections as proposed are in effect the public benefit anticipated as a result of enforcing this proposal will be to provide the public greater access to qualified medical physicists with international training by allowing for greater flexibility in obtaining international credit evaluations and to provide greater flexibility to medical physicists who wish to receive certification and training in multiple areas of medical physics. The public will ALSO benefit by having access to medical physicists skilled in different aspects of a medical physics.

Mr. Freshour has also determined that for the first five-year period the sections are in effect there will be no fiscal implication to state or local government as a result of enforcing the sections as proposed. There will be no effect to individuals required to comply with the rules as proposed. There will be no effect on small or micro businesses.

Comments on the proposal may be submitted to Rita Chapin, P.O. Box 2018, Austin, Texas 78768-2018, or e-mail comments to: rules.development@tmb.state.tx.us. A public hearing will be held at a later date.

The amendments are proposed under the authority of the Texas Occupations Code Annotated, §153.001, which provides authority for the Board to recommend rules to establish licensing and other fees and recommend rules necessary to administer and enforce this chapter.

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

§160.7.Qualifications for Licensure.

(a) - (c) (No change.)

(d) International academic credit. Degrees and course work received at international universities shall be acceptable only if such course work could be counted as transfer credit by regionally accredited universities. An applicant having an international degree(s) must furnish at the applicant's own expense [a Foreign Educational Credentials Evaluation from the Office of International Education Services of the American Association of Collegiate Registrars and Admissions Officers (AACRAO) or] an International Credential Evaluation from the Foreign Credential Service of America (FCSA), a credential evaluation from an American Board of Radiology (ABR) approved Credentials Evaluation organization, or another similar entity as approved by the board. The degree evaluation must be sent directly to the board by the evaluation service. An applicant must submit with the application complete certified copies of academic transcripts showing proof of the degree(s) awarded (or equivalent degree [masters or doctorate]) and the date [it was] awarded. Documents written in languages other than English shall be accompanied by a certified English translation.

(e) Approved specialty examination. An applicant under this section must successfully pass [complete] one of the following examinations in each specialty for which application is submitted:

(1) - (4) (No change.)

(f) Jurisprudence Examination. Applicants for licensure must pass a jurisprudence examination ("JP exam"), which shall be conducted on the licensing requirements and other laws, rules, or regulations applicable to the medical physicist profession in this state. The jurisprudence examination shall be developed and administered as follows:

(1) Questions for the JP Exam may be prepared by board staff with input from the Advisory Committee and board, or contracted out to a third party vendor. Board staff shall make arrangements for a facility by which applicants can take the examination;

(2) Applicants must pass the JP exam with a score of 75 or better within three attempts, unless the Board allows an additional attempt based upon a showing of good cause. An applicant who is unable to pass the JP exam within three attempts must appear before the licensure committee of the board to address the applicant's inability to pass the examination and to re-evaluate the applicant's eligibility for licensure. It is at the discretion of the licensure committee to allow an applicant additional attempts to take the JP exam;

(3) An examinee shall not be permitted to bring books, compends, notes, journals, calculators or other help into the examination room, nor be allowed to communicate by word or sign with another examinee while the examination is in progress without permission of the presiding examiner, nor be allowed to leave the examination room except when so permitted by the presiding examiner.

(4) Irregularities during an examination such as giving or obtaining unauthorized information or aid as evidenced by observation or subsequent statistical analysis of answer sheets, shall be sufficient cause to terminate an applicant's participation in an examination, invalidate the applicant's examination results, or take other appropriate action;

(5) A person who has passed the JP Exam shall not be required to retake the Exam for another or similar license, except as a specific requirement of the board;

(g) Alternative License Procedures for Military Service Members, Military Veterans, and Military Spouses.

(1) An applicant who is a military service member, military veteran, or military spouse may be eligible for alternative demonstrations of competency for certain licensure requirements. Unless specifically allowed in this subsection, an applicant must meet the requirements for licensure as specified in this chapter.

(2) To be eligible, an applicant must be a military service member, military veteran, or military spouse and meet one of the following requirements:

(A) holds an active unrestricted medical physicist license issued by another state that has licensing requirements that are substantially equivalent to the requirements for a Texas medical physicist license; or

(B) within the five years preceding the application date held a medical physicist license in this state.

(3) The executive director may waive any prerequisite to obtaining a license for an applicant described by this subsection, after reviewing the applicant's credentials.

(4) Applications for licensure from applicants qualifying under this section shall be expedited by the board's licensure division. Such applicants shall be notified, in writing or by electronic means, as soon as practicable, of the requirements and process for renewal of the license.

(5) Alternative Demonstrations of Competency Allowed. Applicants qualifying under this section, notwithstanding:

(A) the one year expiration in §160.8(a)(2) of this title (relating to Application Procedures), are allowed an additional six months to complete the application prior to it becoming inactive; and

(B) the 20 day deadline in §160.8(a)(6) of this title, may be considered for permanent licensure up to five days prior to the board meeting.

(h) Applicants with Military Experience.

(1) For applications filed on or after March 1, 2014, the Board shall credit, with respect to an applicant who is a military service member or military veteran as defined in §160.2 of this title (relating to Definitions), verified military service, training, or education toward the licensing requirements, other than an examination requirement, for a license issued by the Board.

(2) This section does not apply to an applicant who:

(A) has had a medical physicist license suspended or revoked by another state or a Canadian province;

(B) holds a medical physicist license issued by another state or a Canadian province that is subject to a restriction, disciplinary order, or probationary order; or

(C) has an unacceptable criminal history.

§160.10Temporary [Training] Licensure.

(a) To be eligible for a temporary [training ] license, a person must meet the educational requirements set out in §160.7 of this chapter (relating to Qualifications for Licensure).

(b) A temporary [training] license shall be issued for each specialty for a one-year period.

(c) The holder of a temporary license may apply for up to twelve temporary licenses.

(d) Upon application for the seventh temporary license, the Board shall perform an evaluation of an applicant's progress toward certification in a medical physicist area of specialty. This evaluation will include, but is not limited to:

(1) information on the applicant's current participation in any medical physicist training program;

(2) identification of the medical physicist specialty/specialties an applicant is working toward;

(3) the number of certification examinations taken during the previous six years and the results of said examinations;

(4) any medical physicist certification(s) successfully completed during the previous six years. If this evaluation determines that satisfactory progress has not been made toward completion of a medical physicist certification, an application for an additional temporary license may be denied.

(e) The board may, in its discretion, allow a holder of a Temporary License to apply for more than twelve licenses.

[(c) Each training license may be renewed annually up to four times. The licenses do not have to be for consecutive years.]

(f) [(d)] The application for [renewal of] a temporary [training] license shall include information regarding the experience in the medical physics specialty completed by the renewal applicant during the previous one-year period.

(g) [(e)] The work experience must be under the supervision of a licensed medical physicist holding a license in the specialty area. The work experience must be completed in accordance with a supervision plan approved by the board, signed by both the supervisor and the temporary [training] license holder. The supervision plan shall describe the duration of personal, direct and general supervision with particular attention to the aspects of the work of the temporary [training] licensee that could have the greatest effect on the safety of patients, personnel or the public. The board may audit supervision plans for compliance with this section.

(h) [(f)] A supervisor shall supervise no more than two temporary [training] license holders or their full time equivalents, unless approved by the executive director. Supervisors in a CAMPEP approved medical physics training may supervise more than two temporary license holders without approval by the executive director. [board.]

(i) [(g)] A supervisor shall assume responsibility for all of the work conducted under his or her supervision. A supervisor shall approve and sign all formal work product of the temporary [training] license holder, such as reports of machine calibrations, shielding designs, treatment plan reviews, patient specific quality assurance measurements, treatment record reviews, and equipment evaluations.

(j) [(h)] The application procedures set out in §160.8 of this chapter (relating to Application Procedures) shall apply.

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 October 23, 2017.

TRD-201704251

Scott Freshour

Interim Executive Director

Texas Medical Board

Earliest possible date of adoption: December 3, 2017

For further information, please call: (512) 305-7016


CHAPTER 182. USE OF EXPERTS

22 TAC §182.8

The Texas Medical Board (Board) proposes an amendment to §182.8, concerning Expert Physician Reviewers.

The amendment removes language from subsection (c) which requires that a report, prepared by an expert reviewer, include the expert's general qualifications; the rule is further amended to add language requiring the expert's specialty areas be included in such reports.

Scott Freshour, General Counsel for the Board, has determined that for each year of the first five years the section, as proposed, is in effect the public benefit anticipated as a result of enforcing this proposal will be to allow licensees who are the subject of an expert review to be apprised of the specialty area of practice of the expert reviewers.

Mr. Freshour has also determined that for the first five-year period the section is in effect, there will be no fiscal implication to state or local government as a result of enforcing the section as proposed. There will be no impact or effect on government growth. There will be no effect to individuals required to comply with the rule as proposed. There will be no effect on small or micro businesses, or rural communities.

Comments on the proposal may be submitted to Rita Chapin, P.O. Box 2018, Austin, Texas 78768-2018, or e-mail comments to: rules.development@tmb.state.tx.us. A public hearing will be held at a later date.

The amendment is proposed under the authority of the Texas Occupations Code Annotated, §153.001, which provides authority for the Board to adopt rules and bylaws as necessary to: govern its own proceedings; perform its duties; regulate the practice of medicine in this state; enforce this subtitle; and establish rules related to licensure.

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

§182.8.Expert Physician Reviewers.

(a) (No change.)

(b) Procedures for Expert Physician Review. The procedure for the use of Reviewers shall comply with [Section] § 154.0561, Texas Occupations [Tex. Occ.] Code. Reviewers shall be specifically informed that they may communicate with other Reviewers selected to review the case and that they should communicate with other Reviewers to attempt to reach a consensus.

(c) Expert Reviewers' Report. A report shall be prepared by the Expert Physician Reviewers to include the following:

(1) the specialty area [general qualifications ] of each Reviewer; and

(2) the opinions agreed to by at least a majority of the Reviewers regarding:

(A) relevant facts concerning the medical care rendered;

(B) applicable standard of care;

(C) application of the standard of care to the relevant facts;

(D) a determination of whether the standard of care has been violated;

(E) the clinical basis for the determinations, including any reliance on peer-reviewed journals, studies, or reports; and

(3) Notice to Respondent: "PURSUANT TO [SECTION] §164.007 OF THE MEDICAL PRACTICE ACT, THIS DOCUMENT CONSTITUTES INVESTIGATIVE INFORMATION AND IS PRIVILEGED AND CONFIDENTIAL. THIS DOCUMENT IS PROVIDED FOR USE AT THE INFORMAL SETTLEMENT CONFERENCE ONLY AND MAY NOT BE USED FOR ANY OTHER PURPOSE. THIS DOCUMENT IS NOT SUBJECT TO OPEN RECORDS REQUESTS AND IS NOT ADMISSIBLE AS EVIDENCE IN ANY CIVIL JUDICIAL OR ADMINISTRATIVE PROCEEDING. THIS DOCUMENT MAY NOT BE USED BY OR DISSEMINATED BY ANY LICENSEE OR THEIR REPRESENTATIVE IN ANY CONTESTED CASE PROCEEDING, INCLUDING, BUT NOT LIMITED TO, A PROCEEDING BEFORE THE STATE OFFICE OF ADMINISTRATIVE HEARINGS. ACCORDINGLY, THIS DOCUMENT SHOULD NOT BE RELEASED TO ANY PERSON OR ENTITY WITHOUT THE CONSENT OF THE BOARD. PURSUANT TO [SECTIONS] §164.003 AND §164.007 OF THE MEDICAL PRACTICE ACT AND CHAPTER [BOARD RULE] 179 OF THIS TITLE (RELATING TO CONFIDENTIALITY), RELEASE OF THIS DOCUMENT, OR ANY PORTION THEREOF, TO A LICENSEE OR THEIR REPRESENTATIVE PURSUANT TO [SECTION] §164.003 OF THE MEDICAL PRACTICE ACT AND CHAPTER [BOARD RULE] 187 OF THIS TITLE (RELATING TO PROCEDURAL RULES [FOR INFORMAL BOARD PROCEEDINGS]), SHALL NOT CONSTITUTE WAIVER OF PRIVILEGE OR CONFIDENTIALITY."

(d) (No change.)

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 October 23, 2017.

TRD-201704252

Scott Freshour

Interim Executive Director

Texas Medical Board

Earliest possible date of adoption: December 3, 2017

For further information, please call: (512) 305-7016


CHAPTER 188. PERFUSIONISTS

22 TAC §188.5, §188.9

The Texas Medical Board (Board) proposes amendments to §188.5, concerning Procedural Rules for Licensure Applicants, and §188.9, concerning License Renewal.

The amendment to §188.5 removes language from subsection (a)(6) requiring a "sworn" application. This change is in accordance with and pursuant to the passage of SB 674 (85th Regular Session), which amended §603.252 of the Texas Occupations Code.

The amendment to §188.9 removes the reference to "affidavit" which infers that an application for renewal is a "sworn" application. This change is in accordance with and pursuant to the passage of SB 674 (85th Regular Session), which amended §603.252 of the Texas Occupations Code.

Scott Freshour, General Counsel for the Board, has determined that for each year of the first five years the sections as proposed are in effect, the public benefit anticipated as a result of enforcing the proposal will be to have rules that are consistent with statutes.

Mr. Freshour has also determined that for the first five-year period the sections are in effect, there will be no fiscal implication to state or local government as a result of enforcing the sections as proposed. There will be no impact or effect on government growth. There will be no effect to individuals required to comply with the rules as proposed. There will be no effect on small or micro businesses, or rural communities.

Comments on the proposal may be submitted to Rita Chapin, P.O. Box 2018, Austin, Texas 78768-2018, or e-mail comments to: rules.development@tmb.state.tx.us. A public hearing will be held at a later date.

The amendments are proposed under the authority of the Texas Occupations Code Annotated, §§603.151, 603.152 and 603.252, which provide authority for the Board to adopt rules as necessary to: regulate the practice of perfusion; enforce Chapter 603 of the Texas Occupations Code; and perform its duties under Chapter 603 of the Texas Occupations Code.

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

§188.5.Procedural Rules for Licensure Applicants.

(a) An applicant for licensure:

(1) - (5) (No change.)

(6) must complete and submit [an oath swearing that the applicant has submitted] an accurate and complete application.

(b) - (c) (No change.)

§188.9.License Renewal.

(a) - (f) (No change.)

(g) The board may deny renewal of a license, pursuant to §603.401 of the Act, under the following circumstances:

(1) A licensee's falsification of a renewal application [an affidavit] or submission of false information to obtain renewal of a license;

(2) - (4) (No change.)

(h) - (l) (No change.)

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 October 23, 2017.

TRD-201704253

Scott Freshour

Interim Executive Director

Texas Medical Board

Earliest possible date of adoption: December 3, 2017

For further information, please call: (512) 305-7016


CHAPTER 189. COMPLIANCE

22 TAC §189.15

The Texas Medical Board (Board) proposes an amendment to §189.15, concerning Determination of Successful Completion of an Order.

The proposed amendment amends the language in subsection (d) to clarify the provisions related to tolling and extension of an Order's time period resulting from tolling. The amendments also add a new subsection (e) to include a description of "partial tolling" and new subsection (f) to delineate the terms, requirements or conditions that may not be tolled.

Scott Freshour, General Counsel for the Board, has determined that for each year of the first five years the section, as proposed, is in effect, the public benefit anticipated as a result of enforcing the proposal will be to have rules that clearly delineate the effect of tolling on board orders and describe the limits of tolling, as it applies to certain requirements, conditions or terms in an order.

Mr. Freshour has also determined that for the first five-year period the section is in effect, there will be no fiscal implication to state or local government, as a result of enforcing the section as proposed. There will be no impact on government growth. There will be no effect to individuals required to comply with the rule as proposed. There will be no effect on small or micro businesses, or rural communities.

Comments on the proposal may be submitted to Rita Chapin, P.O. Box 2018, Austin, Texas 78768-2018, or email comments to: rules.development@tmb.state.tx.us. A public hearing will be held at a later date.

The amendment is proposed under the authority of the Texas Occupations Code Annotated, §153.001, which provides authority for the Board to adopt rules and bylaws as necessary to: govern its own proceedings; perform its duties; regulate the practice of medicine in this state; enforce this subtitle; and establish rules related to licensure.

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

§189.15.Determination of Successful Completion of an Order.

(a) - (c) (No change.)

(d) Tolling. If any provision(s) of the order is [are] tolled, the term of the order shall be extended for the same length of time that the order was tolled. There [there] shall be no determination of Successful Completion until the tolling of the order is lifted and all terms, requirements, provisions or conditions are completed within the extended time period. The [, the term of the order is extended according to the period of time that the order was tolled, the order's terms are timely completed, and the] completion of the tolled provisions shall be [is] verified by a board Compliance Officer.

(e) Partial Tolling. While a term or provision of an order is tolled, the compliance monitoring of that particular requirement, term or provision [period] shall be suspended, while compliance monitoring shall continue for remaining requirements, terms or provisions that are not tolled. [and the probationer will not be allowed to complete any provisions required by the order, unless otherwise permitted by other provisions in the order.]

(f) Exclusions from tolling. The following terms, requirements or provisions shall not be tolled:

(1) completion of continuing education;

(2) payment of administrative penalties;

(3) passing the jurisprudence or SPEX; or

(4) any other term, requirement, provision specifically excluded from the tolling.

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 October 23, 2017.

TRD-201704254

Scott Freshour

Interim Executive Director

Texas Medical Board

Earliest possible date of adoption: December 3, 2017

For further information, please call: (512) 305-7016


CHAPTER 193. STANDING DELEGATION ORDERS

22 TAC §193.8

The Texas Medical Board (Board) proposes an amendment to §193.8, concerning Prescriptive Authority Agreements: Minimum Requirements.

The amendment changes the requirements set forth in paragraphs (9) - (11) and adds a new paragraph (12), relating to the frequency physicians must meet with physician assistants to whom they delegate and supervise. These changes are in accordance with, and pursuant to, the passage of SB 1625 (85th Regular Session), which amended §157.0512 of the Texas Occupations Code.

Scott Freshour, General Counsel for the Board, has determined that for each year of the first five years the section, as proposed, is in effect the public benefit anticipated as a result of enforcing this proposal will be to have rules that are consistent with statutes.

Mr. Freshour has also determined that for the first five-year period the section is in effect there will be no fiscal implication to state or local government as a result of enforcing the section, as proposed. There will be no effect to individuals required to comply with the rule as proposed. There will be no effect on small or micro businesses, or rural communities.

Comments on the proposal may be submitted to Rita Chapin, P.O. Box 2018, Austin, Texas 78768-2018, or e-mail comments to: rules.development@tmb.state.tx.us. A public hearing will be held at a later date.

The amendment is proposed under the authority of the Texas Occupations Code Annotated, §153.001, which provides authority for the Board to adopt rules and bylaws as necessary to: govern its own proceedings; perform its duties; regulate the practice of medicine in this state; enforce this subtitle; and establish rules related to licensure.

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

§193.8.Prescriptive Authority Agreements: Minimum Requirements.

Prescriptive authority agreement must, at a minimum:

(1) - (8) (No change.)

(9) describe a prescriptive authority quality assurance and improvement plan and specify methods for documenting the implementation of the plan that includes the following:

(A) chart review, with the number of charts to be reviewed determined by the physician and advanced practice registered nurse or physician assistant; [and]

(B) periodic face-to-face meetings between the advanced practice registered nurse [or physician assistant] and the physician at a location determined by the physician and the advanced practice registered nurse; and [or physician assistant.]

(C) periodic meetings between the physician assistant and the physician.

(10) The periodic face-to-face meetings between the physician and advanced practice registered nurse described by paragraph (9)(B) of this section must include:

(A) the sharing of information relating to patient treatment and care, needed changes in patient care plans, and issues relating to referrals;

(B) discussion of patient care improvement; and

(C) documentation of the periodic face-to-face meetings.

(11) The periodic face-to-face meetings between the physician and advanced practice registered nurse described by paragraph (9)(B) of this section shall occur as follows:

(A) If during the seven years preceding the date the agreement is executed, the advanced practice registered nurse [or physician assistant] was not in a practice that included the exercise of prescriptive authority with required physician supervision for at least five years:

(i) at least monthly until the third anniversary of the date the agreement is executed; and

(ii) at least quarterly after the third anniversary of the date the agreement is executed, with monthly meetings held between the quarterly meetings by means of a remote electronic communications system, including videoconferencing technology or the Internet; or

(B) if during five of the last seven years preceding the date the agreement is executed, the advanced practice registered nurse [or physician assistant] was in a practice that included the exercise of prescriptive authority with required physician supervision, but the agreement is not being entered into with the same supervising physician who delegated and supervised during the five year period:

(i) at least monthly until the first anniversary of the date the agreement is executed; and

(ii) at least quarterly after the first anniversary of the date the agreement is executed, with monthly meetings held between the quarterly meetings by means of a remote electronic communications system, including videoconferencing technology or the Internet; or

(C) if during five of the last seven years preceding the date the agreement is executed, the advanced practice registered nurse [or physician assistant] was in a practice that included the exercise of prescriptive authority with required physician supervision, and the agreement is being entered into with the same supervising physician who delegated and supervised during the five year period:

(i) at least quarterly; and

(ii) monthly meetings held between the quarterly meetings by means of a remote electronic communications system, including videoconferencing technology or the Internet. 12 The periodic meetings between the physician and physician assistant described by paragraph (9)(C) of this section must:

(A) include:

(i) the sharing of information relating to patient treatment and care, needed changes in patient care plans, and issues relating to referrals; and

(ii) discussion of patient care improvement;

(B) be documented; and

(C) take place at least once per month in a manner determined by the physician and the physician assistant.

(13) [(12)] The prescriptive authority agreement may include other provisions agreed to by the physician and advanced practice registered nurse or physician assistant.

(14) [(13)] If the parties to the prescriptive authority agreement practice in a physician group practice, the physician may appoint one or more alternate supervising physicians designated under paragraph (8) of this section, if any, to conduct and document the quality assurance meetings in accordance with the requirements of this chapter.

(15) [(14)] The prescriptive authority agreement need not describe the exact steps that an advanced practice registered nurse or physician assistant must take with respect to each specific condition, disease, or symptom.

(16) [(15)] A physician, advanced practice registered nurse, or physician assistant who is a party to a prescriptive authority agreement must retain a copy of the agreement until the second anniversary of the date the agreement is terminated.

(17) [(16)] A party to a prescriptive authority agreement may not by contract waive, void, or nullify any provision of this section or §157.0513 of the Occupations Code.

(18) [(17)] In the event that a party to a prescriptive authority agreement is notified that the individual has become the subject of an investigation by the board, the Texas Board of Nursing, or the Texas Physician Assistant Board, the individual shall immediately notify the other party to the prescriptive authority agreement.

(19) [(18)] The prescriptive authority agreement and any amendments must be reviewed at least annually, dated, and signed by the parties to the agreement. The prescriptive authority agreement and any amendments must be made available to the board, the Texas Board of Nursing, or the Texas Physician Assistant Board not later than the third business day after the date of receipt of request, if any.

(20) [(19)] The prescriptive authority agreement should promote the exercise of professional judgment by the advanced practice registered nurse or physician assistant commensurate with the advanced practice registered nurse's or physician assistant's education and experience and the relationship between the advanced practice registered nurse or physician assistant and the physician.

(21) [(20)] This section shall be liberally construed to allow the use of prescriptive authority agreements to safely and effectively utilize the skills and services of advanced practice registered nurses and physician assistants.

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 October 23, 2017.

TRD-201704255

Scott Freshour

Interim Executive Director

Texas Medical Board

Earliest possible date of adoption: December 3, 2017

For further information, please call: (512) 305-7016


CHAPTER 194. MEDICAL RADIOLOGIC TECHNOLOGY

SUBCHAPTER B. NON-CERTIFIED TECHNICIANS SUPERVISED BY PHYSICIANS

22 TAC §§194.34 - 194.43

The Texas Medical Board (Board) proposes to repeal Chapter 194, Subchapter B, §§194.34 - 194.43, concerning Medical Radiologic Technology.

The repeal of Chapter 194, Subchapter B is proposed in accordance with Senate Bill No. 674, which repealed requirements under §601.252 of the Texas Occupations Code related to the Medical Board’s registration of non-certified technicians (NCT) who are employed by physicians. The Medical Board provides agency resources to support the general registry for NCTs performing radiologic procedures in Texas. The proposed repeal will eliminate inefficiencies related to Medical Board’s resources allocated to supporting a second registry for a subset of NCTs working for physicians, which creates inefficiencies and potential duplication across the agency’s departments and provides no benefit to the agency, NCT profession or the public.

Scott Freshour, General Counsel for the Board, has determined that for each year of the first five years the repeal as proposed is in effect, the public benefit anticipated as a result of enforcing this proposal will be to have rules that comport with applicable statutes and to increase the Medical Board’s ability to more efficiently provide state resources and support for the medical radiologic technology certification and non-certified technician registration programs in Texas. NCTs and the physicians who employ them will also benefit from the elimination of unnecessary regulations.

Mr. Freshour has also determined that for the first five-year period that the repeal is in effect, there will be no fiscal implication to state or local government as a result of enforcing the repeal as proposed. There will be no effect to individuals required to comply with the repeal as proposed. The impact on government growth will be to decrease fees to the agency related to the secondary registration for NCTs employed by physicians and to repeal an existing regulation. There will be no effect on small or micro businesses or rural communities.

Comments on the proposal may be submitted to Rita Chapin, P.O. Box 2018, Austin, Texas 78768-2018, or e-mail comments to: rules.development@tmb.state.tx.us. A public hearing will be held at a later date.

The repeal is proposed under the authority of the Texas Occupations Code Annotated, §153.001, which provides authority for the Board to adopt rules and bylaws as necessary to: govern its own proceedings; perform its duties; regulate the practice of medicine in this state; enforce this subtitle; and establish rules related to licensure. The amendments are further proposed under the authority of Texas Occupations Code Annotated, Chapter 601, as amended by Senate Bill 674 (85th Legislature Regular Session) (2017).

§194.34.Purpose.

§194.35.Definitions.

§194.36.Registration.

§194.37.Annual Renewal.

§194.38.Non-Certified Technician's Scope of Practice.

§194.39.Suspension, Revocation or Nonrenewal of Registration.

§194.40.Disciplinary Guidelines.

§194.41.Procedure.

§194.42.Compliance.

§194.43.Construction.

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 October 23, 2017.

TRD-201704256

Scott Freshour

Interim Executive Director

Texas Medical Board

Earliest possible date of adoption: December 3, 2017

For further information, please call: (512) 305-7016


CHAPTER 195. PAIN MANAGEMENT CLINICS

22 TAC §195.3

The Texas Medical Board (Board) proposes amendments to §195.3, concerning Inspections.

The amendment implements the legislature's intent that Chapter 168.052 of the Medical Practice Act allows inspection of clinics or facilities not certified under Chapter 168.101 to determine if they are required to be certified. The amendment also clarifies the legislature's intent that subpoenas requiring immediate production, inspection, and copying of medical and billing are authorized in Board inspections and investigations in order to protect the public health and welfare. The amendment also sets forth criteria establishing the grounds on which a clinic or facility may be inspected to determine if it is required to be certified as a pain management clinic under Chapter 168.101 of the Medical Practice Act. Finally, the rules recognize the new grant of authority for the Board to enforce compliance with Board subpoenas by filing a suit to enforce in district court.

Scott Freshour, General Counsel for the Board, has determined that for each year of the first five years the section, as proposed, is in effect the public benefit anticipated as a result of enforcing this proposal will be to protect the public and address the opioid prescribing crisis by providing the Board additional tools to investigate improper and nontherapeutic prescribing practices.

Mr. Freshour has also determined that for the first five-year period that the section is in effect there will be no fiscal implication to state or local government as a result of enforcing the section as proposed. There will be no effect to individuals required to comply with the rule as proposed. There will be no effect on small or micro businesses.

Comments on the proposal may be submitted to Rita Chapin, P.O. Box 2018, Austin, Texas 78768-2018, or email comments to: rules.development@tmb.state.tx.us. A public hearing will be held at a later date.

The amendment is proposed under the authority of the Texas Occupations Code Annotated, §153.001, which provides authority for the Board to adopt rules and bylaws as necessary to: govern its own proceedings; perform its duties; regulate the practice of medicine in this state; enforce this subtitle; and establish rules related to licensure.

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

§195.3.Inspections.

(a) The board may conduct inspections to enforce these rules, including inspections of a pain management clinic and of documents of a physician's practice and records of a physician(s) and mid-level practitioner(s) practicing at such a clinic, as set out in subsections (b) and (c) below of this section. [The board may contract with another state agency or qualified person to conduct these inspections.]

(b) The board may inspect a pain management clinic certified under this chapter, including the documents of a physician practicing at the clinic, to determine if the clinic is being operated in compliance with applicable laws and rules. If other violations of the Medical Practice Act or board rules are found during an inspection, the board may bring an enforcement action for such violations. The board may utilize the services of another state or local agency, as needed, in carrying out inspections under this section.

(c) The board may inspect a clinic or facility that is not certified under this chapter, including the documents of a physician practicing at the clinic or facility, to determine whether the clinic or facility is required to be certified under §168.101 of the Medical Practice Act. In addition to a registration violation, if other violations of the Medical Practice Act or board rules are found during an inspection, the board may bring an enforcement action for such violations.

(d) The following criteria will be reviewed and evaluated in determining whether an inspection of a clinic or facility pursuant to subsection (c) of this section should be conducted. The board must find that at least one of the criteria listed in paragraphs (1) - (8) of this subsection exists before the board conducts an inspection of a clinic or facility pursuant to subsection (c) of this section. If, after evaluation of the criteria described in paragraphs (1) - (8) of this subsection, the board suspects that a clinic or facility is required to be certified under §168.101 of the Act, the board shall inspect such clinic or facility.

(1) the patient population of a clinic or facility includes multiple patients from outside the geographical area of service for which the clinic or facility provides service, based on a review of the Texas Physician Monitoring Program (PMP) reports;

(2) the patient population of the clinic or facility includes several patients at the same address who are all being treated for chronic pain;

(3) data from the PMP indicating that the volume of prescribing of a physician, or mid-level provider(s) supervised by the physician at a clinic or facility, places them in the top 50 prescribers in the state for opioids, benzodiazepines, barbiturates, or carisoprodol, excluding prescribers at registered pain management clinics, clinics or facilities engaged in treating cancer patients, and certified hospice facilities;

(4) information from the PMP that a physician or mid-level provider(s) supervised by the physician is prescribing to multiple patients, opioids in combination with one, or all of the following: benzodiazepines, barbiturates, or carisoprodol in a clinic or facility;

(5) complaints and/or information related to inappropriate prescribing practices, including those from law enforcement agencies or health care regulators, regarding a clinic or facility, or a physician or midlevel provider(s) supervised by the physician, working at the clinic or facility;

(6) A patient overdose death related to controlled substances prescribed by a specific physician, or a physician's mid-level provider(s);

(7) arrest of a physician or a mid-level provider related to improper or fraudulent prescribing of controlled substances;

(8) information developed during the course of a board investigation of a physician or a physician's mid-level provider indicating that the physician or mid-level provider is prescribing to a majority of patients opioids, benzodiazepines, barbituates, or carisprodol in a clinic or facility.

(e) [(b)] Unless it would jeopardize an ongoing investigation, the board shall provide at least five business days' notice before conducting an on-site inspection of a registered pain management clinic certified under this section.

(f) When inspecting clinics or facilities that are not certified, the board may utilize a subpoena instanter requiring immediate production, inspection and copying of medical and billing records. If immediate production is not made in compliance with the subpoena, the board, acting through the attorney general, may file suit to enforce the subpoena in a district court in Travis County.

(g) [(c)] This section does not require the board to make an on-site inspection of a physician's office.

(h) [(d)] The board shall conduct inspections of pain management clinics certified under this chapter if the board suspects that the ownership or physician supervision is not in compliance with board 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 October 23, 2017.

TRD-201704257

Scott Freshour

Interim Executive Director

Texas Medical Board

Earliest possible date of adoption: December 3, 2017

For further information, please call: (512) 305-7016


PART 24. TEXAS BOARD OF VETERINARY MEDICAL EXAMINERS

CHAPTER 577. GENERAL ADMINISTRATIVE DUTIES

SUBCHAPTER B. STAFF

22 TAC §577.15

The Texas Board of Veterinary Medical Examiners (Board) proposes this amendment to §577.15, concerning the Fee Schedule.

Overview

The purpose of the proposed amendment is to increase license renewal fees to cover increased costs for administering Chapter 801, Occupations Code, in fiscal years 2018 and 2019. There are three necessary increased costs that the agency must cover. First, increased vendor costs for the Prescription Monitoring Program (PMP) require the agency to contribute an additional $35,402 annually for operation and maintenance of the program. Additionally, the agency's contract with the Board's peer assistance program, Professional Recovery Network (PRN), requires an additional $12,000 annually for fiscal years 2018 and 2019. Finally, the agency is required to increase fees to generate $148,910 during the 2018-2019 biennium to compensate for an additional staff member approved by the legislature.

Fiscal Note

John Helenberg, 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. Helenberg has also determined that for each year of the first five years that the rule is in effect, there will be approximately $121,857 additional revenue collected by state government as a result of enforcing or administering the rule.

Public Benefit and Cost Note

Mr. Helenberg 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 agency can cover the cost of administering Chapter 801, Occupations Code, including necessary expenses for the PMP, PRN, and an additional staff member. The anticipated economic costs to persons required to comply with the rule include the increased license renewal fees for licensees.

Local Employment Impact Statement

Mr. Helenberg has determined that 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 §2001.022, Government Code.

Economic Impact Statement and Regulatory Flexibility Analysis

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

Takings Impact Assessment

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

Request for Public Comments

The Texas Board of Veterinary Medical Examiners invites comments on the proposed amendment from any interested persons, including any member of the public. A written statement should be mailed or delivered to Michelle Griffin, Interim General Counsel, 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 rule is proposed under the authority of §801.151(a), Occupations Code, which states that the Board may adopt rules necessary to administer the chapter, and the authority of 801.154, Occupations Code, which states that the Board by rule shall set fees in amounts that are reasonable and necessary so that the fees, in the aggregate, cover the costs of administering Chapter 801, Occupations Code.

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

§577.15.Fee Schedule.

The Texas Board of Veterinary Medical Examiners has established the following fixed fees as reasonable and necessary for the administration of its functions. Other variable fees exist, including but not limited to costs as described in §575.10 of this title (relating to Costs of Administrative Hearings), and are not included in this schedule.

Figure: 22 TAC §577.15 (.pdf)

[Figure: 22 TAC §577.15]

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 October 23, 2017.

TRD-201704258

Michelle Griffin

Interim General Counsel

Texas Board of Veterinary Medical Examiners

Earliest possible date of adoption: December 3, 2017

For further information, please call: (512) 305-7573