Assignment: NR565 Week2 State Specific Guidelines for Prescribing Controlled Substances Medical Devices 

Assignment: NR565 Week2 State Specific Guidelines for Prescribing Controlled Substances Medical Devices 

Assignment: NR565 Week2 State Specific Guidelines for Prescribing Controlled Substances Medical Devices 

The State is Virginia

Purpose

The purpose of this assignment is to provide the student with an opportunity to explore the most recent guidelines and recommendations in the student’s state of practice for pain management therapies and education; as well as to understand specific state regulations governing controlled substance prescriptions and medical devices.

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Activity Learning Outcomes

Through this assignment, the student will demonstrate the ability to:

Identify and describe at least one current state specific guideline for pain management therapy and education.
Explore other organizations or pain initiatives that are offered by the state (if applicable) and federal bodies.
Describe state specific laws that apply to the authority to prescribe controlled substances and medical devices.
Explore the state’s Prescription Drug Monitoring Program (PDMP).
Preparing the Assignment:

The State Specific Guidelines for Prescribing Controlled Substances & Medical Devices assignment is worth 125 points and will be graded on the quality of required components as summarized in the directions and grading criteria/rubric.
Follow the directions and the grading criteria located in the rubric closely. Any questions about this assignment may be posted under the Q & A Forum or emailed to your faculty.
The document provided should be used and your answers provided within the table provided on this document
· Links to an external site..

· Sources/links should be obtained directly from the state’s regulatory organization(s).

· It is recommended that you keep a copy of this assignment to provide to potential employers or your Board of Nursing to demonstrate your knowledge of your state laws.

Requirements:

Guidelines and recommendations for your state:
In response to the opioid epidemic, individual states have developed and adopted voluntary guidelines or recommendations for the treatment of acute and chronic non-cancer pain. Based on research done on the state where you will practice clinically, include the following:
Provide the name of your practicing state’s organization, group or task force that created guidelines or recommendations for pain management therapies and education.
Briefly describe an overview of its development and include a web address where this information can be found. If your state does not have guidelines, discuss a federal guideline. (Note: you may need to contact your state’s board of nursing, pharmacy, or medicine if you cannot locate it on your own).
Some states have multiple organizations or initiatives (ex: Ohio) in place to combat the opioid epidemic and advocate for safer opioid prescribing. Explore whether your state has other resources, groups or organizations where prescribers can reference best practices for pain management treatment. If applicable, provide a brief overview of the group’s recommendations or initiatives. If your state does not have another state-specific resource, discuss the guidelines published by the American Pain Society OR Centers for Disease Control and Prevention.
Discuss when the use of opioids is appropriate and for what duration should they be prescribed? Provide a reference for your response. (This question is worth 13 points. 5 points for when opioids are appropriate, 5 points for a safe duration of use, and 3 points for a current edition APA formatted reference.)
State specific laws on controlled substance prescribing for the nurse practitioner:
Research your state laws on advanced practice nurses’ authority to prescribe controlled substances. Based on research done on the state where you will practice clinically, include the following:
Identify the law, rule, code, or statute that describes the advanced practice nurse’s authority to prescribe controlled substances in your state.
Discuss the provisions of the law, rule, code, or statute with regard to the following:
Conditions or limits on prescribing schedule I-V controlled substances.
Requirements (if any) in documentation for treating acute and chronic pain.
Are there specific requirements for advanced practice nurses to reference the state’s prescription drug monitoring database before prescribing a controlled substance? If so, what are they?
State Prescription Drug Monitoring Program (PDMP):
Research your state’s PDMP* and provide the following information:
Name of the state’s program.
Website for the state PMDP.
Discuss the registration requirements and process.
Discuss the standards and procedures for the access and review of database information.
State specific laws on medical devices prescribing for the nurse practitioner:
Research your state laws on advanced practice nurses’ authority to prescribe medical devices. These are also called Durable Medical Equipment (DME). Based on research done on the state where you will practice clinically, include the following:
Identify the law, rule, code, or statute that describes the advanced practice nurse’s authority to prescribe medical devices or DME in your state.
Discuss the provisions of the law, rule, code, or statute regarding the following:
Conditions or limits on prescribing medical devices or DME.
Requirements (if any) in documentation needed to support order of medical devices or DME.
Rubric
State specific guidelines and recommendations (35%):

Description

Points

Provide the name of your practicing state’s organization, group or task force that created guidelines or recommendations for pain management therapies and education.

5

Where you found this information (weblink):

5

Overview of your state’s guideline development with web address.

6

Locate federal guidelines and provide a link to federal guidelines you could use in practice as a NP

6

Provide a brief overview of the group’s recommendations or initiatives (provide link to where you found information).

6

Provide a brief overview of the guidelines published by the American Pain Society OR Centers for Disease Control and Prevention (provide link to where you found information).

6

Discuss when the use of opioids is appropriate and for what duration should they be prescribed? Provide a reference for your response. (This question is worth 10 points. 4 points for when opioids are appropriate, 4 points for a safe duration of use, and 2 points for a current edition APA formatted reference.)

10

Total

44

 

State specific laws on controlled substance prescribing for the nurse practitioner (28%):

Description

Points

Identify the law, rule, code, or statute that describes the advanced practice nurse’s authority to prescribe controlled substances in your state. Link to where you found law, rule, code, or statute for your state.

5

What does the law, rule, code, or statute say?

6

Conditions or limits on prescribing schedule I-V controlled substances.

6

Requirements (if any) in documentation for treating acute and chronic pain. If your state has no requirements for this, confirm with a link of where you found this information.

6

Are there specific requirements for advanced practice nurses to reference the state’s prescription drug monitoring database before prescribing a controlled substance? Yes or No

6

If yes, what are they? If not, how would they be helpful?

6

Total

35

 

State Prescription Drug Monitoring Program (PDMP) (19%):

Description

Points

Name of the state’s program.

6

Website for the state PMDP.

6

Discuss the registration requirements and process.

6

Discuss the standards and procedures for the access and review of database information.

6

Total

24

 

State specific laws on medical devices prescribing for the nurse practitioner (18%):

Description

Points

Link to where you found law, rule, code, or statute for your state regarding prescribing DME in your state.

5

What does the law, rule, code, or statute say regarding prescribing DME in your state?

6

Conditions or limits on prescribing medical devices or DME.

6

Requirements (if any) in documentation needed to support order of medical devices or DME.

5

Total

22

Rubric
Week 2: State Specific Guideline Rubric

Week 2: State Specific Guideline Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning Outcome Provide the name of your practicing state’s organization, group or task force that created guidelines or recommendations for pain management therapies and education.

5 pts

Complete

0 pts

Incomplete

5 pts

This criterion is linked to a Learning Outcome Where you found this information (weblink):

5 pts

Complete

0 pts

Incomplete

5 pts

This criterion is linked to a Learning Outcome Overview of your state’s guideline development with web address.

6 pts

Complete

0 pts

Incomplete

6 pts

This criterion is linked to a Learning Outcome Locate federal guidelines and provide a link to federal guidelines you could use in practice as a NP

6 pts

Complete

0 pts

Incomplete

6 pts

This criterion is linked to a Learning Outcome Provide a brief overview of the group’s recommendations or initiatives (provide link to where you found information).

6 pts

Complete

0 pts

Incomplete

6 pts

This criterion is linked to a Learning Outcome Provide a brief overview of the guidelines published by the American Pain Society OR Centers for Disease Control and Prevention (provide link to where you found information).

6 pts

Complete

0 pts

Incomplete

6 pts

This criterion is linked to a Learning Outcome Discuss when the use of opioids is appropriate and for what duration should they be prescribed? Provide a reference for your response. (This question is worth 10 points. 4 points for when opioids are appropriate, 4 points for a safe duration of use, and 2 points for a current edition APA formatted reference.)

10 pts

Complete

0 pts

Incomplete

10 pts

This criterion is linked to a Learning Outcome Identify the law, rule, code, or statute that describes the advanced practice nurse’s authority to prescribe controlled substances in your state. Link to where you found law, rule, code, or statute for your state.

5 pts

Complete

0 pts

Incomplete

5 pts

This criterion is linked to a Learning Outcome What does the law, rule, code, or statute say?

6 pts

Complete

0 pts

Incomplete

6 pts

This criterion is linked to a Learning Outcome Conditions or limits on prescribing schedule I-V controlled substances.

6 pts

Complete

0 pts

Incomplete

6 pts

This criterion is linked to a Learning Outcome Requirements (if any) in documentation for treating acute and chronic pain. If your state has no requirements for this, confirm with a link of where you found this information.

6 pts

Complete

0 pts

Incomplete

6 pts

This criterion is linked to a Learning Outcome Are there specific requirements for advanced practice nurses to reference the state’s prescription drug monitoring database before prescribing a controlled substance? Yes or No

6 pts

Complete

0 pts

Incomplete

6 pts

This criterion is linked to a Learning Outcome If yes, what are they? If not, how would they be helpful?

6 pts

Complete

0 pts

Incomplete

6 pts

This criterion is linked to a Learning Outcome Name of the state’s program.

6 pts

Complete

0 pts

Incomplete

6 pts

This criterion is linked to a Learning Outcome Website for the state PMDP.

6 pts

Complete

0 pts

Incomplete

6 pts

This criterion is linked to a Learning Outcome Discuss the registration requirements and process.

6 pts

Complete

0 pts

Incomplete

6 pts

This criterion is linked to a Learning Outcome Discuss the standards and procedures for the access and review of database information.

6 pts

Complete

0 pts

Incomplete

6 pts

This criterion is linked to a Learning Outcome Link to where you found law, rule, code, or statute for your state regarding prescribing DME in your state.

5 pts

Complete

0 pts

Incomplete

5 pts

This criterion is linked to a Learning Outcome What does the law, rule, code, or statute say regarding prescribing DME in your state?

6 pts

Complete

0 pts

Incomplete

6 pts

This criterion is linked to a Learning Outcome Conditions or limits on prescribing medical devices or DME.

6 pts

Complete

0 pts

Incomplete

6 pts

This criterion is linked to a Learning Outcome Requirements (if any) in documentation needed to support order of medical devices or DME.

5 pts

Complete

0 pts

Incomplete

5 pts       

Assignment: NR565 Week2 State Specific Guidelines for Prescribing Controlled Substances Medical Devices Sample

Complete the following table with information specific to the state where you plan to practice as a nurse practitioner. Please refer to the rubric in the course to identify how much each prompt is worth.  Most are worth 5 or 6 points with one question being worth 10 points.  The 10-point question is noted in the table.

• Sources should be obtained directly from the state’s regulatory organization(s) and must be cited appropriately.
• It is recommended that you keep a copy of this paper to provide to potential employers or your Board of Nursing to demonstrate your knowledge of your state laws.
  

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Guidelines and recommendations for your state: In response to the opioid epidemic, individual states have developed and adopted voluntary guidelines or recommendations for the treatment of acute and chronic non-cancer pain. Based on research done on the state where you will practice clinically, include the following:
Provide the name of your practicing state’s organization, group, or task force that created guidelines or recommendations for pain management therapies and education.	Organization, group, or task force name Discuss when the use of opioids is appropriate and for what duration they should be prescribed   Virginia follows the guidelines and recommendations for pain management provided by the Centers for Disease Control and Prevention (CDC)	Where you found this information (weblink): https://doi.org/10.15585/mmwr.rr7103a1
Briefly describe an overview of its development and include a web address where this information can be found. If your state does not have guidelines, discuss a federal guideline. (Note: you may need to contact your state’s board of nursing, pharmacy, or medicine if you cannot locate it on your own).	Overview of your state’s guideline development with web address. Virginia does not have its guidelines for pain management and instead relies on the guidelines provided by the CDC, a federal organization. The most recent CDC guidelines for pain management and prescribing opioids for outpatients aged 18 and over were published on November 4th, 2022, as an update to the CDC’s 2016 guidelines for prescribing opioids for chronic pain. These guidelines cover the management of acute, subacute, and chronic pain but do not apply to pain related to sickle-cell disease or cancer. The CDC used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to develop the guidelines, which are based on systematic reviews of the scientific evidence and take into account benefits and harms, patient and clinician values and preferences, and resource allocation. The CDC also received input from a range of groups, including the Board of Scientific Counselors of the National Center for Injury Prevention and Control, the public, and peer reviewers. The CDC advises that the recommendations should not be used as inflexible standards of care for all patients but rather should be considered and adapted based on each patient’s unique circumstances.	Locate federal guidelines and provide a link to federal guidelines you could use in practice as an NP As a nurse practitioner, I would refer to the CDC guidelines on pain management in my practice. The guidelines can be accessed through the attached link. https://doi.org/10.15585/mmwr.rr7103a1
Some states have multiple organizations or initiatives (ex: Ohio) in place to combat the opioid epidemic and advocate for safer opioid prescribing. Explore whether your state has other resources, groups, or organizations where prescribers can reference best practices for pain management treatment. If applicable, provide a brief overview of the group’s recommendations or initiatives. If your state does not have another state-specific resource, discuss the guidelines published by the American/ Pain Society OR Centers for Disease Control and Prevention.	Provide a brief overview of the group’s recommendations or initiatives (provide a link to where you found information). In recognition of the negative impact of the opioid epidemic on health and communities, Virginia has developed a valuable resource called the Virginia Framework for Addiction Analysis and Community Transformation (FAACT). In 2019, FAACT was named the best in its class among the Government Innovation Awards (Bittner, 2020). FAACT is a data platform that combines datasets from various organizations, including law enforcement, the judiciary, and the healthcare system, to provide insights into the factors contributing to opioid abuse and to develop effective strategies for addressing the epidemic. The data collected includes information on opioids, criminal activity, and illegal drug use. By analyzing this data, first responders can gain a better understanding of the patterns of opioid abuse in their communities and develop targeted interventions to prevent and reduce abuse (Bittner, 2020). For example, data visualization may reveal that drug abusers in a particular county are more likely to use drugs on certain days of the week. If this pattern is identified, officials can plan outreach initiatives or other interventions for those specific days to try to prevent opioid abuse (Bittner, 2020). Additionally, the data can be used to improve treatment for those struggling with opioid addiction. Suppose the data show that there is a link between childhood trauma and later drug addiction. In that case, healthcare providers can use this information to make recommendations to help prevent future addiction and misuse of opioids.	Provide a brief overview of the guidelines published by the American Pain Society OR Centers for Disease Control and Prevention (provide a link to where you found information). The CDC recommends considering the following when prescribing opioids for pain management: deciding whether or not to initiate treatment with opioids, choosing appropriate opioids and dosages, determining the length of the initial prescription, and evaluating the risks and potential harms of opioid use. These recommendations can be found on the CDC’s website. https://www.cdc.gov/opioids/patients/guideline.html
Discuss when the use of opioids is appropriate and for what duration should they be prescribed. Provide a reference for your response. (This question is worth 10 points. 4 points for when opioids are appropriate, 4 points for a safe duration of use, and 2 points for a current edition APA formatted reference)	The CDC recommends a cautious approach to the use of opioids for pain management. For acute pain, the CDC recommends that healthcare providers try non-pharmacological interventions and non-opioid medications first, and only consider using opioids in cases of 1.    Severe traumatic injuries, such as crush injuries and burns (Dowell et al., 2022) 2.    Invasive surgeries associated with moderate to severe postoperative pain (Dowell et al., 2022) 3.    Severe acute pain where nonsteroidal anti-inflammatory drugs (NSAIDs) or other therapies are contraindicated or are likely to be ineffective (Dowell et al., 2022) 4.    Opioids may also be considered for the management of subacute and chronic pain, but the CDC advises that the benefits and risks of using opioids in these cases should be carefully weighed. The CDC recommends that healthcare providers evaluate the benefits and harms of opioid therapy within 1 to 4 weeks of starting the medication and re-evaluate the benefits and harms of continued therapy with patients every 3 months or more frequently (Dowell et al., 2022). If the benefits of using opioids do not outweigh the risks, the CDC advises healthcare providers to optimize other therapies and work with patients to taper their opioid doses or discontinue the medications. However, the CDC advises against abrupt discontinuation of opioids, as this can lead to acute withdrawal symptoms, serious psychological distress, exacerbation of pain, and thoughts of suicide. Instead, the CDC recommends a gradual tapering process to minimize these risks.
State-specific laws on controlled substance prescribing for the nurse practitioner: Research your state laws on advanced practice nurses’ authority to prescribe controlled substances. Based on research done on the state where you will practice clinically, include the following:
Identify the law, rule, code, or statute that describes the advanced practice nurse’s authority to prescribe controlled substances in your state.	Link to where you found law, rule, code, or statute for your state. https://law.lis.virginia.gov/vacode/title54.1/chapter29/section54.1-2957.01/	What does the law, rule, code, or statute say? The law titled “§ 54.1-2957.01. Prescription of certain controlled substances and devices by licensed nurse practitioners” outlines several provisions related to the prescribing authority of nurse practitioners in Virginia. According to the law, licensed nurse practitioners (NPs) have the authority to prescribe schedule II through schedule VI controlled substances and devices. NPs who do not meet the requirements for practice without a written or electronic practice agreement must prescribe controlled substances or devices only if such prescribing is authorized by a written or electronic practice agreement with a patient care team physician or if the NP is licensed as a clinical nurse specialist, with a licensed physician. The law also directs the Boards of Medicine and Nursing to promulgate regulations governing the prescriptive authority of NPs as necessary to ensure an appropriate standard of care for patients. There are no limits on the functions and procedures of certified RN anesthetists or NPs who are otherwise authorized by law or regulation. Additionally, the law includes restrictions on NPs who are authorized to prescribe drugs and devices, including the requirement to disclose their NP status to patients at the initial encounter and the requirement that physicians do not serve as patient care team physicians for more than six NPs at a time.   The information was obtained from the Virginia General Assembly website and the link to the source is provided on the left.
Discuss the provisions of the law, rule, code, or statute regarding the following:	Conditions or limits on prescribing schedule I-V controlled substances. According to Virginia state law, nurse practitioners who are licensed to practice have the authority to prescribe Schedule II through Schedule VI controlled substances and devices (Virginia General Assembly, 2023a)	Requirements (if any) in the documentation for treating acute and chronic pain. If your state has no requirements for this, confirm with a link to where you found this information. The Virginia state law on the treatment of acute pain with opioids includes provisions on the initiation of opioid treatment for patients with acute pain, including the use of short-acting opioids and limits on the supply of controlled substances containing opioids that can be prescribed. The law also requires practitioners to consider and document the reasons for prescribing doses of opioids that exceed 50 MME per day and to consult with a pain management specialist or document reasonable justification for doses exceeding 120 MME per day (Virginia General Assembly, 2023b). The law also requires the prescription of naloxone for certain patients at risk of overdose and limits the co-prescribing of opioids with certain other medications due to the increased risk of fatal overdose (Virginia General Assembly, 2023c). Buprenorphine is generally not indicated for acute pain in the outpatient setting, except in cases where a prescriber with a SAMHSA waiver is treating a patient with a primary diagnosis of addiction.   When treating patients with chronic pain, Virginia state law requires healthcare practitioners to consider non-pharmacologic and non-opioid treatment options before prescribing opioids. When initiating and treating with opioids, practitioners must carefully consider and document the reasons for prescribing doses exceeding 50 MME per day, consult with a pain management specialist or document reasonable justification for doses exceeding 120 MME per day, prescribe naloxone for certain patients at risk of overdose, and document the rationale for continuing opioid therapy every three months (Virginia General Assembly, 2023b). Buprenorphine mono-product in tablet form is not to be prescribed for chronic pain, and co-prescribing of opioids with certain other medications is generally not allowed due to the increased risk of fatal overdose. Practitioners must also regularly evaluate patients for opioid use disorder and initiate treatment, consult with an appropriate healthcare provider, or refer the patient for evaluation and treatment if indicated.
Are there specific requirements for advanced practice nurses to reference the state’s prescription drug monitoring database before prescribing a controlled substance?	Yes, or No Yes	If yes, what are they? If not, how would they be helpful? In Virginia, advanced practice nurses and other practitioners who are authorized to prescribe controlled substances are required by law to register with and use the state’s Prescription Monitoring Program (PMP) database when prescribing controlled substances. This includes consulting the PMP before prescribing a controlled substance to a patient for the first time, before prescribing a controlled substance for the treatment of chronic pain, and before prescribing a controlled substance for a patient who is receiving a prescription for a benzodiazepine or an opioid (Virginia Prescription Monitoring Program, 2021). For patients receiving a controlled substance prescription for chronic pain, practitioners must also consult the PMP at least once every 90 days unless the prescription is for a schedule III or schedule IV controlled substance that is not an opioid (Virginia Prescription Monitoring Program, 2021)
State Prescription Drug Monitoring Program (PDMP): Research your state’s PDMP* and provide the following information:
Name of the state’s program.	Virginia Department of Health Professions Prescription Monitoring Program
Website for the state PMDP.	Login – VA PMP AWA℞E (pmpaware.net)
Discuss the registration requirements and process.	To complete the registration process, the following requirements and procedures are followed 1.    Complete the PMP registration form: Practitioners can request a PMP registration form by contacting the PMP at 877-473-4858 or by visiting the PMP website at Login – VA PMP AWA℞E (pmpaware.net) 2.    Submit the completed form: Practitioners should submit the completed form to the PMP by email, fax, or mail. 3.    Wait for approval: Once the PMP receives the completed registration form, it will review the form and determine whether the practitioner is eligible to register. If the practitioner is approved, the PMP will send a notification with instructions on how to access the PMP database. 4.    Activate the account: Once the practitioner receives the notification from the PMP, they can follow the instructions provided to activate their account and begin using the PMP database.
Discuss the standards and procedures for the access and review of database information.	Access to the Virginia Department of Health Professions PMP database is restricted to authorized practitioners who are registered with the PMP and meet certain requirements, such as being licensed to prescribe controlled substances in Virginia and having a DEA registration number or a Virginia-specific controlled substances registration number. To access and review the database, practitioners must follow certain procedures and maintain the confidentiality of the information contained within it. The PMP may also conduct audits and reviews of practitioners’ use of the database to ensure compliance with laws and regulations.
State-specific laws on medical devices prescribing for the nurse practitioner: Research your state laws on advanced practice nurses’ authority to prescribe medical devices.  These are also called Durable Medical Equipment (DME).  Based on research done on the state where you will practice clinically, include the following:
Identify the law, rule, code, or statute that describes the advanced practice nurse’s authority to prescribe medical devices or DME in your state.	Link to where you found law, rule, code, or statute for your state regarding prescribing DME in your state. https://law.lis.virginia.gov/vacode/title54.1/chapter29/section54.1-2957.01/	What does the law, rule, code, or statute say regarding prescribing DME in your state? According to Virginia state law, advanced practice nurses have the authority to prescribe medical devices or durable medical equipment (DME) in addition to Schedule II to Schedule VI controlled substances.
Discuss the provisions of the law, rule, code, or statute regarding the following:	Conditions or limits on prescribing medical devices or DME. The law requires advanced practice nurses to meet certain requirements to prescribe controlled substances or devices, including entering into a written or electronic practice agreement with a patient care team physician or licensed physician.	Requirements (if any) in documentation needed to support the order of medical devices or DME. There are no specific requirements for documentation to support the ordering of medical devices or DME in Virginia

References

Bittner, J. (2020, February 27). How Virginia communities fight the opioid epidemic. GCN. https://gcn.com/data-analytics/2020/02/how-virginia-communities-fight-the-opioid-epidemic/291177/

CDC. (2022, November 2). Summary of the 2022 clinical practice guideline for prescribing opioids for pain. Cdc.gov. https://www.cdc.gov/opioids/patients/guideline.html

Dowell, D., Ragan, K. R., Jones, C. M., Baldwin, G. T., & Chou, R. (2022). CDC clinical practice guideline for Prescribing Opioids for pain – United States, 2022. Recommendations and Reports: Morbidity and Mortality Weekly Report, 71(3), 1–95. https://doi.org/10.15585/mmwr.rr7103a

Virginia General Assembly. (2023a). § 54.1-2957.01. Prescription of certain controlled substances and devices by licensed nurse practitioners. Virginia.gov. https://law.lis.virginia.gov/vacode/title54.1/chapter29/section54.1-2957.01/

Virginia General Assembly. (2023b). 18VAC85-21-70. Treatment of chronic pain with opioids. Virginia.gov. https://law.lis.virginia.gov/admincode/title18/agency85/chapter21/section70/

Virginia General Assembly. (2023c). 18VAC90-40-160. Treatment of acute pain with opioids. Virginia.gov. https://law.lis.virginia.gov/admincode/title18/agency90/chapter40/section160/

Virginia Prescription Monitoring Program. (2021). 2021 annual report Virginia prescription monitoring program. Virginia.gov. https://www.dhp.virginia.gov/media/dhpweb/docs/pmp/reports/PMPAnnual_2021.pdf