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Chapter 246-853 WAC

Last Update: 10/17/24

OSTEOPATHIC PHYSICIANS AND SURGEONS

WAC Sections

HTMLPDF246-853-020Osteopathic medicine and surgery examination.
HTMLPDF246-853-025Special purpose examination.
HTMLPDF246-853-030Acceptable intern or residency programs.
HTMLPDF246-853-045Inactive credential.
HTMLPDF246-853-050Ethical considerations.
HTMLPDF246-853-065Mandatory one-time training in suicide assessment, treatment, and management.
HTMLPDF246-853-070Categories of creditable continuing professional education activities.
HTMLPDF246-853-075Health equity continuing education training requirements.
HTMLPDF246-853-080Continuing education.
HTMLPDF246-853-085Approved colleges and schools of osteopathic medicine and surgery.
HTMLPDF246-853-090Prior approval not required.
HTMLPDF246-853-100Prohibited publicity and advertising.
HTMLPDF246-853-110Permitted publicity and advertising.
HTMLPDF246-853-120Malpractice suit reporting.
HTMLPDF246-853-135Temporary practice permit.
HTMLPDF246-853-136Temporary practice permit—Military spouse eligibility and issuance.
HTMLPDF246-853-140Mandatory reporting.
HTMLPDF246-853-210Expired license.
HTMLPDF246-853-220Use of drugs or autotransfusion to enhance athletic ability.
HTMLPDF246-853-235Retired active license.
HTMLPDF246-853-245Reentry to practice requirements.
HTMLPDF246-853-290Intent of substance use disorder monitoring.
HTMLPDF246-853-300Definitions used relative to monitoring of an applicable impairing health condition.
HTMLPDF246-853-310Approval of monitoring programs.
HTMLPDF246-853-320Participation in substance use disorder monitoring program.
HTMLPDF246-853-330Confidentiality.
HTMLPDF246-853-340Examination appeal procedures.
HTMLPDF246-853-350Examination conduct.
HTMLPDF246-853-500Adjudicative proceedings.
HTMLPDF246-853-600Sexual misconduct.
HTMLPDF246-853-610Abuse.
HTMLPDF246-853-630Use of laser, light, radiofrequency, and plasma devices as applied to the skin.
HTMLPDF246-853-640Nonsurgical medical cosmetic procedures.
HTMLPDF246-853-650Safe and effective analgesia and anesthesia administration in office-based settings.
HTMLPDF246-853-655Administration of deep sedation and general anesthesia by osteopathic physicians in dental offices.
OPIOID PRESCRIBING—GENERAL PROVISIONS
HTMLPDF246-853-660Intent and scope.
HTMLPDF246-853-661Exclusions.
HTMLPDF246-853-662Definitions.
HTMLPDF246-853-675Patient notification, secure storage, and disposal.
HTMLPDF246-853-680Use of alternative modalities for pain treatment.
HTMLPDF246-853-685Continuing education requirements for opioid prescribing.
OPIOID PRESCRIBING—ACUTE NONOPERATIVE PAIN AND ACUTE PERIOPERATIVE PAIN
HTMLPDF246-853-690Patient evaluation and patient record.
HTMLPDF246-853-695Treatment plan—Acute nonoperative pain.
HTMLPDF246-853-700Treatment plan—Acute perioperative pain.
OPIOID PRESCRIBING—SUBACUTE PAIN
HTMLPDF246-853-705Patient evaluation and patient record.
HTMLPDF246-853-710Treatment plan—Subacute pain.
OPIOID PRESCRIBING—CHRONIC PAIN MANAGEMENT
HTMLPDF246-853-715Patient evaluation and patient record.
HTMLPDF246-853-720Treatment plan.
HTMLPDF246-853-725Written agreement for treatment.
HTMLPDF246-853-730Periodic review.
HTMLPDF246-853-735Consultation—Recommendations and requirements.
HTMLPDF246-853-740Consultation—Exemptions for exigent and special circumstances.
HTMLPDF246-853-745Consultation—Exemptions for the osteopathic physician.
HTMLPDF246-853-750Pain management specialist.
HTMLPDF246-853-755Tapering requirements.
HTMLPDF246-853-760Patients with chronic pain, including those on high doses, establishing a relationship with a new practitioner.
OPIOID PRESCRIBING—SPECIAL POPULATIONS
HTMLPDF246-853-765Special populations—Patients twenty-five years of age or under, pregnant patient, and aging populations.
HTMLPDF246-853-770Episodic care of chronic opioid patients.
OPIOID PRESCRIBING—COPRESCRIBING
HTMLPDF246-853-775Coprescribing of opioids with certain medications.
HTMLPDF246-853-780Coprescribing of opioids for patients receiving medication assisted treatment.
HTMLPDF246-853-785Coprescribing of naloxone.
OPIOID PRESCRIBING—PRESCRIPTION MONITORING PROGRAM
HTMLPDF246-853-790Prescription monitoring program—Required registration, queries, and documentation.
HTMLPDF246-853-990Osteopathic fees and renewal cycle.
DISPOSITION OF SECTIONS FORMERLY CODIFIED IN THIS TITLE
246-853-040Renewal of licenses. [Statutory Authority: RCW 18.57.005. WSR 91-20-120 (Order 199B), § 246-853-040, filed 9/30/91, effective 10/31/91; WSR 90-24-055 (Order 100B), recodified as § 246-853-040, filed 12/3/90, effective 1/31/91. Statutory Authority: 1988 c 206 § 604. WSR 88-23-124 (Order PM 801), § 308-138-070, filed 11/23/88; Order PL 262, § 308-138-070, filed 1/13/77.] Repealed by WSR 98-05-060, filed 2/13/98, effective 3/16/98. Statutory Authority: RCW 43.70.280.
246-853-060Continuing professional education required. [Statutory Authority: RCW 43.70.280. WSR 98-05-060, § 246-853-060, filed 2/13/98, effective 3/16/98. Statutory Authority: RCW 18.57.005. WSR 90-24-055 (Order 100B), recodified as § 246-853-060, filed 12/3/90, effective 1/31/91. Statutory Authority: RCW 18.57.005, 18.57A.020 and 18.57A.070. WSR 84-05-011 (Order PL 457), § 308-138-200, filed 2/7/84. Statutory Authority: 1979 c 117 § 3(4). WSR 79-12-066 (Order 324), § 308-138-200, filed 11/29/79.] Repealed by WSR 24-21-095, filed 10/17/24, effective 11/17/24. Statutory Authority: RCW 18.57.005 and 43.70.041.
246-853-130General provisions for mandatory reporting rules. [Statutory Authority: RCW 18.57.005, 18.57A.020, and 18.130.250. WSR 15-16-085, § 246-853-130, filed 7/31/15, effective 8/31/15. Statutory Authority: RCW 18.57.005. WSR 91-20-120 (Order 199B), § 246-853-130, filed 9/30/91, effective 10/31/91; WSR 90-24-055 (Order 100B), recodified as § 246-853-130, filed 12/3/90, effective 1/31/91. Statutory Authority: RCW 18.57.005 and 18.130.070. WSR 87-11-062 (Order PM 651), § 308-138-321, filed 5/20/87.] Repealed by WSR 20-09-025, filed 4/6/20, effective 5/7/20. Statutory Authority: RCW 18.57.005, 18.130.050, and 18.340.020.
246-853-150Health care institutions. [Statutory Authority: RCW 18.57.005. WSR 90-24-055 (Order 100B), recodified as § 246-853-150, filed 12/3/90, effective 1/31/91. Statutory Authority: RCW 18.57.005 and 18.130.070. WSR 87-11-062 (Order PM 651), § 308-138-323, filed 5/20/87.] Repealed by WSR 20-09-025, filed 4/6/20, effective 5/7/20. Statutory Authority: RCW 18.57.005, 18.130.050, and 18.340.020.
246-853-160Medical associations or societies. [Statutory Authority: RCW 18.57.005. WSR 90-24-055 (Order 100B), recodified as § 246-853-160, filed 12/3/90, effective 1/31/91. Statutory Authority: RCW 18.57.005 and 18.130.070. WSR 87-11-062 (Order PM 651), § 308-138-324, filed 5/20/87.] Repealed by WSR 20-09-025, filed 4/6/20, effective 5/7/20. Statutory Authority: RCW 18.57.005, 18.130.050, and 18.340.020.
246-853-170Health care service contractors and disability insurance carriers. [Statutory Authority: RCW 18.57.005. WSR 90-24-055 (Order 100B), recodified as § 246-853-170, filed 12/3/90, effective 1/31/91. Statutory Authority: RCW 18.130.270 [ 18.130.070]. WSR 88-01-104 (Order PM 698), § 308-138-325, filed 12/22/87.] Repealed by WSR 20-09-025, filed 4/6/20, effective 5/7/20. Statutory Authority: RCW 18.57.005, 18.130.050, and 18.340.020.
246-853-180Courts. [Statutory Authority: RCW 18.57.005. WSR 91-20-120 (Order 199B), § 246-853-180, filed 9/30/91, effective 10/31/91; WSR 90-24-055 (Order 100B), recodified as § 246-853-180, filed 12/3/90, effective 1/31/91. Statutory Authority: RCW 18.57.005 and 18.130.070. WSR 87-11-062 (Order PM 651), § 308-138-326, filed 5/20/87.] Repealed by WSR 20-09-025, filed 4/6/20, effective 5/7/20. Statutory Authority: RCW 18.57.005, 18.130.050, and 18.340.020.
246-853-190State and federal agencies. [Statutory Authority: RCW 18.57.005. WSR 93-24-028, § 246-853-190, filed 11/22/93, effective 12/23/93; WSR 91-20-120 (Order 199B), § 246-853-190, filed 9/30/91, effective 10/31/91; WSR 90-24-055 (Order 100B), recodified as § 246-853-190, filed 12/3/90, effective 1/31/91. Statutory Authority: RCW 18.57.005 and 18.130.070. WSR 87-11-062 (Order PM 651), § 308-138-327, filed 5/20/87.] Repealed by WSR 20-09-025, filed 4/6/20, effective 5/7/20. Statutory Authority: RCW 18.57.005, 18.130.050, and 18.340.020.
246-853-200Professional review organizations. [Statutory Authority: RCW 18.57.005. WSR 90-24-055 (Order 100B), recodified as § 246-853-200, filed 12/3/90, effective 1/31/91. Statutory Authority: RCW 18.130.270 [ 18.130.070]. WSR 88-01-104 (Order PM 698), § 308-138-328, filed 12/22/87.] Repealed by WSR 20-09-025, filed 4/6/20, effective 5/7/20. Statutory Authority: RCW 18.57.005, 18.130.050, and 18.340.020.
246-853-221How do advanced registered nurse practitioners qualify for prescriptive authority for Schedule II - IV drugs? [Statutory Authority: RCW 18.57.005 and 18.57.280. WSR 01-16-008, § 246-853-221, filed 7/19/01, effective 8/19/01.] Repealed by WSR 06-05-050, filed 2/13/06, effective 3/16/06. Statutory Authority: RCW 18.57.005, 18.57.280.
246-853-222Criteria for joint practice arrangement. [Statutory Authority: RCW 18.57.005 and 18.57.280. WSR 01-16-008, § 246-853-222, filed 7/19/01, effective 8/19/01.] Repealed by WSR 06-05-050, filed 2/13/06, effective 3/16/06. Statutory Authority: RCW 18.57.005, 18.57.280.
246-853-223Endorsement of joint practice arrangements for ARNP licensure. [Statutory Authority: RCW 18.57.005 and 18.57.280. WSR 01-16-008, § 246-853-223, filed 7/19/01, effective 8/19/01.] Repealed by WSR 06-05-050, filed 2/13/06, effective 3/16/06. Statutory Authority: RCW 18.57.005, 18.57.280.
246-853-224Process for joint practice arrangement termination. [Statutory Authority: RCW 18.57.005 and 18.57.280. WSR 01-16-008, § 246-853-224, filed 7/19/01, effective 8/19/01.] Repealed by WSR 06-05-050, filed 2/13/06, effective 3/16/06. Statutory Authority: RCW 18.57.005, 18.57.280.
246-853-225Seventy-two-hour limit. [Statutory Authority: RCW 18.57.005 and 18.57.280. WSR 01-16-008, § 246-853-225, filed 7/19/01, effective 8/19/01.] Repealed by WSR 06-05-050, filed 2/13/06, effective 3/16/06. Statutory Authority: RCW 18.57.005, 18.57.280.
246-853-226Education for prescribing Schedule II - IV drugs. [Statutory Authority: RCW 18.57.005 and 18.57.280. WSR 01-16-008, § 246-853-226, filed 7/19/01, effective 8/19/01.] Repealed by WSR 06-05-050, filed 2/13/06, effective 3/16/06. Statutory Authority: RCW 18.57.005, 18.57.280.
246-853-227Jurisdiction. [Statutory Authority: RCW 18.57.005 and 18.57.280. WSR 01-16-008, § 246-853-227, filed 7/19/01, effective 8/19/01.] Repealed by WSR 06-05-050, filed 2/13/06, effective 3/16/06. Statutory Authority: RCW 18.57.005, 18.57.280.
246-853-230HIV/AIDS education and training. [Statutory Authority: RCW 18.57.005, 18.130.050, and 18.340.020. WSR 20-09-025, § 246-853-230, filed 4/6/20, effective 5/7/20. Statutory Authority: RCW 43.70.280. WSR 98-05-060, § 246-853-230, filed 2/13/98, effective 3/16/98. Statutory Authority: RCW 18.57.005. WSR 91-20-120 (Order 199B), § 246-853-230, filed 9/30/91, effective 10/31/91; WSR 90-24-055 (Order 100B), recodified as § 246-853-230, filed 12/3/90, effective 1/31/91. Statutory Authority: 1988 c 206 § 604. WSR 88-23-124 (Order PM 801), § 308-138-350, filed 11/23/88.] Repealed by WSR 21-02-017, filed 12/28/20, effective 1/28/21. Statutory Authority: RCW 18.57.005.
246-853-240Application for registration. [Statutory Authority: RCW 18.57.005. WSR 91-20-120 (Order 199B), § 246-853-240, filed 9/30/91, effective 10/31/91; WSR 90-24-055 (Order 100B), recodified as § 246-853-240, filed 12/3/90, effective 1/31/91. Statutory Authority: 1988 c 206 § 604. WSR 88-23-124 (Order PM 801), § 308-138-360, filed 11/23/88.] Repealed by WSR 98-05-060, filed 2/13/98, effective 3/16/98. Statutory Authority: RCW 43.70.280.
246-853-260USMLE examination application deadline. [Statutory Authority: RCW 18.57.005 and 18.130.050. WSR 94-15-068, § 246-853-260, filed 7/19/94, effective 8/19/94. Statutory Authority: RCW 18.57.005 and 18.130.175. WSR 91-10-043 (Order 159B), § 246-853-260, filed 4/25/91, effective 5/26/91.] Repealed by WSR 15-16-085, filed 7/31/15, effective 8/31/15. Statutory Authority: RCW 18.57.005, 18.57A.020, and 18.130.250.
246-853-270Renewal expiration date. [Statutory Authority: RCW 18.57.005 and 18.130.175. WSR 91-10-043 (Order 159B), § 246-853-270, filed 4/25/91, effective 5/26/91.] Repealed by WSR 98-05-060, filed 2/13/98, effective 3/16/98. Statutory Authority: RCW 43.70.280.
246-853-275Change of mailing address and notice of official documents. [Statutory Authority: RCW 18.57.005. WSR 93-24-028, § 246-853-275, filed 11/22/93, effective 12/23/93.] Repealed by WSR 98-05-060, filed 2/13/98, effective 3/16/98. Statutory Authority: RCW 43.70.280.
246-853-400Brief adjudicative proceedings—Denials based on failure to meet education, experience, or examination prerequisites for licensure. [Statutory Authority: RCW 18.57.005 and chapter 18.57 RCW. WSR 92-20-001 (Order 303B), § 246-853-400, filed 9/23/92, effective 10/24/92.] Repealed by WSR 20-09-025, filed 4/6/20, effective 5/7/20. Statutory Authority: RCW 18.57.005, 18.130.050, and 18.340.020.
246-853-510Use of controlled substances for pain control. [Statutory Authority: RCW 18.57.005, 18.130.050, and chapters 18.57, 18.18.57A [18.57A] RCW. WSR 07-11-058, § 246-853-510, filed 5/11/07, effective 6/11/07.] Repealed by WSR 11-10-062, filed 5/2/11, effective 7/1/11. Statutory Authority: RCW 18.57.285, 18.57A.090, 18.57.005, 18.57A.020.
246-853-520What specific guidance should an osteopathic physician follow? [Statutory Authority: RCW 18.57.005, 18.130.050, and chapters 18.57, 18.18.57A [18.57A] RCW. WSR 07-11-058, § 246-853-520, filed 5/11/07, effective 6/11/07.] Repealed by WSR 11-10-062, filed 5/2/11, effective 7/1/11. Statutory Authority: RCW 18.57.285, 18.57A.090, 18.57.005, 18.57A.020.
246-853-530What knowledge should an osteopathic physician who elects to treat chronic pain patients possess? [Statutory Authority: RCW 18.57.005, 18.130.050, and chapters 18.57, 18.18.57A [18.57A] RCW. WSR 07-11-058, § 246-853-530, filed 5/11/07, effective 6/11/07.] Repealed by WSR 11-10-062, filed 5/2/11, effective 7/1/11. Statutory Authority: RCW 18.57.285, 18.57A.090, 18.57.005, 18.57A.020.
246-853-540How will the board evaluate prescribing for pain? [Statutory Authority: RCW 18.57.005, 18.130.050, and chapters 18.57, 18.18.57A [18.57A] RCW. WSR 07-11-058, § 246-853-540, filed 5/11/07, effective 6/11/07.] Repealed by WSR 11-10-062, filed 5/2/11, effective 7/1/11. Statutory Authority: RCW 18.57.285, 18.57A.090, 18.57.005, 18.57A.020.
246-853-663Patient evaluation. [Statutory Authority: RCW 18.57.285, 18.57A.090, 18.57.005, 18.57A.020. WSR 11-10-062, § 246-853-663, filed 5/2/11, effective 7/1/11.] Repealed by WSR 18-20-087, filed 10/1/18, effective 11/1/18. Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297.
246-853-664Treatment plan. [Statutory Authority: RCW 18.57.285, 18.57A.090, 18.57.005, 18.57A.020. WSR 11-10-062, § 246-853-664, filed 5/2/11, effective 7/1/11.] Repealed by WSR 18-20-087, filed 10/1/18, effective 11/1/18. Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297.
246-853-665Informed consent. [Statutory Authority: RCW 18.57.285, 18.57A.090, 18.57.005, 18.57A.020. WSR 11-10-062, § 246-853-665, filed 5/2/11, effective 7/1/11.] Repealed by WSR 18-20-087, filed 10/1/18, effective 11/1/18. Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297.
246-853-666Written agreement for treatment. [Statutory Authority: RCW 18.57.285, 18.57A.090, 18.57.005, 18.57A.020. WSR 11-10-062, § 246-853-666, filed 5/2/11, effective 7/1/11.] Repealed by WSR 18-20-087, filed 10/1/18, effective 11/1/18. Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297.
246-853-667Periodic review. [Statutory Authority: RCW 18.57.285, 18.57A.090, 18.57.005, 18.57A.020. WSR 11-10-062, § 246-853-667, filed 5/2/11, effective 7/1/11.] Repealed by WSR 18-20-087, filed 10/1/18, effective 11/1/18. Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297.
246-853-668Long-acting opioids, including methadone. [Statutory Authority: RCW 18.57.285, 18.57A.090, 18.57.005, 18.57A.020. WSR 11-10-062, § 246-853-668, filed 5/2/11, effective 7/1/11.] Repealed by WSR 18-20-087, filed 10/1/18, effective 11/1/18. Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297.
246-853-669Episodic care. [Statutory Authority: RCW 18.57.285, 18.57A.090, 18.57.005, 18.57A.020. WSR 11-10-062, § 246-853-669, filed 5/2/11, effective 7/1/11.] Repealed by WSR 18-20-087, filed 10/1/18, effective 11/1/18. Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297.
246-853-670Consultation—Recommendations and requirements. [Statutory Authority: RCW 18.57.285, 18.57A.090, 18.57.005, 18.57A.020. WSR 11-10-062, § 246-853-670, filed 5/2/11, effective 7/1/11.] Repealed by WSR 18-20-087, filed 10/1/18, effective 11/1/18. Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297.
246-853-671Consultation—Exemptions for exigent and special circumstances. [Statutory Authority: RCW 18.57.285, 18.57A.090, 18.57.005, 18.57A.020. WSR 11-10-062, § 246-853-671, filed 5/2/11, effective 7/1/11.] Repealed by WSR 18-20-087, filed 10/1/18, effective 11/1/18. Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297.
246-853-672Consultation—Exemptions for the osteopathic physician. [Statutory Authority: RCW 18.57.285, 18.57A.090, 18.57.005, 18.57A.020. WSR 11-10-062, § 246-853-672, filed 5/2/11, effective 7/1/11.] Repealed by WSR 18-20-087, filed 10/1/18, effective 11/1/18. Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297.
246-853-673Pain management specialist. [Statutory Authority: RCW 18.57.285, 18.57A.090, 18.57.005, 18.57A.020. WSR 11-10-062, § 246-853-673, filed 5/2/11, effective 7/1/11.] Repealed by WSR 18-20-087, filed 10/1/18, effective 11/1/18. Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297.

PDF246-853-020

Osteopathic medicine and surgery examination.

(1) An applicant for licensure as an osteopathic physician must successfully pass:
(a) Parts I, II, and III of the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) or Parts I, II, and III of the exam administered by the National Board of Osteopathic Medical Examiners (NBOME); or
(b) The Washington Osteopathic Principles and Practices (OP&P) Examination with a minimum score of seventy-five percent in each section; the Comprehensive Osteopathic Variable-Purpose Examination (COMVEX) administered by NBOME with a minimum passing score as established by NBOME; or other state administered OP&P exam approved by the board.
(2) In addition to the exams identified in subsection (1)(b) of this section, the applicant must also pass at least one of the following:
(a) The Federation of State Licensing Board (FLEX) Examination taken prior to June 1985 passed with a FLEX weighted average of a minimum seventy-five percent; or
(b) The FLEX I and FLEX II Examination with a minimum score of seventy-five on each component; or
(c) The United States Medical Licensing Examination (USMLE) Steps I, II, and III after December 1993 with a minimum score as established by the Federation of State Medical Boards and the National Board of Medical Examiners.
[Statutory Authority: RCW 18.57.005, 18.57A.020, and 18.130.250. WSR 15-16-085, § 246-853-020, filed 7/31/15, effective 8/31/15. Statutory Authority: RCW 18.57.005. WSR 93-24-028, § 246-853-020, filed 11/22/93, effective 12/23/93. Statutory Authority: RCW 18.57.005 and 18.130.175. WSR 91-10-043 (Order 159B), § 246-853-020, filed 4/25/91, effective 5/26/91. Statutory Authority: RCW 18.57.005. WSR 90-24-055 (Order 100B), recodified as § 246-853-020, filed 12/3/90, effective 1/31/91. Statutory Authority: RCW 18.57.005(2), 18.57A.020 and 18.130.050(1). WSR 88-14-113 (Order 745), § 308-138-055, filed 7/6/88. Statutory Authority: RCW 18.57A.020, 18.57.005 and 18.130.050. WSR 88-09-030 (Order PM 723), § 308-138-055, filed 4/15/88. Statutory Authority: RCW 18.57.005. WSR 85-10-025 (Order PL 527), § 308-138-055, filed 4/24/85. Statutory Authority: 1979 c 117 § 3(3). WSR 79-12-068 (Order PL 321), § 308-138-055, filed 11/29/79.]


PDF246-853-025

Special purpose examination.

(1) The board of osteopathic medicine and surgery, upon review of an application for licensure pursuant to RCW 18.57.130 or reinstatement of an inactive license, may require an applicant to pass a special purpose examination, e.g., SPEX, and/or any other examination deemed appropriate. An applicant may be required to take an examination when the board has concerns with the applicant's ability to practice competently for reasons which may include but are not limited to the following:
(a) Resolved or pending malpractice suits;
(b) Pending action by another state licensing authority;
(c) Actions pertaining to privileges at any institution; or
(d) Not having practiced for an interval of time.
(2) As a result of a determination in a disciplinary proceeding a licensee may be required to pass the SPEX examination.
(3) The minimum passing score on the SPEX examination shall be seventy-five. The passing score for any other examination under this rule shall be determined by the board.
[Statutory Authority: RCW 18.57.005 and 18.130.050. WSR 94-15-068, § 246-853-025, filed 7/19/94, effective 8/19/94. Statutory Authority: RCW 18.57.005 and chapter 18.57 RCW. WSR 92-20-001 (Order 303B), § 246-853-025, filed 9/23/92, effective 10/24/92.]


PDF246-853-030

Acceptable intern or residency programs.

The board accepts the following training programs.
(1) Nationally approved one-year internship programs;
(2) The first year of a residency program approved by the American Osteopathic Association, the American Medical Association or by their recognized affiliate residency accrediting organizations.
[Statutory Authority: RCW 18.57.005. WSR 90-24-055 (Order 100B), recodified as § 246-853-030, filed 12/3/90, effective 1/31/91. Statutory Authority: 1979 c 117 § 3(3). WSR 79-12-068 (Order PL 321), § 308-138-065, filed 11/29/79.]


PDF246-853-045

Inactive credential.

An osteopathic physician may obtain an inactive credential. Refer to the requirements of chapter 246-12 WAC.
[Statutory Authority: RCW 18.57.005 and 43.70.041. WSR 24-21-095, s 246-853-045, filed 10/17/24, effective 11/17/24. Statutory Authority: RCW 43.70.280. WSR 98-05-060, § 246-853-045, filed 2/13/98, effective 3/16/98. Statutory Authority: RCW 18.57.005 and chapter 18.57 RCW. WSR 92-20-001 (Order 303B), § 246-853-045, filed 9/23/92, effective 10/24/92.]


PDF246-853-050

Ethical considerations.

The following acts and practices are unethical and unprofessional conduct warranting appropriate disciplinary action:
(1) The division or "splitting" of fees with other professionals or nonprofessionals as prohibited by chapter 19.68 RCW. Specifically, a person authorized by this board shall not:
(a) Employ another to so solicit or obtain, or remunerate another for soliciting or obtaining, patient referrals.
(b) Directly or indirectly aid or abet an unlicensed person to practice acupuncture or medicine or to receive compensation therefrom.
(2) Use of testimonials, whether paid for or not, to solicit or encourage use of the licensee's services by members of the public.
(3) Making or publishing, or causing to be made or published, any advertisement, offer, statement or other form of representation, oral or written, which directly or by implication is false, misleading or deceptive.
[Statutory Authority: RCW 18.57.005. WSR 90-24-055 (Order 100B), recodified as § 246-853-050, filed 12/3/90, effective 1/31/91. Statutory Authority: RCW 18.57A.020. WSR 79-02-011 (Order 297), § 308-138-180, filed 1/11/79.]


PDF246-853-065

Mandatory one-time training in suicide assessment, treatment, and management.

A licensed osteopathic physician, except for osteopathic physicians holding a post-graduate training limited license, must complete a board-approved one-time training that is at least six hours long in suicide assessment, treatment, and management. This training must be completed by the end of the first full continuing education reporting period after January 1, 2016, or the first full continuing education reporting period after initial licensure, whichever is later.
(1) Until July 1, 2017, a board-approved training must be an empirically supported training in suicide assessment, including screening and referral, suicide treatment, and suicide management, and meet any other requirement in RCW 43.70.442.
(2) Beginning July 1, 2017, training accepted by the board must be on the department's model list developed in accordance with rules adopted by the department that establish minimum standards for training programs. The establishment of the model list does not affect the validity of training completed prior to July 1, 2017.
(3) A board-approved training must be at least six hours in length and may be provided in one or more sessions.
(4) The hours spent completing the training in suicide assessment, treatment, and management under this section count toward meeting any applicable continuing education requirements.
[Statutory Authority: RCW 18.57.005, 18.130.050, and 43.70.442. WSR 17-12-100, § 246-853-065, filed 6/6/17, effective 7/7/17.]


PDF246-853-070

Categories of creditable continuing professional education activities.

For those licensed osteopathic physicians unable to satisfy the one hundred fifty hour continuing professional education requirement by meeting the certification options in WAC 246-853-080(2), the following are categories of creditable continuing medical education activities approved by the board. The credits must be earned in the thirty-six month period preceding application for renewal of licensure. One clock hour shall equal one credit hour.
(1) Category 1 - A minimum of sixty credit hours of the total one hundred fifty hour requirements are mandatory under this general category.
(a) Category 1-A - Formal educational programs sponsored by nationally recognized osteopathic or medical institutions, organizations and their affiliates.
Examples of recognized sponsors include, but are not limited to:
(i) Formal medical associations including, but not limited to, the American Osteopathic Association (AOA) or the American Medical Association (AMA);
(ii) Accredited osteopathic or medical schools and hospitals;
(iii) Osteopathic or medical societies and specialty practice organizations;
(iv) Continuing medical education institutes;
(v) Governmental health agencies and institutions;
(vi) Residencies, fellowships and preceptorships; or
(vii) Interactive online courses and materials that assign a specific number of credits or contact hours and are provided by nationally recognized osteopathic and medical institutions, organizations, and their affiliates.
(b) Category 1-B - Preparation in publishable form of an original scientific paper (defined as one which reflects a search of the literature, appends a bibliography, and contains original data gathered by the author) and initial presentation before a postdoctoral audience qualified to critique the author's statements. Maximum allowable credit for the initial presentation will be ten credit hours per scientific paper. A copy of the paper in publishable form shall be submitted to the board. Publication of the above paper or another paper in a professional journal approved by the board may receive credits as approved by the board up to a maximum of fifteen credit hours per scientific paper.
(c) Category 1-C - Serving as a teacher, lecturer, preceptor or moderator-participant in any formal educational program. Such teaching would include classes in colleges of osteopathic medicine and medical colleges and lecturing to hospital interns, residents and staff. Total credits allowed under Category 1-C are forty-five per three-year period, with one hour's credit for each hour of actual instruction.
(2)(a) Category 2-A - Home study - The board strongly believes that participation in formal professional education programs is essential in fulfilling a physician's total education needs. The board is also concerned that the content and educational quality of many unsolicited home study materials are not subject to impartial professional review and evaluation. It is the individual physician's responsibility to select home study materials that will be of actual benefit. For these reasons, the board has limited the number of credits which may be granted for home study, and has adopted strict guidelines in granting these credits.
(i) Reading - Credits may be granted for reading the Journal of the AOA or AMA, and other selected journals published by recognized osteopathic organizations. One-half credit per issue is granted for reading alone. An additional one-half credit per issue is granted if the quiz found in the AOA Journal is completed and returned to the division of continuing medical education. Credit for all other reading is limited to recognized scientific journals listed in Index Medicus. One-half credit per issue is granted for reading these recognized journals.
(ii) Listening - Credits may be granted for listening to programs distributed by the AOA audio-educational service. Other audio programs sponsored by nationally recognized organizations and companies are also eligible for credit. One-half credit per audio program may be granted. An additional one-half credit may be granted for each AOA audio-educational service program if the quiz card for the tape found in the AOA Journal is completed and returned.
(iii) Other home study courses - Subject-oriented and refresher home study courses and programs sponsored by recognized professional organizations are eligible for credit. The number of credit hours indicated by the sponsor will be accepted by the board.
(b) A maximum of ninety credit hours per three-year period may be granted for all home study activities under Category 2-A.
(c) Category 2-B - Preparation and personal presentation of a scientific exhibit at a county, regional, state or national professional meeting. Total credits allowed under Category 2-B are thirty per three-year period, with ten credits granted for each new and different scientific exhibit. Appropriate documentation must be submitted with the request for credit.
(d) Category 2-C - All other programs and modalities of continuing professional education. Included under this category are informal educational activities such as observation at medical centers; programs dealing with experimental and investigative areas of medical practice, and programs conducted by nonrecognized sponsors.
(e) Total credits allowed under Category 2-C are thirty hours per three-year period.
[Statutory Authority: RCW 18.57.005, 18.130.050, and 18.340.020. WSR 20-09-025, § 246-853-070, filed 4/6/20, effective 5/7/20. Statutory Authority: RCW 18.57.005. WSR 90-24-055 (Order 100B), recodified as § 246-853-070, filed 12/3/90, effective 1/31/91. Statutory Authority: 1979 c 117 § 3(4). WSR 79-12-066 (Order 324), § 308-138-210, filed 11/29/79.]


PDF246-853-075

Health equity continuing education training requirements.

(1) An osteopathic physician must complete two hours of health equity continuing education training every four years as described in WAC 246-12-800 through 246-12-830.
(2) The two hours of health equity continuing education an osteopathic physician completes count toward meeting applicable continuing education requirements.
[Statutory Authority: RCW 43.70.613, 18.57.005, and 18.130.050. WSR 23-23-078, § 246-853-075, filed 11/13/23, effective 12/14/23.]


PDF246-853-080

Continuing education.

(1) Licensed osteopathic physicians and surgeons must complete one hundred fifty hours of creditable continuing medical education (CME) every three years in accordance with chapter 246-12 WAC, Part 7.
(2) To satisfy the CME requirements in subsection (1) of this section, a licensed osteopathic physician and surgeon may:
(a) Certify or recertify with the American Board of Osteopathic Medical Specialties (ABOMS) or the American Board of Medical Specialties (ABMS) within the last six years;
(b) Hold a current American Osteopathic Association (AOA) certificate of excellence in CME; or
(c) Hold a current American Medical Association (AMA) physician's recognition award (PRA).
[Statutory Authority: RCW 18.57.005, 18.130.050, and 18.340.020. WSR 20-09-025, § 246-853-080, filed 4/6/20, effective 5/7/20. Statutory Authority: RCW 43.70.280. WSR 98-05-060, § 246-853-080, filed 2/13/98, effective 3/16/98. Statutory Authority: RCW 18.57.005. WSR 90-24-055 (Order 100B), recodified as § 246-853-080, filed 12/3/90, effective 1/31/91. Statutory Authority: 1979 c 117 § 3(4). WSR 79-12-066 (Order 324), § 308-138-220, filed 11/29/79.]


PDF246-853-085

Approved colleges and schools of osteopathic medicine and surgery.

For the purposes of meeting the qualifications under RCW 18.57.020, the board approves those colleges or schools of osteopathic medicine accredited by the American Osteopathic Association Commission on Osteopathic College Accreditation.
[Statutory Authority: RCW 18.57.005, 18.57.020 and chapter 18.57 RCW. WSR 07-08-070, § 246-853-085, filed 3/30/07, effective 4/30/07.]


PDF246-853-090

Prior approval not required.

(1) It will not be necessary for a physician to inquire into the prior approval of any continuing medical education. The board will accept any continuing professional education that reasonably falls within these regulations and relies upon each individual physician's integrity in complying with this requirement.
(2) Continuing professional education program sponsors need not apply for nor expect to receive prior board approval for continuing professional education programs. The continuing professional education category will depend solely upon the status of the organization or institution. The number of creditable hours may be determined by counting the contact hours of instruction and rounding to the nearest quarter hour. The board relies upon the integrity of program sponsors to present continuing professional education that constitutes a meritorious learning experience.
[Statutory Authority: RCW 18.57.005. WSR 90-24-055 (Order 100B), recodified as § 246-853-090, filed 12/3/90, effective 1/31/91. Statutory Authority: 1979 c 117 § 3(4). WSR 79-12-066 (Order 324), § 308-138-230, filed 11/29/79.]


PDF246-853-100

Prohibited publicity and advertising.

An osteopathic physician shall not use or allow to be used any form of public communications or advertising connected with his or her profession or in his or her professional capacity as an osteopathic physician which:
(1) Is false, fraudulent, deceptive or misleading;
(2) Uses testimonials that are false, fraudulent, deceptive, unethical, misleading, or are compensated for in any form;
(3) Guarantees any treatment or result;
(4) Makes claims of professional superiority;
(5) States or includes prices for professional services except as provided for in WAC 246-853-110;
(6) Fails to identify the physician as an osteopathic physician as described in RCW 18.57.140;
(7) Otherwise exceeds the limits of WAC 246-853-110.
[Statutory Authority: RCW 18.57.005, 18.130.050, and 18.340.020. WSR 20-09-025, § 246-853-100, filed 4/6/20, effective 5/7/20. Statutory Authority: RCW 18.57.005. WSR 91-20-120 (Order 199B), § 246-853-100, filed 9/30/91, effective 10/31/91; WSR 90-24-055 (Order 100B), recodified as § 246-853-100, filed 12/3/90, effective 1/31/91; WSR 85-22-016 (Order PL 562), § 308-138-300, filed 10/30/85. Statutory Authority: 1979 c 117 § 3(5). WSR 79-12-064 (Order PL 322), § 308-138-300, filed 11/29/79.]


PDF246-853-110

Permitted publicity and advertising.

To facilitate the process of informed selection of a physician by potential patients, a physician may publish or advertise the following information, provided that the information disclosed by the physician in such publication or advertisement complies with all other ethical standards promulgated by the board;
(1) Name, including name of professional service corporation or clinic, and names of professional associates, addresses and telephone numbers;
(2) Date and place of birth;
(3) Date and fact of admission to practice in Washington and other states;
(4) Accredited schools attended with dates of graduation, degrees and other scholastic distinction;
(5) Teaching positions;
(6) Membership in osteopathic or medical fraternities, societies and associations;
(7) Membership in scientific, technical and professional associations and societies;
(8) Whether credit cards or other credit arrangements are accepted;
(9) Office and telephone answering service hours;
(10) Fee for an initial examination and/or consultation;
(11) Availability upon request of a written schedule of fees or range of fees for specific services;
(12) The range of fees for specified routine professional services, provided that the statement discloses that the specific fee within the range which will be charged will vary depending upon the particular matter to be handled for each patient, and the patient is entitled without obligation to an estimate of the fee within the range likely to be charged;
(13) Fixed fees for specified routine professional services, the description of which would not be misunderstood by or be deceptive to a prospective patient, provided that the statement discloses that the quoted fee will be available only to patients whose matters fall into the services described, and that the client is entitled without obligation to a specific estimate of the fee likely to be charged.
[Statutory Authority: RCW 18.57.005. WSR 90-24-055 (Order 100B), recodified as § 246-853-110, filed 12/3/90, effective 1/31/91. Statutory Authority: 1979 c 117 § 3(5). WSR 79-12-064 (Order PL 322), § 308-138-310, filed 11/29/79.]


PDF246-853-120

Malpractice suit reporting.

Every osteopathic physician shall, within sixty days after settlement or judgment, notify the board of any and all malpractice settlements or judgments in excess of twenty thousand dollars as a result of a claim or action for damages alleged to have been caused by a physician's incompetency or negligence in the practice of osteopathic medicine. Every osteopathic physician shall also report the settlement or judgment of three or more claims or actions for damages during a year as the result of the alleged physician's incompetence or negligence in the practice of osteopathic medicine regardless of the dollar amount of the settlement or judgment.
[Statutory Authority: RCW 18.57.005. WSR 90-24-055 (Order 100B), recodified as § 246-853-120, filed 12/3/90, effective 1/31/91. Statutory Authority: RCW 18.57A.020, 18.57.005 and 18.130.050. WSR 88-09-030 (Order PM 723), § 308-138-320, filed 4/15/88. Statutory Authority: 1979 c 117 § 3(6). WSR 79-12-065 (Order 323), § 308-138-320, filed 11/29/79.]


PDF246-853-135

Temporary practice permit.

A temporary permit to practice osteopathic medicine and surgery may be issued to an individual licensed in another state that has substantially equivalent licensing standards to those in Washington.
(1) The temporary permit may be issued upon receipt of:
(a) Documentation from the reciprocal state that the licensing standards used for issuing the license are substantially equivalent to the current Washington licensing standards;
(b) A completed application form on which the applicant indicates he or she wishes to receive a temporary permit and application and temporary permit fees;
(c) Verification of all state licenses, whether active or inactive, indicating that the applicant is not subject to charges or disciplinary action for unprofessional conduct or impairment;
(d) Verification from the federation of state medical board's disciplinary action data bank that the applicant has not been disciplined by a state board or federal agency.
(2) A temporary practice permit grants the individual the full scope to practice osteopathic medicine and surgery.
(3) The temporary permit shall expire upon issuance of a license by the board or one hundred eighty days after issuance of the temporary permit, whichever occurs first. The applicant must not be subject to denial of a license or issuance of a conditional license under this chapter.
(4) A temporary permit shall be issued only once to each applicant. An applicant who does not complete the application process shall not receive a subsequent temporary permit.
[Statutory Authority: RCW 18.57.005 and 18.130.075. WSR 10-03-071, § 246-853-135, filed 1/15/10, effective 2/15/10. Statutory Authority: RCW 18.57.005 and chapter 18.57 RCW. WSR 92-20-001 (Order 303B), § 246-853-135, filed 9/23/92, effective 10/24/92.]


PDF246-853-136

Temporary practice permit—Military spouse eligibility and issuance.

A military spouse or state registered domestic partner of a military person may receive a temporary practice permit while completing any specific additional requirements that are not related to training or practice standards for osteopathic physicians and surgeons. The board adopts the procedural rules as adopted by the department of health in WAC 246-12-051.
[Statutory Authority: RCW 18.57.005, 18.130.050, and 18.340.020. WSR 20-09-025, § 246-853-136, filed 4/6/20, effective 5/7/20.]


PDF246-853-140

Mandatory reporting.

Osteopathic physician and surgeon licensees must comply with the uniform mandatory reporting rules found in WAC 246-16-200 through 246-16-270.
[Statutory Authority: RCW 18.57.005, 18.130.050, and 18.340.020. WSR 20-09-025, § 246-853-140, filed 4/6/20, effective 5/7/20. Statutory Authority: RCW 18.57.005. WSR 90-24-055 (Order 100B), recodified as § 246-853-140, filed 12/3/90, effective 1/31/91. Statutory Authority: RCW 18.57.005 and 18.130.070. WSR 87-11-062 (Order PM 651), § 308-138-322, filed 5/20/87.]


PDF246-853-210

Expired license.

(1) If the license has expired for three years or less, the osteopathic physician must meet the requirements of chapter 246-12 WAC.
(2) If the license has expired for over three years, and the osteopathic physician has been in active practice in another United States jurisdiction, the osteopathic physician must:
(a) Submit verification of active practice from any other United States jurisdiction;
(b) Meet the requirements of chapter 246-12 WAC.
(3) If the license has expired for over three years, and the osteopathic physician has not been in active practice in another United States jurisdiction, the osteopathic physician:
(a) May be required to be reexamined as provided in RCW 18.57.080;
(b) Must meet the requirements of chapter 246-12 WAC.
[Statutory Authority: RCW 18.57.005 and 43.70.041. WSR 24-21-095, s 246-853-210, filed 10/17/24, effective 11/17/24. Statutory Authority: RCW 43.70.280. WSR 98-05-060, § 246-853-210, filed 2/13/98, effective 3/16/98. Statutory Authority: RCW 18.57.005. WSR 91-20-120 (Order 199B), § 246-853-210, filed 9/30/91, effective 10/31/91; WSR 90-24-055 (Order 100B), recodified as § 246-853-210, filed 12/3/90, effective 1/31/91. Statutory Authority: RCW 18.57.005 and 18.130.070. WSR 87-11-062 (Order PM 651), § 308-138-330, filed 5/20/87. Statutory Authority: RCW 18.57.005 and 18.57A.020. WSR 82-17-005 (Order PL 402), § 308-138-330, filed 8/5/82.]


PDF246-853-220

Use of drugs or autotransfusion to enhance athletic ability.

(1) A physician shall not prescribe, administer or dispense anabolic steroids, growth hormones, testosterone or its analogs, human chorionic gonadotropin (HCG), other hormones, or any form of autotransfusion for the purpose of enhancing athletic ability and/or for nontherapeutic cosmetic appearance.
(2) A physician shall complete and maintain patient medical records which accurately reflect the prescription, administering or dispensing of any substance or drug described in this rule or any form of autotransfusion. Patient medical records shall indicate the diagnosis and purpose for which the substance, drug or autotransfusion is prescribed, administered or dispensed and any additional information upon which the diagnosis is based.
(3) A violation of any provision of this rule shall constitute grounds for disciplinary action under RCW 18.130.180(7). A violation of subsection (1) of this rule shall also constitute grounds for disciplinary action under RCW 18.130.180(6).
[Statutory Authority: RCW 18.57.005. WSR 90-24-055 (Order 100B), recodified as § 246-853-220, filed 12/3/90, effective 1/31/91. Statutory Authority: RCW 18.57.005(2), 18.57A.020 and 18.130.050(1). WSR 88-21-081 (Order PM 780), § 308-138-340, filed 10/19/88; WSR 88-14-113 (Order 745), § 308-138-340, filed 7/6/88.]


PDF246-853-235

Retired active license.

(1) To obtain a retired active license an osteopathic physician must comply with chapter 246-12 WAC, Part 5, excluding WAC 246-12-120 (2)(c) and (d).
(2) An osteopathic physician with a retired active license may not receive compensation for health care services.
(3) An osteopathic physician with a retired active license may practice under the following conditions:
(a) In emergent circumstances calling for immediate action; or
(b) Intermittent circumstances on a part-time or full-time nonpermanent basis.
(4) A retired active license expires each year on the license holder's birthday. Retired active credential renewal fees are accepted no sooner than ninety days prior to the expiration date.
(5) An osteopathic physician with a retired active license shall complete and report one hundred fifty hours of continuing medical education every three years.
[Statutory Authority: RCW 18.57.005, 18.57A.020, and 18.130.250. WSR 15-16-085, § 246-853-235, filed 7/31/15, effective 8/31/15.]


PDF246-853-245

Reentry to practice requirements.

(1) An osteopathic physician and surgeon who has not actively practiced medicine for a period of at least three years in any jurisdiction in the United States must fulfill one of the following:
(a) Successfully pass a board approved competency evaluation;
(b) Successfully pass a board approved exam;
(c) Successfully complete a board approved retraining program arranged by the osteopathic physician; or
(d) Successfully complete a board approved reentry to practice or monitoring program.
(2) For the purposes of this section, a person is considered to have actively practiced medicine if they can demonstrate that they hold an active, unrestricted license as an osteopathic physician and surgeon in the United States.
[Statutory Authority: RCW 18.57.005, 18.130.050, and 18.340.020. WSR 20-09-025, § 246-853-245, filed 4/6/20, effective 5/7/20. Statutory Authority: RCW 18.57.005, 18.57A.020, and 18.130.250. WSR 15-16-085, § 246-853-245, filed 7/31/15, effective 8/31/15.]


PDF246-853-290

Intent of substance use disorder monitoring.

It is the intent of the legislature that the board of osteopathic medicine and surgery seek ways to identify and support the rehabilitation of osteopathic physicians and surgeons where practice or competency may be impaired due to an applicable impairing health condition. The legislature intends that osteopathic physicians be treated so that they can return to or continue to practice osteopathic medicine and surgery in a way which safeguards the public. The legislature specifically intends that the board of osteopathic medicine and surgery establish an alternate program to the traditional administrative proceedings against osteopathic physicians and surgeons.
In lieu of disciplinary action under RCW 18.130.160 and if the board of osteopathic medicine and surgery determines that the unprofessional conduct may be the result of an applicable impairing health condition, the board may refer the registrant/licensee to a voluntary substance use disorder monitoring program approved by the board.
[Statutory Authority: RCW 18.57.005 and 2022 c 43. WSR 24-14-032, § 246-853-290, filed 6/25/24, effective 7/26/24. Statutory Authority: 2020 c 80. WSR 23-19-059, § 246-853-290, filed 9/15/23, effective 10/16/23. Statutory Authority: RCW 18.57.005 and 18.130.175. WSR 91-10-043 (Order 159B), § 246-853-290, filed 4/25/91, effective 5/26/91.]


PDF246-853-300

Definitions used relative to monitoring of an applicable impairing health condition.

The definitions in this section apply throughout WAC 246-853-290 through 243-853-320 and 243-853-990 unless the context clearly requires otherwise.
(1) "Aftercare" means that period of time after intensive treatment that provides the osteopathic physician and the osteopathic physician's family with group, or individualized counseling sessions, discussions with other families, ongoing contact and participation in self-help groups, and ongoing continued support of treatment program staff.
(2) "Contract" is a comprehensive, structured agreement between the recovering osteopathic physician and the monitoring program wherein the osteopathic physician consents to comply with the monitoring program and the required components for the osteopathic physician's recovery activity.
(3) "Drug" means a chemical substance alone or in combination, including alcohol.
(4) "Impairing health condition" means a mental or physical health condition that impairs or potentially impairs the osteopathic physician's ability to practice with reasonable skill and safety which may include a substance use disorder characterized by the inappropriate use of either alcohol or other drugs, or both to a degree that it interferes in the functional life of the licensee, as manifested by health, family, job (professional services), legal, financial, or emotional problems.
(5) "Monitoring program" means an approved voluntary substance use disorder monitoring program or physician health monitoring program that the board has determined meets the requirements of the law and rules established by the board, according to the Washington Administrative Code, which enters into a contract with osteopathic physicians who have an impairing health condition. The substance monitoring program oversees compliance of the osteopathic physician's recovery activities as required by the board. Monitoring programs may provide either evaluation or treatment, or both to participating osteopathic physicians.
(6) "Osteopathic physician support group" is a group of either osteopathic physicians or other health care professionals, or both meeting regularly to support the recovery of its members. The group provides a confidential setting with a trained and experienced facilitator in which participants may safely discuss drug diversion, licensure issues, return to work, and other professional issues related to recovery.
(7) "Random drug screens" are laboratory tests to detect the presence of drugs of use disorder in body fluids which are performed at irregular intervals not known in advance by the person to be tested. The collection of the body fluids must be observed by a treatment or health care professional or other board or monitoring program-approved observer.
(8) "Recovering" means that an osteopathic physician with an impairing health condition is in compliance with a treatment plan of rehabilitation in accordance with criteria established by the monitoring program.
(9) "Rehabilitation" means the process of restoring an osteopathic physician to a level of professional performance consistent with public health and safety.
(10) "Treatment facility" is a facility approved by the bureau of alcohol and substance abuse, department of social and health services as specified in RCW 18.130.175.
(11) "Twelve-step groups" are groups such as Alcoholics Anonymous, Narcotics Anonymous, and related organizations based on a philosophy of anonymity, belief in a power greater than oneself, peer group association, and self-help.
[Statutory Authority: RCW 18.57.005 and 2022 c 43. WSR 24-14-032, § 246-853-300, filed 6/25/24, effective 7/26/24. Statutory Authority: 2020 c 80. WSR 23-19-059, § 246-853-300, filed 9/15/23, effective 10/16/23. Statutory Authority: RCW 18.57.005 and 18.130.175. WSR 91-10-043 (Order 159B), § 246-853-300, filed 4/25/91, effective 5/26/91.]


PDF246-853-310

Approval of monitoring programs.

The board will approve the monitoring program to facilitate the recovery of osteopathic physicians. The board will enter into a contract with the monitoring program on an annual basis.
(1) A monitoring program may provide evaluations or treatment, or both to the participating osteopathic physicians.
(2) A monitoring program staff must have the qualifications and knowledge of both impairing health conditions and the practice of osteopathic medicine and surgery as defined in chapter 18.57 RCW to be able to evaluate:
(a) Drug screening laboratories;
(b) Laboratory results;
(c) Providers of treatment for impairing health conditions, both individual and facilities;
(d) Osteopathic physician support groups;
(e) Osteopathic physicians' work environment; and
(f) The ability of the osteopathic physicians to practice with reasonable skill and safety.
(3) A monitoring program will enter into a contract with the osteopathic physician and the board to oversee the osteopathic physician's compliance with the requirement of the program.
(4) The program staff of the monitoring program will evaluate and recommend to the board, on an individual basis, whether an osteopathic physician will be prohibited from engaging in the practice of osteopathic medicine and surgery for a period of time and restrictions, if any, on the osteopathic physician's access to controlled substances in the work place.
(5) A monitoring program shall maintain records on participants.
(6) A monitoring program will be responsible for providing feedback to the osteopathic physician as to whether treatment progress is acceptable.
(7) A monitoring program shall report to the board any osteopathic physician who fails to comply with the requirements of the monitoring program.
(8) A monitoring program shall provide the board with a statistical report on the program, including progress of participants, at least annually, or more frequently as requested by the board.
(9) The board shall provide the monitoring program guidelines on treatment, monitoring, or limitations on the practice of osteopathic medicine and surgery for those participating in the program.
(10) A monitoring program shall provide for the board a complete financial breakdown of cost for each individual osteopathic physician participant by usage at an interval determined by the board in the annual contract.
(11) A monitoring program shall provide for the board a complete annual audited financial statement.
(12) A monitoring program shall enter into a written contract with the board and submit monthly billing statements supported by documentation.
[Statutory Authority: RCW 18.57.005 and 2022 c 43. WSR 24-14-032, § 246-853-310, filed 6/25/24, effective 7/26/24. Statutory Authority: RCW 18.57.005 and 18.130.175. WSR 91-10-043 (Order 159B), § 246-853-310, filed 4/25/91, effective 5/26/91.]


PDF246-853-320

Participation in substance use disorder monitoring program.

(1) The osteopathic physician who has been investigated by the board may accept board referral into the monitoring program. This may occur as a result of disciplinary action.
(a) The osteopathic physician shall undergo a complete physical and psychosocial evaluation before entering the monitoring program. This evaluation is to be performed by a health care professional(s) with expertise in impairing health conditions. The person(s) performing the evaluation shall not be the provider of the recommended treatment.
(b) The osteopathic physician shall enter into a contract with the board and the monitoring program to comply with the requirements of the program which may include, but not be limited to:
(i) The osteopathic physician will undergo treatment of an impairing health condition by a treatment facility.
(ii) An agreement to abstain from the use of all mind-altering substances, including alcohol, except for medications prescribed by an authorized prescriber, as defined in RCW 69.41.030 and 69.50.101. The prescriber shall notify the monitoring program of all drugs prescribed within 14 days of the date care was provided.
(iii) Completion of any prescribed aftercare program of the treatment facility. This may include individual or group psychotherapy, or both.
(iv) Directing the treatment counselor(s) and authorized prescriber(s) to provide reports to the appropriate monitoring program at specified intervals. Reports shall include treatment prognosis, goals, drugs prescribed, etc.
(v) Submitting to random drug screening, with observed specimen collection, as specified by the monitoring program.
(vi) Attending osteopathic physician support groups facilitated by health care professionals or twelve-step group meetings, or both as specified by the contract.
(vii) Complying with specified employment conditions and restrictions as defined by the contract.
(viii) Signing a waiver allowing the monitoring program to release information to the board if the osteopathic physician does not comply with the requirements of the contract.
(c) The osteopathic physician is responsible for paying the costs of the physical and psychosocial evaluation, treatment of the impairing health condition, random urine screens, and other personal expenses incurred in compliance with the contract.
(d) The osteopathic physician may be subject to disciplinary action under RCW 18.130.160 and 18.130.180 if the osteopathic physician does not consent to be referred to the monitoring program, does not comply with specified practice restrictions, or does not successfully complete the program.
(2) An osteopathic physician who is not being investigated by the board or subject to current disciplinary action, or not currently being monitored by the board for an impairing health condition, may voluntarily participate in the monitoring program without being referred by the board. Such voluntary participants shall not be subject to disciplinary action under RCW 18.130.160 and 18.130.180 for their impairing health condition, and shall not have their participation made known to the board if they continue to satisfactorily meet the requirements of the monitoring program:
(a) The osteopathic physician shall undergo a complete physical and psychosocial evaluation before entering the monitoring program. This evaluation will be performed by a health care professional with expertise in impairing health conditions. The person(s) performing the evaluation shall not also be the provider of the recommended treatment.
(b) The osteopathic physician shall enter into a contract with the monitoring program to comply with the requirements of the program which shall include, but not be limited to:
(i) Treatment for an impairing health condition by a treatment facility.
(ii) Agreeing to abstain from the use of all mind-altering substances, including alcohol, except for medications prescribed by an authorized prescriber, as defined in RCW 69.41.030 and 69.50.101. Said prescriber shall notify the monitoring program of all drugs prescribed within 14 days of the date care was provided.
(iii) Completion of any prescribed aftercare program of the treatment facility. This may include individual or group psychotherapy, or both.
(iv) Directing the treatment counselor(s) and authorized prescriber(s) to provide reports to the monitoring program at specified intervals. Reports shall include treatment prognosis, goals, drugs prescribed, etc.
(v) Submitting to random drug screening, with observed specimen collection, as specified by the monitoring program.
(vi) Attending osteopathic physician support groups facilitated by a health care professional or twelve-step group meetings, or both as specified by the individual's contract.
(vii) Complying with specified employment conditions and restrictions as defined by the contract.
(viii) Signing a waiver allowing the monitoring program to release information to the board if the osteopathic physician does not comply with the requirements of the contract. The osteopathic physician may be subject to disciplinary action under RCW 18.130.160 and 18.130.180 for noncompliance with the contract or if they do not successfully complete the program.
(c) The osteopathic physician is responsible for paying the costs of the physical and psychosocial evaluation, treatment of impairing health condition, random urine screens, and other personal expenses incurred in compliance with the contract.
[Statutory Authority: RCW 18.57.005 and 2022 c 43. WSR 24-14-032, § 246-853-320, filed 6/25/24, effective 7/26/24. Statutory Authority: RCW 18.57.005 and 18.130.175. WSR 91-10-043 (Order 159B), § 246-853-320, filed 4/25/91, effective 5/26/91.]


PDF246-853-330

Confidentiality.

(1) The treatment and pretreatment records of license holders referred to or voluntarily participating in approved monitoring programs shall be confidential, shall be exempt from RCW 42.17.250 through 42.17.450 and shall not be subject to discovery by subpoena or admissible as evidence except for monitoring records reported to the disciplinary authority for cause as defined in WAC 246-853-320. Records held by the board under this section shall be exempt from RCW 42.17.250 through 42.17.450 and shall not be subject to discovery by subpoena except by the license holder.
(2) Notwithstanding subsection (1) of this section, board orders shall be subject to RCW 42.17.250 through 42.17.450.
[Statutory Authority: RCW 18.57.005 and 18.130.175. WSR 91-10-043 (Order 159B), § 246-853-330, filed 4/25/91, effective 5/26/91.]


PDF246-853-340

Examination appeal procedures.

(1) Any candidate who takes and does not pass the osteopathic practices and principles examination, may request review of the results of the examination by the Washington state board of osteopathic medicine and surgery.
(a) The board will not modify examination results unless the candidate presents clear and convincing evidence of error in the examination content or procedure, or bias, prejudice, or discrimination in the examination process.
(b) The board will not consider any challenges to examination scores unless the total of the potentially revised score would result in issuance of a license.
(2) The procedure for requesting an informal review of examination results is as follows:
(a) The request must be in writing and must be received by the department within thirty days of the date on the letter of notification of examination results sent to the candidate.
(b) The following procedures apply to an appeal of the results of the written examination.
(i) In addition to the written request required in (a) of this subsection, the candidate must appear personally in the department office in Olympia for an examination review session. The candidate must contact the department to make an appointment for the examination review session.
(ii) The candidate's incorrect answers will be available during the review session. The candidate will be given a form to complete in defense of the examination answers. The candidate must specifically identify the challenged questions on the examination and must state the specific reason(s) why the candidate believes the results should be modified.
(iii) The candidate may not bring in any resource material for use while completing the informal review form.
(iv) The candidate will not be allowed to remove any notes or materials from the office upon completing the review session.
(c) The board will schedule a closed session meeting to review the examinations, score sheets, and forms completed by the candidate. The candidate will be notified in writing of the board's decision.
(i) The candidate will be identified only by candidate number for the purpose of this review.
(ii) Letters of referral or requests for special consideration will not be read or considered by the board.
(d) Any candidate not satisfied with the results of the informal examination review may request a formal hearing before the board to challenge the examination results.
(3) The procedures for requesting a formal hearing are as follows:
(a) The candidate must complete the informal review process before requesting a formal hearing.
(b) The request for formal hearing must be received by the department within twenty days of the date on the notice of the results of the board's informal review.
(c) The written request must specifically identify the challenged portion(s) of the examination and must state the specific reason(s) why the candidate believes the examination results should be modified.
(d) Candidates will receive at last twenty days notice of the time and place of the formal hearing.
(e) The hearing will be restricted to the specific portion(s) of the examination the candidate had identified in the request for formal hearing.
(f) The formal hearing will be conducted pursuant to the Administrative Procedure Act, chapter 34.05 RCW.
[Statutory Authority: RCW 18.57.005 and 18.130.175. WSR 91-10-043 (Order 159B), § 246-853-340, filed 4/25/91, effective 5/26/91.]


PDF246-853-350

Examination conduct.

Any applicant who fails to follow written or oral instructions relative to the conduct of the examination, is observed talking or attempting to give or receive information, or use unauthorized materials during any portion of the examination will be terminated from the examination and not permitted to complete it.
[Statutory Authority: RCW 18.57.005 and 18.130.175. WSR 91-10-043 (Order 159B), § 246-853-350, filed 4/25/91, effective 5/26/91.]


PDF246-853-500

Adjudicative proceedings.

The board adopts the model procedural rules for adjudicative proceedings as adopted by the department of health and contained in chapter 246-11 WAC, including subsequent amendments.
[Statutory Authority: RCW 18.57.005 and 18.130.050. WSR 94-15-068, § 246-853-500, filed 7/19/94, effective 8/19/94.]


PDF246-853-600

Sexual misconduct.

(1) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise:
(a) "Patient" means a person who is receiving health care or treatment, or has received health care or treatment without a termination of the osteopathic physician-patient relationship. The determination of when a person is a patient is made on a case-by-case basis with consideration given to a number of factors, including the nature, extent and context of the professional relationship between the osteopathic physician and the person. The fact that a person is not actively receiving treatment or professional services is not the sole determining factor.
(b) "Osteopathic physician" means a person licensed to practice osteopathic medicine and surgery under chapter 18.57 RCW.
(c) "Key third party" means a person in a close personal relationship with the patient and includes, but is not limited to, spouses, partners, parents, siblings, children, guardians and proxies.
(2) An osteopathic physician shall not engage in sexual misconduct with a current patient or a key third party. An osteopathic physician engages in sexual misconduct when he or she engages in the following behaviors with a patient or key third party:
(a) Sexual intercourse or genital to genital contact;
(b) Oral to genital contact;
(c) Genital to anal contact or oral to anal contact;
(d) Kissing in a romantic or sexual manner;
(e) Touching breasts, genitals or any sexualized body part for any purpose other than appropriate examination or treatment;
(f) Examination or touching of genitals without using gloves;
(g) Not allowing a patient the privacy to dress or undress;
(h) Encouraging the patient to masturbate in the presence of the osteopathic physician or masturbation by the osteopathic physician while the patient is present;
(i) Offering to provide practice-related services, such as medication, in exchange for sexual favors;
(j) Soliciting a date;
(k) Engaging in a conversation regarding the sexual history, preferences or fantasies of the osteopathic physician.
(3) Sexual misconduct also includes sexual contact with any person involving force, intimidation, or lack of consent; or a conviction of a sex offense as defined in RCW 9.94A.030.
(4) An osteopathic physician shall not engage in any of the conduct described in subsection (2) of this section with a former patient or key third party if the osteopathic physician:
(a) Uses or exploits the trust, knowledge, influence, or emotions derived from the professional relationship; or
(b) Uses or exploits privileged information or access to privileged information to meet the osteopathic physician's personal or sexual needs.
(5) To determine whether a patient is a current patient or a former patient, the board will analyze each case individually, and will consider a number of factors including, but not limited to, the following:
(a) Documentation of formal termination;
(b) Transfer of the patient's care to another health care provider;
(c) The length of time that has passed;
(d) The length of time of the professional relationship;
(e) The extent to which the patient has confided personal or private information to the osteopathic physician;
(f) The nature of the patient's health problem;
(g) The degree of emotional dependence and vulnerability.
(6) This section does not prohibit conduct that is required for medically recognized diagnostic or treatment purposes if the conduct meets the standard of care appropriate to the diagnostic or treatment situation.
(7) It is not a defense that the patient, former patient, or key third party initiated or consented to the conduct, or that the conduct occurred outside the professional setting.
(8) A violation of any provision of this rule shall constitute grounds for disciplinary action.
[Statutory Authority: RCW 18.57.005, 18.130.050, 18.130.062, and Executive Order 06-03. WSR 17-01-164, § 246-853-600, filed 12/21/16, effective 1/21/17. Statutory Authority: RCW 18.57.005, 18.130.050 and chapters 18.57, 18.57A RCW. WSR 07-12-091, § 246-853-600, filed 6/6/07, effective 7/7/07.]


PDF246-853-610

Abuse.

(1) An osteopathic physician commits unprofessional conduct if the osteopathic physician abuses a patient or key third party. "Osteopathic physician," "patient" and "key third party" are defined in WAC 246-853-600. An osteopathic physician abuses a patient when he or she:
(a) Makes statements regarding the patient's body, appearance, sexual history, or sexual orientation that have no legitimate medical or therapeutic purpose;
(b) Removes a patient's clothing or gown without consent;
(c) Fails to treat an unconscious or deceased patient's body or property respectfully;
(d) Engages in any conduct, whether verbal or physical, which unreasonably demeans, humiliates, embarrasses, threatens, or harms a patient.
(2) A violation of any provision of this rule shall constitute grounds for disciplinary action.
[Statutory Authority: RCW 18.57.005, 18.130.050 and chapters 18.57, 18.57A RCW. WSR 07-12-091, § 246-853-610, filed 6/6/07, effective 7/7/07.]


PDF246-853-630

Use of laser, light, radiofrequency, and plasma devices as applied to the skin.

(1) For the purposes of this section, laser, light, radiofrequency, and plasma (LLRP) devices are medical devices that:
(a) Use a laser, noncoherent light, intense pulsed light, radiofrequency, or plasma to topically penetrate skin and alter human tissue, or use high frequency ultrasound or other technologies to deliver energy to or through the skin; and
(b) Are classified by the federal Food and Drug Administration as prescriptive devices.
(2) Because an LLRP device is used to treat disease, injuries, deformities, and other physical conditions in human beings, the use of an LLRP device is the practice of osteopathic medicine under RCW 18.57.001. The use of an LLRP device can result in complications such as visual impairment, blindness, inflammation, burns, scarring, hypopigmentation and hyperpigmentation.
(3) Use of medical devices using any form of energy to penetrate or alter human tissue for a purpose other than those in subsection (1) of this section constitutes surgery and is outside the scope of this section.
OSTEOPATHIC PHYSICIAN RESPONSIBILITIES
(4) An osteopathic physician must be appropriately trained in the physics, safety, and techniques of using LLRP devices prior to using such a device, and must remain competent for as long as the device is used.
(5) An osteopathic physician must use an LLRP device in accordance with standard medical practice.
(6) Prior to authorizing treatment with an LLRP device, an osteopathic physician must take a history, perform an appropriate physical examination, make an appropriate diagnosis, recommend appropriate treatment, obtain the patient's informed consent (including informing the patient that a nonphysician may operate the device), provide instructions for emergency and follow-up care, and prepare an appropriate medical record.
(7) Regardless of who performs LLRP device treatment, the osteopathic physician is ultimately responsible for the safety of the patient.
(8) Regardless of who performs LLRP device treatment, the osteopathic physician is responsible for assuring that each treatment is documented in the patient's medical record.
(9) The osteopathic physician must ensure that there is a quality assurance program for the facility at which LLRP device procedures are performed regarding the selection and treatment of patients. An appropriate quality assurance program shall include the following:
(a) A mechanism to identify complications and problematic effects of treatment and to determine their cause;
(b) A mechanism to review the adherence of supervised professionals to written protocols;
(c) A mechanism to monitor the quality of treatments;
(d) A mechanism by which the findings of the quality assurance program are reviewed and incorporated into future protocols required by subsection (10)(d) of this section and osteopathic physician supervising practices; and
(e) Ongoing training to maintain and improve the quality of treatment and performance of the treating professionals.
OSTEOPATHIC PHYSICIAN DELEGATION OF LLRP TREATMENT
(10) An osteopathic physician who meets the requirements in subsections (1) through (9) of this section may delegate an LLRP device procedure to a properly trained and licensed professional, whose licensure and scope of practice allows the use of a prescriptive LLRP medical device, provided all the following conditions are met:
(a) The treatment in no way involves surgery as that term is understood in the practice of osteopathic medicine;
(b) Such delegated use falls within the supervised professional's lawful scope of practice;
(c) The LLRP device is not used on the globe of the eye;
(d) An osteopathic physician has a written office protocol for the supervised professional to follow in using the LLRP device. A written office protocol must include at a minimum the following:
(i) The identity of the individual osteopathic physician authorized to use the LLRP device and responsible for the delegation of the procedure;
(ii) A statement of the activities, decision criteria, and plan the supervised professional must follow when performing procedures delegated pursuant to this rule;
(iii) Selection criteria to screen patients for the appropriateness of treatments;
(iv) Identification of devices and settings to be used for patients who meet selection criteria;
(v) Methods by which the specified device is to be operated and maintained;
(vi) A description of appropriate care and follow-up for common complications, serious injury, or emergencies; and
(vii) A statement of the activities, decision criteria, and plan the supervised professional shall follow when performing delegated procedures, including the method for documenting decisions made and a plan for communication or feedback to the authorizing osteopathic physician concerning specific decisions made.
(e) The supervised professional has appropriate training including, but not limited to:
(i) Application techniques of each LLRP device;
(ii) Cutaneous medicine;
(iii) Indications and contraindications for such procedures;
(iv) Preprocedural and postprocedural care;
(v) Potential complications; and
(vi) Infectious disease control involved with each treatment.
(f) The delegating osteopathic physician ensures that the supervised professional uses the LLRP device only in accordance with the written office protocol, and does not exercise independent medical judgment when using the device;
(g) The delegating osteopathic physician shall be on the immediate premises during the patient's initial treatment and be able to treat complications, provide consultation, or resolve problems, if indicated. The supervised professional may complete the initial treatment if the physician is called away to attend to an emergency;
(h) Existing patients with an established treatment plan may continue to receive care during temporary absences of the delegating osteopathic physician provided there is a local back-up physician, licensed under chapter 18.57 or 18.71 RCW, who satisfies the requirements of subsection (4) of this section. The local back-up physician must agree in writing to treat complications, provide consultation or resolve problems if medically indicated. In case of an emergency the delegating osteopathic physician or a back-up physician shall be reachable by phone and able to see the patient within 60 minutes.
[Statutory Authority: 2020 c 80. WSR 23-19-059, § 246-853-630, filed 9/15/23, effective 10/16/23. Statutory Authority: RCW 18.57.005, 18.130.050, and 18.340.020. WSR 20-09-025, § 246-853-630, filed 4/6/20, effective 5/7/20. Statutory Authority: RCW 18.57.005, 18.57A.020, and 18.130.250. WSR 15-16-085, § 246-853-630, filed 7/31/15, effective 8/31/15. Statutory Authority: RCW 18.57.005, 18.57A.020, 18.130.050. WSR 08-20-125, § 246-853-630, filed 10/1/08, effective 11/1/08.]


PDF246-853-640

Nonsurgical medical cosmetic procedures.

(1) The purpose of this rule is to set forth the duties and responsibilities of an osteopathic physician who delegates the injection of medications or substances for cosmetic purposes or the use of prescription devices for cosmetic purposes. These procedures can result in complications such as visual impairment, blindness, inflammation, burns, scarring, disfiguration, hypopigmentation and hyperpigmentation. The performance of these procedures is the practice of osteopathic medicine under RCW 18.57.001(4).
(2) This rule does not apply to:
(a) Surgery;
(b) The use of prescription lasers, noncoherent light, intense pulsed light, radiofrequency, or plasma as applied to the skin. This is covered in WAC 246-853-630;
(c) The practice of a profession by a licensed health care professional under methods or means within the scope of practice permitted by such license;
(d) The use of nonprescription devices; and
(e) Intravenous therapy.
(3) Definitions. These definitions apply throughout this section unless the context clearly requires otherwise.
(a) "Nonsurgical medical cosmetic procedure" means a procedure or treatment that involves the injection of a medication or substance for cosmetic purposes, or the use of a prescription device for cosmetic purposes.
(b) "Osteopathic physician" means an individual licensed under chapter 18.57 RCW.
(c) "Prescription device" means a device that the federal Food and Drug Administration has designated as a prescription device, and can be sold only to persons with prescriptive authority in the state in which they reside.
osteopathic physician responsibilities
(4) An osteopathic physician must be appropriately trained in a nonsurgical medical cosmetic procedure prior to performing the procedure or delegating the procedure. The osteopathic physician must keep a record of his or her training in the office and available for review upon request by a patient or a representative of the board.
(5) Prior to authorizing a nonsurgical medical cosmetic procedure, an osteopathic physician must:
(a) Take a history;
(b) Perform an appropriate physical examination;
(c) Make an appropriate diagnosis;
(d) Recommend appropriate treatment;
(e) Obtain the patient's informed consent;
(f) Provide instructions for emergency and follow-up care; and
(g) Prepare an appropriate medical record.
(6) Regardless of who performs the nonsurgical medical cosmetic procedure, the osteopathic physician is ultimately responsible for the safety of the patient.
(7) Regardless of who performs the nonsurgical medical cosmetic procedure, the osteopathic physician is responsible for ensuring that each treatment is documented in the patient's medical record.
(8) The osteopathic physician must ensure that there is a quality assurance program for the facility at which nonsurgical medical cosmetic procedures are performed regarding the selection and treatment of patients. An appropriate quality assurance program must include the following:
(a) A mechanism to identify complications and untoward effects of treatment and to determine their cause;
(b) A mechanism to review the adherence of supervised health care practitioners to written protocols;
(c) A mechanism to monitor the quality of treatments;
(d) A mechanism by which the findings of the quality assurance program are reviewed and incorporated into future protocols required by subsection (10) of this section and osteopathic physician supervising practices; and
(e) Ongoing training to maintain and improve the quality of treatment and performance of supervised health care practitioners.
(9) An osteopathic physician may not sell or give a prescription device or medication to an individual who does not possess prescriptive authority in the state in which the individual resides or practices.
(10) The osteopathic physician must ensure that all equipment used for procedures covered by this section is inspected, calibrated, and certified as safe according to the manufacturer's specifications.
physician delegation
(11) An osteopathic physician who meets the above requirements may delegate a nonsurgical medical cosmetic procedure to a properly trained physician assistant, registered nurse or licensed practical nurse, provided all the following conditions are met:
(a) The treatment in no way involves surgery as that term is understood in the practice of medicine;
(b) The osteopathic physician delegates procedures that are within the delegate's lawful scope of practice;
(c) The delegate has appropriate training in, at a minimum:
(i) Techniques for each procedure;
(ii) Cutaneous medicine;
(iii) Indications and contraindications for each procedure;
(iv) Preprocedural and postprocedural care;
(v) Recognition and acute management of potential complications that may result from the procedure; and
(vi) Infectious disease control involved with each treatment.
(d) The osteopathic physician has a written office protocol for the delegate to follow in performing the nonsurgical medical cosmetic procedure. A written office protocol must include, at a minimum, the following:
(i) The identity of the osteopathic physician responsible for the delegation of the procedure;
(ii) Selection criteria to screen patients for the appropriateness of treatment;
(iii) A description of appropriate care and follow-up for common complications, serious injury, or emergencies; and
(iv) A statement of the activities, decision criteria, and plan the delegate shall follow when performing delegated procedures, including the method for documenting decisions made and a plan for communication or feedback to the authorizing osteopathic physician concerning specific decisions made.
(e) The osteopathic physician ensures that the delegate performs each procedure in accordance with the written office protocol;
(f) Each patient signs a consent form prior to treatment that lists foreseeable side effects and complications, and the identity and license of the delegate or delegates who will perform the procedure; and
(g) Each delegate performing a procedure covered by this section must be readily identified by a name tag or similar means so that the patient understands the identity and license of the treating delegate.
(12) If an osteopathic physician delegates the performance of a procedure that uses a medication or substance, whether or not approved by the federal Food and Drug Administration for the particular purpose for which it is used, the osteopathic physician must be on-site during the procedure.
(13) If the physician is unavailable to supervise a delegate as required by this section, the osteopathic physician must make arrangements for an alternate physician to provide the necessary supervision. The alternate supervisor must be familiar with the protocols in use at the site, will be accountable for adequately supervising the treatment pursuant to the protocols, and must have comparable training as the primary supervising osteopathic physician.
(14) An osteopathic physician may not permit a delegate to further delegate the performance of a nonsurgical medical cosmetic procedure to another individual.
[Statutory Authority: 2020 c 80. WSR 23-19-059, § 246-853-640, filed 9/15/23, effective 10/16/23. Statutory Authority: RCW 18.57.005, 18.57A.020, and 18.130.050(4). WSR 11-08-024, § 246-853-640, filed 3/31/11, effective 5/1/11.]


PDF246-853-650

Safe and effective analgesia and anesthesia administration in office-based settings.

(1) Purpose. The purpose of this rule is to promote and establish consistent standards, continuing competency, and to promote patient safety. The board of osteopathic medicine and surgery establishes the following rule for physicians licensed under chapter 18.57 RCW who perform surgical procedures and use anesthesia, analgesia or sedation in office-based settings.
(2) Definitions. The definitions in this subsection apply throughout this section unless the context clearly requires otherwise:
(a) "Board" means the board of osteopathic medicine and surgery.
(b) "Deep sedation" or "analgesia" means a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
(c) "General anesthesia" means a state of unconsciousness intentionally produced by anesthetic agents, with absence of pain sensation over the entire body, in which the patient is without protective reflexes and is unable to maintain an airway, and cardiovascular function may be impaired. Sedation that unintentionally progresses to the point at which the patient is without protective reflexes and is unable to maintain an airway is not considered general anesthesia.
(d) "Local infiltration" means the process of infusing a local anesthetic agent into the skin and other tissues to allow painless wound irrigation, exploration and repair, and other procedures, including procedures such as retrobulbar or periorbital ocular blocks only when performed by a board eligible or board certified ophthalmologist. It does not include procedures in which local anesthesia is injected into areas of the body other than skin or muscle where significant cardiovascular or respiratory complications may result.
(e) "Major conduction anesthesia" means the administration of a drug or combination of drugs to interrupt nerve impulses without loss of consciousness, such as epidural, caudal, or spinal anesthesia, lumbar or brachial plexus blocks, and intravenous regional anesthesia. Major conduction anesthesia does not include isolated blockade of small peripheral nerves, such as digital nerves.
(f) "Minimal sedation" means a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected. Minimal sedation is limited to oral, intranasal, or intramuscular medications.
(g) "Moderate sedation" or "analgesia" means a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
(h) "Office-based surgery" means any surgery or invasive medical procedure requiring analgesia or sedation, including, but not limited to, local infiltration for tumescent liposuction, performed in a location other than a hospital or hospital-associated surgical center licensed under chapter 70.41 RCW, or an ambulatory surgical facility licensed under chapter 70.230 RCW.
(i) "Physician" means an osteopathic physician licensed under chapter 18.57 RCW.
(3) Exemptions. This rule does not apply to physicians when:
(a) Performing surgery and medical procedures that require only minimal sedation (anxiolysis), or infiltration of local anesthetic around peripheral nerves. Infiltration around peripheral nerves does not include infiltration of local anesthetic agents in an amount that exceeds the manufacturer's published recommendations.
(b) Performing surgery in a hospital or hospital-associated surgical center licensed under chapter 70.41 RCW, or an ambulatory surgical facility licensed under chapter 70.230 RCW.
(c) Performing surgery utilizing or administering general anesthesia. Facilities in which physicians administer general anesthesia or perform procedures in which general anesthesia is a planned event are regulated by rules related to a hospital or hospital-associated surgical center licensed under chapter 70.41 RCW, an ambulatory surgical facility licensed under chapter 70.230 RCW, or a dental office under WAC 246-853-655.
(d) Administering deep sedation or general anesthesia to a patient in a dental office under WAC 246-853-655.
(e) Performing oral and maxillofacial surgery, and the physician:
(i) Is licensed both as a physician under chapter 18.57 RCW and as a dentist under chapter 18.32 RCW;
(ii) Complies with dental quality assurance commission regulations;
(iii) Holds a valid:
(A) Moderate sedation permit; or
(B) Moderate sedation with parenteral agents permit; or
(C) General anesthesia and deep sedation permit; and
(iv) Practices within the scope of their specialty.
(4) Application of rule. This rule applies to physicians practicing independently or in a group setting who perform office-based surgery employing one or more of the following levels of sedation or anesthesia:
(a) Moderate sedation or analgesia; or
(b) Deep sedation or analgesia; or
(c) Major conduction anesthesia.
(5) Accreditation or certification.
(a) A physician who performs a procedure under this rule must ensure that the procedure is performed in a facility that is appropriately equipped and maintained to ensure patient safety through accreditation or certification and in good standing from an accrediting entity approved by the board.
(b) The board may approve an accrediting entity that demonstrates to the satisfaction of the board that it has all of the following:
(i) Standards pertaining to patient care, recordkeeping, equipment, personnel, facilities and other related matters that are in accordance with acceptable and prevailing standards of care as determined by the board;
(ii) Processes that assure a fair and timely review and decision on any applications for accreditation or renewals thereof;
(iii) Processes that assure a fair and timely review and resolution of any complaints received concerning accredited or certified facilities; and
(iv) Resources sufficient to allow the accrediting entity to fulfill its duties in a timely manner.
(c) A physician may perform procedures under this rule in a facility that is not accredited or certified, provided that the facility has submitted an application for accreditation by a board-approved accrediting entity, and that the facility is appropriately equipped and maintained to ensure patient safety such that the facility meets the accreditation standards. If the facility is not accredited or certified within one year of the physician's performance of the first procedure under this rule, the physician must cease performing procedures under this rule until the facility is accredited or certified.
(d) If a facility loses its accreditation or certification and is no longer accredited or certified by at least one board-approved entity, the physician shall immediately cease performing procedures under this rule in that facility.
(6) Competency. When an anesthesiologist or certified registered nurse anesthetist is not present, the physician performing office-based surgery and using a form of sedation defined in subsection (4) of this section must be competent and qualified both to perform the operative procedure and to oversee the administration of intravenous sedation and analgesia.
(7) Qualifications for administration of sedation and analgesia may include:
(a) Completion of a continuing medical education course in conscious sedation;
(b) Relevant training in a residency training program; or
(c) Having privileges for conscious sedation granted by a hospital medical staff.
(8) At least one licensed health care practitioner currently certified in advanced resuscitative techniques appropriate for the patient age group must be present or immediately available with age-size appropriate resuscitative equipment throughout the procedure and until the patient has met the criteria for discharge from the facility. Certification in advanced resuscitative techniques includes, but is not limited to, advanced cardiac life support (ACLS), pediatric advanced life support (PALS), or advanced pediatric life support (APLS).
(9) Sedation assessment and management. Sedation is a continuum. Depending on the patient's response to drugs, the drugs administered, and the dose and timing of drug administration, it is possible that a deeper level of sedation will be produced than initially intended.
(a) If an anesthesiologist or certified registered nurse anesthetist is not present, a physician intending to produce a given level of sedation should be able to "rescue" a patient who enters a deeper level of sedation than intended.
(b) If a patient enters into a deeper level of sedation than planned, the physician must return the patient to the lighter level of sedation as quickly as possible, while closely monitoring the patient to ensure the airway is patent, the patient is breathing, and that oxygenation, heart rate and blood pressure are within acceptable values. A physician who returns a patient to a lighter level of sedation in accordance with this subsection (9)(b) does not violate subsection (10) of this section.
(10) Separation of surgical and monitoring functions.
(a) The physician performing the surgical procedure must not administer the intravenous sedation, or monitor the patient.
(b) The licensed health care practitioner, designated by the physician to administer intravenous medications and monitor the patient who is under moderate sedation, may assist the operating physician with minor, interruptible tasks of short duration once the patient's level of sedation and vital signs have been stabilized, provided that adequate monitoring of the patient's condition is maintained. The licensed health care practitioner who administers intravenous medications and monitors a patient under deep sedation or analgesia must not perform or assist in the surgical procedure.
(11) Emergency care and transfer protocols. A physician performing office-based surgery must ensure that in the event of a complication or emergency:
(a) All office personnel are familiar with a written and documented plan to timely and safely transfer patients to an appropriate hospital.
(b) The plan must include arrangements for emergency medical services and appropriate escort of the patient to the hospital.
(12) Medical record. The physician performing office-based surgery must maintain a legible, complete, comprehensive, and accurate medical record for each patient.
(a) The medical record must include all of the following:
(i) Identity of the patient;
(ii) History and physical, diagnosis and plan;
(iii) Appropriate lab, X-ray or other diagnostic reports;
(iv) Appropriate preanesthesia evaluation;
(v) Narrative description of procedure;
(vi) Pathology reports, if relevant;
(vii) Documentation of which, if any, tissues and other specimens have been submitted for histopathologic diagnosis;
(viii) Provision for continuity of postoperative care; and
(ix) Documentation of the outcome and the follow-up plan.
(b) When moderate or deep sedation, or major conduction anesthesia is used, the patient medical record must include a separate anesthesia record that documents:
(i) The type of sedation or anesthesia used;
(ii) Name, dose, and time of administration of drugs;
(iii) Documentation at regular intervals of information obtained from the intraoperative and postoperative monitoring;
(iv) Fluids administered during the procedure;
(v) Patient weight;
(vi) Level of consciousness;
(vii) Estimated blood loss;
(viii) Duration of procedure; and
(ix) Any complication or unusual events related to the procedure or sedation/anesthesia.
[Statutory Authority: RCW 18.57.005 and 18.130.050. WSR 23-08-068, § 246-853-650, filed 4/4/23, effective 5/5/23; WSR 11-01-117, § 246-853-650, filed 12/17/10, effective 1/17/11.]


PDF246-853-655

Administration of deep sedation and general anesthesia by osteopathic physicians in dental offices.

(1) The purpose of this section is to govern the administration of deep sedation and general anesthesia by osteopathic physicians in dental offices. The board establishes these standards to promote effective perioperative communication and appropriately timed interventions, and mitigate adverse events and outcomes.
(2) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.
(a) "Administering osteopathic physician" means an individual licensed under chapter 18.57 RCW, who has successfully completed an accredited anesthesiology residency, who administers deep sedation or general anesthesia to a patient in a dental office.
(b) "Deep sedation" has the same meaning as in WAC 246-853-650.
(c) "Dental office" means any facility where dentistry is practiced, as defined in chapter 18.32 RCW, except a hospital licensed under chapter 70.41 RCW or ambulatory surgical facility licensed under chapter 70.230 RCW.
(d) "General anesthesia" has the same meaning as in WAC 246-853-650.
(e) "Perioperative" includes the three phases of surgery: Preoperative, intraoperative, and postoperative.
(3) An administering osteopathic physician is responsible for the perioperative anesthetic management and monitoring of a patient and shall ensure patient care, recordkeeping, equipment, personnel, facilities, and other related matters are in accordance with acceptable and prevailing standards of care including, but not limited to, the following:
(a) Preoperative requirements. An administering osteopathic physician shall ensure the patient has undergone a preoperative health evaluation and document review of the evaluation. The administering osteopathic physician shall also conduct and document a risk assessment to determine whether a patient is an appropriate candidate for deep sedation or general anesthesia and discussion of the risks of deep sedation or general anesthesia with the patient. For a pediatric patient, this assessment must include:
(i) Whether the patient has specific risk factors that may warrant additional consultation before administration of deep sedation or general anesthesia, and how each patient meets criteria for deep sedation or general anesthesia in an outpatient environment. This must include a specific inquiry into whether the patient has signs and symptoms of sleep-disordered breathing or obstructive sleep apnea;
(ii) A discussion with a parent or guardian of a pediatric patient of the particular risks of deep sedation or general anesthesia for a patient who: (A) Is younger than six years old; (B) has special needs; (C) has airway abnormalities; or (D) has a chronic condition. This discussion must include reasoning why the pediatric patient can safely receive deep sedation or general anesthesia in an outpatient environment and any alternatives.
(b) Medical record. The administering osteopathic physician must ensure the anesthesia record be complete, comprehensive, and accurate for each patient, including documentation at regular intervals of information from intraoperative and postoperative monitoring. The recordkeeping requirements under WAC 246-853-650 and 246-817-770 apply to an administering osteopathic physician, including the elements of a separate anesthesia record. The anesthesia record must also include temperature measurement and a heart rate and rhythm measured by electrocardiogram. For a pediatric patient, the administering osteopathic physician shall ensure vital signs are postoperatively recorded at least at five-minute intervals until the patient begins to awaken, then recording intervals may be increased to 10 to 15 minutes.
(c) Equipment. An administering osteopathic physician shall ensure the requirements for equipment and emergency medications under WAC 246-817-724 and 246-817-770 are met, regardless of any delineated responsibility for furnishing of the equipment or medications in a contract between the administering osteopathic physician and dental office. Additionally, for a pediatric patient, an administering osteopathic physician shall ensure there is a complete selection of equipment for clinical application to the pediatric patient. The administering osteopathic physician shall also ensure equipment is available in the recovery area to meet the requirements in this section for monitoring during the recovery period. The administering osteopathic physician shall ensure all equipment and medications are checked and maintained on a scheduled basis.
(d) Recovery and discharge requirements. An administering osteopathic physician shall ensure that:
(i) An osteopathic physician licensed under chapter 18.57 RCW, having successfully completed an accredited anesthesiology residency, allopathic physician licensed under chapter 18.71 RCW, or a certified registered nurse anesthetist licensed under chapter 18.79 RCW, capable of managing complications, providing cardiopulmonary resuscitation, and currently certified in advanced cardiac life support measures appropriate for the patient age group is immediately available for a patient recovering from anesthesia. For a pediatric patient, the osteopathic physician, allopathic physician, or certified registered nurse anesthetist shall also be trained and experienced in pediatric perioperative care;
(ii) At least one licensed health care practitioner experienced in postanesthetic recovery care and currently certified in advanced cardiac life support measures appropriate for the patient age group visually monitors the patient, at all times, until the patient has met the criteria for discharge from the facility. Consideration for prolonged observation must be given to a pediatric patient with an anatomic airway abnormality, such as significant obstructive sleep apnea. A practitioner may not monitor more than two patients simultaneously, and any such simultaneous monitoring must take place in a single recovery room. If a practitioner is qualified to administer deep sedation or general anesthesia, the practitioner may not simultaneously administer deep sedation or general anesthesia and perform recovery period monitoring functions. The practitioner shall provide: (A) Continuous respiratory monitoring via pulse oximetry and cardiovascular monitoring via electrocardiography during the recovery period; (B) monitoring, at regular intervals, during the recovery period of the patient for color of mucosa, skin, or blood, oxygen saturation, blood pressure, and level of consciousness; and (C) measurement of temperature at least once during the recovery period. If a patient's condition or other factor for the patient's health or safety preclude the frequency of monitoring during the recovery period required by this section, the practitioner shall document the reason why such a departure from these requirements is medically necessary;
(iii) Emergency equipment, supplies, medications, and services comply with the provisions of WAC 246-817-770 and are immediately available in all areas where anesthesia is used and for a patient recovering from anesthesia. Resuscitative equipment and medications must be age and size-appropriate, including for care of a pediatric patient, pediatric defibrillator paddles, and vasoactive resuscitative medications and a muscle relaxant such as dantrolene sodium, which must be immediately available in appropriate pediatric concentrations, as well as a written pediatric dose schedule for these medications. The administering osteopathic physician shall ensure that support personnel have knowledge of the emergency care inventory. All equipment and medications must be checked and maintained on a scheduled basis; and
(iv) Before discharge, the patient is awake, alert, and behaving appropriately for age and developmental status, normal patient vital signs, and if applicable, a capable parent or guardian present to assume care of the patient.
(e) Emergency care and transfer protocol. An administering osteopathic physician shall monitor for, and be prepared to treat, complications involving compromise of the airway and depressed respiration, particularly with a pediatric patient. The administering osteopathic physician shall ensure that in the event of a complication or emergency, his or her assistive personnel and all dental office clinical staff are well-versed in emergency recognition, rescue, and emergency protocols, and familiar with a written and documented plan to timely and safely transfer a patient to an appropriate hospital.
(4)(a) An administering osteopathic physician shall submit to the board a report of any patient death or serious perioperative complication, which is or may be the result of anesthesia administered by the osteopathic physician.
(b) The administering osteopathic physician shall notify the board or the department of health, by telephone, email, or fax within 72 hours of discovery and shall submit a complete written report to the board within 30 days of the incident. The written report must include the following:
(i) Name, age, and address of the patient;
(ii) Name of the dentist and other personnel present during the incident;
(iii) Address of the facility or office where the incident took place;
(iv) Description of the type of anesthetic being utilized at the time of the incident;
(v) Dosages, if any, of any other drugs administered to the patient;
(vi) A narrative description of the incident including approximate times and evolution of symptoms; and
(vii) Additional information which the board may require or request.
[Statutory Authority: RCW 18.57.005 and 18.130.050. WSR 22-17-111, § 246-853-655, filed 8/22/22, effective 9/22/22.]


OPIOID PRESCRIBING—GENERAL PROVISIONS

PDF246-853-660

Intent and scope.

WAC 246-853-660 through 246-853-790 govern the prescribing of opioids in the treatment of pain.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-660, filed 10/1/18, effective 11/1/18. Statutory Authority: RCW 18.57.285, 18.57A.090, 18.57.005, 18.57A.020. WSR 11-10-062, § 246-853-660, filed 5/2/11, effective 7/1/11.]


PDF246-853-661

Exclusions.

WAC 246-853-660 through 246-853-790 do not apply to:
(1) The treatment of patients with cancer-related pain;
(2) The provision of palliative, hospice, or other end-of-life care;
(3) The provision of procedural premedications;
(4) The treatment of patients who have been admitted to any of the following facilities for more than 24 hours:
(a) Acute care hospitals licensed under chapter 70.41 RCW;
(b) Psychiatric hospitals licensed under chapter 71.12 RCW;
(c) Nursing homes licensed under chapter 18.51 RCW and nursing facilities as defined in WAC 388-97-0001;
(d) Long-term acute care hospitals as defined in RCW 74.60.010; or
(e) Residential treatment facilities as defined in RCW 71.12.455; or
(5) The treatment of patients in residential habilitation centers as defined in WAC 388-825-089 when the patient has been transferred directly from a facility listed in subsection (4) of this section.
[Statutory Authority: RCW 18.57.005, 18.57.800, and 18.130.050. WSR 23-16-142, § 246-853-661, filed 8/2/23, effective 9/2/23. Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-661, filed 10/1/18, effective 11/1/18. Statutory Authority: RCW 18.57.285, 18.57A.090, 18.57.005, 18.57A.020. WSR 11-10-062, § 246-853-661, filed 5/2/11, effective 7/1/11.]


PDF246-853-662

Definitions.

The definitions in this section apply in WAC 246-853-660 through 246-853-790 unless the context clearly requires otherwise.
(1) "Aberrant behavior" means behavior that indicates misuse, diversion, or substance use disorder. This includes, but is not limited to, multiple early refills or obtaining prescriptions of the same or similar drugs from more than one osteopathic physician or other health care practitioner.
(2) "Acute pain" means the normal, predicted physiological response to a noxious chemical, thermal, or mechanical stimulus and typically is associated with invasive procedures, trauma, and disease. Acute pain is considered to be six weeks or less in duration.
(3) "Biological specimen test" or "biological specimen testing" means tests of urine, hair, or other biological samples for various drugs and metabolites.
(4) "Cancer-related pain" means pain resulting from cancer in a patient who is less than two years postcompletion of curative anticancer treatment with current evidence of disease.
(5) "Chronic pain" means a state in which pain persists beyond the usual course of an acute disease or healing of an injury, or that may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain over months or years. Chronic pain may include pain resulting from cancer or treatment of cancer in a patient who is two years postcompletion of curative anticancer treatment with no current evidence of disease.
(6) "High-dose" means 90 milligrams MED, or more, per day.
(7) "High-risk" is a category of patient at increased risk of morbidity or mortality, such as from comorbidities, polypharmacy, history of substance use disorder or abuse, aberrant behavior, high-dose opioid prescription, or the use of any central nervous system depressant.
(8) "Hospice" means a model of care that focuses on relieving symptoms and supporting patients with a life expectancy of six months or less.
(9) "Hospital" means any institution, place, building, or agency licensed by the department under chapter 70.41 or 71.12 RCW, or designated under chapter 72.23 RCW to provide accommodations, facilities, and services over a continuous period of 24 hours or more, for observation, diagnosis, or care of two or more individuals not related to the operator who are suffering from illness, injury, deformity, or abnormality, or from any other condition for which obstetrical, medical, or surgical services would be appropriate for care or diagnosis.
(10) "Low-risk" means a category of patient at low risk of opioid-induced morbidity or mortality, based on factors and combinations of factors such as medical and behavioral comorbidities, polypharmacy, and dose of opioids of less than a 50 milligram morphine equivalent dose.
(11) "Medication assisted treatment" or "MAT" means the use of pharmacologic therapy, often in combination with counseling and behavioral therapies, for the treatment of substance use disorders.
(12) "Moderate-risk" means a category of patient at a moderate risk of opioid-induced morbidity or mortality, based on factors and combinations of factors such as medical and behavioral comorbidities, polypharmacy, past history of substance use disorder or abuse, aberrant behavior, and dose of opioids between 50 and 90 milligram morphine equivalent doses.
(13) "Morphine equivalent dose" or "MED" means a conversion of various opioids to a morphine equivalent dose by the use of accepted conversion tables.
(14) "Multidisciplinary pain clinic" means a facility that provides comprehensive pain management and includes care provided by multiple available disciplines, practitioners, or treatment modalities.
(15) "Nonoperative pain" means acute pain which does not occur as a result of surgery.
(16) "Opioid analgesic" or "opioid" means a drug that is either an opiate derived from the opium poppy or opiate-like that is a semi-synthetic or synthetic drug. Examples include morphine, codeine, hydrocodone, oxycodone, fentanyl, meperidine, and methadone.
(17) "Palliative" means care that improves the quality of life of patients and their families facing serious, advanced, or life-threatening illness. With palliative care particular attention is given to the prevention, assessment, and treatment of pain and other symptoms, and to the provision of psychological, spiritual, and emotional support.
(18) "Pain" means an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
(19) "Perioperative pain" means acute pain that occurs as the result of surgery.
(20) "Prescription monitoring program" or "PMP" means the Washington state prescription monitoring program authorized under chapter 70.225 RCW.
(21) "Practitioner" means an advanced registered nurse practitioner licensed under chapter 18.79 RCW, a dentist licensed under chapter 18.32 RCW, a physician licensed under chapter 18.71 or 18.57 RCW, a physician assistant licensed under chapter 18.71A RCW, or a podiatric physician licensed under chapter 18.22 RCW.
(22) "Subacute pain" is considered to be a continuation of pain, of six to 12 weeks in duration.
(23) "Substance use disorder" means a primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. Substance use disorder is not the same as physical dependence or tolerance characterized by behaviors that include, but are not limited to, impaired control over drug use, craving, compulsive use, or continued use despite harm.
[Statutory Authority: 2020 c 80. WSR 23-19-059, § 246-853-662, filed 9/15/23, effective 10/16/23. Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-662, filed 10/1/18, effective 11/1/18. Statutory Authority: RCW 18.57.285, 18.57A.090, 18.57.005, 18.57A.020. WSR 11-10-062, § 246-853-662, filed 5/2/11, effective 7/1/11.]


PDF246-853-675

Patient notification, secure storage, and disposal.

(1) The osteopathic physician shall discuss with the patient educating them of risks associated with the use of opioids, including the risk of dependence and overdose, as appropriate to the medical condition, type of patient, and phase of treatment. The osteopathic physician shall document such notification in the patient record.
(2) Patient notification must occur, at a minimum, at the following points of treatment:
(a) The first issuance of a prescription for an opioid; and
(b) The transition between phases of treatment, as follows:
(i) Acute nonoperative pain or acute perioperative pain to subacute pain; and
(ii) Subacute pain to chronic pain.
(3) Patient written notification must include information regarding:
(a) Pain management alternatives to opioid medications as provided in RCW 69.50.317 (1)(b) and WAC 246-853-680;
(b) The safe and secure storage of opioid prescriptions;
(c) The proper disposal of unused opioid medications including, but not limited to, the availability of recognized drug take-back programs; and
(d) The patient's right to refuse an opioid prescription or order for any reason. If a patient indicates a desire to not receive an opioid, the osteopathic physician shall document the patient's request and avoid prescribing or ordering opioids, unless the request is revoked by the patient.
(4) The requirements in this section do not apply to the administration of an opioid including, but not limited to, the following situations:
(a) Emergent care;
(b) Where patient pain represents a significant health risk;
(c) Procedures involving the actual administration of an opioid or anesthesia;
(d) When the patient is unable to grant or revoke consent; or
(e) MAT for substance use disorders.
(5) If the patient is under eighteen years old or is not competent, the discussion required by subsection (1) of this section must include the patient's parent, guardian, or the person identified in RCW 7.70.065, unless otherwise provided by law.
(6) The requirements of this section may be satisfied with a document provided by the department of health.
(7) The requirements of this section may be satisfied by an osteopathic physician designating any individual who holds a credential issued by a disciplining authority under RCW 18.130.040 to provide the information.
[Statutory Authority: RCW 18.57.005, 18.57.810, 18.57A.810, and 69.50.317. WSR 20-03-148, § 246-853-675, filed 1/21/20, effective 2/21/20. Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-675, filed 10/1/18, effective 11/1/18.]


PDF246-853-680

Use of alternative modalities for pain treatment.

The osteopathic physician shall consider multimodal pharmacologic and nonpharmacologic therapy for pain rather than defaulting to the use of opioid therapy alone whenever reasonable, evidence-based, clinically appropriate alternatives exist. An osteopathic physician may combine opioids with other medications and treatments including, but not limited to, acetaminophen, acupuncture, chiropractic, cognitive behavior therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), osteopathic manipulative treatment, physical therapy, massage, or sleep hygiene.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-680, filed 10/1/18, effective 11/1/18.]


PDF246-853-685

Continuing education requirements for opioid prescribing.

(1) In order to prescribe an opioid in Washington state, an osteopathic physician licensed to prescribe opioids shall complete a one-time continuing education requirement regarding best practices in the prescribing of opioids and the current opioid prescribing rules in this chapter. The continuing education must be at least one hour in length.
(2) The osteopathic physician shall complete the one-time continuing education requirement described in subsection (1) of this section by the end of the osteopathic physician's first full continuing education reporting period after January 1, 2019, or during the first full continuing education reporting period after initial licensure, whichever is later.
(3) The continuing education required under this section counts toward meeting any applicable continuing education requirements.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-685, filed 10/1/18, effective 11/1/18.]


OPIOID PRESCRIBING—ACUTE NONOPERATIVE PAIN AND ACUTE PERIOPERATIVE PAIN

PDF246-853-690

Patient evaluation and patient record.

Prior to prescribing opioids for acute nonoperative pain or acute perioperative pain, the osteopathic physician shall:
(1) Conduct and document an appropriate history and physical examination, including screening for risk factors for overdose and severe postoperative pain;
(2) Evaluate the nature and intensity of the pain or anticipated pain following surgery; and
(3) Inquire about any other medications the patient is prescribed or is taking, including date, type, dosage and quantity prescribed.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-690, filed 10/1/18, effective 11/1/18.]


PDF246-853-695

Treatment plan—Acute nonoperative pain.

The osteopathic physician shall comply with the requirements in this section when prescribing opioid analgesics for acute nonoperative pain and shall document completion of these requirements in the patient record:
(1) The osteopathic physician shall consider prescribing nonopioid analgesics as the first line of pain control in patients in accordance with the provisions of WAC 246-853-680, unless not clinically appropriate.
(2) The osteopathic physician, or their designee, shall conduct queries of the PMP in accordance with the provisions of WAC 246-853-790 to identify any Schedule II-V medications or drugs of concern received by the patient and document their review and any concerns.
(3) If the osteopathic physician prescribes opioids for effective pain control, such prescription must not be in a greater quantity than needed for the expected duration of pain severe enough to require opioids.
(a) A three-day supply or less will often be sufficient.
(b) More than a seven-day supply will rarely be needed.
(c) The osteopathic physician shall not prescribe beyond a seven-day supply without clinical documentation in the patient record to justify the need for such a quantity.
(4) The osteopathic physician shall reevaluate the patient who does not follow the expected course of recovery. If significant and documented improvement in function or pain control has not occurred, the osteopathic physician shall reconsider the continued use of opioids or whether tapering or discontinuing opioids is clinically indicated.
(5) Follow-up visits for pain control must include objectives or metrics to be used to determine treatment success if opioids are to be continued. This includes, at a minimum:
(a) Change in pain level;
(b) Change in physical function;
(c) Change in psychosocial function;
(d) Additional planned diagnostic evaluations to investigate causes of continued acute nonoperative pain or other treatments.
(6) Long-acting or extended release opioids are not indicated for acute nonoperative pain. Should an osteopathic physician need to prescribe a long-acting opioid for acute pain, the osteopathic physician must document the reason in the patient record.
(7) An osteopathic physician shall not discontinue medication assisted treatment medications when treating acute pain, except as consistent with the provisions of WAC 246-853-780.
(8) If the osteopathic physician elects to treat a patient with opioids beyond the six-week time period of acute nonoperative pain, the osteopathic physician shall document in the patient record that the patient is transitioning from acute pain to subacute pain. Rules governing the treatment of subacute pain in WAC 246-853-705 and 246-853-710 shall apply.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-695, filed 10/1/18, effective 11/1/18.]


PDF246-853-700

Treatment plan—Acute perioperative pain.

The osteopathic physician shall comply with the requirements in this section when prescribing opioid analgesics for perioperative pain and shall document completion of these requirements in the patient record:
(1) The osteopathic physician shall consider prescribing nonopioid analgesics as the first line of pain control in patients in accordance with the provisions of WAC 246-853-680, unless not clinically appropriate.
(2) The osteopathic physician, or their designee, shall conduct queries of the PMP in accordance with the provisions of WAC 246-853-790 to identify any Schedule II–V medications or drugs of concern received by the patient and document in the patient record their review and any concerns.
(3) If the osteopathic physician prescribes opioids for effective pain control, such prescription shall be in no greater quantity than needed for the expected duration of pain severe enough to require opioids.
(a) A three-day supply or less will often be sufficient.
(b) More than a fourteen-day supply will rarely be needed for perioperative pain.
(c) The osteopathic physician shall not prescribe beyond a fourteen-day supply from the time of discharge without clinical documentation in the patient record to justify the need for such a quantity. For more specific best practices, the osteopathic physician may refer to clinical practice guidelines.
(4) The osteopathic physician shall reevaluate a patient who does not follow the expected course of recovery. If significant and documented improvement in function or pain control has not occurred, the osteopathic physician shall reconsider the continued use of opioids or whether tapering or discontinuing opioids is clinically indicated.
(5) Follow-up visits for pain control should include objectives or metrics to be used to determine treatment success if opioids are to be continued. This includes, at a minimum:
(a) Change in pain level;
(b) Change in physical function;
(c) Change in psychosocial function; and
(d) Additional planned diagnostic evaluations or other treatments.
(6) If the osteopathic physician elects to prescribe a combination of opioids with a medication listed in WAC 246-853-775 or to a patient known to be receiving a medication listed in WAC 246-853-775 from another practitioner, the osteopathic physician must prescribe in accordance with WAC 246-853-775.
(7) If the osteopathic physician elects to treat a patient with opioids beyond the six-week time period of acute perioperative pain, the osteopathic physician shall document in the patient record that the patient is transitioning from acute to subacute pain. Rules governing the treatment of subacute pain in WAC 246-853-705 and 246-853-710 shall apply unless there is documented improvement in function or pain control and there is a documented plan and timing for discontinuation of all opioid medications.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-700, filed 10/1/18, effective 11/1/18.]


OPIOID PRESCRIBING—SUBACUTE PAIN

PDF246-853-705

Patient evaluation and patient record.

The osteopathic physician shall comply with the requirements in this section when prescribing opioid analgesics for subacute pain and shall document completion of these requirements in the patient record.
(1) Prior to prescribing opioids for subacute pain, the osteopathic physician shall:
(a) Conduct an appropriate history and physical examination or review, and update the patient's existing history and examination taken during the acute nonoperative or acute perioperative phase;
(b) Evaluate the nature and intensity of the pain;
(c) Inquire about other medications the patient is prescribed or taking, including date, type, dosage, and quantity prescribed;
(d) Conduct, or cause their designee to conduct, a query of the PMP in accordance with the provisions of WAC 246-853-790 to identify any Schedule II–V medications or drugs of concern received by the patient and document the review for any concerns;
(e) Screen and document the patient's potential for high-risk behavior and adverse events related to opioid therapy. If the osteopathic physician determines the patient is high-risk, consider lower dose therapy, shorter intervals between prescriptions, more frequent visits, increased biological specimen testing, and prescribing rescue naloxone;
(f) Obtain a biological specimen test if the patient's function is deteriorating or if pain is escalating; and
(g) Screen or refer the patient for further consultation for psychosocial factors which may be impairing recovery including, but not limited to, depression or anxiety.
(2) The osteopathic physician treating a patient for subacute pain with opioids shall ensure that, at a minimum, the following are documented in the patient record:
(a) The presence of one or more recognized diagnoses or indications for the use of opioid pain medication;
(b) The observed significant and documented improvement in function or pain control forming the basis to continue prescribing opioid analgesics beyond the acute pain episode;
(c) The result of any queries of the PMP and any concerns the osteopathic physician may have;
(d) All medications the patient is known to be prescribed or taking;
(e) An appropriate pain treatment plan, including the consideration of, or attempts to use, nonpharmacological modalities and nonopioid therapy;
(f) Results of any aberrant biological specimen testing and the risk-benefit analysis if opioids are to be continued;
(g) Results of screening or referral for further consultation for psychosocial factors which may be impairing recovery including, but not limited to, depression or anxiety;
(h) Results of screening for the patient's level of risk for aberrant behavior and adverse events related to opioid therapy;
(i) The risk-benefit analysis of any combination of prescribed opioid and benzodiazepines or sedative-hypnotics, if applicable; and
(j) All other required components of the patient record, as established in statute or rule.
(3) Follow-up visits for pain control must include objectives or metrics to be used to determine treatment success if opioids are to be continued. This includes, at a minimum:
(a) Change in pain level;
(b) Change in physical function;
(c) Change in psychosocial function; and
(d) Additional planned diagnostic evaluations or other treatments.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-705, filed 10/1/18, effective 11/1/18.]


PDF246-853-710

Treatment plan—Subacute pain.

(1) The osteopathic physician shall recognize the progression of a patient from the acute nonoperative or acute perioperative phase to the subacute phase and take into consideration the risks and benefits of continued opioid prescribing for the patient.
(2) If tapering has not begun prior to the six- to twelve-week subacute phase, the osteopathic physician shall reevaluate the patient who does not follow the expected course of recovery. If significant and documented improvement in function or pain control has not occurred, the osteopathic physician shall reconsider the continued use of opioids or whether tapering or discontinuing opioids is clinically indicated. The osteopathic physician shall make reasonable attempts to discontinue the use of opioids prescribed for the acute pain event by no later than the twelve-week conclusion of the subacute phase.
(3) If the osteopathic physician prescribes opioids for effective pain control, such prescription must not be in a greater quantity than needed for the expected duration of pain severe enough to require opioids. The osteopathic physician shall not prescribe beyond a fourteen-day supply of opioids without clinical documentation to justify the need for such a quantity during the subacute phase.
(4) If the osteopathic physician elects to prescribe a combination of opioids with a medication listed in WAC 246-853-775 or prescribes opioids to a patient known to be receiving a medication listed in WAC 246-853-775 from another practitioner, the osteopathic physician shall prescribe in accordance with WAC 246-853-775.
(5) If the osteopathic physician elects to treat a patient with opioids beyond the six- to twelve-week subacute phase, the osteopathic physician shall document in the patient record that the patient is transitioning from subacute pain to chronic pain. Rules governing the treatment of chronic pain in WAC 246-853-715 through 246-853-760 shall apply.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-710, filed 10/1/18, effective 11/1/18.]


OPIOID PRESCRIBING—CHRONIC PAIN MANAGEMENT

PDF246-853-715

Patient evaluation and patient record.

(1) For the purposes of this section, "risk assessment tool" means professionally developed, clinically accepted questionnaires appropriate for identifying a patient's level of risk for substance abuse or misuse.
(2) The osteopathic physician shall evaluate and document the patient's health history and physical examination in the patient record prior to treating for chronic pain.
(a) History. The patient's health history must include:
(i) The nature and intensity of the pain;
(ii) The effect of pain on physical and psychosocial function;
(iii) Current and past treatments for pain, including medications and their efficacy;
(iv) Review of any significant comorbidities;
(v) Any current or historical substance use disorder;
(vi) Current medications and, as related to treatment of pain, the efficacy of medications tried; and
(vii) Medication allergies.
(b) Evaluation. The patient evaluation prior to opioid prescribing must include:
(i) Appropriate physical examination;
(ii) Consideration of the risks and benefits of chronic pain treatment for the patient;
(iii) Medications the patient is taking including indication(s), date, type, dosage, quantity prescribed, and, as related to treatment of the pain, efficacy of medications tried;
(iv) Review of the PMP to identify any Schedule II–V medications or drugs of concern received by the patient in accordance with the provisions of WAC 246-853-790;
(v) Any available diagnostic, therapeutic, and laboratory results;
(vi) Use of a risk assessment tool and assignment of the patient to a high-, moderate-, or low-risk category. The osteopathic physician should use caution and shall monitor a patient more frequently when prescribing opioid analgesics to a patient identified as high-risk.
(vii) Any available consultations, particularly as related to the patient's pain;
(viii) Pain related diagnosis, including documentation of the presence of one or more recognized indications for the use of pain medication;
(ix) Treatment plan and objectives including:
(A) Documentation of any medication prescribed;
(B) Biologic specimen testing ordered; and
(C) Any labs or imaging ordered;
(x) Written agreements, also known as a "pain contract," for treatment between the patient and the osteopathic physician; and
(xi) Patient counseling concerning risks, benefits, and alternatives to chronic opioid therapy.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-715, filed 10/1/18, effective 11/1/18.]


PDF246-853-720

Treatment plan.

(1) When the patient enters the chronic pain phase, the osteopathic physician shall reevaluate the patient by treating the situation as a new disease.
(2) The chronic pain treatment plan must state the objectives that will be used to determine treatment success and must include:
(a) Any change in pain relief;
(b) Any change in physical and psychosocial function; and
(c) Additional diagnostic evaluations or other planned treatments.
(3) After treatment begins, the osteopathic physician shall adjust drug therapy to the individual health needs of the patient.
(4) The osteopathic physician shall complete patient notification in accordance with the provisions of WAC 246-853-675.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-720, filed 10/1/18, effective 11/1/18.]


PDF246-853-725

Written agreement for treatment.

The osteopathic physician shall use a written agreement for treatment with the patient who requires long-term opioid therapy for chronic pain that outlines the patient's responsibilities. This written agreement for treatment must include:
(1) The patient's agreement to provide biological samples for biological specimen testing when requested by the osteopathic physician;
(2) The patient's agreement to take medications at the dose and frequency prescribed with a specific protocol for lost prescriptions and early refills or renewals;
(3) Reasons for which opioid therapy may be discontinued including, but not limited to, the patient's violation of an agreement;
(4) The requirement that all chronic opioid prescriptions are provided by a single prescriber, single clinic, or a multidisciplinary pain clinic;
(5) The requirement that all chronic opioid prescriptions are to be dispensed by a single pharmacy or pharmacy system whenever possible;
(6) The patient's agreement to not abuse substances that can put the patient at risk for adverse outcomes;
(7) A written authorization for:
(a) The osteopathic physician to release the agreement for treatment to:
(i) Local emergency departments;
(ii) Urgent care facilities;
(iii) Other practitioners caring for the patient who might prescribe pain medications; and
(iv) Pharmacies.
(b) The osteopathic physician to release the agreement to other practitioners so other practitioners can report violations of the agreement to the osteopathic physician treating the patient's chronic pain and to the PMP.
(8) Acknowledgment that it is the patient's responsibility to safeguard all medications and keep them in a secure location; and
(9) Acknowledgment that if the patient violates the terms of the agreement, the violation and the osteopathic physician's response to the violation will be documented, as well as the rationale for changes in the treatment plan.
For the purposes of this section, "refill" means a second or subsequent filling of a previously issued prescription that is authorized to be dispensed when the patient has exhausted their current supply. For the purposes of WAC 246-853-660 through 246-853-790, refills are subject to the same limitations and requirements as initial prescriptions.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-725, filed 10/1/18, effective 11/1/18.]


PDF246-853-730

Periodic review.

(1) The osteopathic physician shall periodically review the course of treatment for chronic pain. The osteopathic physician shall base the frequency of visits, biological testing, and PMP queries, in accordance with the provisions of WAC 246-853-790 on the patient's risk category:
(a) For a high-risk patient, at least quarterly;
(b) For a moderate-risk patient, at least semiannually;
(c) For a low-risk patient, at least annually;
(d) Immediately upon indication of concerning or aberrant behavior; and
(e) More frequently at the osteopathic physician's discretion.
(2) During the periodic review, the osteopathic physician shall determine:
(a) The patient's compliance with any medication treatment plan;
(b) If pain, function, or quality of life have improved, diminished, or are maintained using objective evidence; and
(c) If continuation or modification of medications for pain management treatment is necessary based on the osteopathic physician's evaluation of progress towards treatment objectives.
(3) Periodic patient evaluations must also include:
(a) History and physical exam related to the pain;
(b) Use of validated tools to document either maintenance of function and pain control or improvement in function and pain level; and
(c) Review of the PMP to identify any Schedule II–V medications or drugs of concern received by the patient at a frequency determined by the patient's risk category, and otherwise in accordance with the provisions of WAC 246-853-790 and subsection (1) of this section.
(4) The osteopathic physician shall assess the appropriateness of continued use of the current treatment plan if the patient's progress or compliance with the current treatment plan is unsatisfactory. The osteopathic physician shall consider tapering, changing, or discontinuing treatment in accordance with the provisions of WAC 246-853-755.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-730, filed 10/1/18, effective 11/1/18.]


PDF246-853-735

Consultation—Recommendations and requirements.

(1) The osteopathic physician shall consider referring the patient for additional evaluation and treatment as needed to achieve treatment objectives. Special attention should be given to those chronic pain patients who are under eighteen years of age or who are potential high-risk patients. The management of pain in patients with a history of substance abuse or with comorbid psychiatric disorders may require extra care, monitoring, documentation, and consultation with, or referral to, an expert in the management of such patients.
(2) The mandatory consultation threshold is one hundred twenty milligrams MED. Unless the consultation is exempted under WAC 246-853-740 or 246-853-745, an osteopathic physician who prescribes a dosage amount that meets or exceeds the mandatory consultation threshold must comply with the pain management specialist consultation requirements described in WAC 246-853-750. The mandatory consultation must consist of at least one of the following:
(a) An office visit with the patient and the pain management specialist;
(b) A consultation between the pain management specialist and the osteopathic physician;
(c) An audio-visual evaluation conducted by the pain management specialist remotely, where the patient is present with either the osteopathic physician or with a licensed health care practitioner designated by the osteopathic physician or the pain management specialist; or
(d) Other chronic pain evaluation services as approved by the board.
(3) The osteopathic physician shall document in the patient record each consultation with the pain management specialist. If the pain management specialist provides a written record of the consultation to the osteopathic physician, the osteopathic physician shall maintain it as part of the patient record.
(4) The osteopathic physician shall use great caution when prescribing opioids to children or adolescents with chronic pain; appropriate referral to a specialist is encouraged.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-735, filed 10/1/18, effective 11/1/18.]


PDF246-853-740

Consultation—Exemptions for exigent and special circumstances.

An osteopathic physician is not required to consult with a pain management specialist as defined in WAC 246-853-750 when the osteopathic physician has documented adherence to all standards of practice as defined in WAC 246-853-715 through 246-853-760, and when one or more of the following conditions are met:
(1) The patient is following a tapering schedule;
(2) The patient requires treatment for acute pain, which may or may not include hospitalization, requiring a temporary escalation in opioid dosage with expected return to their baseline dosage level or below;
(3) The osteopathic physician documents reasonable attempts to obtain a consultation with a pain management specialist and the circumstances justifying prescribing above one hundred twenty milligrams MED per day without first obtaining a consultation; or
(4) The osteopathic physician documents the patient's pain and function is stable and the patient is on a nonescalating dosage of opioids.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-740, filed 10/1/18, effective 11/1/18.]


PDF246-853-745

Consultation—Exemptions for the osteopathic physician.

An osteopathic physician is exempt from the consultation requirement in WAC 246-853-735 if one or more of the following qualifications are met:
(1) The osteopathic physician is a pain management specialist under WAC 246-853-750;
(2) The osteopathic physician has successfully completed every four years a minimum of twelve continuing education hours on chronic pain management approved by the profession's continuing education accrediting organizations. At least two of these hours must be in substance use disorders;
(3) The osteopathic physician is a pain management practitioner working in a multidisciplinary chronic pain treatment center or a multidisciplinary academic research facility; or
(4) The osteopathic physician has a minimum three years of clinical experience in a chronic pain management setting, and at least thirty percent of their current practice is the direct provision of pain management care.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-745, filed 10/1/18, effective 11/1/18.]


PDF246-853-750

Pain management specialist.

(1) A pain management specialist shall meet one or more of the following qualifications:
(a) An osteopathic physician shall be board certified or board eligible by an American Board of Medical Specialties-approved board (ABMS) or by the American Osteopathic Association (AOA) in physical medicine and rehabilitation, rehabilitation medicine, neurology, rheumatology, or anesthesiology;
(b) Have a subspecialty certificate in pain medicine by an ABMS-approved board;
(c) Have a certification of added qualification in pain management by the AOA;
(d) Be credentialed in pain management by an entity approved by the board; or
(e) Have a minimum of three years of clinical experience in a chronic pain management care setting including:
(i) Successful completion of a minimum of at least 18 continuing education hours in pain management during the past three years for an osteopathic physician; and
(ii) At least 30 percent of the osteopathic physician's current practice is the direct provision of pain management care or in a multidisciplinary pain clinic.
(2) An allopathic physician shall meet requirements in WAC 246-919-945.
(3) A physician assistant shall meet requirements in WAC 246-918-895.
(4) A dentist shall meet requirements in WAC 246-817-965.
(5) An advanced registered nurse practitioner (ARNP) shall meet requirements in WAC 246-840-493.
(6) A podiatric physician shall meet requirements in WAC 246-922-750.
[Statutory Authority: 2020 c 80. WSR 23-19-059, § 246-853-750, filed 9/15/23, effective 10/16/23. Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-750, filed 10/1/18, effective 11/1/18.]


PDF246-853-755

Tapering requirements.

(1) The osteopathic physician shall assess and document the appropriateness of continued use of the current treatment plan if the patient's response to or compliance with the current treatment is unsatisfactory.
(2) The osteopathic physician shall consider tapering, changing, discontinuing treatment, or referral for a substance use disorder evaluation when:
(a) The patient requests;
(b) The patient experiences a deterioration in function or pain;
(c) The patient is noncompliant with the written agreement;
(d) Other treatment modalities are indicated;
(e) There is evidence of misuse, abuse, substance use disorder, or diversion;
(f) The patient experiences a severe adverse event or overdose;
(g) There is unauthorized escalation or doses; or
(h) The patient is receiving an escalation in opioid dosage with no improvement in pain, function, or quality of life.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-755, filed 10/1/18, effective 11/1/18.]


PDF246-853-760

Patients with chronic pain, including those on high doses, establishing a relationship with a new practitioner.

(1) When a patient receiving chronic opioid pain medications changes to a new practitioner, it is normally appropriate for the new practitioner to initially maintain the patient's current opioid doses. Over time, the practitioner may evaluate if any tapering or other adjustments in the treatment plan can or should be done.
(2) An osteopathic physician's treatment of a new high-dose chronic pain patient is exempt from the mandatory consultation requirements of WAC 246-853-735 and the tapering requirements of WAC 246-853-755 if:
(a) The patient was previously being treated with a dosage of opioids in excess of one hundred twenty milligrams MED for chronic pain under an established written agreement for treatment of the same chronic condition or conditions;
(b) The patient's dose is stable and nonescalating;
(c) The patient has a demonstrated history in their record of compliance with treatment plans and written agreements as documented by medical records and PMP queries; and
(d) The patient has documented functional stability, pain control, or improvements in function or pain control, at the dose in excess of one hundred twenty milligrams MED.
(3) With respect to the treatment of a new patient under subsection (1) or (2) of this section, this exemption applies for the first three months of newly established care, after which the requirements of WAC 246-853-735 and 246-853-755 shall apply.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-760, filed 10/1/18, effective 11/1/18.]


OPIOID PRESCRIBING—SPECIAL POPULATIONS

PDF246-853-765

Special populations—Patients twenty-five years of age or under, pregnant patient, and aging populations.

(1) Patients twenty-five years of age or under. In the treatment of pain for patients twenty-five years of age or under, the osteopathic physician shall treat pain in a manner equal to that of an adult but must account for the weight of the patient and reduce the dosage prescribed accordingly.
(2) Pregnant patients. The osteopathic physician shall not discontinue the use of MAT opioids, such as methadone or buprenorphine, by a pregnant patient without oversight by the MAT prescribing practitioner. The osteopathic physician shall weigh carefully the risks and benefits of opioid detoxification during pregnancy.
(3) Aging populations. As people age, their tolerance and metabolizing of opioids may change. The osteopathic physician shall consider the distinctive needs of patients who are sixty-five years of age or older and who have been on chronic opioid therapy or who are initiating opioid treatment.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-765, filed 10/1/18, effective 11/1/18.]


PDF246-853-770

Episodic care of chronic opioid patients.

(1) When providing episodic care for a patient who the osteopathic physician knows is being treated with opioids for chronic pain, such as for emergency or urgent care, the osteopathic physician shall review the PMP to identify any Schedule II–V or drugs of concern received by the patient and document in the patient record their review and any concerns.
(2) An osteopathic physician providing episodic care to a patient who the osteopathic physician knows is being treated with opioids for chronic pain should provide additional opioids to be equal to the severity of the acute pain. If opioids are provided, the osteopathic physician shall limit the use of opioids to the minimum amount necessary to control the acute nonoperative pain, acute perioperative pain, or similar acute exacerbation of pain until the patient can receive care from the practitioner who is managing the patient's chronic pain treatment.
(3) The osteopathic physician providing episodic care shall report known violations of the patient's written agreement to the patient's treatment practitioner who provided the agreement for treatment, when reasonable.
(4) The osteopathic physician providing episodic care shall coordinate care with the patient's chronic pain treatment practitioner if that person is known to the osteopathic physician providing episodic care, when reasonable.
(5) For the purposes of this section, "episodic care" means medical care provided by a practitioner other than the designated primary practitioner in the acute care setting; for example, urgent care or emergency department.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-770, filed 10/1/18, effective 11/1/18.]


OPIOID PRESCRIBING—COPRESCRIBING

PDF246-853-775

Coprescribing of opioids with certain medications.

(1) The osteopathic physician must not knowingly prescribe opioids in combination with the following Schedule II–IV medications without documentation in the patient record of clinical judgment:
(a) Benzodiazepines;
(b) Barbiturates;
(c) Sedatives;
(d) Carisoprodol; or
(e) Sleeping medications, also known as Z drugs.
(2) If a patient receiving an opioid prescription is known to be concurrently prescribed one or more of the medications listed in subsection (1) of this section, the osteopathic physician prescribing opioids shall consult with the other prescriber(s) to establish a patient care plan for the use of the medications concurrently or consider whether one of the medications should be tapered.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-775, filed 10/1/18, effective 11/1/18.]


PDF246-853-780

Coprescribing of opioids for patients receiving medication assisted treatment.

(1) Where practicable, the osteopathic physician providing acute nonoperative pain or acute perioperative pain treatment to a patient known to be receiving MAT shall prescribe opioids for pain relief either in consultation with the MAT prescribing practitioner or pain specialist.
(2) The osteopathic physician shall not discontinue MAT medications when treating acute nonoperative pain or acute perioperative pain without documentation of the reason for doing so, nor shall use of these medications be used to deny necessary intervention.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-780, filed 10/1/18, effective 11/1/18.]


PDF246-853-785

Coprescribing of naloxone.

(1) The osteopathic physician shall confirm or provide a current prescription for naloxone when high dose opioids are prescribed.
(2) The osteopathic physician should counsel and provide an option for a current prescription for naloxone to patients being prescribed opioids as clinically indicated.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-785, filed 10/1/18, effective 11/1/18.]


OPIOID PRESCRIBING—PRESCRIPTION MONITORING PROGRAM

PDF246-853-790

Prescription monitoring program—Required registration, queries, and documentation.

(1) The osteopathic physician shall register to access the PMP or demonstrate proof of having registered to access the PMP if they prescribe opioids in Washington state.
(2) The osteopathic physician may delegate the retrieval of a required PMP query to an authorized designee, in accordance with WAC 246-470-050.
(3) At a minimum, the osteopathic physician shall ensure a PMP query is performed prior to the issuance of any prescription of an opioid or of a benzodiazepine.
(4) For the purposes of this section, the requirement to consult the PMP does not apply in situations when it cannot be accessed by the osteopathic physician or their authorized designee due to a temporary technological or electrical failure.
(5) In cases of technical or electrical failure, the osteopathic physician shall document in the patient record the date(s) and time(s) of attempts to access the PMP and shall check the PMP for that patient as soon as is practicable after the failure is resolved, but not later than the next prescription.
(6) Pertinent concerns discovered in the PMP shall be documented in the patient record.
[Statutory Authority: RCW 18.57.800, 18.57A.800 and 2017 c 297. WSR 18-20-087, § 246-853-790, filed 10/1/18, effective 11/1/18.]


PDF246-853-990

Osteopathic fees and renewal cycle.

(1) Licenses must be renewed every year on the physician's birthday as provided in chapter 246-12 WAC, except postgraduate training limited licenses.
(2) Postgraduate training limited licenses must be renewed every year to correspond to program dates.
(3) The following nonrefundable fees will be charged for osteopathic physicians:
Title of Fee
Fee
Original application
 
 
Endorsement application
$375.00
 
UW online access fee (HEAL-WA)
16.00
Active license renewal
 
 
Renewal
375.00
 
Late renewal penalty
190.00
 
Expired license reissuance
250.00
 
UW online access fee (HEAL-WA)
16.00
 
Substance use disorder monitoring surcharge
50.00
Inactive license renewal
 
 
Renewal
310.00
 
Expired license reissuance
225.00
 
Late renewal penalty
155.00
 
UW online access fee (HEAL-WA)
16.00
 
Substance use disorder monitoring surcharge
50.00
Retired active license renewal
 
 
Renewal
195.00
 
Late renewal penalty
100.00
 
UW online access fee (HEAL-WA)
16.00
 
Substance use disorder monitoring surcharge
50.00
Endorsement/state exam application
500.00
Reexam
100.00
Verification of license
50.00
Limited license
 
 
Application
285.00
 
Renewal
265.00
 
UW online access fee (HEAL-WA)
16.00
 
Substance use disorder monitoring surcharge
50.00
Temporary permit application
70.00
Duplicate certificate
20.00
[Statutory Authority: RCW 18.57.005 and 2022 c 43. WSR 24-14-032, § 246-853-990, filed 6/25/24, effective 7/26/24. Statutory Authority: 2020 c 80. WSR 23-19-059, § 246-853-990, filed 9/15/23, effective 10/16/23. Statutory Authority: 2016 c 42 and RCW 18.130.175, and 43.10.250. WSR 16-21-062, § 246-853-990, filed 10/14/16, effective 2/1/17. Statutory Authority: RCW 18.130.250, 43.70.250, and 18.130.186. WSR 15-07-004, § 246-853-990, filed 3/6/15, effective 4/6/15. Statutory Authority: RCW 43.70.250, 43.70.280, and 2013 c 129. WSR 13-21-069, § 246-853-990, filed 10/16/13, effective 1/1/14. Statutory Authority: RCW 43.70.110 (3)(c) and 43.70.250. WSR 12-19-088, § 246-853-990, filed 9/18/12, effective 11/1/12. Statutory Authority: RCW 43.70.250, 43.70.110. WSR 11-14-038, § 246-853-990, filed 6/28/11, effective 8/15/11. Statutory Authority: RCW 43.70.110, 43.70.250, 2008 c 329. WSR 08-15-014, § 246-853-990, filed 7/7/08, effective 7/7/08. Statutory Authority: RCW 43.70.250, [43.70.]280 and 43.70.110. WSR 05-12-012, § 246-853-990, filed 5/20/05, effective 7/1/05. Statutory Authority: RCW 43.70.250. WSR 99-24-063, § 246-853-990, filed 11/29/99, effective 12/30/99. Statutory Authority: RCW 43.70.280. WSR 98-05-060, § 246-853-990, filed 2/13/98, effective 3/16/98. Statutory Authority: RCW 43.70.250 and chapters 18.57, 18.57A, 18.22 and 18.59 RCW. WSR 94-22-055, § 246-853-990, filed 11/1/94, effective 1/1/95. Statutory Authority: RCW 43.70.250. WSR 92-14-054 (Order 281), § 246-853-990, filed 6/25/92, effective 7/26/92; WSR 91-21-034 (Order 200), § 246-853-990, filed 10/10/91, effective 11/10/91; WSR 91-13-002 (Order 173), § 246-853-990, filed 6/6/91, effective 7/7/91. Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-853-990, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.250. WSR 90-04-094 (Order 029), § 308-138-080, filed 2/7/90, effective 3/10/90. Statutory Authority: RCW 43.24.086. WSR 87-10-028 (Order PM 650), § 308-138-080, filed 5/1/87. Statutory Authority: 1983 c 168 § 12. WSR 83-17-031 (Order PL 442), § 308-138-080, filed 8/10/83. Formerly WAC 308-138-060.]