AGENDA

Advisory Committee on Advanced Practice Registered Nursing November 9, 2021

10:00 a.m. to 2:30 p.m.

Charge: The committee shall advise the Board regarding the practice and regulation of advanced practice registered nurses and may make recommendations to the Committee on Prescriptive Governance. 1. Welcome/Introductions/Announcements 10:00 a.m.-10:10 a.m. 2. Election of Advisory Committee Chair 10:10 a.m.-10:30a.m.

3. Public Comments 10:30 A.M.-11:00 a.m.

4. Legislative Report 11:00 p.m.-11:30 p.m.

Lunch 11:30 -12:15

5. APRN Licensure and Practice: Review Requested Update 12:15 p.m.-12:45 p.m.

6. General Information/Updates 12:45 p.m.-1:20 p.m.

a. Interim Executive Director: Charity Robl b. Board of Nursing Offices/Contact c. RN/APRN 2021 Renewal Period d. Update Initial APRN Application and Application Guidance e. Sample/Summary of APRN Practice Questions Received

7. Agenda Building for 2022 1:20 p.m.- 1:40 p.m.

8. Schedule 2022 Meetings: 1:40 p.m. -2:00 p.m.

9. Other/Adjourn 1:55 p.m.- 2:15 p.m.

The Board’s Committee on Advanced Practice Registered Nursing meeting is being held in person at the Board of Nursing offices. The meeting will also be streamed live via You Tube. The link to the meeting on YouTube will be available to the public on the homepage of the Board’s website.

https://www.youtube.com/channel/UCiflxnHvbm3yayo1dkGsA0w.

Written comments may be submitted regarding re the meeting’s topics in advance of the meeting by email to PracticeAPRN@nursing.ohio.gov with “COMMITTEE” in the subject line. Written comments and questions must be received no later than 8:00 a.m. November 9, 2021, so that they may be distributed to the committee members to review prior to the meeting.

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MEMORANDUM

To: Members, Ohio Board of Nursing

From: Tom Dilling, Public and Government Affairs Officer/Liaison Betsy Houchen, Executive Director

Subject: Legislation, 134th General Assembly

Date: September 14, 2021

HB 122, Telehealth HB 122 was introduced on February 16, 2021. The bill was passed by the House on April 15, 2021. The bill is scheduled to be heard in Senate Health Committee for the first time on September 15, 2021. The bill generally provides for the use of telehealth services by health care professionals:

• Permits specified health care professionals to provide telehealth services.• Requires telehealth services provided by health care professionals to be done according to

specified conditions and standards.• Permits certain health care licensing boards to adopt rules as necessary to carry out the bill’s

provisions regarding telehealth services provided by health care professionals.• Provides that a health care professional is not liable in damages under a claim that the

telehealth services provided do not meet the standard of care that would apply if services wereprovided in-person.

• Permits a health care professional to negotiate with a health plan issuer to establish areimbursement rate for fees associated with the administrative costs of providing telehealthservices.

The bill explicitly requires a health plan issuer to reimburse a health care professional for a covered telehealth service, but the bill does not require a specific reimbursement amount. The bill allows the Superintendent of Insurance to adopt rules as necessary to carry out the bill’s requirements relating to insurance coverage of telehealth services. Under the bill, these rules are exempt from the existing requirement that an agency remove two rules for each new rule it implements. the bill renames the existing term “telemedicine services” as “telehealth services,” but substantively retains the existing definition: providing health care services using information and communication technology by a health care professional, within the professional’s scope of practice, who is located at a site other than the site where the recipient (either the patient or a consulting health care professional) is located.

The bill establishes several conditions regarding the provision of telehealth services by a health care professional. Each professional may use synchronous or asynchronous technology to provide telehealth services to a patient during an initial visit if the appropriate standard of care for an initial visit is satisfied. Additionally, a professional may use synchronous or asynchronous technology to provide telehealth services to a patient during an annual visit if the appropriate standard of care for an annual visit is satisfied. A health care professional may also deny any patient telehealth services and instead require the patient to undergo an in-person visit.

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When a health care professional is providing telehealth services, the bill requires the professional to comply with all state and federal law requirements concerning the protection of patient information. Additionally, a health care professional must ensure that any username or password information and electronic communications transmitted between the professional and a patient are securely transmitted and stored.

The bill specifies that if a health care professional is a physician, physician assistant, or advanced practice registered nurse, the health care professional may provide telehealth services to a patient located outside of Ohio if the health care professional is permitted to do so by the laws of the state in which the patient is located. Under the bill, these health care professionals may also provide telehealth services using medical devices that enable remote monitoring of a patient. The bill notes that its provisions do not eliminate or modify any other provisions of the Revised Code that require a health care professional, who is not a physician, to practice under the supervision of, in collaboration with, in consultation with, or pursuant to the referral of another health care professional.

Board position: The Board is an interested party to this legislation. APRNs are specifically named in the bill as an eligible provider of telehealth services.

HB 138, Emergency Medical Services HB 138 was introduced on February 18, 2021. The House passed the bill on June 23, 2021. The bill has been referred to Senate Health. The bill modifies the scope of emergency medical services that may be provided by first responders, emergency medical technicians-basic, emergency medical technicians-intermediate, and paramedics (EMS personnel). Existing law enumerates the services that each type of EMS personnel may provide. The bill eliminates this enumeration and, instead, requires the State Board of Emergency Medical, Fire, and Transportation Services to establish the scope of emergency medical services for each type of EMS personnel through the rulemaking process. The bill makes two additional changes related to the practice of EMS personnel. First, the bill permits EMS personnel to comply with a do-not-resuscitate (DNR) order issued by a physician assistant or advanced practice registered nurse rather than to comply with a DNR order only when issued by a physician. Second, the bill requires the medical director or cooperating physician advisory board of each EMS organization to establish protocols to be followed by EMS personnel when providing all services. Current law requires that these protocols be established only for circumstances when communications fail or are prevented, and a patient’s life is in immediate danger.

Board position: The Board is an interested party to this legislation.

HB 142, Regards Doula Services HB 142 was introduced on February 23, 2021. The bill was initially referred to the House Health Committee and re-referred to the House Families, Aging, and Human Services Committee on or about May 5, 2021. The bill has been heard twice in that Committee. The bill would create a doula advisory board within the Nursing Board in a four-year pilot program, as well as a path for doulas to become professionally certified. These paths are augmented by the creation of four-year pilot programs in Medicaid to support payments for doula services and a four-year pilot program in the Department of Rehabilitation and Corrections to support doula nursery services in prisons. Doulas are individuals who provide emotional support to expectant mothers and families. They are non-clinical and do not deliver infants, but they can provide education about parenting and children to families.

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Board position: The Board is an interested party to this legislation. Board staff met in June with the Rep. Crawley and with legislative staff to discuss technical clarifications to the bill and related research that may be helpful. Rep. Crawley resigned from the Ohio legislature in June 2021 to fill a seat on the Franklin County Board of Commissioners. HB 176, Revise Athletic Training Laws HB 142 was introduced on March 4, 2021. The House passed a substitute version of the bill on May 5, 2021. The bill would revise the law governing the practice of athletic training and to amend the version of section 4755.62 of the Revised Code that is scheduled to take effect on October 9, 2021, to continue the changes to that section on and after that date. With respect to the activities and services that an athletic trainer is permitted to perform under current law, the bill maintains these for each athletic trainer who opts not to practice under a collaboration agreement. But, for an athletic trainer who enters into a collaboration agreement with a physician or podiatrist, the bill authorizes such a trainer to engage in additional activities and services. The bill would authorize the athletic trainer to practice under the referral of a certified nurse practitioner. Board position: The Board is an interested party to this legislation. HB 193, Electronic Prescriptions HB 193 was introduced on March 9, 2021. The House passed a substitute version of the bill on June 23, 2021. The bill has been referred to the Senate Health Committee. The bill generally limits pharmacist dispensing of schedule II-controlled substances to those prescribed electronically, rather than in writing or electronically as under current law, with exceptions for technical failures, nursing home and hospice care, and cases in which an electronic prescription may cause a delay in care. In 2018, Congress passed the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, which requires electronic prescribing for schedule II-V controlled substances covered under a Medicare Part D or Medicare Advantage prescription drug plan beginning January 1, 2021. Board position: The Board is monitoring this legislation. HB 203 and SB 131, Licensure Reciprocity HB 203 was introduced on March 4, 2021, and the bill has had three hearings in the House State and Local Government Committee. SB 131 was introduced on March 16, 2021, and the bill was referred to Senate Workforce and Higher Education Committee on March 17, 2021, where the bill has had two hearings. The bills would require an occupational licensing authority to issue a license or government certification to an applicant who holds a license, government certification, or private certification or has satisfactory work experience in another state under certain circumstances. The three circumstances under which a licensing authority must issue a license or government certification include “Issuance to out-of-state license or government certification holders,” “Issuance to private certification holders,” and “Issuance to individuals with satisfactory work experience.” Board position: The Board is an interested party to this legislation. Following SB 3 becoming law this year, the Board should seek exemption from these bills as the preferred route to better facilitate consistent professional licensure portability between states. HB 286 and SB 189, Agency Order Appeal—Local Court of Common Pleas HB 286 was introduced on May 4, 2021. The bill was reported out of House Civil Justice Committee on June 22, 2021, after 5 committee hearings. SB 189 was introduced on May 26, 2021, and has been heard one time in Senate Judiciary Committee. The bills would eliminate the current provision that an appeal from an order issued by any of the following agencies be made to the Franklin County Court of Common Pleas (Franklin County CCP): (1) Liquor Control Commission, (2) Ohio Casino Control Commission, (3) State Medical Board, (4) State Chiropractic Board, (5) Board of Nursing, and (6)

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Bureau of Workers’ Compensation regarding participation in the health partnership program administered by the Bureau. Board position: The Board is an interested party to this legislation. HB 402, Ohio Midwife Practice Act HB 402 was introduced on August 24, 2021, proposing to regulate the practice of certified professional midwives. The bill would establish licensing provisions for certified professional midwives and create a stand-alone board to regulate their practice. The scope of practice in statute would authorize the prescription and use of certain drugs by the professional midwife. Board position: The Board is an interested party to this legislation. SB 151, Infant Medical Treatment SB 151 was introduced on March 31, 2021. The bill is assigned to Senate Health and had its first hearing on June 2, 2021. The bill establishes standards and conditions regarding the medical care and treatment provided to certain pregnant women and infants by hospitals and physicians. These standards and conditions must be satisfied when care and treatment are provided to any of the following: A woman who is at least 21 weeks pregnant but not more than 26 weeks pregnant; A woman who is less than 21 weeks pregnant but has reached a point in the pregnancy for which an infant’s survival has been demonstrated; A woman who is pregnant and expecting an infant with a disability; and an infant who is delivered of a woman described above. The standards and conditions of care that a hospital or physician must adhere to when providing care and treatment to one of the above-described individuals depends on the location in which the care and treatment take place. Board position: The Board is monitoring this legislation.

_________________________ Additional information and details related to the content and status of any state bill mentioned in the legislative report may be found at https://www.legislature.ohio.gov/legislation/search. The Health Policy Institute of Ohio has released a new fact sheet that outlines actions state and local policymakers can take to support the health and well-being of Ohioans of color and move Ohio toward a more economically vibrant and healthier future. The fact sheet, titled “State and Local Policymakers: Ensuring Ohioans of Color Have a Fair Opportunity for Good Health,” is the first in a series of three that provides action steps that can be taken to address the health impacts of racism (see attached). The publication highlights eight action steps that policymakers can take, including examples from policymakers in Ohio and across the country. Also attached, please find a copy of HPIO’s Policy Brief entitled “Connections between racism and health: Taking action to eliminate racism and advance equity.”

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PB 1

09.10.2021

Health Policy Fact SheetTM

State and local policymakers Ensuring Ohioans of color have a fair opportunity for good health

Connections between racism and health

Why is action needed?Ensuring that every Ohioan has a fair opportunity to achieve good health and well-being is a

shared value in both the public and private sectors. However, Ohioans of color continue to face

barriers to health where they live, work, learn, play and age. These barriers are tied to centuries

of unjust historical and modern-day policies, practices and beliefs, whether intentional or

unintentional, that are rooted in racism. Allowing these barriers to continue to exist will only result

in a more economically unstable and unhealthy Ohio.

7KLV�IDFW�VKHHW��WKH�ÀUVW�RI�D�VHULHV�RI�WKUHH��RXWOLQHV�DFWLRQV�SROLF\PDNHUV�FDQ�WDNH�WR�VXSSRUW�WKH�health and well-being of Ohioans of color and move Ohio toward a more economically vibrant

and healthier future. The remaining two fact sheets will provide information on how private

sector partners, community groups and individuals can take action to advance equitable

opportunities for Ohioans of color.

Why do Ohioans of color face barriers to health? Unjust historical and modern-day policies and practices have led to a cascade of

consequences that channel stress into communities of color and limit opportunities for good

health. For example, decades of racist housing policies, such as historical redlining and present-

day predatory lending practices, have resulted in neighborhood segregation, concentrated

poverty and disinvestment from Black communities in Ohio that continue to this day.1

As a result, Ohioans of color are more likely to experience harmful community conditions — such

as food deserts and unsafe, unstable housing — that impact health.2 These conditions, rooted in

FXUUHQW�DQG�SDVW�UDFLVW�SROLFLHV�DQG�SUDFWLFHV��PDNH�LW�PRUH�GLIÀFXOW�IRU�FRPPXQLWLHV�WR�DFFHVV�healthy foods or provide safe spaces for children to learn, grow and play. These policies and

practices have also perpetuated racist stereotypes and beliefs that diminish the potential of

2KLRDQV�RI�FRORU�WR�VXFFHHG��7KH�ÀJXUH�EHORZ�KLJKOLJKWV�WKH�LPSDFW�RQ�2KLRDQV�LI�WKH�SOD\LQJ�ÀHOG�ZDV�OHYHOHG�E\�DGYDQFLQJ�IDLU�SROLFLHV�DQG�SUDFWLFHV�

13,373 Hispanic children and 58,507 Black children would

not experience food insecurity

13,746 Hispanic Ohioans and 116,923 Black Ohioans would

have broadband internet access

7,143 Hispanic Ohioans and 68,009 Black Ohioans would not spend more than 50% of their income on housing

15,881 Hispanic children and 47,255 Black children would

not be treated unfairly due to their race

According to analysis from the 2021 Health Value Dashboard��LI�WKH�SOD\LQJ�ÀHOG�ZDV�OHYHOHG���

Food insecurity

Internet access

Housing affordability

Unfair treatment

Source: Health Policy Institute of Ohio. 2021 Health Value DashboardTM�(TXLW\�3URÀOHV��April 2021. See methodology section for more details.

1

5

1.3.1

PB 1

OverviewData and research evidence are clear that racism is a systemic and ongoing crisis with serious consequences for the health and wellbeing of Ohioans.

In recent months, the link between racism and health has come to the forefront of public discussion as COVID-19 infections, hospitalizations and deaths have disproportionately a!ected Ohioans of color. At the same time, Ohio and the rest of the nation are grappling with weeks of protests and public calls to address racism in light of the disparate and excessive use of police force against communities of color. These issues have exposed the many obstacles communities of color face, including higher rates of poverty, exposure to environmental hazards and overall poor health outcomes.

As state and local leaders commit to address racism as a public health crisis, this publication outlines action steps that can be taken to eliminate racism and advance equity. This brief provides: • A definition and explanation of racism • A brief summary of research on the connections

between racism and health • Action steps that individuals, groups, private

organizations and state and local government leaders can take to eliminate racism and advance equity

Why should we focus on racism? Ohio consistently ranks among the bottom half of states on measures of health and wellbeing. For example, Ohio ranks 38 out of 50 states on America’s Health Rankings 2019 report. In the Health Policy Institute of Ohio’s 2019 Health Value Dashboard, Ohio ranks 46 out of 50 states and D.C. on health value, a composite measure of population health and healthcare spending, landing in the bottom quartile. This means that Ohioans are less healthy and spend more on health care than people in most other states.

A key reason for Ohio’s poor performance is that many Ohioans, particularly communities of color, face barriers to health. Ohio is in the bottom quartile (42 out of 50 states) for African-American child wellbeing based on the Annie E. Casey Foundation 2017 Race for Results Report, indicating that Black/African-American children in Ohio do not have adequate supports to achieve optimal health.

Equally concerning, the 2019 Health Value Dashboard·V�HTXLW\�SURÀOHV�VKRZ�WKDW�2KLRDQV�of color face large gaps in outcomes across socio-economic factors, community conditions and health care. This, in turn, drives poorer health outcomes among Ohioans of color, such as higher rates of infant mortality and premature death.

08.14.2020updated 09.09.2021

3 key findings for policymakers

• Racism is a health crisis. The research is clear that racism is an ongoing crisis resulting in inequities and disparities that have led to serious consequences for the health and wellbeing of Ohioans of color.

• Racism manifests directly and indirectly across all levels of society. Most conversations on racism focus on the individual level (internalized or interpersonal racism). However, systemic racism (institutional or structural) is an even more pervasive driver of the poor outcomes faced by communities of color.

• Many opportunities to dismantle racism exist. While addressing the impact of hundreds of years of racism in our country is daunting, progress is possible and there are multiple opportunities for action.

Health Policy BriefTM

Connections between racism and healthTaking action to eliminate racism and advance equity

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MEMORANDUM TO: Members, Advisory Committee on Advanced Practice Registered Nursing FROM: Lisa Emrich, Program Manager Anita DiPasquale, Staff Attorney DATE: November 4, 2021 RE: Draft Revision to APRN Practice and Licensure in Ohio Attached for review is the draft revised copy of the APRN Practice and Licensure in Ohio document. The revisions are tracked, and reflect changes and updates recommended by the committee. The revisions include:

• Addition of definitions and legal references regarding abortion as it pertains to the prohibitions of prescribing any drug or device to perform or induce an abortion. Page 7.

• Addition of information regarding APRNs entering into consult agreements with Pharmacists. Page 11.

• Edits to existing language regarding the APRN Consensus Model. Please note that a similar but alternative phrase is also noted in the document for your consideration. Page 17.

February 2021 1

APRN Licensure and Practice in Ohio (DRAFT REVISIONS) The purpose of this document is to provide licensees and the public an overview of license and practice requirements for APRNs established in the Nurse Practice Act (NPA), Ohio Revised Code Chapter 4723. and the administrative rules adopted by the Ohio Board of Nursing and is not intended to be all-inclusive. APRNs are responsible for knowing and complying with the NPA and rules, and any other applicable state and federal law.

The NPA and administrative rules are accessible on the Board website: www.nursing.ohio.gov under the “Law and Rules” section. This document is comprised of two parts. The first part is a summary of APRN information. The second part is “Frequently Asked Questions”.

Designations of APRNs in Ohio APRNs in Ohio may be designated as a: Certified Registered Nurse Anesthetist (CRNA); Certified Nurse-Midwife (CNM); Clinical Nurse Specialist (CNS); or Certified Nurse Practitioner (CNP). A separate APRN license is required for each designation. A RN may hold one or more APRN license designations.

Definitions “Nursing specialty” is defined by Section 4723.01(V), ORC, and Rule 4723-8-01(G), OAC, to mean a specialty in practice as a certified registered nurse anesthetist, clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner. (Emphasis added.)

“Practice of nursing as an advanced practice registered nurse” is defined by Section 4723.01(P), ORC, and Rule 4723-8-01(F) to mean providing to individuals and groups nursing care that requires knowledge and skill obtained from advanced formal education, training and clinical experience. Such nursing care includes the care described in Sections 4723.43, 4723.433, 4723.434, and 4723.435 of the Revised Code.

APRN Licensure The NPA establishes minimum requirements for APRN initial and continued licensure. The following summarizes the requirements for initial APRN licensure:

• An active Ohio RN license. • As of January 1, 2001, an earned masters or doctoral degree with a major in a

nursing specialty (nursing specialty equates to the applicable resulting national certification achieved) or in a related field that qualifies the nurse to sit for the certification examination of a national certifying organization approved by the Board.1

1 Except that, under 4723.41(B)(2), ORC, a CRNA, CNM, or CNP applicant who is practicing or has practiced in another jurisdiction is exempt from the educational requirements in 4723.41(A)(2), ORC, if all of the following are the case: (1) The applicant submits documentation that prior to January 1, 2001, they obtained certification in the applicant's nursing specialty with a qualified national certifying organization; and, (2) The applicant submits documentation satisfactory to the board that the applicant has maintained

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• As of January 1, 2001, a minimum of one current national certification in a nursing specialty/population focus by a national certifying organization approved by the Board that qualifies the nurse for the APRN designation and license.2

• For CNMs, CNSs and CNPs, proof of completion of a course that is not less than

45 contact hours in advanced pharmacology with content that meets Section 4723.482(B), ORC. The course must be completed no longer than five years prior to submitting the application for APRN licensure. Not all advanced pharmacology courses contain the content required by Section 4723.482(B), ORC, which may be completed through qualifying continuing education to meet the requirements for licensure.

• For CNMs, CNSs and CNPs applicants from another jurisdiction, proof of

prescriptive authority in another jurisdiction and completion of a two-hour course in Ohio prescribing law.

• Submission of a complete APRN license application with accompanying fees.

The following summarizes requirements for APRN license renewal:

• Documentation that qualifying national certification has been maintained, with

exception of grandfathered CNSs.3

• Ohio RN license is active

• CE requirements have been or will be met by the renewal deadline. A complete APRN renewal application with fee payment has been submitted, which includes, for CNMs, CNSs, and CNPs, the names/business addresses of collaborating physician or podiatrist(s), by the renewal deadline

APRN Education Programs are not Regulated by the Board

• The Board does not regulate nursing education programs that prepare RNs for APRN licensure in Ohio, nor does the Board maintain a list of APRN education programs.

• The APRN program completed must qualify the applicant to sit for the certification examination of a national certifying organization approved by the Board.

that certification. A similar exemption applies to applicants who were issued a certificate of authority by the Board prior to January 1, 2001 (4723.41(C), ORC). 2 Except that, under Section 4723.41(B)(2), ORC, a CNS applicant who is practicing or has practiced in another jurisdiction is exempt from the examination requirement of 4723.41(A)(3), if ( the applicant submits documentation that prior to January 1, 2011, the applicant earned either: (a) A master's or doctoral degree with a major in a clinical area of nursing from a qualified educational institution, or, (b) A master's or doctoral degree in nursing or a related field and was certified as a CNS by the American Nurses Credentialing Center or another national certifying organization approved at that time by the Board. A similar exemption applies to applicants who were issued a certificate of authority by the Board prior to January 1, 2001 (4723.41(D), ORC 3 Section 4723-8-08(A)(2), OAC provides that, a CNS, originally issued a certificate of authority on or before December 31, 2000 in accordance with division (C) of section 4723.41(C), ORC, as that division existed prior to March 20, 2013, is not required to provide documentation of having maintained certification in the holder's specialty, but shall submit documentation satisfactory to the Board of completion of continuing education in compliance with paragraph (E) of rule 4723-8-10, OAC.

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• Questions or concerns regarding an APRN education program should be addressed to the accrediting agency or the Ohio Department of Higher Education.

Approved National Certifying Organizations

• Each year in accordance with Section 4723.46, ORC, and Rule 4723-8-06, OAC, the Board approves National Certifying Organizations.

• One of the criteria for Board approval is that the organization has testing requirements that measure the theoretical and clinical content of a nursing specialty that are developed in accordance with accepted standards of validity and reliability, and that the testing is open to RNs who have successfully completed the APRN program required by the specific national certifying organization.

• The Board’s list of approved National Certifying Organizations is published and available on the Board of Nursing website: www.nursing.ohio.gov under the “Practice Resources/Practice APRN” section.

Certifying Examinations and National Certifications Issued by the Board Approved National Certifying Organization

• National Certifying Organizations administer and maintain the national certifying examinations required for APRN licensure and licensure maintenance.

• The National Certifying Organization establishes criteria that must be met for an APRN to re-certify and maintain their national certification. APRNs must contact the National Certifying Organization for its initial certification and re-certification requirements.

• The resulting national certification(s) reflects the APRN’s nursing specialty in practice as a CRNA, CNS, CNM or CNP.

• It is the APRN or APRN applicant’s responsibility to contact the National Certifying Organization and request their national certification documentation be sent directly to the Board.

NPA and Rules Define APRN Scope of Practice: • Sections 4723.43, and 4723.433, 4723.434, and 4723.435, ORC, define the scope of

practice of each APRN designation (CNM, CNS, CNP and CRNA) including practice limitations and prescriptive authority.

• Additional sections of the NPA and Administrative Rules (ORC Sections: 4723.431, 4723.481; 4723.4810; 4723.483; 4723.488; 4723.50; and Chapter 4723-9, OAC) specify requirements and parameters of prescriptive authority, including limitations on issuing prescriptions for schedule II controlled substances, and use of opioids to treat acute and subacute and chronic pain.

• Rule 4723-8-02, OAC, Standards of practice, says that an APRN shall provide to patients nursing care that requires knowledge and skill obtained from advanced formal education, which includes a clinical practicum, and clinical experience as specified in Sections 4723.41, 4723.43 and 4723.482, ORC and this chapter. Each APRN shall practice in accordance with (1) the APRN’s education and clinical experience; (2) national certification as provided in section 4723.41 of the Revised Code; and (3) Chapter 4723, ORC and rules adopted under that chapter.

• Rule 4723-8-01(F), OAC, defines "Practice of nursing as an advanced practice registered nurse" as “providing to individuals and groups nursing care that requires knowledge and skill obtained from advanced formal education, training and clinical experience. Such nursing care includes the care described in section 4723.43 of the Revised Code.”

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CRNA Scope of Practice, Sections 4723.43(B), 4723.433, 4723.434, 4723.435, ORC4 • CRNAs have a supervised practice and do not practice under a standard care

arrangement. • With the supervision and in the immediate presence of a physician, podiatrist, or dentist,

a CRNA may administer anesthesia and perform anesthesia induction, maintenance, and emergence and may perform with supervision pre-anesthetic preparation and evaluation, post-anesthesia care, and clinical support functions, consistent with the nurse’s education and certification, and in accordance with rules adopted by the Board.

• There are specific limitations regarding anesthesia care by a CRNA when supervised by a dentist or podiatrist.

• During the time period that begins on a patient's admission for a surgery or procedure to a health care facility where the certified registered nurse anesthetist practices and ends with the patient's discharge from recovery, a CRNA under the conditions established in Section 4723.434, ORC, may provide orders to registered nurses, licensed practical nurses and respiratory therapists to administer medications and treatments to the patient. A written policy adopted by a health care facility as described in section 4723.434, ORC, shall establish standards and procedures to be followed by certified registered nurse anesthetists when directing registered nurses, licensed practical nurses, and respiratory therapists to provide supportive care, including monitoring vital signs, conducting electrocardiograms, and administering intravenous fluids; and, to administer treatments, drugs, and intravenous fluids to treat conditions related to the administration of anesthesia.

• When performing clinical support functions as authorized by section 4723.43, ORC, a certified registered nurse anesthetist may direct a registered nurse, licensed practical nurse, or respiratory therapist to provide supportive care, including monitoring vital signs, conducting electrocardiograms, and administering intravenous fluids, if the nurse or therapist is authorized by law to provide such care. In addition, the certified registered nurse anesthetist may direct the nurse or therapist to administer treatments, drugs, and intravenous fluids to treat conditions related to the administration of anesthesia if the nurse or therapist is authorized by law to administer treatments, drugs, and intravenous fluids and a physician, podiatrist, or dentist ordered the treatments, drugs, and intravenous fluids.

• CRNAs are not authorized to prescribe a drug for use outside of the health care facility where the nurse practices.

National Certifying Organization and Certifying Examination for CRNAs

• National Board of Certification and Recertification of Nurse Anesthetists CNM Scope of Practice, Section 4723.43(A), ORC

• CNM practice requires a written standard care arrangement (SCA) with a qualified collaborating physician. Section 4723.431, ORC.

• A CNM may provide the management of preventive services and those primary care services necessary to provide health care to women antepartally, intrapartally, postpartally, and gynecologically, consistent with the nurse’s education and certification and in accordance with rules adopted by the Board. CNMs provide for immediate newborn care.

• CNMs are prohibited from performing version, delivering breech or face presentations, using forceps or doing any obstetric operation, or treating any abnormal condition except in emergencies.

4 See H.B. 197, eff. March 27, 2020.

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• A CNM may, in collaboration with one or more physicians, prescribe drugs and therapeutic devices.

National Certifying Organization and Certifying Examination for CNMs

• American Midwifery Certification Board CNS Scope of Practice, Section 4723.43(D), ORC

• CNS practice requires a written SCA with a qualified collaborating physician or podiatrist. Section 4723.431.

• A CNS may provide and manage the care of individuals and groups with complex health problems and provide health care services that promote, improve, and manage health care within the nurse’s nursing specialty, consistent with the nurse’s education and in accordance with rules adopted by the Board.

• A CNS in collaboration with one or more physicians may prescribe drugs and therapeutic devices. When collaborating with a podiatrist, the CNS’s scope of practice is limited to the procedures that the podiatrist has authority to perform under Section 4731.51, ORC.

National Certifying Organizations for CNSs

• American Association of Critical-Care Nurses Certification Corporation (AACN) • American Nurses Credentialing Center (ANCC)

Currently Available National Certification Examinations for CNSs (Each CNS certification validates condition ranges from wellness through acute care)

• Adult-Gerontology (AACN; ANCC) • Pediatrics (AACN) • Neonatal (AACN) • PMHNS (ANCC)

CNP Scope of Practice, Section 4723.43(C), ORC

• CNP practice requires a written SCA with a qualified collaborating physician or podiatrist. Section 4723.431, ORC.

• CNPs may provide preventive and primary care services, provide services for acute

illnesses, and evaluate and promote patient wellness, consistent with the CNP’s advanced formal education, training, and clinical experience, in their population focus, national certification, and in accordance with rules adopted by the Board.

• A CNP may, in collaboration with one or more physicians, prescribe drugs and therapeutic devices. When collaborating with a podiatrist, the CNP’s scope of practice is limited to the procedures that the podiatrist has authority to perform under Section 4731.51, ORC.

National Certifying Organizations for CNPs

• American Association of Nurse Practitioners Certification Board • American Association of Critical-Care Nurses Certification Corporation • American Nurses Credentialing Center • National Certification Corporation • Pediatric Nursing Certification Board

February 2021 6

Currently Available National Certification Examinations for CNPs • Family Across the Lifespan (ANCC; AANPCB) • Adult-Gerontology Acute Care (ANCC; AACN) * • Adult-Gerontology Primary Care (ANCC; AANPCB) * • Pediatric Acute Care (PNCB)* • Pediatric Primary Care (PNCB) (ANCC will soon retire its exam) * • Neonatal (NCC) • Women’s Health Care (NCC) • Psychiatric/Mental Health Across the Lifespan (ANCC)

*These are distinct, separate examinations for the population specific to the particular national certification. If a program prepares an individual to practice both acute and primary care in pediatrics or in adult-gerontology, both the primary and acute care national certifications must be obtained and maintained for authorized practice in acute care and primary care. (Section 4723.43(C), ORC)

Prescriptive Authority for CNMs, CNSs and CNPs APRNs designated as CNMs, CNSs and CNPs are authorized to prescribe. Section 4723.481, ORC. The general guidance below regarding prescriptive authority is not inclusive of all requirements.

• Prescribing must be in accordance with the Exclusionary Formulary set forth in Rule

4723-9-10(B), OAC.

• When issuing a prescription, APRNs must comply with the state and federal prescribing law and rules, including those adopted by the State of Ohio Board of Pharmacy, DEA, and Ohio State Medical Board (see Rules 4723-9-10, 4723-8-02(D), OAC)

• APRNs must register with OARRS and obtain and review OARRS reports as required

by Rule 4723-9-12, OAC.

• Prescribing must be consistent with the APRN’s scope of practice, national certification, SCA, standards of practice, and the prescriptive authority of the collaborating physician. Section 4723.481, ORC, Rule 4723-9-10, OAC.

• A collaborating physician may not collaborate with more than five APRNs at the same

time in the prescribing component of their practices. Section 4723.431, ORC.

• APRNs may prescribe a schedule II controlled substance only if: the patient has a terminal condition as defined in Section 2133.01, ORC, a physician has previously prescribed the schedule II medication, and the supply does not exceed 72 hours. Section 4723.481(C)(1), ORC. Exceptions to this apply only if the APRN issues the prescription from one of the locations listed in Section 4723.481(C)(2), ORC.

• APRNs are limited in their prescribing of opioid analgesics to treat acute pain, sub-

acute pain and chronic pain. Rule 4723-9-10, OAC.

• Rules 4723-9-13 and 4723-9-14, OAC, establish requirements for APRNs who provide medication assisted treatment and withdrawal management, including additional requirements regarding the qualifications of the physician with whom the APRN may enter into a SCA.

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• APRNs may provide or furnish drugs to up to two sexual partners of a patient diagnosed

with chlamydia, gonorrhea, or trichomoniasis. Section 4723.4810, ORC. • APRNs are prohibited from prescribing any drug or device to perform or induce an

abortion, or to otherwise perform or induce an abortion. Section 4723.151(C), ORC. See Section 2919.11, ORC. “Abortion defined. As used in the Revised Code, "abortion" means the purposeful termination of a human pregnancy by any person, including the pregnant woman herself, with an intention other than to produce a live birth or to remove a dead fetus or embryo. Abortion is the practice of medicine or surgery for the purposes of section 4731.41 of the Revised Code.” See also, Ohio Attorney General Opinion Number 2005-012, https://www.ohioattorneygeneral.gov/getattachment/8b33b778-0db7-4d8c-a1b6-f46722461012/2005-012.aspx (The administration by a nurse of a drug that is prescribed or administered for the purpose of terminating a pregnancy with a living fetus or embryo, with an intention other than to produce a live birth and with the result of terminating the pregnancy, constitutes "performing or inducing an abortion" as referred to in Section 4723.28(B)(30), ORC.)

Standard Care Arrangements CNSs and CNPs are required to enter into a SCA with a collaborating physician or podiatrist and a CNM must enter into a SCA with a collaborating physician.

• Collaborating physicians must be authorized to practice in Ohio and, with the exception

of CNPs and CNSs with national certification in Psychiatric-Mental Health by ANCC, must be practicing in a specialty that is the same as or similar to the nurse’s nursing specialty. The collaborating physician for CNPs and CNSs certified in Psychiatric-Mental Health must be practicing in psychiatry, pediatrics, or primary care or family practice. Section 4723.431, ORC. If an APRN provides medication-assisted treatment or withdrawal management, pursuant to Rules 4723-9-13 and 4723-9-14, OAC, the treatment or management must be within the collaborating physician's normal course of practice.

• SCAs must meet all criteria specified in Section 4723.431, ORC and Rule 4723-8-04,

OAC.

• When the SCA is modified reapproval of the SCA by the parties is required.

• In the event a physician or podiatrist terminates their collaborative relationship with an APRN before the SCA expires, or the collaboration is terminated due to the death of the physician or podiatrist, the APRN is responsible to report the termination or death to the Board. The APRN may then practice for up to 120 days under the terms of the SCA without a collaborating physician or podiatrist.

Practice Parameters

• The APRN scope of practice is specified in Section 4723.43, ORC.

o The statutory definition of CNM practice is to provide the management of preventive services and those primary care services necessary to provide health care to women antepartally, intrapartally, postpartally, and gynecologically, consistent with the nurse’s education and certification, which includes immediate newborn care, and in accordance with rules adopted by the Board.

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§ Although a CNM’s education and national certification may address a CNM providing newborn care for up to 28 days, and performing circumcision, this practice is not authorized by Section 4723.43(A), ORC. National certification cannot expand the CNM’s scope from that specified in Ohio law.

o A CNS provides and manages the care of individuals and groups with complex

health problems and provides health care services that promote, improve, and manage health care within the nurse’s nursing specialty, consistent with the nurse’s education.

A CNS whose graduate program prepared the CNS as a pediatric CNS may manage, for example, pediatric patients with cystic fibrosis in both their optimum state of health and in conditions of high acuity.

o The CNP scope of practice states the CNP may provide preventive and primary care services, provide services for acute illnesses, and evaluate and promote patient wellness within the nurse’s specialty, consistent with the nurse’s education and certification.

A CNP whose education and national certification is in Women’s Health Care is authorized to provide preventive and primary care services, provide services for acute illnesses, and evaluate and promote patient wellness “consistent with” the specialty practice that is outlined in the Women’s Health Care national certification. A CNP whose national certification is Pediatric Acute Care would practice “consistent with” the population focus or nursing specialty practice that is outlined in that specific certification. It would be the same for CNPs with national certification in Adult-Gerontology Primary Care, and with the other national certifications listed above for CNPs.

• A CNM, CNS and CNP may delegate the authority to administer medication to an

unlicensed individual pursuant to Section 4723.489, ORC. The drug to be administered cannot be for IV administration nor can it be a controlled substance. The delegation cannot occur in a hospital inpatient care unit as defined in Section 3727.50, ORC, a hospital emergency department or a freestanding emergency department, or an ambulatory surgical facility as defined in Section 3702.30, ORC.

• Each CNM, CNS, and CNP is required to utilize and incorporate into their practice,

knowledge of the Medical Practice Act (Chapter 4731, ORC) and the rules adopted thereunder by the Ohio State Medical Board that govern the practice of the APRN’s collaborating physician or podiatrist.

• A CRNA is required to utilize and incorporate into their practice knowledge of the Dental

Practice Act (Chapter 4715, ORC) and the Medical Practice Act (Chapter 4731, ORC) and administrative rules that govern the CRNA’s supervising physician’s, podiatrist’s or dentist’s practice.

• APRNs must comply with the standards related to competent practice as a CNM, CNP,

CRNA, or CNS. Rule 4723-4-05, OAC. FAQs. Below are FAQs related to the NPA and administrative rules for APRNs.

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SCA FAQs

Q: I plan to practice as a CNS but do not intend to prescribe drugs. Am I required to enter into a SCA if I do not prescribe drugs?

A: Yes, a SCA is required for a CNM, CNS or a CNP to practice.

Q: Do collaborating physicians and CNSs and/or CNPs have to have “identical” practices?

A: No. The collaborating physician or podiatrist “must be practicing in a specialty that is the same as or similar to the nurse's nursing specialty.” The physician’s practice must minimally be “similar.” A CNP or CNS who is certified in psych/mental health is also authorized to collaborate with a physician practicing psychiatry, pediatrics, primary care or family practice. Section 4723.431(A)(2), ORC. If an APRN is engaged in medication assisted treatment, additional requirements apply, as discussed below.

Q: Is there a limit on the number of physicians with whom an APRN may enter into a SCA? Is there a limit on the number of APRNs with whom a physician may enter into a SCA?

A: There is a limit on the number of APRNs with whom a collaborating physician or podiatrist may collaborate at the same time in the prescribing component of the APRNs’ practices. A “physician or podiatrist shall not collaborate at the same time with more than five nurses in the prescribing component of their practices.” Section 4723.431(A), ORC. There is no limit on the number of physicians or podiatrists with whom an APRN may collaborate and enter into a SCA. There is also no limit on the number of APRNs with whom a physician or podiatrist may enter into a SCA. Section 4723.431(A), ORC.

Q: Am I required to periodically check the licensure of my collaborating physician or podiatrist?

A: Previously, Rule 4723-8-4, OAC, required such verification but that is no longer required by rule. However, best practice would be to periodically verify the collaborating physician's licensure and to be aware of any restrictions as this can impact the APRN’s own practice. For example, under 4723.481(B), APRN prescriptive authority cannot exceed that of the collaborating physician. If for example, the physician is restricted from prescribing controlled substances, the APRN’s prescriptive authority is similarly restricted.

Prescribing FAQs

Q: How can I determine if I am authorized to prescribe a certain drug? Is there a formulary?

A: The Exclusionary Formulary is established in Rule 4723-9-10(B), OAC. It states:

Exclusionary Formulary. A certified nurse practitioner, clinical nurse specialist or certified nurse midwife shall not prescribe or furnish any drug or device in violation of federal or Ohio law, or rules adopted by the board, including this rule. The prescriptive authority of a certified nurse practitioner, clinical nurse specialist and certified nurse midwife shall not exceed the prescriptive authority of the collaborating physician or podiatrist.

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Section 4723.481, ORC and Chapter 4723-9, OAC, authorize CNMs, CNSs, and CNPs to prescribe drugs or therapeutic devices consistent with the APRN’s scope of practice; the Exclusionary Formulary; the statement of services and prescribing parameters established in the executed SCA; and the collaborating physician's practice, including the physician's prescribing limitations. In addition, an APRN who intends to prescribe controlled substances must first obtain a DEA registration. Rule 4723-9-10(D)(9), OAC. Prescribing resources including alerts and prescribing guidelines are available on the Board website under the Prescribing Resources section.

Q: I am completing DATA waiver training and have questions about medication assisted treatment (MAT) practice. Is it true that to prescribe pursuant to a DATA waiver, a CNM, CNS, or CNP, must enter into a SCA with at least one collaborating physician who also has a DATA waiver? Is it sufficient to enter into a SCA with a collaborating physician who has a DATA-waiver but who does not practice MAT?

A: To prescribe pursuant to a DATA waiver, the APRN must have entered into a SCA with at least one physician who also has a DATA waiver because under Section 4723.481(B), ORC, an APRN’s prescriptive authority cannot exceed that of the collaborating physician. In addition, MAT must be “within the collaborating physician's normal course of practice and expertise.” Rule 4723-9-13(B), OAC.

Q: Where do APRNs locate information on how to obtain specific drugs needed for their office/clinics, some of which are controlled substances?

A: The purchase, storage, maintenance, and dispensing of drugs is primarily governed by law and rule enforced by the State of Ohio Board of Pharmacy and the DEA. See https://www.pharmacy.ohio.gov. Law and rules enforced by the Board governing APRN prescribing and personally furnishing of drugs include Section 4723.481, ORC, and Chapter 4723-9, OAC, including Rule 4723-9-08, OAC, “Safety standards for personally furnishing drugs and therapeutic devices.”

Q: I practice as a CNP within a group medical practice and am being asked to provide cross- coverage with the potential for prescribing to the patients of other providers in the practice. Is this permitted?

A: It depends on the specific circumstances. A CNM, CNS and CNP’s authority to practice is based on the APRN’s licensure and the statement of services described in the SCA entered into by the APRN and the APRN’s collaborating physician. This includes a description of the APRN’s prescriptive practices. See Section 4723.431(B), ORC, and Rule 4723-8-04(D)(5), OAC. Section 4723.481, ORC, and Rule 4723-9-10, OAC, establish the prescribing standards for APRNs, including that they prescribe in a valid prescriber-patient relationship. Establishing a valid prescriber-patient relationship may include, but is not limited to:

• Obtaining a relevant history of the patient; • Conducting a physical or mental examination of the patient; • Rendering a diagnosis; prescribing medication; • Consulting with the collaborating physician when necessary; and • Documenting these steps in the patient's medical record.

While the rule generally guides how a valid prescriber-patient relationship may be

February 2021 11

determined, it is not necessary that every subpart be present to establish a valid relationship. Pertinent considerations may include whether:

• The APRN is part of or is collaborating with a member of the patient’s provider group;

• Cross coverage prescribing is addressed in the SCA; • The APRN has access to the patient’s medical records during the encounter; • The APRN documents care provided to the patient in the patient’s medical record.

Rule 4723-9-10 can be accessed at http://codes.ohio.gov/oac/4723-9-10. In addition, Section 4723.481(B), ORC, states that the prescriptive authority of the APRN shall not exceed that of the collaborating physician, and Rule 4723-8-02(D), OAC, requires each APRN to incorporate into their practice the law and rules established by the Ohio State Medical Board that apply to their collaborating physician’s practice. The APRN should review Medical Board Rule 4731-11-09, OAC, “Prescribing to Persons Not Seen by the Physician.”

Q: May an APRN establish a consult agreement with a pharmacist for management of a patient’s drug therapy?

A: Following adoption of HB203 in December 2020, APRNs designated as CNPs, CNMs, and CNSs, are authorized under certain specific circumstances to establish drug therapy consult agreements with pharmacists. Prior to HB203, only physicians were authorized to enter into drug therapy consult agreements. This topic is addressed in the Winter 2021 Momentum article, available on the Board website under Publications at: https://nursing.ohio.gov/wp-content/uploads/2021/01/Momentum-Winter-2021.pdf

Scope of Practice FAQs

Q: As an APRN, I have been asked how I am authorized to make “medical diagnoses” and to prescribe. Where can I find this?

A: While Section 4723.151(A), ORC, prohibits a nurse from making a “medical diagnosis”, this prohibition does not prevent an APRN from practicing within their scope (Section 4723.151(B), ORC), which may include prescribing and diagnosing consistent with the statutory scope.

Q: What is the scope of practice for a CNP who is certified in Women’s Health Care (WHC)? Are they limited to managing the health care of adolescent and adult female patients? Can they manage male or pediatric patients? And Q: I am a WHC CNP and have worked in medical oncology in a comprehensive breast center for the past 4 years. I recently accepted a position in a general oncology practice. With my WHC NP certification, am I authorized to manage care of male oncology patients who have various oncological diagnoses if it is included in my SCA?

A: A CNP would follow Section 4723.43(C), ORC, which defines the practice as within the nurse’s nursing specialty, consistent with the nurse's education and national certification, and in accordance with rules adopted by the Board. The authority of a CNP with WHC certification to practice as an APRN is based on the WHC education program and the resulting CNP’s national certification focused on the WHC CNP treating female

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patients for women's health issues. The NCC 2021 Candidate Guide Women’s Health Care Practitioner5 discusses care of “women” and does not address the topic of “pediatrics” or “children” or “growth and development.” It addresses the diagnosis and management of male patients only in the context of sexual and reproductive health. A CNP cannot expand their practice to another nursing specialty or population focus by adding it to their SCA. A WHC CNP who wants to expand their practice to diagnose and manage male oncology patients would need to qualify and obtain an additional nursing specialty through national certification in an applicable population focus.

Q: As an CNP with national certification in adult-gerontology primary care what is the youngest age of patients I may manage? And Q: As a CNP with national certification in pediatric primary or acute care, what is the upper age limit of patient I can provide care to?

A: A nurse authorized to practice as a CNP may practice within the nurse's nursing specialty, consistent with the nurse's education and national certification, and in accordance with rules adopted by the Board. Section 4723.43(C), ORC. The law and rules do not establish bright line age ranges to define age specific patient populations. Rather, it is the national certification that determines the population (including age parameters) of patients for whom the APRN is prepared and authorized to provide care. An APRN with questions about the age ranges or growth and development stages addressed by their national certification would look to the national certifying organization itself. For example, does it state that national certification validates competency with patients “up to late adolescence,” or “from early adolescence through adult,” etc.? To manage the care of a population different than the one validated by the CNP’s current national certification, the APRN would need to obtain the additional national certification. A CNP with national certification in pediatric primary or acute care is qualified to manage developmental and physical health care needs into young adulthood and are expected to engage in transition planning for adolescents to adult health care services. The National Association of Pediatric Nurse Practitioners has published a recent position indicating that it is imperative that adolescent and young adults participate in a process of transfer and integration to an adult model of care as pediatric conditions continue into adulthood. See NAPNAP Position Statement on Age Parameters for Pediatric Nurse Practitioner Practice, at https://www.jpedhc.org/article/S089.

Q: Is a CRNA authorized to administer drugs, such as low dose ketamine infusion, for example, for the purpose of pain relief or for the treatment of treatment-resistant depression? The treatments involve low doses of the drugs and are not intended to induce anesthesia and are not related to pre- or post-anesthesia care.

A: A nurse authorized to practice as a CRNA, “with the supervision and in the immediate presence of a physician, podiatrist, or dentist, may administer anesthesia and perform anesthesia induction, maintenance, and emergence, and may perform with supervision preanesthetic preparation and evaluation, post-anesthesia care, and clinical support functions, consistent with the nurse's education and certification, and in accordance with

5 https://www.nccwebsite.org/content/documents/cms/whnp-candidate_guide.pdf

February 2021 13

rules adopted by the board.” Section 4723.43(A), ORC. CRNAs may also provide orders in certain circumstances for the administration of drugs and intravenous fluids to their patients in the health care facilities where the CRNAs practice. While CRNAs may themselves select and administer drugs used in performing anesthesia induction, maintenance, and emergence, and order drugs to be administered, they cannot themselves order or themselves independently select and administer drugs not related to their CRNA scope as defined in 4723.43(B).

However, a CRNA may act in the capacity of a RN, and as a RN, may administer drugs pursuant to an order from an authorized provider who is acting within the course of the individual’s professional practice (e.g., a physician, a PA, or an APRN-CNP, APRN-CNS, or APRN-CNM). Rule 4723-4-03, OAC, requires that when a RN provides nursing care in accordance with Section 4723.01(B)(5), ORC, the RN must have a specific current order for the medication, treatment, or regimen that the nurse is to administer or carry out. If the stated purpose of the medication administration is other than for sedation, the RN must still also consider the sedating effects of the medication and take steps to ensure patient safety as required by Chapter 4723-4, OAC.

Q: My CNM education and national certification included performing circumcisions of newborns. I performed these in another state. Am I permitted to provide this procedure in Ohio?

A: No. The statutory scope for CNMs in Section 4723.43(A), ORC, is to provide the management of preventive services and those primary care services necessary to provide health care to women antepartally, intrapartally, postpartally, and gynecologically, consistent with the nurse's education and certification, and in accordance with rules adopted by the Board. This scope of CNM practice does not include circumcisions. Any parameters or limitations established in the statutorily defined scope cannot be expanded through education or national certification.

Q: How can an APRN determine whether they may include a specific procedure, task or activity in their practice?

A: It is important for each APRN to understand the limits of their authorized scope of practice, and to know the limits of their individual knowledge, skills and abilities. The Board does not maintain a list of procedures that a particular APRN may or may not perform. An APRN is authorized to practice within the respective APRN scope as set forth in Section 4723.43, ORC, the APRN’s nursing specialty as determined by their national certification, and standards of practice including those set forth in Chapter 4723-8, OAC, including for example, Rule 4723-8-02, OAC. The Board adopted an APRN Decision Making Model to assist APRNs in determining whether a specific procedure, task or activity is consistent with standards of practice, appropriate to perform based on the individual APRN’s knowledge, skills, and ability and is appropriate based on the clinical setting. The Decision Making Model is available on the Board website under Practice Resources, APRN. Also, the regulations pertaining to SCAs in Chapter 4723-8, OAC, require that the SCA include a statement of services to be provided by the APRN and a plan for the incorporation of new technology in the APRN’s practice.

Q: Do a CNP’s documentation, assessments, orders or progress notes need to be reviewed

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and co-signed by a physician, or podiatrist?

A: The law and rules do not require co-signature by another health care provider of an APRN’s prepared documentation. However, an employer, facility or payor may institute requirements that exceed those required by the Board. Also, if the CNP and collaborating physician agree to include a co-signature requirement in the SCA, then it would be required.

Q: I am a CNP certified in Family Across the Lifespan, which is primary care. How may I determine the limits of my individual scope if employed in a hospital?

A: There is no limit as to the settings where any APRN may practice. There are limits on the patient conditions the CNP with this certification may manage regardless of the setting. The CNP must review the defined scope of practice in Section 4723.43(C), ORC; the national certification in the population foci that determines the CNP’s nursing specialty, and the SCA that is entered with a qualified collaborating physician, which may contain practice limitations. National certification in “Family” does not include the management of patients with high acuity unstable/critical conditions. If management of these patient conditions is an expectation, national certification in Adult-Gerontology Acute Care or Pediatric Acute Care would be needed.

Q: I am a CNP certified in Pediatrics Primary Care. When I initially completed my graduate education program, obtained national certification and entered practice, children with severe asthma were sent to specialists for management. As I continued my practice and maintained my national certification, completing many hours of continuing education, including content on management of severe asthma, I began to manage these asthmatic patients myself after learning that new management techniques and medications lessen the frequency of severe attacks and hospitalization. Am I permitted to do this although it was not addressed in my initial graduate program and initial certification?

A: Yes. Maintenance of national certification in your nursing specialty means that you are maintaining your knowledge of current practice standards, medications and techniques necessary for your application and management of your patients.

Q: I am a CNS and will soon enter into a SCA with a physician practicing bariatric medicine and surgery. I am aware of the Exclusionary Formulary, which will permit me to prescribe phentermine for weight loss. I am told that there are additional parameters specific for prescribing of controlled substances for weight loss, but I did not find anything specific in Chapter 4723-9, OAC. Where can I find these?

A: Rule 4723-8-02(D), states APRNs “shall utilize and incorporate into the nurse's practice, knowledge of Chapter 4731. of the Revised Code and rules adopted under that chapter that govern the practice of the nurse's collaborating physician or podiatrist.”

• This requires an APRN to comply with the same practice/prescribing parameters

established by the Medical Board that apply to the collaborating physician or podiatrist.

• In this case the CNS must, in addition to meeting all other requirements, prescribe phentermine in accordance with Medical Board Rules, including 4731-11-04, OAC, Controlled substances; Utilization of short term anorexiants for weight reduction.

Q: Is a CNP who holds national certification in Family authorized to provide hospice and

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palliative care to patients?

A: Yes. A FNP is authorized to provide primary advanced practice nursing care to patients across the lifespan. This may include managing the patients’ complex and non-curative care for purposes of minimizing symptoms and providing comfort care.

APRN Delegation to Unlicensed Persons Q: May APRNs delegate nursing tasks to unlicensed individuals? May APRNs delegate medication administration to unlicensed individuals?

A: Yes. Unlicensed persons such as STNAs, nursing assistants and medical assistants have no authorized scope of practice and may only engage in nursing tasks that are delegated to them by a licensed provider who is authorized to delegate the task.

• Nursing delegation is defined in Rule 4723-13-01(B), OAC, as the transfer of

responsibility for the performance of a selected nursing task from a licensed nurse authorized to perform the task to an individual who does not otherwise have the authority to perform the task.

• The application of Chapter 4723-13, OAC is dependent on the individual patient and

clinical circumstances as well as the knowledge and ability of the unlicensed individual to whom the task is delegated, all of which must be considered by the nurse prior to delegating. While law and rules governing nursing practice do not provide a list of delegable tasks, they do set certain limitations. Rule 4723-13-05(D) OAC, for example, states that a RN, or a LPN at the direction of an RN, may delegate to an unlicensed person the administration of only the following medications (unless otherwise authorized by law): over the counter topical medications to be applied to intact skin for the purpose of improving a skin condition or providing a barrier and over the counter eye drops, ear drops, or suppository medications, foot soak treatments, and enemas.

• By contrast, APRNs are not limited to the list of medications provided in Rule 4723-

13-05(D) when delegating medication administration to unlicensed persons. APRNs must however comply with all requirements of Section 4723.48, ORC, and Section 4723.489, ORC, including specific requirements as to the unlicensed person's documented education and demonstrated knowledge, skills, and ability to administer the drug safely, and, the requirement that the APRN is on site during the delegated medication administration. In addition, the APRN is prohibited from delegating the administration of controlled substances or intravenous medications to an unlicensed person. The delegation of the authority to administer medications is also prohibited from occurring in a hospital inpatient care unit as defined in Section 3727.50, ORC, a hospital emergency department or a freestanding emergency department, or an ambulatory surgical facility as defined in Section 3702.30, ORC. Sections 4723.48 and 4723.489, ORC.

Licensure, Titles & Academic Credentials Q: As an APRN-CNP who has also earned a DNP, may I identify myself as Dr. Jones?

A: Law and rules enforced by the Board require APRNs to display and identify their applicable licensure to patients when providing direct patient care and require APRNs to identify themselves with their applicable licensure when interacting through any form of telecommunication with patients or with other healthcare providers on behalf of a patient.

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Law and rules enforced by the Board do not address nurses’ use of academic credentials or titles, such as Dr., MSN, DNP, or PhD, etc., or noting of specific certifications they have achieved. Rule 4723-4-06(B), OAC, provides “At all times when a certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist is providing direct nursing care to a patient, the nurse shall display the applicable title or initials set forth in [Section 4723.03, ORC] to identify relevant approval either as a certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist. (C) At all times when a licensed nurse is engaged in nursing practice and interacting with the patient, or health care providers on behalf of the patient, through any form of telecommunication, the licensed nurse shall identify to each patient or health care provider the nurse's title or initials set forth in [Section 4723.03, ORC] to identify applicable licensure as a registered nurse, licensed practical nurse, certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist.” In addition, Rule 4723-8-03, OAC, requires that when an APRN is providing direct patient care, the APRN display and identify the applicable title and designation as set forth in the rule. Law and rules enforced by other entities or agencies may also impact identification.

Pronouncing Death Q: May a Nurse Practitioner pronounce death in patients in the hospital (but not on life support or in critical care), in hospice, or in an extended care facility.

A: Section 4723.36, ORC, provides the circumstances under which an APRN-CNP or APRN-CNS, or a RN, may determine and pronounce death. It is pasted below for your convenience and can also be accessed here: http://codes.ohio.gov/orc/4723.36. See also Ohio Medical Board Rule 4731-14-01, OAC, “Who may pronounce death,” at http://codes.ohio.gov/oac/4731-14-01.

4723.36, ORC, Determination of death by certified nurse practitioner or clinical nurse specialist. (A) A certified nurse practitioner or clinical nurse specialist may determine and pronounce an individual's death, but only if the individual's respiratory and circulatory functions are not being artificially sustained and, at the time the determination and pronouncement of death is made, either or both of the following apply: (1) The individual was receiving care in one of the following: (a) A nursing home licensed under section 3721.02, ORC, or by a political subdivision under section 3721.09, ORC; (b) A residential care facility or home for the aging licensed under Chapter 3721, ORC; (c) A county home or district home operated pursuant to Chapter 5155, ORC; (d) A residential facility licensed under section 5123.19, ORC. (2) The certified nurse practitioner or clinical nurse specialist is providing or supervising the individual's care through a hospice care program licensed under Chapter 3712, ORC, or any other entity that provides palliative care. (B) A registered nurse may determine and pronounce an individual's death, but only if the individual's respiratory and circulatory functions are not being artificially sustained and, at the time the determination and pronouncement of death is made, the registered nurse is

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providing or supervising the individual's care through a hospice care program licensed under Chapter 3712, ORC, or any other entity that provides palliative care. (C) If a certified nurse practitioner, clinical nurse specialist, or registered nurse determines and pronounces an individual's death, the nurse shall comply with both of the following: (1) The nurse shall not complete any portion of the individual's death certificate. (2) The nurse shall notify the individual's attending physician of the determination and pronouncement of death in order for the physician to fulfill the physician's duties under section 3705.16, ORC. The nurse shall provide the notification within a period of time that is reasonable but not later than twenty-four hours following the determination and pronouncement of the individual's death.

The APRN Consensus Model Q: What is the APRN Consensus Model?

A: The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education (July 7, 2008) (APRN Consensus Model) is not an Ohio law or rule. It is a national model that explains the broad schematic for APRNs that is generally accepted and recognized in the United States. It is endorsed by multiple national organizations including the National Council of State Boards of Nursing (NCSBN), national accreditors of APRN graduate programs, and national certifying organizations. It is the model by which national certifying organizations determine and provide their certification examinations to qualifying candidates. While recognizing that not all elements of the Consensus Model are consistent with Ohio law and rule, the Board’s Advisory Committee on Advanced Practice Registered Nursing recommended to the Board, and the Board agreed, that the APRN Consensus Model’s approach as to role and population foci is consistent with the Board’s approach and would continue to be followed. The APRN Consensus Model includes certification in one or more specialized areas of population foci as a requirement for licensure, which is consistent with Ohio law and rules regulating APRNs. Additional information and the full model is available at the NCSBN website, https://www.ncsbn.org/aprn-consensus.htm (Note for Committee: May consider alternative language: Ohio has not achieved all elements of the Consensus Model. )

Q: I am a family nurse practitioner and I wish to subspecialize in pediatric oncology. Does the Board require that I obtain a certification in that subspecialty or an additional license?

A: No, these subspecialities are not individually regulated. APRN practice must be consistent with their national certification(s). APRNs who hold national certification in a particular nursing specialty/population focus, may further subspecialize their practice. For example, a CNS who holds national certification in Pediatrics, may subspecialize in pediatric oncology, or a CNP who holds national certification in Adult-gerontology primary care may subspecialize in urological disorders.

Law and rules referenced in this FAQ may be accessed online at: www.nursing.ohio.gov (click on Laws and Rules) or at: https://codes.ohio.gov/orc/

Deleted: T

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October 2021

Steps to Complete for RNs Applying for APRN Licensure

This document can be used as a guide when you apply for APRN Licensure1. Please note the differences in requirements, as specified, based on the four APRN designations of CNP, CNS, CNM, and CRNA. Beginning in September 2021, two questions on the application must be answered “yes” to proceed with the application. This assures that when you submit the application, you have met the requirements.

• Do you currently hold a master’s or doctoral degree with a major in a nursing specialty that qualified you to take an APRN national certification examination of a national certifying organization approved by the Board?

• Do you currently hold APRN national certification from a Board approved national

certifying organization? Locate the APRN Application

• Log into your eLicense account • Locate your RN license or RN application banner • Click on the “options” button and select “Apply for an Endorsement” from the drop-down

list. The application fee is $150 plus a $3.50 state transaction fee.

Initial APRN Licensure

¨ Licensed as an RN ¨ Completion of a master’s or doctoral degree with a major in a nursing specialty that

qualifies you to take an APRN national certification examination ¨ Official transcript showing a master’s or doctoral degree emailed directly from the APRN

education program to licensureaprn@nursing.ohio.gov. o For CNP, CNS and CNM applicants, the transcript must also reflect an advanced

pharmacology course completed within the last five years ¨ National certification emailed directly from an approved National Certification Organization

to licensureaprn@nursing.ohio.gov ¨ Continuing education in Ohio law and rules that govern schedule II prescribing for those

applying for a CNP, CNS and CNM license if you completed an APRN program not located in Ohio

¨ Court documents or other information, if applicable, uploaded with the application

1 The Ohio eLicense system refers to the APRN license as an “endorsement” added to the RN license.

October 2021

Reciprocity2 APRN Licensure Upon receipt of your APRN application, if you are licensed as an RN or hold a temporary permit as an RN in Ohio, the Board may issue an APRN temporary permit which authorizes you to practice as an APRN until you complete the application process. APRN temporary permits may be issued based on verification from another state/jurisdiction, emailed to licensureaprn@nursing.ohio.gov, that you hold a valid, unrestricted license in that state/jurisdiction. Out-of-State CNPs, CNSs, and CNMs Applying for Reciprocity

¨ Two-hours of continuing education in Ohio laws that govern drugs and prescriptive authority

¨ Official transcript showing a master’s or doctoral degree3 and an advanced pharmacology course emailed directly from the APRN education program to licensureaprn@nursing.ohio.gov

¨ Documentation of prescribing in another jurisdiction for a continuous period of 1 year within the last 3 years, including some controlled substances

¨ National certification4 emailed directly from an approved National Certification Organization to licensureaprn@nursing.ohio.gov

¨ Application for Endorsement, including payment of fees ¨ Court documents or other information, if applicable, uploaded with the application

Out-of-State CRNAs Applying for Reciprocity ¨ Official transcript showing a master’s or doctoral degree5 emailed directly from the APRN

education program to licensureaprn@nursing.ohio.gov ¨ National certification emailed directly from an approved National Certification Organization

to licensureaprn@nursing.ohio.gov ¨ Application for Endorsement, including payment of fees ¨ Court documents or other information, if applicable, uploaded with the application

2 Ohio law refers to this as “licensure by endorsement”. See ORC 4723.41(C). But the more commonly used term is licensure by “reciprocity”. 3 Reciprocity applicants who are CNPs or CNMs are not required to hold a master’s or graduate degree if national certification was obtained on or before December 31, 2000, and the national certification has been maintained (Section 4723.41(B)(2)(a), ORC). If you meet this grandfather provision, please email licensureaprn@nursing.ohio.gov. 4 If reciprocity applicant is a CNS who obtained a master’s or doctoral degree with a major in a clinical area of nursing from an educational institution accredited by a national or regional accrediting organization, the applicant is not required to have passed a national certification examination. (Section 4723.41(B)(2)(b)(i), ORC). If you meet this grandfather provision, please email licensureaprn@nursing.ohio.gov. 5 Reciprocity applicants who are CRNAs are not required to hold a master’s or graduate degree if national certification was obtained on or before December 31, 2000, and the national certification has been maintained (Section 4723.41(B)(2)(a), ORC). If you meet this grandfather provision, please email licensureaprn@nursing.ohio.gov.

October 2021

After submitting the application, return to your eLicense account and verify that your application reflects “submitted.” If it reflects “pending” or “generate fee” it means you have not completed all the information, or you did not pay the fees. If you have questions about the status of your application, review the Applicant Checklist in the Ohio eLicense portal, or email licensureaprn@nursing.ohio.gov.

Sample/Summary of APRN Email Questions Received Q. What are the regulations for APRN-CNPs on prescribing short course weight loss medications? I have a SCA with all physicians in my office setting. A. An APRN-CNP's authority to practice is based on the APRN’s licensure and the SCA statement of services, including a description of the APRN’s prescriptive practices. Rule 4723-8-04(C)(5), OAC. Section 4723.481(B), ORC, says that the prescriptive authority of the APRN shall not exceed that of the collaborating physician and Rule 4723-8-02(D), OAC, requires each APRN to incorporate into their practice the law and rules enforced by the State Medical Board that apply to their collaborating physician’s practice. For these reasons the APRN would be accountable to practice consistent with Medical Board Rule, OAC 4731-11-04, Controlled substances: Utilization of short term anorexiants for weight reduction, as it applies to the APRNs practice. You can access that rule here: http://codes.ohio.gov/oac/4731-11-04v1 The attached Spring 2016 Momentum article contains a related article. [NOTE: an updated version of the article will appear in the forthcoming Winter 2022 Momentum.] Q: My practice location is in Pennsylvania and I have a patient who recently moved to Ohio and wants to continue to be treated by me via our telepsych services. I am licensed in Ohio, but I do not currently have an active SCA. How long do I have to get an SCA in place so I can continue to provide her care? I am in Pennsylvania and would see her from here while she is in Columbus. I am just clarifying the time limit, since it may be hard to find a collaborating physician for a SCA for the one patient. Thank you for your time. A: The practice of nursing occurs where the patient is located at the time. Section 4723.431(A), ORC, requires that an APRN-CNP has entered into a SCA with a qualified collaborating physician before engaging in practice as an APRN in Ohio. The APRN then has up to 30 days after they begin practice to report the names and business addresses of the collaborating physician to the Board. The submission of the collaborating physician’s name and business address to the Board is done by the APRN through his/her eLicense online portal. Go to elicense.ohio.gov and log into the eLicense account with the Board. Once logged in, click the button located on the APRN license banner/icon and then click “update collaborating physician” from the drop-down list. The electronic form will require the APRN to attach a document that provides the name and business address of the collaborating physician(s).

Q: Are Certified Nurse Practitioners who are certified in either Family or Adult authorized complete a 72- hour hold/pink slip for involuntary emergent care for individuals at risk of harm to self or others? I heard from a Physician Assistant colleague that only Certified Nurse Practitioners who are certified in PMHNPs may do this A: The authority for complete an emergent 72-hour hold/pink slip is external to the Ohio Nurse Practice Act. Section 5122.10, ORC, Emergency Hospitalization, states a CNP who is certified as in psychiatric-mental health, or a CNS who is certified in psychiatric-mental health, may initiate Emergency Hospitalization. It states in part: “Any of the following who has reason to believe that a person is a mentally ill person subject to court order and represents a substantial risk of physical harm to self or others if allowed to remain at liberty pending examination may take the person into custody and may immediately transport the person to a hospital or, notwithstanding section 5119.33, ORC, to a general hospital not licensed by the department of mental health and addiction services where the person may be held for the period prescribed in this section: (a) A psychiatrist; (b) A licensed physician; (c) A licensed clinical psychologist; (d) A clinical nurse specialist who is certified as a psychiatric-mental health CNS by the American nurses credentialing center; (e) A certified nurse practitioner who is certified as a psychiatric-mental health NP by the American nurses credentialing center; (f) A health officer; (g) A parole officer; (h) A police officer; ….. Q: I am a physician. Is there a limit to the physical practice distance between a supervising Physician and a Certified Nurse Practitioner engaged in psychiatry/mental health practice? A: Section 4723.431, ORC, requires the APRN-CNP to collaborate with a podiatrist or a physician who meets all requirements of Section 4723.431(A)(2), ORC. Rule 4723-8-01(B), OAC, says, in part, "Collaboration" or "collaborating" means: “that a podiatrist or physician has entered into a standard care arrangement with the nurse and is continuously available to communicate with the clinical nurse specialist or certified nurse practitioner either in person, or by electronic communication; [and meets all other requirements of 4723-8, OAC, including quality assurance provisions, etc....]" No, there is no general requirement that the physician be on site or even practice at the same location as the APRN-CNP. However, there is a significant exception if the APRN will be prescribing any Schedule II drugs from a privately owned practice. Section 4723.481(C)(2)(m), ORC, requires that in order to prescribe Schedule II drugs from a privately owned practice, the APRN must enter into an SCA with at least one collaborating

physician who is an owner of the practice, and, who “practices primarily at” the same location as the APRN-CNP. Q: I graduated from my APRN program and passed my Psychiatric Mental Health Nurse Practitioner exam on 10/7/2019. I have not practiced yet as a PMHNP due to family obligations but will be looking for a part time job in the near future. I just went online to renew my RN license, but did not see an APRN license. Why is it not an APRN license showing, as I was credentialed through the ANCC, know that ANCC sent my certification to the Board and that it does not expire until 2024? A: Did you apply for a license to practice as an APRN in the state of Ohio? Licensure to practice as an APRN in Ohio requires 1.) a current Ohio RN license, 2.) a current national certification, 3.) completion of an application for licensure to practice as an APRN including payment of the application fee, etc. Further information, including APRN Applicant Guidance and sample forms are available at: https://nursing.ohio.gov/licensing-certification-ce/ Q: I currently practice as a Certified Nurse Practitioner with Family certification. I am interested in opening a mobile IV hydration business in Ohio, to provide wellness infusions, vitamin infusions, etc. Can I own and operate a mobile IV hydration business in Ohio without a collaborating physicain? A: To practice as a Family CNP, the CNP must first enter into a SCA with at least one qualified collaborating physician. See Section 4723.431(A), ORC, and Rule 4723-8-04, OAC. Nothing in law enforced by the Board prohibits an APRN from owning their own practice although there are restrictions on APRN prescribing of Schedule II drugs from a private practice that is not owned by a physician. (If Schedule II prescribing is contemplated, you will want to carefully review requirements and restrictions related to ownership in Section 4723.481(C)(2)(m), ORC.) Regarding nurse ownership of a practice, you may wish to review Section 4723.16, ORC, and to consult an attorney and/or other business advisor, as you deem appropriate. The Board cannot advise whether or how to begin a business or advise which choice of entity (LLC, sole proprietor, etc.) is appropriate. Also, while the Board regulates nursing practice scope and standards, it does not does not license, inspect, or oversee facilities though other entities might, and law and rule regarding procurement, storage, and maintenance of any drugs needed for a practice is enforced primarily by the Ohio Board of Pharmacy. Finally, you may also wish to review information available from the Ohio Secretary of State, https://www.ohiosos.gov/businesses/information-on-starting-and-maintaining-a-business/starting-a-business The above are informal staff advisory opinions that represent the views of the undersigned, based on the facts presented. They are limited to questions arising under Chapter 4723 of the Revised Code and the rules adopted thereunder, and do not purport to interpret other laws or rules. If you have any further questions or desire additional information, please contact this office again.