ASC - Cytotechnologist State Licensure Information Bulletin

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Cytotechnologist Scope of Practice (PDF)

Approved by the ASC Executive Board 11/7/06

May 2006

Chapters:

INTRODUCTION

OPPONENTS AND ADVOCATES

CYTOTECHNOLOGISTS AND MEDICAL TECHNOLOGISTS

DEFINITIONS

STATUS OF STATE LICENSURE

THE LICENSING PROCESS

REFERENCES

The American Society of Cytopathology surveyed its members and other interested parties in 2005 on the issue of state licensure for cytotechnologists in order to gather information on the current status of licensure, determine membership views and to assist with formation of a position on the issue. The survey was developed in response to recent advocacy of licensure at the state level. State proposals for licensure of laboratory professionals are currently initiated primarily by the American Society of Clinical Laboratory Scientists and state laboratory professional organizations.

There were 317 respondents to the ASC survey ( PowerPoint document). Only 72% of participants were members of ASC. The majority of respondents were staff cytotechnologists (47%) with 27% cytotechnology supervisors, 9% pathologists and 4% laboratory managers responding. Massachusetts, New York, Minnesota and Ohio states had the highest participation. Most respondents indicated that their state did not currently require state licensure for cytotechnologists. Of the participants, 49% were opposed to state licensure for cytotechnologists, 34% were in favor, and 16% were undecided. Of those opposed, 55% were strongly opposed; of those in support, 36% were strongly in favor. Twenty percent of the respondents remain neutral or open to changing their position. When asked if ASC should support state licensing, 54% voted "no", 27% voted "yes" and the remainder were undecided.

Respondents indicated why they would support licensure: it raises the professionalism of cytotechnologists to that of other allied health professionals (48%); it imposes barriers to the practice for inappropriately trained, incompetent or impaired cytotechnologists (43%), and it may provide an incentive for employers to provide expense-free continuing education (37%). The most common reasons cited for opposition to licensure included the cost of obtaining and maintaining a license or multiple licenses and continuing education (64%); patient safety is not ensured through licensing (58%); the complexity of applying for multiple state licenses when relocating (56%); and scope of practice language may be unduly restrictive to practice opportunities (51%).

There was consensus agreement on two issues: that states should not adopt personnel standards for cytotechnologists that are more stringent than CLIA (80%) and that demonstration of continued competency (for example, continuing education) is a desirable component of licensure (65%). Highlighted by the survey was the fact that, even in those states with licensure, respondents lacked knowledge about the specifics of licensure. For those respondents currently residing in states with a licensure requirement, the response was "don't know" (responses in parentheses) for questions such as "does your state define a scope of practice for cytotechnologists?" (49%); "does your state recognize licenses from other states?" (26%); "if your state has unique licensing requirements, do they differ depending upon the position occupied (e.g. cytotechnologist or supervisor)?" (37%); does the state have any unique licensing requirements, such as hours/units in a particular topic?" (30%); "does the state take disciplinary actions or sanctions against unlicensed cytotechnologists practicing in the state?" (66%); "is the licensing board thorough in verifying credentials for licensing and license renewal?" (43%); "is there a licensing board?" (31%) and "if so, does the board include a cytotechnologist?" (55%).

It is interesting to note that of the states with licensure, the respondents indicated that the majority of states do not provide continuing education (74%) and that their employer does not reimburse for licensing fees (74%). Also, despite fears regarding the complexity of obtaining licenses in multiple states, only 7% of respondents indicated that they or someone they knew had difficulty transferring a license state to state, but when it occurred, this difficulty was describe as "very difficult" (40%) or "moderately difficult" (24%).

The ASC tasked the Legislative and Regulatory Proceedings Committee with assembling the following facts about state licensure for technologists in order to educate and inform their members and other interested parties. The items are presented in bullet format for ease of presentation. State requirements for cytotechnologists are summarized on a Microsoft excel document. For more specific information regarding licensure in particular states, points of contact for licensing states are are on this Microsoft excel document.

OPPONENTS AND ADVOCATES

The College of American Pathologists (CAP) advocates against technologist licensure laws. Their reasons include the following:

Licensure has no benefits for quality.
Establishes independent scope of practice and limits the discretion of a pathologist in selecting, qualifying, assigning and directing personnel in the clinical laboratory.
Establishes Clinical Laboratory Boards with pathologist members having little or no influence over Board activities and direction.
Potentially exacerbates workforce shortages by restricting pools of eligible workers.

The American Society of Clinical Laboratory Scientists (ASCLS) is lobbying state legislatures to introduce new laboratory technologist and technician licensing bills.
Their reasons include the following:

Protection of scope of practice
Elevate status to that of other allied health care professionals who are licensed
Provide professional credibility
Hold professionals accountable for practice or ethical violations

The American Society for Clinical Pathology issued a policy statement (#05-02) in June, 2005 supporting the concept of state licensure for laboratory professionals for the reasons below:

Establishes minimum entry-level standards for personnel providing laboratory testing, including waived testing
Assures personnel competency through periodic self assessment, competency evaluation and continuing education
Improves test quality by maintaining laboratory personnel performance and competency longitudinally
Ensures sufficient academic and clinical training
Personnel standards established by CLIA for performing moderate and high complexity laboratory testing are minimal and do not address waived testing
Protects the patient and public health from significant harm caused by incompetent or poorly trained personnel performing laboratory testing

CYTOTECHNOLOGISTS AND MEDICAL TECHNOLOGISTS

State-mandated licensure sometimes pits medical technologists against cytotechnologists in terms of protecting scope of practice. The Clinical Laboratory Improvement Amendments of 1988 (CLIA '88) personnel standards are more restrictive for cytotechnologists than for medical technologists. CLIA provides no minimal personnel standards for individuals performing "waived" tests and performance of moderately complex testing requires only a high school diploma or equivalent with documented training in performance of the test. Additionally, numerous other professionals (registered nurses, licensed practical nurses, pharmacists, physicians, and medical assistants) are free to perform laboratory tests, often with little or no experience in laboratory science. The ASCP membership survey indicated overwhelming support for state licensure, including support by the pathologist members. Among laboratory professionals, medical technologists outnumber cytotechnologists:

Total Board of Registry (BOR)-certified MT since 1931: 220,015
Total MT BOR-registered current: 76,759
MT-associate members of ASCP current: 40,891
Total CT/SCT BOR-certified since 1957: 14,438
Total CT/SCT BOR-registered, current: 11,131
CT/SCT associate members of ASCP, current: 6,173
CT/SCT members of ASC: 1,287
CT/SCT members of ASCT: 929

DEFINITIONS

Accreditation: “Process by which an agency evaluates and recognizes an institution or program of study as meeting certain predetermined standards” (Schwabbauer, 1992). For example, the College of American Pathologists (CAP) accredits clinical laboratories.

Agency: "National certifying agency of laboratory personnel that is acceptable to the Secretary of the United States Department of Health and Human Resources, including, but not limited to, the American Society of Clinical Pathologists and the National Credentialing Agency for Laboratory Personnel."
(Hawaii Department of Health Regulation Ch 30; 11-110, 2002).

Allied Health Professional: “Any licensed health care provider who is not in the medicine (MD), osteopathy (DO) or dentistry group” (JCAHO, 1982).

Certification: "Process by which a [governmental or] nongovernmental agency grants recognition to an individual who has met certain predetermined education qualifications and technical competencies; certification is voluntary” (Schwabbauer, 1992). “Grants the use of a title by verifying certain qualifications; it does not involve the authorization to practice a profession, nor does it regulate a profession." Certification may be roughly equated with "title protection"; one must be certified to use the specified title, but not necessarily to practice. Certification does not restrict scope of practice nor evaluate longitudinal competency.

Credentialling: "Encompasses a broad spectrum of efforts to establish professional standards and regulations for practice." (Porter, Gordon, Zgliczynski, 2001).

Legislation: "The act of making a law or laws; the law or laws so made" (Webster, 1974).

License: "A process by which an agency of the government grants permission to an individual to engage in a given occupation upon finding that the applicant has attained the minimal degree of competency required to ensure that the public health, safety and welfare will be reasonably protected" (Simberg & Roederer, 1978). Licenses are mandatory for practice. If an occupation is licensed, it is illegal to perform outside one's scope of practice as defined by the law. Additionally, it is illegal to perform one's professional duties without an active, valid license.

Licensure: "A legislatively established process of credentialling which grants a practitioner the legal right to practice through law. It restricts this right to only those persons who hold a license. Some will protect both the title and practice of the profession (practice acts and laws). Others will protect only the title granted to practitioners (title acts or laws)" (Porter, Gildon, Zgliczynski, 2001).

Licensing Board: A governmental agency entrusted with the responsibility to administer the licensing program; responsibilities are state-specific but often include approval of and renewal of applications, establishment of fees, formulation and promulgation of rules and regulations pertaining to the practice; advisor to state legislature; disciplinary body (issue subpoenas, examine witnesses, administer oaths, investigate allegations of practice violations; reprimand licensee; prohibit, restrict, revoke or deny license).

Reciprocity: "A mutual exchange of privileges" (Webster, 1974); for state licenses, typically one state will recognize another's license to practice as valid only when that state's requirements are as or more stringent than those of the accepting state. Reciprocity allows individuals to "transfer" their license from state to state, often with reduction of paperwork or associated fees.

Registration: “The process by which a non-governmental agency or association identifies an individual by maintaining [listing] his/ her name on a roster upon request of the individual” (Schwabbauer, 1992). For example, the Board of Registry of the ASCP maintains a list or registry of all individuals who have been certified by their organization.

Regulation: "The act of governing or directing according to rule or method" (Webster, 1974) Regulations interpret legislation and provide for procedures for implementation and enforcement. Once state licensure laws are enacted, regulations are written that outline the license requirements and the duties of the state to provide licensing.

STATUS OF STATE LICENSURE

States requiring licensure of cytotechnologists

California
Florida
Hawaii
Louisiana
Montana
New York
Rhode Island
Tennessee
West Virginia
Puerto Rico

States requiring "certification" of cytotechnologists

Georgia (licenses clinical laboratories; certifies technologists)
Nevada (closely approximates requirements for licensure, including individual application, fees, revocation, suspension, but is termed "certification")

States currently or previously considering licensure of laboratory personnel

Illinois (2005) HB1193 "Clinical Laboratory Science Practice Act"
Indiana (2005) No bill yet in assembly
Massachusetts (2005) HB3655 "Clinical Laboratory Science Practice Act"
Minnesota (2005) No bill yet; POC= Rick Panning (Licensure Chair, ASCLS-MN; president of Fairview Laboratory Services, Minneapolis, MN)
Missouri (2005) HB550 "Clinical Laboratory Science Practice Act"
Pennsylvania (2004) No bill yet; POC= Charles Wilson, President, Pennsylvania Society for Clinical Laboratory Science (Children's Hospital of Philadelphia)
Iowa (2004) No bill yet; POC= Bonnie Rubin (University Hygienic Laboratory)
Vermont (2001) H.0071 "Licensure of Clinical Laboratories and Clinical Laboratory Personnel"

THE LICENSING PROCESS

Common Elements of Licensure

Education: Entry level qualifications of eligibility to practice a particular profession; continuing education requirements

Examination: Successful completion of a profession-specific licensing and/or certifying examination (national or state-administered)

Ethical Standards: Guidelines delineating professional responsibilities and behavior; enforcement of those standards

Experience: "Grandfathering" of individuals currently in the field and alternative avenues of qualification

Education- Entry Level:
- Baccalaureate Degree; Bachelor's of Art / Science; Bachelor's Degree in Cytotechnology
- Completion of "X" semester hours in an accredited college with specified hours or credits in physical / chemical / biological sciences, mathematics
- Completion of an accredited program in cytotechnology
- Frequently mirrors CLIA guidelines, especially regarding "grandfathering"
Education- Continuing education credits:
- 10 to 15 credit hours annually
- Courses generally must be "approved" by the board; specific requirements vary state to state; most are liberal in approving hours from recognized national organizations or universities and may list these in the regulations
- May approve individual presentations in specialty, community or service organization presentations, academic coursework, research, formal self-study in specialty (North Dakota); hospital seminars, journal clubs, in-service training, teaching activities in laboratory science; publication of papers or books; posters or exhibits, and tumor board attendance (West Virginia)
- Some states exclude CE not directly related to clinical laboratory practice such as cardiopulmonary resuscitation or first aid, personal reading of professional journals, committee meetings, computer classes, general safety practices (North Dakota)
- Some states require specific CE hours in areas such as HIV/AIDS, Laws and Rules, Preventing Medical Errors (Florida)
Examination:
- "Certification by an approved accrediting agency" (successful completion of ASCP registry examination; IAC examination); nearly all states accept certification as the only examination necessary
- State examination (New York only)
Ethical Standards:
- Primarily stated in regulations in negative terms: reasons for denial, suspension and revocation of license
Experience:
- Grandfather clauses reflect CLIA 88 regulations
- Before 1 Sep 1992, has successfully completed at least 60 semester hours in an accredited college or university with at least 12 semester hours in science, eight of which are in biology, and:
  - Completed 12 months of training in and accredited program of cytotechnology; OR
  - Completed 6 months of formal training in an accredited program of cytotechnology and 6 months of full-time experience in a clinical laboratory under the direct supervision of a pathologist who is certified in anatomic pathology by the American Board of Pathology or the American Osteopathic Board of Pathology
- Before 1 Sep 1994, has full-time experience of at least 2 years within the preceding 5 years examining slide preparations under the supervision of a pathologist who is certified in anatomic pathology by the American Board of Pathology or the American Osteopathic Board of Pathology or other physician certified as a specialist in cytology and before 1 January 1969, must have:
  - Graduated from a high school; and
  - Completed 6 months of training in cytotechnology in a laboratory that is acceptable to the department and was directed by a pathologist or other physician certified as a specialist in cytology.

Other Elements of Licensure
Fees:
(Range is $25 to $205; renewal cycle 1-3 years)

Initial application fee (Hawaii, $25)
License fee (usually includes application fee)
Provisional permit fee (for individuals qualified for, but awaiting completion of certifying examination)(North Dakota; 3 years)
Temporary permit fee (to allow individuals to begin work while application is being processed; in some states, there is no fee although permit granted; permit valid from 90 days to 1 year)
Reciprocity fee (Montana, $100)
Renewal fee
Late/ delinquent fee
Restoration fee (Hawaii, $20)
Inactivation fee (Montana, $25; Florida, $205)
Duplicate license fee (California, $13)
"Insufficient funds" charge (Nevada; $25)
State regulatory fee (Tennessee $10)
Transcript fees (from credentialling organizations, colleges, universities)

Copies of all certificates of attendance for CE
Copies of high school diploma/GED; specialty diploma, certificate of board certification
Official copies of college transcripts
2 x 2" photograph (Montana, Tennessee, Louisiana)
Fingerprints; criminal background check and paperwork (Louisiana; Fee=$50)
Certified copies of birth certificate, notarized copy of marriage certificate (Louisiana)
Copy of certificate of citizenship and/or naturalization (if applicable) (Louisiana)
Mandatory questions regarding child support (Nevada)
Notorization of the application (North Dakota, Montana, Louisiana)
Job description (West Virginia)
Certified translations of all documents in another language (California)
Documentation of legal entry into country and right to work if non-US citizen (Tennessee)
Verification of competency, proficiency and experience if not certified (West Virginia, Louisiana)
Fines for violations (New York, up to $500; Hawaii, up to $1000 / day)
Board notification of changes in work, address, or name

Reciprocity granted by:

Montana
North Dakota
Rhode Island

Reasons for restriction, suspension, revocation, denial of licensure

Obtaining or attempting to obtain a license by means of fraud, deceit, misrepresentation or concealment of facts
Conviction of a felony or offense that has a direct bearing upon the individual's ability to serve the public; conviction of a crime
Violation of any provisions of the state regulations applying to laboratory personnel
Unprofessional, unethical or dishonorable conduct
Sexual misconduct (Florida)
Failure to meet minimum Board standards
Board determines that individual has not been rehabilitated after conviction of an offense
Practice without a license or on an expired license
Practice outside of one's scope of practice
Fraudulent issue of test results or issuance of false test results; falsification of medical records
Professional incompetence (Tennessee; Hawaii)
Performing a test and rendering a report thereon to a person who is not authorized by law to submit a specimen (Hawaii)
Being habituated to the excessive use of drugs or alcohol; or performing laboratory testing while impaired (Hawaii)
Failure to pay child support (Nevada)

(Tennessee has an excellent matrix system for disciplinary guidelines that is categorized by severity of harm and scope of the infraction)

State Licensing Board/ Board of Examiners

Responsibilities are outlined in state law and regulations
- Establish application fees
- Review applications and approve applicants
- Resolve controversies and challenges regarding "scope of practice" IAW regulations
- Advise the state on issues regarding laboratory personnel
- Determine and apply disciplinary actions
- Formulate rules/ regulations pertaining to practice
Serve the public; responsible for public health and safety
Generally contain at least one physician on the board (not necessarily a pathologist)
May or may not specify cytotechnologist on the board (e.g. "Clinical laboratory specialist" may apply to cytotechnologist but does not require CT)
In some states, responsible for accrediting cytotechnology training programs
May be empowered to perform laboratory and/or CT school inspections

Scope of Practice / Practice Restrictions

Variable, from very broad to very strict; interpretation often left to Boards
Without specific language, Board tends to restrict practice of one specialty against "infringement" upon the practice of another specialty where practices may overlap
In some states (FL), the board has ruled to delegate scope of practice tasks based upon the laboratory service indicated by CPT codes

This bulletin was written by the 2004-2005 Legislative and Regulatory Proceedings Committee:

Barbara Crothers, D.O. (chairperson)
Helen Banks, CT(ASCP)
Anna Berry, M.D.
Gail Mueller, CT(ASCP)
Joel S. Bentz, M.D.
Gary Gill, CT(ASCP)
Jim Navin, M.D.

REFERENCES

Crothers BA. Licensing your livelihood: state-mandated cytotechnologist licensure. ASC Bulletin 2005; 52(3): 49, 50, 52.
Available at: http://www.cytopathology.org/members/Assets/bulletin/2005
/ASC_Bulletin_May_Final
Elgert PA, McKenzie SB. Point-CounterPoint: State Licensure. LabMedicine 2004; 35(12): 751-754.
Available at: http://www.labmedicine.com
Gatscha RM. More about cytotechnologist licensure. ASCT Journal of Cytotechnology 2004; 2(4):150-154.
Gross SJ. Of Foxes and Hen Houses: Licensing and the Health Professions. Westport, Conn.: Greenwood Press (Quorum Books); 1984.
Mooney B. New trends in the clinical laboratory: licensure legislation is on the front burner. Advance Med Lab Prof 2004; 16(1): 27-29.
Available at: http://laboratorian.advanceweb.com/common/editorialsearch
/Aviewer.aspx?AN=MT_04jan12_mtp27.html&AD=01-12-2004
Moriarty AT, DuBray-Benstein, B. The upsides and downsides of state licensure for cytotechnologists. CAP Today Jan 2005.
Available at: http://www.cap.org/apps/docs/cap_today/pap_ngc
/0105NCG_licensure.html
Ogden-Grable H, Watters MC. Point-CounterPoint: State-mandated licensure of laboratory personnel. What are the pros and cons? What is the current legislation? . LabMedicine 2004; 35(10): 597-598.
Available to ASCP associate members at: http://www.labmedicine.com.
Personnel Licensure. American Society for Clinical Laboratory Sciences.
Available at: http://www.ascls.org/jobs/grads/personnel_licensure.asp
Scott JH, Bell DJ, Mongillo D. Latest news from Washington–Advocacy update on current political and regulatory issues. CAP 2004.
Available at: http://www.cap.org/apps/docs/annual_meeting/presentations/2004/
monday/SS105_Current_Political_And_Regulatory_Issues (CAP’s position)
Stewart CA and Shulze FM. ASCP Survey on Laboratory Personnel State Licensure. LabMedicine 2005;36(9):524-7.
Available at: http://www.labmedicine.com
The American Society for Clinical Pathology Policy Statement #05-02. State Licensure of Laboratory Personnel. Approved June 2005.
Available at: http://www.ascp.org/511live/Timssnet/News/TNT_news.cfm
Wentz J, Huelsman D. Point-CounterPoint: State Licensure. LabMedicine 2004; 35(11):695-696.
Available at: http://www.labmedicine.com

State Legislation Regarding CT licensure

CALIFORNIA: Business and Professions Code Chapter 3, Division 2
FLORIDA: 2004 Florida Statutes: Title XXXII, Chapter 483 http://www.flsenate.gov/Statutes/index.cfm?App_mode=Display_Index&Title_Request=XXXII#TitleXXXII
GEORGIA: Official Code of Georgia Annotated Chapter 22, Title 31 (OCGA Sec 31-22)
HAWAII: HRS 321-11&13; 1139 HOUSE OF REPRESENTATIVES H.B. NO. TWENTIETH LEGISLATURE, 1999 STATE OF HAWAII; CLINICAL LABORATORY PERSONNEL. 1 SECTION 1. Section 321-13, Hawaii Revised Statutes
MONTANA: Montana Code Annotated Chapter 37-34 (2003) http://data.opi.state.mt.us/bills/mca/37/34/37-34.htm
NEW YORK: Chapter 755, Article 165; Laws of 2004
http://www.op.nysed.gov.chapter755.htm
NORTH DAKOTA: North Dakota Century Code Chapter 43-48 (NDCC 43-48-04)(1989)http://www.state.nd.us/lr/cencode/t43c48.pfd
RHODE ISLAND: General Laws of Rhode Island, Section R23-16.3-CLS.
TENNESSEE: Tennessee Medical Laboratory Act (TCA 68-29-129)
WEST VIRGINIA: Division of Health Legislative Rule Governing Clinical Laboratory Technicians and Technologist Licensure and Certification (62 CSR 57) (1997)