Practice Of The Certified Nurse-Midwife

A. Scope of practice: Practice by CNMs encompasses independently providing a full range of primary health care services for clients from adolescence to beyond menopause. These services include primary care; sexual and reproductive health care; gynecologic health; family planning services; pre-conception care; care during pregnancy, childbirth, and the postpartum period; and care of the normal newborn up to six weeks of age. CNMs provide care for all individuals who seek midwifery care, inclusive of all gender identities and sexual orientations. CNMs provide initial and ongoing comprehensive assessment, diagnosis, and treatment. They conduct physical examinations; independently prescribe, distribute, and administer dangerous drugs, devices, and contraceptive methods, and controlled substances in Schedules II through V of Sections 30-31-1 NMSA 1978, Controlled Substances Act; admit, manage, and discharge clients; order and interpret laboratory and diagnostic tests; and order the use of medical devices. Midwifery care also includes health promotion, disease prevention, and individualized wellness education and counseling. These services are provided in partnership with clients in diverse settings such as ambulatory care clinics, private offices, community and public health systems, homes, hospitals, and birth centers. A CNM practices within a health care system that provides for consultation, collaborative management, or referral as indicated by the health status of the client. A CNM practices in accordance with the ACNM "standards for the practice of midwifery". A CNM who expands beyond the ACNM "core competencies" to incorporate new procedures that improve care for their clients shall comply with the guidelines set out in the ACNM "standards for the practice of midwifery", standard VIII. Practice guidelines for home births should be informed by the most recent edition of the "ACNM home birth practice manual." B. Prescriptive authority: (1) Dangerous drugs: A CNM who prescribes, distributes, or administers a dangerous drug or device shall do so in accordance with Section 26-1 NMSA 1978, New Mexico Drug, Device and Cosmetic Act. (2) Controlled substances: (a) A CNM shall not prescribe nor distribute controlled substances in Schedule I of Section 26-1 1978 NMSA, Controlled Substances Act. (b) A CNM shall not prescribe, distribute, or administer controlled substances in Schedules II-V of the Controlled Substances Act unless the CNM is registered with the New Mexico board of pharmacy and the United States drug enforcement administration (DEA) to prescribe, distribute, and administer controlled substances. (c) A CNM who prescribes, distributes, or administers a controlled substance in Schedules II-V of Section 26-1 NMSA 1978, Controlled Substances Act, shall do so in accordance with the Controlled Substances Act. (d) An individual employed as a CNM by the United States military, the United States veterans administration, or the United States public health service, and operating in the official capacity of 16.11.2 NMAC 7 that employment, who is prescribing, distributing or administering controlled substances under that facility’s United States drug enforcement administration registration is exempt from the Subparagraphs (a), (b) and (c) of Paragraph (2) of this subsection. (e) A CNM may prescribe, provide samples of, and dispense any dangerous drug to a client if, at the time of the prescription, the CNM has a valid CNM-client relationship. The relationship includes: (i) the CNM has sufficient information to ensure that a dangerous drug or controlled substance is indicated and necessary for treatment of a condition when the CNM prescribes a dangerous drug or controlled substance; (ii) the CNM has sufficient information to ensure that a dangerous drug or controlled substance is not contraindicated for the individual; (iii) the CNM provides a client with appropriate information on the proper dosage, route, frequency, and duration of a drug treatment; (iv) the CNM informs the client of possible untoward effects and side effects of a proposed treatment; (v) the CNM provides care for a client in the event of an untoward effect or a side effect that requires care; (vi) the CNM provides for client education regarding a condition and the condition’s treatment to enhance client compliance with plan of care; (vii) the CNM provides for appropriate follow-up care, including further testing, treatment and education, as appropriate; and (viii) the CNM documents, at minimum, the indication, drug, and dosage of any prescribed drugs in a health record for the individual. (3) Prescriptions: A CNM may prescribe by telephone, by written prescription, by e-mail, or through an electronic health record (EHR) system. Controlled substances may only be prescribed by written or electronic prescription. A CNM prescription shall have the CNM's name, office address, and telephone number printed on it. In the event that a CNM is writing a prescription printed with the names of more than one CNM, the name of the CNM writing the individual prescription shall be indicated. The name and address of the client, the date of the prescription, the name and quantity of the drug prescribed, and directions for use shall be included on a prescription. (4) Labeling: When distributing a drug, a CNM shall label it with the client's name and date of birth; the date; instructions for use; and the CNM’s name, address, and telephone number. C. Guidelines for management of chronic pain or other conditions with controlled substances: The treatment of chronic pain or other conditions with various modalities, including controlled substances such as opioids, is a legitimate practice when done in the usual course of CNM practice. The goal when treating chronic pain is to reduce or eliminate pain and also to avoid development of or contribution to addiction, drug misuse and overdose. Effective dosages should be prescribed, with both under- and over-prescribing to be avoided, using client protection as a guiding principle. The CNM should provide control of the client’s pain for its duration, while effectively addressing other aspects of the client’s functioning, including physical, psychological, social, and work- related factors. A CNM may treat clients with substance use disorder, physical dependence, or tolerance who have pain, however such clients require very close monitoring and precise documentation. (1) If, in a CNM’s professional opinion, a client is seeking pain medication for reasons that are not medically justified, the CNM is not required to prescribe controlled substances for the client. (2) When prescribing, dispensing, or administering controlled substances for management of chronic pain, a CNM shall: (a) obtain a PMP report for the client covering the preceding 12 months from the New Mexico board of pharmacy and any other state’s report that is applicable and available; (b) complete a history and physical examination and include an evaluation of the client’s psychological and pain status, any previous history of significant pain, past history of alternate treatments for pain, potential for substance misuse, coexisting disease or medical conditions, and the presence of medical indications or contra-indications related to controlled substances; (c) be familiar with and employ screening tools, as well as the spectrum of available modalities for therapeutic purposes, in the evaluation and management of pain, and consider an integrative approach to pain management in collaboration with other care providers, including but not limited to acupuncturists, chiropractors, doctors of oriental medicine, exercise physiologists, massage therapists, pharmacists, physical therapists, psychiatrists, or psychologists; 16.11.2 NMAC 8 (d) develop a written individual treatment plan taking age, gender, and culture into consideration, with stated objectives by which treatment can be evaluated, such as degree of pain relief, improved physical and psychological function, or other accepted measures, and include any need for further testing, consultation, referral, or use of other treatment modalities as appropriate; (e) discuss the risks and benefits of using controlled substances with the client or legal guardian and document this discussion in the medical record; (f) make a written agreement with the client or legal guardian outlining client responsibilities, including a provision stating that the chronic pain client will receive all chronic pain management prescriptions from one practitioner and one pharmacy whenever possible; (g) maintain complete and accurate records of care provided and drugs prescribed, including the indications for use, the name of the drug, quantity, prescribed dosage, and number of refills authorized; (h) when indicated by the client’s condition, consult with health care professionals who are experienced in the area of the chronic pain or other conditions, though not necessarily specialists in pain control, both early in the course of long-term treatment and at least every six months; (i) when treating a client with addiction, substance use disorder or physical dependence, use drug screening prior to and during the course of treatment to identify the drugs the client is consuming and compare the screening results with clients’ self-reports (this should be included in the written agreement, see Subparagraph (f) above); (j) note possible indications of drug misuse by a client and take appropriate steps to further investigate and to avoid contributing to drug misuse; such steps may include termination of treatment. Information about some of the indications may be available only through PMP reports. The following list of possible indications of drug misuse is non-exhaustive: (i) receiving controlled substances from multiple prescribers; (ii) receiving controlled substances for more than 12 consecutive weeks; (iii) receiving more than one controlled substance analgesic; (iv) receiving a new prescription for any long-acting controlled substance analgesic formulation, including oral or transdermal dosage forms or methadone; (v) overutilization, including but not limited to early refills; (vi) appearing overly sedated or intoxicated upon presentation; or (vii) an unfamiliar client requesting a controlled substance by specific name, street name, color, or identifying marks. (k) comply with the opioid antagonist prescribing practices as set forth in the Pain Relief Act Section 24-2D-1, et.al NMSA1978. D. Prescription Monitoring Program (PMP) Requirements: The department requires participation in the PMP to assist practitioners in balancing the safe use of controlled substances with the need to impede harmful and illegal activities involving these pharmaceuticals. Any practitioner who holds a federal drug enforcement administration registration and a New Mexico controlled substance registration shall register with the board of pharmacy to become a regular participant in PMP inquiry and reporting. A practitioner may authorize delegate(s) to access the prescription monitoring report consistent with board of pharmacy regulation 16.19.29 NMAC. While a practitioner’s delegate may obtain a report from the state’s prescription monitoring program, the practitioner is solely responsible for reviewing the prescription monitoring report and documenting the receipt and review of a report in the client’s medical record. Before a practitioner prescribes or dispenses for the first time, a controlled substance in Schedule II, III, IV or V to a client for a period greater than four days, or if there is a gap in prescribing the controlled substance for 30 days or more, the practitioner shall review a prescription monitoring report for the client for the preceding 12 months. When available, the practitioner shall review similar reports from adjacent states. The practitioner shall document the receipt and review of such reports in the client’s medical record. A prescription monitoring report shall be reviewed a minimum of once every three months during the continuous use of a controlled substance in Schedule II, III, IV or V for each patient. The practitioner shall document the review of these reports in the patient’s medical record. Nothing in this section shall be construed as preventing a practitioner from reviewing prescription monitoring reports with greater frequency than that required by this section. (1) A practitioner does not have to obtain and review a prescription monitoring report before prescribing, ordering, or dispensing a controlled substance in Schedule II, III, IV or V: (a) for a period of four days or less; or (b) to a client in a nursing facility; or (c) to a client in hospice care. 16.11.2 NMAC 9 (d) or when prescribing, dispensing, or administering of: testosterone, pregabalin, lacosamide, ezogabine or stimulant therapy for pediatric clients less than age 14. (2) Upon review of a prescription monitoring report for a client, the practitioner shall identify, be aware, and document if a patient is currently: (a) receiving opioids from multiple prescribers; (b) receiving opioids and benzodiazepines concurrently; (c) receiving opioids for more than 12 consecutive weeks; (d) receiving more than one controlled substance analgesic; (e) receiving opioids totaling more than 90 morphine milligram equivalents per day; (f) exhibiting potential for misuse of opioids and other controlled substances, such as any of the following indicators: (g) over-utilization; (h) requests to fill early; (i) requests for a controlled substance or specific opioid by specific name, street name; color, or identifying marks; (j) requests to pay cash when insurance is available; (k) receiving opioids from multiple pharmacies; or (l) appearing overly sedated or intoxicated upon presentation. (m) receiving a new prescription for any long-acting controlled substance analgesic formulation, including oral or transdermal dosage forms or methadone. (3) Upon recognizing any of the above conditions described in Subparagraph (j) of Paragraph (2) of Subsection C of 16.11.2.11 NMAC, the practitioner, using professional judgement based on prevailing standards of practice, shall take action as appropriate to prevent, mitigate, or resolve any potential problems or risks that may result in opioid misuse or overdose. These steps may involve counseling the client on known risks and realistic benefits of opioid therapy, prescription and training for naloxone, consultation with or referral to a pain management specialist, or offering or arranging treatment for opioid or substance use disorder. The practitioner shall document actions taken to prevent, mitigate, or resolve the potential problems or risks. (4) Practitioners licensed to practice in an opioid treatment program, as defined in 7.32.8 NMAC, shall review a prescription monitoring report upon a client’s initial enrollment into the Opioid Treatment Program and every three months thereafter while prescribing, ordering, administering, or dispensing opioid treatment medications in Schedule II-V for the purpose of treating opioid use disorder. The practitioner shall document the receipt and review of a report in the client’s medical record. E. Immediate reporting: A CNM must report within 48 hours to the division any neonatal or maternal mortality in clients for whom the provider has cared in the perinatal period in a setting other than a licensed health facility; this includes stillbirths. These will be reviewed by the division on a case-by-case basis for compliance with these CNM regulations. F. Other rules: a CNM shall fulfill the requirements of all relevant department rules including: (1) "bureau of vital records and health statistics," 7.2.2 NMAC; (2) "control of disease and conditions of public health significance," 7.4.3 NMAC; (3) "newborn genetic screening," 7.30.6 NMAC; (4) "prevention of infant blindness," 7.30.7 NMAC; (5) “requirement for freestanding birth centers,” 7.10.2 NMAC; and (6) “birthing workforce retention fund,” 7.30.9 NMAC. [16.11.2.11 NMAC - Rp, 16.11.2.10 NMAC, 5/7/2024] 16.11.2.12 LICENSE DENIAL, SUSPENSION, OR REVOCATION; DISCIPLINARY ACTION: The department may deny, revoke, or suspend any license held or applied for or reprimand or place a license on probation on the grounds of incompetence, unprofessional conduct, or other grounds listed in this section, pursuant to Subsection V of Section 24-1-3, NMSA 1978. A. Grounds for action: (1) Incompetence: A CNM who fails to possess and apply the knowledge, skill, or care that is ordinarily possessed and exercised by CNMs or as defined by the ACNM "core competencies for basic midwifery practice" is considered incompetent. Charges of incompetence may be based upon a single act of incompetence or upon a course of conduct or series of acts or omissions which extend over a period of time and which, taken as a whole, demonstrate incompetence. Conduct of such a character that could result in harm to the client or to the 16.11.2 NMAC 10 public from the act or omission or series of acts or omissions constitutes incompetence, whether or not actual harm resulted. (2) Unprofessional conduct: For purposes of this rule "unprofessional conduct" includes, but is not limited to, the following: (a) verbally or physically abusing a client; (b) engaging in sexual contact with or toward a client; (c) abandonment of a client; (d) engaging in the practice of midwifery when judgment or physical ability is impaired by alcohol or drugs or controlled substances; (e) practice that is beyond the scope of CNM licensure; (f) dissemination of a client's health information or treatment plan to individuals not entitled to such information and where such information is protected by law from disclosure; (g) falsifying or altering client records or personnel records for the purpose of reflecting incorrect or incomplete information; (h) obtaining or attempting to obtain any fee for client services for one's self or for another through fraud, misrepresentation, or deceit; (i) aiding, abetting, assisting, or hiring an individual to violate any rule of the department; (j) failure to follow established procedure regarding controlled substances; (k) failure to make or to keep accurate, intelligible entries in records as required by the ACNM “standards for the practice of midwifery”; (l) obtaining or attempting to obtain a license to practice certified nurse-midwifery for one's self or for another through fraud, deceit, misrepresentation, or any other act of dishonesty in any phase of the licensure or relicense process; (m) practicing midwifery in New Mexico without a valid New Mexico license or permit or aiding, abetting or assisting another to practice midwifery without a valid New Mexico license; (n) delegation of midwifery assessment, evaluation, judgment, or medication administration to a non-licensed person; or (o) failure to provide information requested by the department pursuant to this rule within 20 business days of receiving the request. (3) Failure to comply with the New Mexico Parental Responsibility Act, Section 40-5A-1 through 40-5A-13, NMSA 1978. (4) Dereliction of any duty imposed by law. (5) Conviction of a felony pursuant to Paragraph (1) of Subsection A of Section 28-2-4 NMSA. (6) Conviction or entered into an agreed disposition, of a misdemeanor offense related to the practice of midwifery as determined on a case-by-case basis. (7) Failure to report in writing to the division any complaint or claim made against the CNM’s practice as a registered, certified, or licensed health care provider in any jurisdiction, including as a registered nurse. Such notification shall include the credentialing jurisdiction and the location, time, and content of the complaint or claim. It shall be made within 20 business days of the CNM becoming aware of the complaint or claim. (8) Conduct resulting in the suspension or revocation of a registration, license, or certification to perform as a health care provider. (9) Failure to report a CNM who appears to have violated the rule for the practice of certified nurse-midwifery. Anyone reporting an alleged violation of this rule shall be immune from liability under this rule unless the person acted in bad faith or with malicious purpose. (10) Failure to report to the department a change in contact information within 30 days of the change as set forth in Subsection G of 16.11.2.9 NMAC. (11) Non-compliance for requirements of CEs as determined by audit as set forth in Paragraph (2) of Subsection B of 16.11.2.10 NMAC. (12) Violation of any of the provisions of this rule. B. Non-disciplinary proceedings: For non-disciplinary actions involving denial of renewal of a license the applicant will be provided a notice of contemplated action and the right to the hearing procedures set forth in Paragraphs (4) and (5) of Subsection C of 16.11.2.12 NMAC. 16.11.2 NMAC 11 C. Disciplinary proceedings: Disciplinary proceedings shall be conducted in accordance with Sections 61-1-1 through 61-1-31 NMSA 1978 of the Uniform Licensing Act (ULA). Disciplinary proceedings related to a CNM’s treatment of a client, for chronic pain or other conditions, with a controlled substance shall be conducted in accordance with Sections 24-2D-1 through 24-2D-6 NMSA 1978 of the Pain Relief Act, in addition to this rule. (1) Filing of a complaint: (a) A written complaint must be filed with the division before a disciplinary proceeding may be initiated. (i) A complaint is an allegation of a wrongful act(s) or omission(s). (ii) An allegation of a wrongful act may include knowledge of a judgment or settlement against a licensee. (b) A written complaint may be filed by any person, including a member of the board. (2) Investigation of a complaint: (a) All complaints alleging a violation of the rules adopted by the department shall be investigated to determine whether a violation of applicable law or rule has occurred. (b) The investigation may result in a notice of contemplated action (NCA), as defined in the ULA, being issued by the department if a violation occurred or it may result in a dismissal of the complaint if no actionable violation can be substantiated. Once dismissal of a complaint is made following an investigation, the licensee will be notified of the dismissal. (3) Notice of contemplated action: (a) The NCA shall be drafted by the department. (b) The director of the division, or her/his designee shall sign all NCAs. (c) The NCAs shall contain written information in accordance with the requirements of the ULA and shall be served on the licensee in accordance with the ULA. (4) Request for a hearing, notice of hearing and request for continuance: (a) Every licensee shall be afforded notice and an opportunity to be heard. (b) Within 20 days of receiving the NCA, a licensee may request a hearing in writing by certified mail. The department shall notify the licensee of the time and place of hearing within 20 days of receipt of the request. The hearing shall be held no more than 60 nor less than 15 days from the date of service of the notice of hearing. However, if the ULA designates time requirements different from the above stated time requirements, the ULA time requirements shall prevail. The department shall notify the licensee of these prevailing time requirements when it sends the NCA. (c) The licensee may request to explore a settlement by negotiating a stipulation and agreement with the administrative attorney of the department at any time prior to the hearing; if a settlement is negotiated, the proposed stipulation and agreement shall be presented to the department for final approval; the proposed stipulation and agreement does not divest the department of its authority to require a formal hearing or final approval, amendment, or rejection; if a settlement is not reached, a hearing shall be held. (d) Once a hearing has been scheduled, if a request for a continuance is made it shall be presented to the department’s hearing officer, in writing, at least 10 days prior to the scheduled hearing. The hearing officer may approve or deny the request. (e) If a person fails to appear after requesting a hearing, the department may proceed to consider the matter and make a decision. (f) If no request for a hearing is made within the time and manner stated in the NCA, the department may take the action contemplated in the NCA. Such action shall be final and reportable to NPDB. (g) The department shall keep a record of the number of complaints received and the disposition of said complaints as either substantiated or unsubstantiated. (5) Administrative hearing: (a) All hearings shall be conducted by a hearing officer designated by the secretary or authorized representative of the department. The hearing officer shall have authority to rule on all non-dispositive motions. (b) All hearings before the department shall be conducted in the same manner as a hearing in a court of law with the exception that the rules of evidence may be relaxed in the hearing pursuant to the ULA. 16.11.2 NMAC 12 (i) Hearsay evidence is admissible if it is of a kind commonly relied upon by reasonable prudent people in the conduct of serious affairs. (ii) Disciplinary action against a CNM license must not be based solely on hearsay evidence. (c) The hearing officer may take testimony, examine witnesses and direct a continuance of any case. (d) The hearing officer shall have the power to issue subpoenas to compel the attendance of witnesses or the production of books, documents or records pertinent to the matter of a case before the department. (e) The hearing officer shall issue a report and recommended finding to the department secretary. (f) Decision of the department: the secretary of the department shall render a final administrative determination after reviewing the report and recommended findings issued by the hearing officer. Copies of the written decision shall be mailed via certified mail to the licensee in accordance with the ULA and placed in the CNM’s licensure file. The department shall mail a copy of the written decision to the authority(ies) that license(s) the CNM as a registered nurse and shall report the decision to the NPDB if the decision is to uphold the disciplinary action. D. Reinstatement of a suspended or revoked license: (1) Individuals who request reinstatement of their license or who request that their probation be lifted or altered shall provide the department with substantial evidence to support their request. This evidence must be in the form of notarized written reports or sworn written testimony from individuals who have personal knowledge of the individual’s activities and progress during the period of probation, suspension, or revocation. (2) For reinstatement of licenses for reasons other than noncompliance with Section 40-5A-1 to -13 NMSA 1978, Parental Responsibility Act, requests for reinstatement of a revoked license shall not be considered by the department prior to the expiration of one year from the date of the order of revocation. The date of the order of revocation is the controlling date, unless otherwise specified in the order. Reinstatement of a revoked license requires proof of meeting the renewal requirements set forth in this rule and payment of the reinstatement of revoked license fee of Paragraph (4) of Subsection F of 16.11.2.9 NMAC. (3) Requests for reinstatement of a suspended license shall be considered at such time as provided by the department in the order of suspension. Reinstatement of a suspended license requires proof of meeting the renewal requirements as set forth in this rule, any remedial education, supervised practice or other condition specified in the order for suspension required by the department and payment of the reinstatement of current or suspended license fee of Paragraph (4) of Subsection F of 16.11.2.9 NMAC. (4) When a license is revoked solely because the licensee is not in compliance with the Parental Responsibility Act, Section 40-5A-1 to 13 NMSA 1978, the license shall be reinstated upon presentation of a subsequent statement of compliance.