Section 04 030 380 - ADMINISTRATIVE RULES FOR NATUROPATHIC PHYSICIANSPart 1 GENERAL INFORMATION ON LICENSURE OF NATUROPATHIC PHYSICIANSSection 1.1 The Purpose of Licensure To protect the public health, safety and welfare, the Vermont Secretary of State has the duty to license and regulate naturopathic physicians. Vermont Statutes Annotated Title 26, Chapter 81("Chapter 81").
Section 1.2 Laws That Govern Licensure Chapter 81 governs the issuance of licenses and the regulation of professional practice for naturopathic physicians. Chapter 81 also authorizes rulemaking authority to carry out these regulatory duties. In enforcing Chapter 81, the Director of the Office of Professional Regulation (the "Director") follows the Administrative Procedure Act (Vermont Statutes Annotated, Title 3 §§ 801-849), Vermont Open Meeting Law (Vermont Statutes Annotated, Title 1 §§ 311-314), Access To Public Records (Vermont Statutes Annotated, Title 1 §§ 315-320), and Professional Regulation (Vermont Statutes Annotated, Title 3 §§ 121-131).
These laws set forth the rights of applicants, licensed naturopathic physicians, and the public. The complete text of these laws is available at most libraries and town clerks' offices. "Vermont Statutes Online" is available at http://www.leg.state.vt.us. The text of statutes and administrative rules governing naturopathic physician practice is available at http://www.vtprofessionals.org.
Part 2 INFORMATION FOR APPLICANTS Section 2.1 Application Applications and information about licensure requirements are available from the Office of Professional Regulation ("Office"). An applicant must submit a completed application form with all supporting documentation and the fee to the Office.
The Office reviews applications only after the supporting documentation is received, including evidence of a degree and examination results, as required in Rule 2. 2, or evidence of a license in another jurisdiction and its licensing standards, as required by 26 V.S.A. § 4129.
Initial licenses issued within 90 days of the renewal date will not be required to renew or pay the renewal fee. The license will be issued through the next full license period. Applicants issued an initial license more than 90 days prior to the renewal expiration date will be required to renew and pay the renewal fee.
Section 2.2 Qualifications for Licensure as a Naturopathic Physician (a) Degree requirement: The degree required is a doctoral degree in naturopathic medicine from a program accredited by the Council on Naturopathic Medical Education (CNME), or a degree determined by the Director to be essentially equivalent and which meets educational standards essentially equivalent to those established by the CNME.(b) Licensing Examination: The Director, or the Director's designee, administers a written examination on naturopathic medicine. The Director currently uses the Naturopathic Physicians Licensing Examinations (NPLEX). To be eligible for licensure as a naturopathic physician in Vermont, an applicant must have passed the NPLEX and the Minor Surgery Clinical Elective Examination. The passing score and the minimal competency requirements for the NPLEX are established by NPLEX. The Director, or the Director's designee, shall administer the licensing examination at least twice a year at a time and place set well in advance.(c) Applicants under this section who have not actively practiced the profession or who have not been enrolled in an approved naturopathic program during the two years immediately preceding the submission of their application must complete the continuing education requirements required by Rule 3.2 prior to receipt of a Vermont license.Part 3 INFORMATION FOR NATUROPATHIC PHYSICIANS Section 3.1 Renewing Licensure Biennially Licenses renew on a fixed biennial schedule: September 30 of the even-numbered years.
Before the expiration date, the Office will mail a renewal application and notice of the renewal fee to the latest address on file with the Office. A license will expire automatically within 14 days if the renewal application and fee are not returned to the Office by the expiration date.
Licensees possessing a special license endorsement to practice naturopathic childbirth must submit proof of current cardiopulmonary resuscitation certification for adults and newborns and for neonatal resuscitation biennially, with each license renewal. See Rule 3.7(b) below. Such licensees must also file with the Director a written plan for consultation with other health care providers for emergency transfer and transport of an infant or a maternity patient, or both, to an appropriate health care facility. The written plan must be submitted to the Director on an approved form with the initial application for the naturopathic childbirth special license endorsement and with subsequent renewals. See Rule 3.7(d) below.
Section 3.2 Continuing Education Requirements (a) As a condition of license renewal, naturopathic physicians must complete a minimum of 30 hours of continuing education during the two-year renewal period and must so certify at the time of license renewal. The continuing education requirement does not apply for the renewal period during which a naturopathic physician initially obtained licensure. It will begin with the first full two-year renewal period. Licensees who complete more than the required 30 hours of continuing education may carry-over a total of 10 (ten) hours of continuing education from the preceding licensure renewal period. Licensees seeking the special license endorsement for prescription medications pursuant to 26 V.S.A. § 4125(d) may apply credits from the Medical Pharmacology course, or a substantially equivalent course approved by the Director, described in Rule 3.5(a) for two (2) renewal cycles.(b) A continuing education program means classes, institutes, lectures, conferences, workshops, naturopathic journals, scientific journals, audio, video, or online presentations, and preceptorships. A program shall consist of study covering new, review, experimental, research and specialty subjects within the scope of practice of naturopathic medicine. Excluded are programs that promote a company, individual, or product and programs on practice economics. However, courses specifically dealing with medical workers compensation or medical recordkeeping in the context of practice economics are acceptable.(c) A physician-level continuing medical education course is acceptable as a continuing education program. A course is considered physician-level if presented by a physician or other medical professional to a predominantly physician audience. Once a continuing education provider is approved by the Director, the continuing education activity sponsored by that provider is approved for credit and no application to the Director must be made for approval. The Office shall maintain a List of Approved Providers which may be obtained from the Office's web site at http://vtprofessionals.org/.(d) Licensees possessing the special license endorsement for prescription medications must complete 10 hours biennially in the pharmacology of legend drugs.(e) Licensees possessing a special license endorsement to practice naturopathic childbirth must complete 15 hours biennially in naturopathic childbirth. A course in neonatal resuscitation may count toward these 15 hours. Ten of the 15 hours may be applied to general requirements for continuing education.(f) At the time of license renewal, each licensee must certify on the official renewal form that he or she has complied with the continuing education requirements. The Office may randomly audit licensees to ensure compliance. A licensee who is audited will be notified in writing by the Office and will be required to produce documentation verifying successful completion of the 30 hours of continuing education during the two-year period at issue. A licensee must maintain documentation for at least two years following the renewal period at issue. The Director may require a licensee who cannot produce satisfactory evidence of successful completion to develop and complete a specific corrective action plan within 90 days, prior to renewal.Section 3.3 Change of Name or Address A licensee is responsible for notifying the Office promptly of any changes in name, mailing address, business address or other relevant contact information. See 3 V.S.A. § 129a(a)(14).
Section 3.4 Professional Standards Naturopathic physicians may be disciplined for unprofessional conduct pursuant to 26 V.S.A. § 4132(a) and 3 V.S.A. § 129a.
Section 3.5 Special License Endorsement for Prescription Medications (a) The naturopathic pharmacology examination, defined at 26 V.S.A. § 4121(13), the passage of which is required for the special prescriptive license endorsement pursuant to 26 V.S.A. § 4125(d), shall be the National Board of Medical Examiners ("NBME") subject matter examination in pharmacology, or the examination(s) given in the Medical Pharmacology course taught within the Department of Pharmacology through Continuing Medical Education at the University of Vermont's College of Medicine, or a substantially equivalent examination approved by the Director after consultation with the Commissioner of Health. In order to obtain the special license endorsement which shall authorize a naturopathic physician to prescribe, dispense, and administer prescription medicines, an otherwise qualified naturopathic physician will be required to pass the NBME pharmacology examination, or the Medical Pharmacology course examination(s) at the University of Vermont, or a substantially equivalent examination approved by the Director, after consultation with the Commissioner of Health. Approval for a substantially equivalent examination may be obtained by applying to the Office at anytime but no later than 90 days before the alternate course begins.(b) For no less than one year after receiving the special license endorsement, and until the first one hundred (100) drug prescriptions are issued, prescriptions shall be reviewed by an objective and independent supervising physician licensed under Chapter 23 or 33 of Title 26, or a naturopathic physician licensed under Chapter 81 of Title 26. The supervising physician shall possess an unencumbered license and have been prescribing and administering prescription drugs without limitation for five years or more in Vermont. The supervising physician shall evaluate the naturopathic physician's ability to:(1) safely prescribe and administer prescription drugs within the naturopath's scope of practice;(2) comply with federal and state statutes; and(3) comply with the applicable administrative rules of the Vermont Board of Pharmacy.(c) The naturopathic and supervising physicians shall have a formal written agreement. The agreement shall address the requirements of subsection (b) of this rule. The agreement shall be available for inspection upon request by the Office.(d) A naturopathic physician who satisfies the supervision requirement in subsection (b) of this rule shall notify the Office that this requirement has been met and file a certificate of completion signed by the supervisor.(e) The Director may waive the prescription review requirement in subsection (b) of this rule if the newly endorsed naturopathic physician can show that they have substantial experience in prescribing prescription medicines under the laws of another jurisdiction that has standards and qualifications for a naturopathic physician to prescribe prescription medications at least equal to those required under these rules.(f) The use of prescription medications in a manner that has not been approved by the FDA is referred to as "off-label." In addition to the use of prescription medications in a manner approved by the FDA, a naturopathic physician who has appropriate competency, training and experience may prescribe medications in an "off-label" manner in conformance with generally accepted standards of practice, including safety and efficacy, for both allopathic and naturopathic physicians.Section 3.6 Advertising (a)26 V.S.A. § 4122 lists five designations that a naturopathic physician licensed in Vermont may use. The five designations are: N.D., Doctor of Naturopathic Medicine, Naturopathic Doctor, Doctor of Naturopathy, and Naturopathic Physician. Licensees must prominently feature at least one of the five designations in any advertising.(b) A licensee who complies with the law in this way may then use the designation "Dr." in the advertisement. The purpose of this rule is to prevent deceptive advertising and to inform the public that the licensee is a naturopathic physician licensed under Title 26, Chapter 81 and not another health care licensee.(c) The terms "board certified" and "diplomate" imply that the licensee has completed an advanced level of training. A licensee advertising either term or similar terms must state the area of specialty, and the private credentialing organization that issued the specialty certification. The purpose of this rule is to provide the public with complete and accurate information about the licensee's credentials and level of training.Section 3.7 Naturopathic Childbirth No licensee may practice naturopathic childbirth without first obtaining a special endorsement on his or her license. To obtain this endorsement, a licensee must:
(a) Show evidence of completion of a naturopathic childbirth or midwifery program from an approved naturopathic college or hospital and furnish a signed log showing evidence that sections (1), (2) and (3) of this subsection have been completed under the direct supervision of a licensed practitioner with specialty training in obstetrics or natural childbirth.(1) The licensee must have taken part in the care of 50 cases each in prenatal and postnatal care. One case may qualify for both areas of care.(2) The licensee must have observed and assisted in the intrapartum care and delivery of 50 natural childbirths in a hospital or alternative birth setting 3 of which must have occurred within the last two years. A minimum of 26 of these births must be under the supervision of a naturopathic physician. No more than 10 of the 50 births may be under the supervision of a medical doctor (allopathic or osteopathic physician). No more than 10 of the births may be observation only. A labor and delivery that starts under the care of a naturopathic physician and includes hospitalization shall count as a birth.(3) The course work must consist of at least 200 hours in naturopathic childbirth.(b) Hold a current cardiopulmonary resuscitation certification for adults and newborns and for neonatal resuscitation. The Director will accept courses in external cardiopulmonary resuscitation which are approved by the Vermont Heart Association or the American Red Cross and for courses in neonatal resuscitation approved by the American Academy of Pediatrics (AAP).(c) Pass a specialty examination in naturopathic childbirth approved by the Director. The Director, or designee, will administer the specialty examination in naturopathic childbirth at least once each year if applications are pending. A licensee may sit for this examination in another state and have the results of the examination transferred to this state.(d) File with the Director a written plan for consultation with other health care providers for emergency transfer and transport of an infant or a maternity patient, or both, to an appropriate health care facility. Licensees must submit the plan to the Director on an approved form with the initial application for a naturopathic childbirth endorsement and with every subsequent renewal of the endorsement.(e) Applicants under this section requesting a naturopathic childbirth endorsement who have not passed the naturopathic childbirth exam within the two years preceding the application shall show evidence of completion of the continuing education requirements required by this section.(f) Licensees possessing a naturopathic childbirth endorsement must, as a condition of renewal: (1) obtain 15 hours in naturopathic childbirth continuing education during each two-year renewal period. A course in neonatal resuscitation may count toward these 15 hours. Ten of the 15 hours may be applied to general requirements for continuing education. See Rule 3.2 above (continuing education requirements).(2) submit proof of current cardiopulmonary resuscitation certification for adults and newborns and for neonatal resuscitation biennially, with each license renewal. See subsection (b) above.(3) have performed 3 natural childbirths in the preceding two year renewal period.(g) Licensing or disciplinary action by an Administrative Law Officer or judicial authority shall be deemed to have an equal effect upon a special endorsement to practice naturopathic childbirth issued to a licensee, unless specifically provided otherwise in the licensing or disciplinary action. When the subject of a licensing or disciplinary proceeding relates specifically to the practice of naturopathic childbirth by a licensee who possesses a special endorsement, the licensing or disciplinary action may, instead of affecting the entire scope of the licensee's practice, suspend, revoke, condition, or restrict only the licensee's authority under the special endorsement.Section 3.8 Informed Consent for Naturopathic Childbirth(a) Before accepting a client for prenatal and natural childbirth, the naturopathic physician must first obtain a written informed consent. Informed consent must be shown in a written statement and signed by the ND and the client to whom care is to be given, in which the ND certifies that full disclosure has been made and acknowledged by the client of the following: (1) The naturopathic physician's credentials.(2) A copy of the written plan for consultation, emergency transfer, and transport.(3) A description of the procedures, benefits, and risks of home birth.(b) The informed consent form must be filed in the client's chart, and a copy must be provided to the client.Section 3.9 Scope and Practice Standards for Naturopathic Childbirth(a) Prenatal Care: (1) Information: The client will be presented accurate information conforming to the requirements of informed consent and also including but not limited to: (A) Financial charges for services.(B) Services the ND provides, and the advantages and disadvantages of home birth.(C) Client responsibilities.(D) Values and ethics of practice.(E) Information on emergency consultation, transfer, and transport.(F) Choices regarding prenatal lab testing, including but not limited to sexually transmitted diseases, blood type and antibody screen, CBC, rubella, HIV, Hepatitis B, and urinalysis.(2) History and Physical Assessment: At the initial prenatal visit, a personal and health history will be obtained, including medical history, family history, current pregnancy history, nutritional history, and physical assessment, including review of systems and prenatal care.(3) On-going Prenatal care: Will be conducted in such a way as to promote the health of the client and baby, screen for problems, develop a relationship with the client and family, exchange information, and do a physical assessment of the prenatal health.(4) Prenatal visits should occur every four weeks through the 32 [nd ]week, every two weeks until the 36 [th ]week, and weekly thereafter. The prenatal visit includes: (A) Physical evaluation including weight, blood pressure, urine screen, fetal heart tones, fundal heights, fetal growth, fetal position and presentation.(B) Discussion during these visits includes: recent illnesses, social or emotional problems, diet, supplements, exercise for pregnancy, birth preparation, partner's role, transport arrangements, newborn care, postpartum care, and parenting.(5) Parents' Responsibilities: (A) Obtain all supplies on birth list.(B) Have an accessible telephone.(C) Have adequate light, heat, water, cleanliness, and accessibility.(D) Post all emergency phone numbers.(E) Make child care arrangements.(F) Arrange for help after the birth.(6) Naturopathic Physician's Responsibilities:(A) Alert parents to signs of labor and when to call.(B) Alert parents to signs of complications that necessitate immediate contact with the naturopathic physician.(C) Be on call or have on-call arrangements if out of town.(D) Arrange for a birth assistant.(E) Make a home visit before the 37 [th ]week.(F) Maintain appropriate equipment for assessing maternal, fetal, and newborn well being, carry anti-hemorrhagic agents, supplies to maintain asepsis, and emergency resuscitation equipment.(G) Maintain a record of the care provided and data gathered for each client, subject to the federal medical records laws and those of the State of Vermont regarding accessibility and confidentiality.(7) Discontinuation of Services: During prenatal care, a naturopathic physician shall evaluate a client and baby and determine continuing appropriateness for the home birth. All concerns shall be shared with the client. If an impasse is reached between what is deemed appropriate by the naturopathic physician and the client or family, it is the right of the ND to refuse or discontinue service and to make appropriate referrals when indicated for the protection of the client, baby, and naturopathic physician.(b) Labor, Birth, and Immediate Postpartum: (1) Labor: During labor and birth, the naturopathic physician shall use all of the resources available to assure and enhance the well being of the mother and baby.(2) The naturopathic physician's labor responsibilities include:(A) Assessing the well being of the laboring woman and baby, fetal heart tones, blood pressure, maternal temperature, position and presentation of the baby, and client's attitude, ability, and energy to cope with labor. A vaginal examination will be performed as necessary to assess progress of labor. Aseptic technique shall be observed with use of OSHA and VOSHA regulations relevant to home birth.(B) Provide adequate fluid and nutrition throughout the labor, provide support and encouragement during the birth process, assist with delivery of the placenta, manage interpartum hemorrhage, and perineal repair as needed.(3) Immediate Care of Newborn: Following the birth the naturopathic physician shall:(A) Maintain a warm environment for the baby.(B) Assess newborn using APGAR scoring and provide appropriate care; continue assessment of newborn vital signs.(C) Encourage and support breast feeding or proper nutrition and feeding habits.(D) Conduct a newborn exam, offering vitamin K and eye prophylaxis.(4) Immediate Postpartum Care: Following the birth, the naturopathic physician shall remain with the client and baby until both are stable and secure and at least two hours have passed since the birth. During this time, the naturopathic physician shall assess maternal well being, bleeding, blood pressure, and uterine size and consistency, examine the perineum, and repair if necessary. Assess the client's ability to urinate and be ambulatory. Postpartum instructions shall be given including information on normal postpartum bleeding, appropriate size and consistency of uterus, perineal care and hygiene, rest and nutritional requirements, breast feeding, newborn care, and indications which warrant contacting the naturopathic physician.(c) Postpartum Follow-up Care: Postpartum visits are recommended at 24 hours, day 3, one week, three weeks and six weeks, with phone consultation as necessary. During these visits, the mother is assessed for normal postpartum recovery and health, breast feeding status, uterine status, lochia status, normal bowel and urinary output, nutritional status and emotional status. The baby is assessed for over all well being, normal nursing or feeding habits, jaundice of the newborn, activity level, growth, vital signs, bowel and urinary patterns, umbilical assessment, and neurological evaluation. A blood sample for newborn metabolic screening shall be obtained after 24 hours and submitted as required by the Vermont Department of Health newborn screening program.(d) Final Postpartum Visit: A six to eight week final visit for mother and baby. At this time, the naturopathic physician shall make inquiries concerning breast feeding, feeding habits, bleeding, activity level, family adjustments, and sexual activity, perform a gynecological exam with a pap smear, and discuss family planning or birth control. Provisions shall be made for ongoing well child care.Section 3.10 Written Plan for Consultation, Emergency Transfer, and Transport (a) The naturopathic physician recognizes that there are certain conditions when medical consultation or transfers, or both, are advisable. Each naturopathic physician practicing naturopathic childbirth must develop a written plan for consultation with other health appropriate care providers, including at least one M.D. or D.O., for emergency transfer and transport of an infant or mother to the appropriate health care facility. The written plan must be submitted to the Director on an approved form with the initial license application and with every subsequent license renewal.(b) Prenatal Medical Conditions: If the following medical conditions present during prenatal care, the naturopathic physician shall consult with the appropriate health care provider:(1) Possible ectopic pregnancy.(3) Persistent breech presentation at 36 weeks.(4) Signs and symptoms of preeclampsia.(5) Suspected post-maturity.(6) Polyhydramnios and oligohydramnios.(7) Indications that the fetus has died in utero.(8) Development of any medical condition potentially detrimental to the pregnancy or the well being of the fetus.(9) Hyperthyroidism currently treated by medication.(10) Acute Toxoplasmosis, Rubella, Cytomegalovirus, or Parvovirus infection, where the client is currently symptomatic.(11) Second or third trimester bleeding.(12) History of intrauterine death after 20 weeks gestation, or stillbirth due to a situation which might recur.(13) Previous myomectomy.(c) Transfer: If the following conditions become apparent during prenatal care, the naturopathic physician shall transfer the client to hospital care for the birth. The naturopathic physician may continue to give co-care and accompany the mother at the birth.(1) Placenta previa or placental abruption.(3) Transverse fetal position.(4) Testing positive for HIV.(5) Suspected premature labor, less than 36 weeks of pregnancy.(6) Premature labor (gestation less than 36 weeks).(8) Primary or active Herpes simplex cervical or vaginal lesion at the time of delivery.(9) Premature rupture of membranes at 37 weeks or less with a positive GBS.(d) Labor and Birth Transfer: If the following conditions become apparent during labor, birth, or immediate postpartum, the naturopathic physician shall facilitate transfer to a hospital setting if time allows or consult with an OB/GYN to determine whether and when transfer is advisable:(3) Fetal distress as indicated by fetal heartbeat monitoring or gross meconium staining.(6) Uncontrolled maternal hemorrhage or retained placenta.(7) Signs of maternal or fetal infection.(8) All stage 4 and any maternal perineal lacerations beyond the naturopathic physician's ability to repair.(9) APGAR score of less than seven at ten minutes or fetal distress not responding to CPR.(10) Any newborn whose vital signs are absent or exhibiting signs of respiratory distress.(11) Obvious congenital anomalies.(e) Decision-making Conflicts: If the client chooses to remain at home against the medical advice of the naturopathic physician during the interpartum period, the naturopathic physician may refer them to an alternative birth provider. If the birth is imminent, the naturopathic physician will leave only if the naturopathic physician has made reasonable attempts to assure that the client is not unattended (i.e., calling an ambulance).Section 3.11 Uncomplicated Childbirth(a) Uncomplicated naturopathic childbirth is the provision of care, support and education to healthy women during the childbearing cycle, including normal pregnancy, labor, childbirth and the postpartum period. There are certain pre-existing medical conditions which may prevent the ability to have a natural home birth assisted by a naturopathic physician.(b) If a history of any of the following disorders or situations is found to be present at the initial interview or if any of the following disorders or situations becomes apparent through history, examination, or laboratory report as prenatal care proceeds, the naturopathic physician must not assume or continue to take responsibility for the client's pregnancy and birth care. For clients already under care, it is the responsibility of the naturopathic physician to arrange for orderly transfer of care to a licensed M.D. or D.O. (1) Uncontrolled insulin dependent diabetes mellitus.(2) Uncontrolled epilepsy.(3) Active non-A hepatitis.(5) Current alcohol or drug addiction.(6) Rh sensitivity with positive antibody titer.(7) Previous cesarean delivery, except as provided for in Rule 3. 14, below.Section 3.12 Previous Cesarean Delivery The following requirements must be met for vaginal birth after cesarean (VBAC). In addition, prenatal consultation is advised when available.
(a) The naturopathic physician must obtain records to ascertain that the client had only one documented previous lower uterine segment cesarean section with uterine closure of more than one layer.(b) There must be at least 18 months from the client's cesarean to the due date of the current pregnancy.(c) The client must obtain ultrasound documentation to determine that the location of the placenta is not previa or is not low and anterior.(d) Signed informed consent must be present in the client's chart. See Appendix A.(e) The naturopathic physician must perform fetal auscultation at least every 15 minutes during active labor and more frequently if necessary and at least every five minutes during the second stage of labor and more frequently if necessary.(f) The birth site must be located within 30 minutes' transport time from a hospital emergency room.(g) A naturopathic physician must be accompanied by another licensed physician or midwife.(h) No labor induction or augmentation of any kind must be done. Specific examples of labor induction or augmentation prohibited by this section include administration of pitocin or its cogeners, or stimulation of the release of pitocin by nipple stimulation, or the use of prostaglandin preparations. This section does not prohibit the use of calmative, sedative or analgesic preparations that are not primarily intended to induce or augment labor, and that are included in the naturopathic physician formulary when, in the judgment of the naturopathic physician, their use for their calmative, sedative or analgesic effects is indicated.(i) Pre-admission forms must be completed for the client before labor, for the hospital to which the client may possibly be transferred.(j) Prenatal records for the client must be sent before labor to the back-up system for the birth (hospital, labor and delivery unit, or physician practice). Effective date: November 1, 2013
04-380 Code Vt. R. 04-030-380-X
STATUTORY AUTHORITY: 26 V.S.A. § 4125
EFFECTIVE DATE: September 1, 2003 Secretary of State Rule Log #03-27
AMENDED: November 1, 2013 Secretary of State Rule Log #13-033