AGENDA Advisory Committee on ... - Ohio Board of Nursing€¦ · Advisory Committee on Advanced Practice Registered Nursing July 6, 2020 10:00 a.m. to 2:30 p.m. Via Virtual Conference

AGENDA

Advisory Committee on Advanced Practice Registered Nursing July 6, 2020 10:00 a.m. to 2:30 p.m.

Via Virtual Conference

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.-10:15 a.m.

2. Draft Rule Review: Detox Rule 10:15 a.m.-10:30 a.m.

3. HB 197: CRNAs and COVID-19 10:30 a.m.- 11:00 a.m.

4. Review Written Public Comments 11:00 A.M.-11:30 a.m.

Lunch 11:30-12:15

5. Legislative Report 12:15 p.m.-12:45 p.m.

6. 6/15/2020 Draft APRN Summary/FAQ Document 12:45 p.m.-1:15 p.m.

7. Use of Title “Doctor.” 1:15 p.m. -1:45 p.m.

8. General Information/Updates 1:45 p.m.-2:15 p.m. b. Planning: LPN Renewal begins 7/1/2020 c. Sample/Summary of APRN Practice Questions

9. Remaining 2020 Meeting November 16.

10. Other/Adjourn 2:15 p.m.-2:30 p.m.

The public may observe the Virtual Meeting of the Board’s Committee on Advanced Practice Registered Nursing live via You Tube. The link to the virtual meeting on YouTube will be available to the public on the homepage of the Board's website on June 29, 2020. However, there will not be opportunity for the public to comment or engage in virtual interaction in real time with committee members through the meeting platform. The Committee will accept written comments regarding the meeting’s topics when submitted in advance of the meeting by email to [email protected] with “COMMITTEE” in the subject line. Written comments and questions must be received no later than 8:00 a.m. July 6, 2020, so that they may be distributed to the committee members to review.

mailto:[email protected]

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MEMORANDUM

TO: ADVISORY COMMITTEE ON ADVANCED PRACTICE

REGISTERED NURSING FROM: HOLLY FISCHER CHIEF LEGAL COUNSEL SUBJECT: Administrative Rules DATE: JUNE 8, 2020

At the May 20-21, 2020 Board meeting, the Board reviewed and approved proposed revisions to rules required for five-year review in Ohio Administrative Code Chapter 8, Advanced Practice Nurse Certification and Practice, Chapter 9: Prescriptive Authority, and Chapter 23: Dialysis Technicians. The Board also reviewed proposed revisions to individual rules that are not slated for five-year review, but are either required to be revised, or recommended to be updated, due to recent legislative action, or for technical reasons. Prior to the May 2020 meeting, rules had also been reviewed by the Advisory Group on Dialysis at its May 18, 2020 meeting, and recommendations of that group were shared with the Board. The Committee on Prescriptive Governance met on March 17, 2020 and was provided an opportunity to recommend revisions to prescribing rules and did not have proposed revisions. On June 1, 2020, interested parties were encouraged to provide feedback on the rules with a requested June 30, 2020 deadline. On March 2, 2020, the Advisory Committee on Advanced Practice Registered Nursing reviewed a memo concerning the 2020 rule proposals. The Committee did not have recommendations for additional revisions to Chapter 4723-8, Advanced Practice Nurse Certification and Practice, or Chapter 4723-9, Prescriptive Authority. Attached for the Committee’s review at its July 6, 2020 meeting is draft Rule 4723-9-14, Standards and procedures for withdrawal management for drug or alcohol addiction (Detoxification). H.B. 49 (132nd GA) implemented Section 4723.51, ORC, requiring that the Board adopt rules for MAT that address both treatment and detoxification. It also required that the Board adopt rule language consistent with language adopted by the Medical Board. The Board reviewed the Medical Board draft rule detoxification language at its May meeting, as did the Advisory Committee on Advanced Practice Nursing (March 2, 2020 meeting). On

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May 20, 2020, the Medical Board’s draft detoxification rule language was approved by CSI. Proposed Rule 4723-9-14 substantively mirrors the Medical Board detoxification rules. Note the Medical Board has a separate rule for definitions, and rules for both Physician Assistants and Physicians. The Nursing Board MAT definitions are in Rule 4723-9-13, and Rule 4723-9-14 references those and adds definitions specific to the new rule matching the Medical Board rule definitions. Also attached for comparison are the previously provided draft Medical Board detoxification rules.

*** DRAFT - NOT YET FILED ***4723-9-14 Standards and procedures for withdrawal management for

drug or alcohol addiction.

(A) Definitions; for purposes of this rule and interpretation of the formulary set forth inrule 4723-9-10 of the Administrative Code:

(1) The definitions set forth in rule 4723-9-13 of the Administrative Code apply inaddition to those definitions set forth in this paragraph;

(2) "Ambulatory detoxification" means withdrawal management delivered in amedical office, public sector clinic, or urgent care facility by trainedpractitioners authorized to prescribe outpatient supplies of drugs approved bythe FDA for the treatment of addiction, prevention of relapse of drugaddiction, or both. Ambulatory detoxification is the provision of medicallysupervised evaluation, withdrawal management, and referral services withoutextended onsite monitoring. For purposes of this rule, ambulatorydetoxification does not include withdrawal management that occurs in thefollowing settings:

(a) A state or local correctional facility, as defined in section 5163.45 of theRevised Code;

(b) In-patient treatment in a hospital, as defined in section 3727.01 of theRevised Code;

(c) An opioid treatment program certified by SAMHSA and accredited by anindependent SAMHSA-approved accrediting body; or

(d) A youth services facility, as defined in section 103.75 of the RevisedCode.

(3) "ASAM" means the American society of addiction medicine;

(4) "Withdrawal management" or "detoxification" is a set of medical interventionsaimed at managing the acute physical symptoms of intoxication andwithdrawal. Detoxification denotes a clearing of toxins from the body of thepatient who is acutely intoxicated and/or dependent on a substance of abuse.Withdrawal management seeks to minimize the physical harm caused by theintoxication and withdrawal of a substance of abuse. Withdrawalmanagement occurs when the patient has a substance use disorder and eitherevidence of the characteristic withdrawal syndrome produced by withdrawalfrom that substance, or evidence that supports the expectation that suchsyndrome would develop without the provision of detoxification services.Withdrawal management alone does not constitute substance abuse treatmentor rehabilitation.

(B) A clinical nurse specialist, certified nurse midwife or certified nurse practitioner whoholds a current valid advanced practice registered nurse license may provide

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*** DRAFT - NOT YET FILED ***

ambulatory detoxification consistent with this rule if the advanced practiceregistered nurse:

(1) Only provides withdrawal management in collaboration with a physician whoprovides withdrawal management as part of the physician's normal course ofpractice and with whom the advanced practice registered nurse has a currentstandard care arrangement;

(2) Complies with the medication withdrawal policies of the healthcare facilities inwhich the advanced practice registered nurse engages in withdrawalmanagement practice; and

(3) Complies with all state and federal laws and rules applicable to prescribing,including holding a DATA 2000 waiver to prescribe buprenorphine ifbuprenorphine is to be prescribed for withdrawal management in a medicaloffice, public sector clinic, or urgent care facility.

(C) Prior to providing ambulatory detoxification for any substance use disorder theadvanced practice registered nurse shall inform the patient that ambulatorydetoxification alone is not substance abuse treatment. If the patient preferssubstance abuse treatment, the advanced practice registered nurse shall comply withthe requirements of section 3719.064 of the Revised Code, by completing thefollowing actions:

(1) Both verbally and in writing give the patient information about all drugsapproved by the FDA for use in medication-assisted treatment includingwithdrawal management. The information given shall be documented in thepatient's record.

(2) If the patient agrees to enter opioid treatment and the advanced practiceregistered nurse determines that such treatment is clinically appropriate, theadvanced practice registered nurse shall refer the patient to an opioidtreatment program licensed or certified by the Ohio department of mentalhealth and addiction services to provide such treatment or to a physician,physician assistant, or advanced practice registered nurse who providestreatment using naltrexone, or who holds the DATA 2000 waiver to provideoffice-based treatment for opioid use disorder. The name of the program orprovider to whom the patient was referred and the date of the referral shall bedocumented in the patient record.

(D) When providing withdrawal management for opioid use disorder an advancedpractice registered nurse may be authorized to use a medical device that is approvedby the FDA as an aid in the reduction of opioid withdrawal symptoms.

(E) Ambulatory detoxification for opioid addiction.

(1) An advanced practice registered nurse shall provide ambulatory detoxification

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only when all of the following conditions are met:

(a) A positive and helpful support network is available to the patient;

(b) The patient has a high likelihood of treatment adherence and retention intreatment; and

(c) There is little risk of medication diversion.

(2) The advanced practice registered nurse shall provide ambulatory detoxificationunder a defined set of policies and procedures or medical protocols consistentwith level of care I-D or II-D as set forth in "The ASAM Criteria, ThirdEdition," under which services are designed to treat the patient's level ofclinical severity to achieve safe and comfortable withdrawal from amood-altering drug and effectively facilitate the patient's transition intotreatment and recovery. "The ASAM Criteria, Third Edition," can be obtainedfrom the website of ASAM at https://www.asam.org/, and may be reviewed atthe board office, located at 17 S. high street, suite 660, Columbus, Ohio,43215 during normal business hours.

(3) Prior to providing ambulatory detoxification, the advanced practice registerednurse shall perform an assessment of the patient. The assessment shall includea thorough medical history and physical examination. The assessment mustfocus on signs and symptoms associated with opioid addiction and includeassessment with a nationally recognized scale, such as one of the following:

(a) Objective Opioid Withdrawal Scale ("OOWS");

(b) Clinical Opioid Withdrawal Scale ("COWS");

(c) Subjective Opioid Withdrawal Scale ("SOWS"),

(4) Prior to providing ambulatory detoxification, the advanced practice registerednurse shall conduct a biomedical and psychosocial evaluation of the patient,to include the following:

(a) A comprehensive medical and psychiatric history;

(b) A brief mental status exam;

(c) A substance abuse history;

(d) Family history and psychosocial supports;

(e) Appropriate physical examination;

(f) Urine drug screen or oral fluid drug testing;

4723-9-14 3


(g) Pregnancy test for women of childbearing age and ability;

(h) Review of the patient's prescription information in OARRS;

(i) Testing for human immunodeficiency virus;

(j) Testing for hepatitis B;

(k) Testing for hepatitis C; and

(l) Consideration of screening for tuberculosis and sexually transmitteddiseases in patients with known risk factor.

(m) For other than toxicology tests for drugs and alcohol, appropriate history,substance abuse history, and pregnancy test, the advanced practiceregistered nurse may satisfy the assessment requirements by reviewingrecords from a physical examination and laboratory testing of thepatient that was conducted within a reasonable period of time prior tothe visit. If any part of the assessment cannot be completed prior to theinitiation of treatment, the advanced practice registered nurse shalldocument the reasons in the medical record.

(5) The advanced practice registered nurse shall request and document review of anOARRS report on the patient.

(6) The advanced practice registered nurse shall inform the patient about thefollowing before the patient is undergoing withdrawal from opioids:

(a) The detoxification process and potential subsequent treatment forsubstance use disorder, including information about all drugs approvedby the FDA for use in medication-assisted treatment;

(b) The risk of relapse following detoxification without entry intomedication-assisted treatment;

(c) The high risk of overdose and death when there is a relapse followingdetoxification; and

(d) The safe storage and disposal of the medications.

(7) The advanced practice registered nurse shall not establish standardized routinesor schedules of increases or decreases of medications but shall formulate atreatment plan based on the needs of the specific patient.

(8) For persons projected to be involved in withdrawal management for six monthsor less, the advanced practice registered nurse shall offer the patient

4723-9-14 4


counseling and follow the procedures described in paragraphs (C)(8) and(C)(9) of rule 4723-9-13 of the Administrative Code.

(9) The advanced practice registered nurse shall require the patient to undergo urineand/or other toxicological screenings during withdrawal management in orderto demonstrate the absence of use of alternative licit and/or illicit drugs. Theadvanced practice registered nurse shall consider referring a patient who has apositive urine and/or toxicological screening to a higher level of care, withsuch consideration documented in the patient's medical record, and conferwith the colloborating physician prior to prescribing abuprenorphine/naloxone combination product to the patient.

(10) The advanced practice registered nurse shall comply with the followingrequirements for the use of medication:

(a) The advanced practice registered nurse may treat the patient's withdrawalsymptoms by use of any of the following drugs as determined to be themost appropriate for the patient:

(i) A drug, excluding methadone, that is specifically FDA approved forthe alleviation of withdrawal symptoms;

(ii) An alpha-2 adrenergic agent along with other non-narcoticmedications as recommended in "The ASAM National PracticeGuideline For the Use of Medications in the Treatment ofAddiction Involving Opioid Use," available at:https://www.asam.org, and available on the board's website athttps://nursing.ohio.gov;

(iii) A combination of buprenorphine and low dose naloxone(buprenorphine/naloxone combination product). However,buprenorphine without naloxone (buprenorphine mono-product)may be used if a buprenorphine/naloxone combination product iscontraindicated, with the contraindication documented in thepatient record.

(b) The advanced practice registered nurse shall not use any of the followingdrugs to treat the patient's withdrawal symptoms:

(i) Methadone;

(ii) Anesthetic agents.

(c) The advanced practice registered nurse shall:

(i) Not initiate treatment with buprenorphine to manage withdrawalsymptoms until between twelve and eighteen hours after the last

4723-9-14 5


dose of short-acting agonist such as heroin or oxycodone, andtwenty-four hours after the last does of long-acting agonist suchas methadone. Treatment with buprenorphine product must be incompliance with the FDA approved "Risk Evaluation andMitigation Strategy" for buprenorphine products, which can befound on the FDA website at:https://www.accessdata.fda.gov/scripts/cder/rems/index.cfm.

(ii) Determine on an individualized basis the appropriate dosage ofmedication to ensure stabilization during withdrawalmanagement.

(a) The dosage level shall be that which is well-tolerated by thepatient.

(b) The dosage level shall be consistent with the minimalstandards of care.

(11) The advanced practice registered nurse shall offer the patient a prescription fora naloxone kit and shall:

(a) Ensure that the patient receives instruction on the kit's use including, butnot limited to, recognizing the signs and symptoms of overdose andcalling 911 in an overdose situation;

(b) Offer the patient a new prescription for naloxone upon expiration or useof the old kit;

(c) Be exempt from this requirement if the patient refuses the prescription. Ifthe patient refuses the prescription the advanced practice registerednurse shall provide the patient with information on where to obtain a kitwithout a prescription.

(12) The advanced practice registered nurse shall take steps to reduce the chancesof medication diversion by using an appropriate frequency of office visits, pillcounts, and weekly checks of OARRS.

(F) The advanced practice registered nurse who provides ambulatory detoxification withmedication management for withdrawal from benzodiazepines or other sedativesshall comply with paragraphs (B), (C), and (D) of this rule and "TIP 45, ATreatment Improvement Protocol for Detoxification and Substance AbuseTreatment" by SAMHSA, available from the SAMHSA website at:https://store.samhsa.gov/ (search for "TIP 45") and available on the board's websiteat: https://nursing.ohio.gov. In addition, ambulatory detoxification with medicationmanagement shall only be provided if:

(1) A positive and helpful support network is available to the patient;

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(2) The patient's use of benzodiazepines was mainly in therapeutic ranges;

(3) The patient does not have polysubstance dependence;

(4) The patient exhibits no more than mild to moderate withdrawal symptoms;

(5) The patient has no comorbid medical condition or severe psychiatric disorder;

(6) The patient has no history of withdrawal seizures or withdrawal delirium;

(7) Prior to providing ambulatory detoxification, the advanced practice registerednurse performs and documents an assessment of the patient that focuses onsigns and symptoms associated with benzodiazepine or other sedative usedisorder, including assessment with a nationally recognized scale, such as the"Clinical Institute Withdrawal Assessment for Benzodiazepines"("CIWA-B");

(8) Prior to providing ambulatory detoxification, the advanced practice registerednurse conducts and documents a biomedical and psychosocial evaluation ofthe patient meeting the requirements of paragraph (E)(4) of this rule.

(9) The advanced practice registered instructs the patient not to drive or operatedangerous machinery during treatment;

(10) The advanced practice registered nurse regularly assesses the patient duringthe course of ambulatory detoxification so that dosage can be adjusted ifneeded;

(a) The patient shall be required to undergo urine and/or other toxicologicalscreening during withdrawal management in order to demonstrate theabsence of use of alternative licit and/or illicit drugs;

(b) The advanced practice registered nurse shall document consideration ofreferral of the patient who has a positive urine and/or toxicologicalscreen to a higher level of care;

(c) The advanced practice registered nurse shall take steps to reduce thechances of diversion by using an appropriate frequency of office visits,pill counts, and weekly checks of OARRS.

(G) An advanced practice registered nurse who provides ambulatory detoxification withmedication management of withdrawal from alcohol addiction shall comply withparagraphs (B), (C), and (D) of this rule and "TIP 45, A Treatment ImprovementProtocol for Detoxification and Substance Abuse Treatment" by SAMHSA,available from the SAMHSA website at: https://store.samhsa.gov/ (search for "TIP45") and available on the board's website at: https://nursing.ohio.gov. In addition,

4723-9-14 7


ambulatory detoxification with medication management shall only be provided if:

(1) A positive and helpful support network is available to the patient;

(2) The patient does not have polysubstance dependence;

(3) The patient exhibits no more than mild to moderate withdrawal symptoms;

(4) The patient has no comorbid medical condition or severe psychiatric disorder;

(5) The patient has no history of withdrawal seizures or withdrawal delirium;

(6) Prior to providing ambulatory detoxification, the advanced practice registerednurse performs and documents an assessment of the patient that focuses onsigns and symptoms associated with alcohol use disorder, includingassessment with a nationally recognized scale, such as the "Clinical InstituteWithdrawal Assessment for Alcohol-revised" ("CIWA-Ar");

(7) Prior to providing ambulatory detoxification, the advanced practice registerednurse conducts and documents a biomedical and psychosocial evaluation ofthe patient meeting the requirements of paragraph (E)(4) of this rule;

(8) The advanced practice registered nurse regularly assesses the patient during thecourse of ambulatory detoxification. The advanced practice registered nurseshall:

(a) Adjust the dosage of medication as medically appropriate;

(b) Require the patient to undergo urine and/or other toxicological screeningin order to demonstrate the absence of illicit drugs;

(c) Document the consideration of referral of the patient who has a positiveurine and/or toxicological screen to a higher level of care.

(9) The advanced practice registered nurse recommends that a patient who issuccessfully treated for alcohol withdrawal symptoms enter a long-termtreatment program to maintain abstinence.

4723-9-14 8

4730-4-01 Definitions.

(A) "Office-based opioid treatment" or "OBOT" means medication-assisted treatment, as that term is defined in this rule, in a private office or public sector clinic that is not otherwise regulated, by practitioners authorized to prescribe outpatient supplies of medications approved by the United States food and drug administration for the treatment of opioid addiction or dependence, prevention of relapse of opioid addiction or dependence, or both. OBOT includes treatment with all controlled substance medications approved by the United Stated food and drug administration for such treatment. OBOT does not include treatment that occurs in the following settings:

(1) A state or local correctional facility, as defined in section 5163.45 of the Revised

Code;

(2) A hospital, as defined in section 3727.01 of the Revised Code;

(3) A provider certified to provide residential and inpatient substance use disorder services, including withdrawal management, by the Ohio department of mental health and addiction services;

(4) An opioid treatment program certified by SAMHSA and accredited by an

independent SAMHSA-approved accrediting body; or

(5) A youth services facility, as defined in section 103.75 of the Revised Code.

(B) "SAMHSA" means the United States substance abuse and mental health services administration.

(C) "Medication-assisted treatment" means alcohol or drug addiction services that are

accompanied by medication that has been approved by the United States food and drug administration for the treatment of substance use disorder, prevention of relapse of substance use disorder, or both.

(D) "Substance use disorder" includes misuse, dependence, and addiction to alcohol and/

or legal or illegal drugs, as determined by diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition" or "DSM-5."

(E) "OARRS" means the "Ohio Automated Rx Reporting System" drug database

established and maintained pursuant to section 4729.75 of the Revised Code.

(F) For purposes of the rules in Chapter 4730-4 of the Administrative Code:

(1) "Qualified behavioral healthcare provider" means the following who is practicing within the scope of the professional license:

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(a) Board certified addictionologist, board certified psychiatrist, or psychiatrist, licensed under Chapter 4731. of the Revised Code;

(b) Licensed independent chemical dependency counselor-clinical supervisor,

licensed independent chemical dependency counselor, licensed chemical dependency counselor III, or licensed chemical dependency counselor II, or licensed chemical dependency counselor assistant licensed under Chapter 4758. of the Revised Code;

(c) Professional clinical counselor, licensed professional counselor, licensed

independent social worker, licensed social worker, or marriage and family therapist, licensed under Chapter 4757. of the Revised Code;

(d) Advanced practice registered nurse, licensed as a clinical nurse specialist

under Chapter 4723. of the Revised Code, who holds certification as a psychiatric mental health clinical nurse specialist issued by the American nurses credentialing center;

(e) Advanced practice registered nurse licensed as a nurse practitioner under

Chapter 4723. of the Revised Code, who holds certification as a psychiatric mental health nurse practitioner issued by the American nurses credentialing center;

(f) Psychologist, as defined in division (A) of section 4732.01 of the Revised

Code, licensed under Chapter 4732. of the Revised Code;

(g) Advanced practice registered nurse licensed under Chapter 4723. of the Revised Code, who holds subspecialty certification as a certified addiction registered nurse-advanced practice issued by the addictions nursing certification board.

(2) Nothing in this paragraph shall be construed to prohibit a physician assistant

licensed under Chapter 4730. of the Revised Code who practices under a supervision agreement with a board certified addiction psychiatrist, board certified addictionologist, or psychiatrist who is licensed as a physician under Chapter 4731. of the Revised Code, from providing services within the normal course of practice and expertise of the supervising physician, including addiction services, other mental health services, and physician delegated prescriptive services in compliance with Ohio and federal laws and rules.

(G) "Community addiction services provider," has the same meaning as in section 5119.01

of the Revised Code.

4730-4-01 4

(H) "Community mental health services provider" has the same meaning as in section 5119.01 of the Revised Code.

(I) "Induction phase" means the phase of opioid treatment during which maintenance

medication dosage levels are adjusted until a patient attains stabilization. (J) "Stabilization phase" means the medical and psychosocial process of assisting the patient

through acute intoxification intoxication and withdrawal management to the attainment of a medically stable, fully supported substance-free state, which may include the use of medications.

(K) “Withdrawal management” or “detoxification” is a set of medical interventions aimed at

managing the acute physical symptoms of intoxication and withdrawal. Detoxification denotes a clearing of toxins from the body of the patient who is acutely intoxicated and/or dependent on a substance of abuse. Withdrawal management seeks to minimize the physical harm caused by the intoxication and withdrawal of a substance of abuse. Withdrawal management occurs when the patient has a substance use disorder and either evidence of the characteristic withdrawal syndrome produced by withdrawal from that substance, or evidence that supports the expectation that such a syndrome would develop without the provision of detoxification services. Withdrawal management alone does not constitute substance abuse treatment or rehabilitation.

(L) “Ambulatory detoxification” means withdrawal management delivered in a medical office,

public sector clinic, or urgent care facility by trained practitioners authorized to prescribe outpatient supplies of drugs approved by the United States food and drug administration for the treatment of addiction, prevention of relapse of drug addiction, or both. Ambulatory detoxification is the provision of medically supervised evaluation, withdrawal management, and referral services without extended onsite monitoring. For purpose of rule 4730-4-02 of the Administrative Code, ambulatory detoxification does not include withdrawal management that occurs in the following settings:

(1) A state or local correctional facility, as defined in section 5163.45 of the Revised Code;

(2) In-patient treatment in a hospital, as defined in section 3727.01 of the Revised Code;

(3) A provider certified to provide residential and inpatient substance use disorder

services, including withdrawal management, by the Ohio department of mental health and addition services;

(4) An opioid treatment program certified by SAMHSA and accredited by an independent

SAMHSA-approved accrediting body; or

(5) A youth services facility, as defined in section 103.75 of the Revised Code.

Rule 4730-4-02 Standards and procedures for withdrawal management for drug or alcohol addiction.

(A) In order to provide ambulatory detoxification, as that term is defined in rule 4730-4-01 of the

Administrative Code, a physician assistant shall comply with all of the following requirements: (1) The physician assistant shall hold a valid prescriber number.

(2) The physician assistant shall provide withdrawal management under the supervision of a

physician who provides withdrawal management as part of the physician’s normal course of practice and with whom the physician assistant has a supervision agreement.

(3) The physician assistant shall comply with all state and federal laws and rules applicable to prescribing, including holding a DATA 2000 waiver to prescribe buprenorphine if buprenorphine is to be prescribed for withdrawal management in a medical office, public sector clinic, or urgent care facility.

(4) The physician assistant who practices in a healthcare facility shall comply with all policies of the healthcare facility concerning the provision of withdrawal management.

(B) Prior to providing ambulatory detoxification, as that term is defined in rule 4730-4-01 of the

Administrative Code, for any substance use disorder the physician assistant shall inform the patient that ambulatory detoxification alone is not substance abuse treatment. If the patient prefers substance abuse treatment, the physician assistant shall comply with the requirements of section 3719.064 of the Revised Code, by completing all of the following actions:

(1) Both orally and in writing, give the patient information about all drugs approved by the U.S. food and drug administration for use in medication-assisted treatment, including withdrawal management. That information was given shall be documented in the patient’s medical record.

(2) If the patient agrees to enter opioid treatment and the physician assistant determines that such treatment is clinically appropriate, the physician assistant shall refer the patient to an opioid treatment program licensed or certified by the Ohio department of mental health and addiction services to provide such treatment or to a physician, physician assistant, or advanced practice registered nurse who provides treatment using Naltrexone or who holds the DATA 2000 waiver to provide office-based treatment for opioid use disorder. The name of the program, physician, physician assistant, or advanced practice registered nurse to whom the patient was referred, and the date of the referral shall be documented in the patient record.

(C) When providing withdrawal management for opioid use disorder a physician assistant may be authorized to use a medical device that is approved by the United States food and drug administration as an aid in the reduction of opioid withdrawal symptoms.

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(D) Ambulatory detoxification for opioid addiction. (1) The physician assistant shall provide ambulatory detoxification only when all of the

following conditions are met: (a) A positive and helpful support network is available to the patient.

(b) The patient has a high likelihood of treatment adherence and retention in

treatment.

(c) There is little risk of medication diversion.

(2) The physician assistant shall provide ambulatory detoxification under a defined set of policies and procedures or medical protocols consistent with American Society of Addiction Medicine’s Level I-D or II-D level of care, under which services are designed to treat the patient’s level of clinical severity, to achieve safe and comfortable withdrawal from a mood-altering drug, and to effectively facilitate the patient’s transition into treatment and recovery. The ASAM Criteria, Third Edition, can be obtained from the website of the American Society of Addiction Medicine at https://www.asam.org/. A copy of the ASAM Criteria may be reviewed at the Medical Board office, 30 East Broad Street, Third Floor, Columbus, Ohio, during normal business hours.

(3) Prior to providing ambulatory detoxification, the physician assistant shall perform an assessment of the patient. The assessment shall include a thorough medical history and physical examination. The assessment must focus on signs and symptoms associated with opioid addiction and include assessment with a nationally recognized scale, such as one of the following:

(a) Objective Opioid Withdrawal Scale (“OOWS”);

(b) Clinical Opioid Withdrawal Scale (“COWS”); or (c) Subjective Opioid Withdrawal Scale (“SOWS”).

(4) Prior to providing ambulatory detoxification, the physician assistant shall conduct a

biomedical and psychosocial evaluation of the patient, to include the following: (a) A comprehensive medical and psychiatric history;

(b) A brief mental status exam;

(c) Substance abuse history;




https://www.asam.org/


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(h) Review of the patient's prescription information in OARRS;



(k) Testing for hepatitis C; and

(l) Consideration of screening for tuberculosis and sexually transmitted diseases in patients with known risk factors.

(m) For other than toxicology tests for drugs and alcohol, appropriate history,

substance abuse history, and pregnancy test, the physician assistant may satisfy the assessment requirements by reviewing records from a physical examination and laboratory testing of the patient that was conducted within a reasonable period of time prior to the visit. If any part of the assessment cannot be completed prior to the initiation of treatment, the physician assistant shall document the reason in the medical record.

(5) The physician assistant shall request and document review of an OARRS report on the patient.

(6) The physician assistant shall inform the patient about the following before the patient is undergoing withdrawal from opioids: (a) The detoxification process and potential subsequent treatment for substance use

disorder, including information about all drugs approved by the United States food and drug administration for use in medication-assisted treatment;

(b) The risk of relapse following detoxification without entry into medication-assisted treatment;

(c) The high risk of overdose and death when there is a relapse following detoxification;

(d) The safe storage and disposal of the medications. (7) The physician assistant shall not establish standardized routines or schedules of

increases or decreases of medications but shall formulate a treatment plan based on the needs of the specific patient.

(8) For persons projected to be involved in withdrawal management for six months or less, the physician assistant shall offer the patient counseling as described in paragraphs (F) and (G) of rule 4730-4-03 of the Administrative Code.

(9) The physician assistant shall require the patient to undergo urine and/or other toxicological screenings during withdrawal management in order to demonstrate the absence of use of alternative licit and/or illicit drugs. The physician assistant shall

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consider referring a patient who has a positive urine/and or toxicological screening to a higher level of care, with such consideration documented in the patient’s medical record, and shall confer with the supervising physician prior to prescribing the buprenorphine/naloxone combination product to the patient.

(10) The physician assistant shall comply with the following requirements for the use of medication:

(a) The physician assistant may treat the patient’s withdrawal symptoms by use of any of the following drugs as determined to be most appropriate for the patient.

(i) A drug, excluding methadone, that is specifically FDA approved for the

alleviation of withdrawal symptoms;

(ii) An alpha-2 adrenergic agent along with other non-narcotic medications as recommended in the American Society of Addiction Medicine’s National Practice Guideline (https://www.asam.org/), which is available from the Medical Board’s website at https://med.ohio.gov;

(iii) A combination of buprenorphine and low dose naloxone (buprenorphine/naloxone combination product). However, buprenorphine without naloxone (buprenorphine mono-product) may be used if a buprenorphine/naloxone combination product is contraindicated, with the contraindication documented in the patient record

(b) The physician assistant shall not use any of the following drugs to treat the patient’s withdrawal symptoms:

(i) Methadone;

(ii) Anesthetic agents

(c) The physician assistant shall comply with the following:

(i) The physician assistant shall not initiate treatment with buprenorphine to manage withdrawal symptoms until between twelve and eighteen hours after the last dose of short-acting agonist such as heroin or oxycodone, and twenty-four to forty-eight hours after the last dose of long-acting agonist such as methadone. Treatment with a buprenorphine product must be in compliance with the United States food and drug administration approved "Risk Evaluation and Mitigation Strategy" for buprenorphine products, which can be found on the United States food and drug administration website at the following address: https://www.accessdata.fda.gov/scripts/cder/rems/index.cfm.

(ii) The physician assistant shall determine on an individualized basis the

appropriate dosage of medication to ensure stabilization during withdrawal management.



https://med.ohio.gov/


https://www.accessdata.fda.gov/scripts/cder/rems/index.cfm

https://www.accessdata.fda.gov/scripts/cder/rems/index.cfm

5

(a) The dosage level shall be that which is well tolerated by the patient. (b) The dosage level shall be consistent with the minimal standards of care.

(iii) In withdrawal management programs of thirty days or less duration, the physician assistant shall not allow more than one week of unsupervised or take-home medications for the patient.

(11) The physician assistant shall offer the patient a prescription for a naloxone kit.

(a) The physician assistant shall ensure that the patient receives instruction on the kit's use including, but not limited to, recognizing the signs and symptoms of overdose and calling 911 in an overdose situation.

(b) The physician assistant shall offer the patient a new prescription for naloxone

upon expiration or use of the old kit. (c) The physician assistant shall be exempt from this requirement if the patient

refuses the prescription. If the patient refuses the prescription the physician assistant shall provide the patient with information on where to obtain a kit without a prescription.

(12) The physician assistant shall take steps to reduce the chances of medication diversion by using the appropriate frequency of office visits, pill counts, and weekly checks of OARRS.

(E) The physician assistant who provides ambulatory detoxification with medication

management for withdrawal from benzodiazepines or other sedatives shall comply with paragraphs (A), (B), and (C) of this rule and “TIP 45, A Treatment Improvement Protocol for Detoxification and Substance Abuse Treatment” by the Substance Abuse and Mental Health Services Administration available from the Substance Abuse and Mental Health Services Administration website at the following link: https://store.samhsa.gov/. (Search for “TIP 45”) and available on the Medical Board’s website at: https://med.ohio.gov.

(1) The physician assistant shall provide ambulatory detoxification with medication

management only when a positive and helpful support network is available to the patient whose use of benzodiazepines was mainly in therapeutic ranges and who does not have polysubstance dependence. The patient should exhibit no more than mild to moderate withdrawal symptoms, have no comorbid medical condition or severe psychiatric disorder, and no past history of withdrawal seizures or withdrawal delirium.

(2) Prior to providing ambulatory detoxification, the physician assistant shall perform and document an assessment of the patient that focuses on signs and symptoms associated with benzodiazepine or other sedative use disorder and include assessment with a nationally recognized scale, such as the “Clinical Institute Withdrawal Assessment for Benzodiazepines” (“CIWA-B”).

https://store.samhsa.gov/




6

(3) Prior to providing ambulatory detoxification, the physician assistant shall conduct and document a biomedical and psychosocial evaluation of the patient meeting the requirements of paragraph (B)(4) of this rule.

(4) The physician assistant shall instruct the patient not to drive or operate dangerous

machinery during treatment.

(5) During the ambulatory detoxification, the physician assistant shall regularly assess the patient during the course of treatment so that dosage can be adjusted if needed.

(a) The physician assistant shall require the patient to undergo urine and/or other

toxicological screenings during withdrawal management in order to demonstrate the absence of use of alternative licit and/or illicit drugs.

(b) The physician assistant shall document consideration of referring the patient who has a positive urine and/or toxicology screening to a higher level of care.

(c) The physician assistant shall take steps to reduce the chances of diversion by

using the appropriate frequency of office visits, pill counts, and weekly checks of OARRS.

(F) The physician assistant who provides ambulatory detoxification with medication

management of withdrawal from alcohol addiction shall comply with paragraphs (A), (B), and (C) of this rule and “TIP 45, A Treatment Improvement Protocol for Detoxification and Substance Abuse Treatment” by the Substance Abuse and Mental Health Services Administration available from the Substance Abuse and Mental Health Services Administration website at the following link: https://store.samhsa.gov/ (Search for “TIP 45”) and available from the Medical Board’s website at: https://med.ohio.gov.

(1) The physician assistant shall provide ambulatory detoxification from alcohol with

medication management only when a positive and helpful support network is available to the patient who does not have a polysubstance dependence. The patient should exhibit no more than mild to moderate withdrawal symptoms, have no comorbid medical conditions or severe psychiatric disorders, and no past history of withdrawal seizures or withdrawal delirium.

(2) Prior to providing ambulatory detoxification, the physician assistant shall perform and document an assessment of the patient. The assessment must focus on signs and symptoms associated with alcohol use disorder and include assessment with a nationally recognized scale, such as the “Clinical Institute Withdrawal Assessment for Alcohol-revised” (“CIWA-AR”).

(3) Prior to providing ambulatory detoxification, the physician assistant shall perform and

document a biomedical and psychosocial evaluation meeting the requirements of paragraph (D)(4) of this rule.

(4) During the course of ambulatory detoxification, the physician assistant shall assess

the patient regularly:

(a) The physician assistant shall adjust the dosage as medically appropriate;



7

(b) The physician assistant shall require the patient to undergo urine and/or other

toxicological screenings in order to demonstrate the absence of illicit drugs;

(c) The physician assistant shall document the consideration of referring a patient who has a positive urine and/or toxicological screening to a higher level of care;

(5) The physician assistant shall recommend that the patient who is successfully treated

for alcohol withdrawal symptoms enter a long-term treatment program to maintain abstinence.

June 30, 2020 Ohio Board of Nursing 17 S. High Street, Suite 660 Columbus, Ohio 43215-3466 SENT VIA EMAIL ONLY TO: [email protected] RE: Comments for 5-Year Rule Review (OAC 4723-9 and OAC 4723-10) To Whom It May Concern: As general counsel for the Ohio Association of Advanced Practice Nurses ("OAAPN"), we respectfully submit these comments regarding certain proposed rule changes that will be the subject of a public hearing scheduled for November 2020. Thank you to the Ohio Board of Nursing for the opportunity to submit these comments.

1. Attached Redlines of OAC 4723-9 and OAC 4723-10 For your convenience, OAAPN has created a redlined version of both OAC 4723-9 and OAC 4723-10, which shows its proposed changes for these two chapters of the Ohio Administrative Code (“OAC”). This letter is meant to further supplement the requested changes. However, the redlines contain suggested changes that may not be described in this letter. Please see the attached Exhibit A and Exhibit B.

2. OAC 4723-8-04(A) OAAPN has received comments from its members that OAC 4723-8-04(A) has created obstacles when an advanced practice registered nurse (“APRN”) has been reassigned to a different department within the same organization. As such, language has been suggested for OAC 4723-8-04(A) which addresses these concerns.

3. OAC 4723-9-1(B) Ohio law no longer rquires a consultation with a physician before the initiation of drug therapy. As such, OAAPN suggests deleting the definition of “consultation” from this section.

4. OAC 4723-9-2(A)(4) The current language in OAC 4723-9-2(A)(4) goes beyond the requirements in ORC 4723.482. As such, OAAPN has proposed a change to allow for evolving ways of evaluating learning.

5. OAC 4723-9-10(K) OAAPN respectfully reiterates the suggested changes to OAC 4723-9-10(K) contained in its previously submitted letter to the Ohio Board of Nursing dated November 19, 2019. For the Board’s convenience, a copy of the November 19, 2019 letter is attached hereto as Exhibit C.

6. CPG Sunsetting There are a number of places throughout the attached redlines where OAAPN has suggested changes that relate to provisions referencing the Committee for Prescriptive Governance (“CPG”). It is our understanding that a bill is currently pending in the Ohio General Assembly which would sunset the CPG. See Ohio S.B. 331. As such, the proposed OAC changes regarding the CPG are dependent upon whether S.B. 331 becomes Ohio law prior to the current OAC rule review being completed. Thank you again for your time and the ability to comment on these rules. OAAPN is happy to meet with the Ohio Board of Nursing to further discuss its proposed changes if an opportunity to do so exists. Sincerely,

Jeana M. Singleton CC: Joscelyn Greaves – OAAPN President

4846-6661-2417, v. 1

Exhibit A

Chapter 4723-8 Advanced Practice Registered Nurse Licensing and Practice


As used in this chapter:

(A) "Advanced practice registered nurse" means an individual who holds a current, valid licenseissued under Chapter 4723. of the Revised Code that authorizes the practice of nursing as anadvanced practice registered nurse and is designated as any of the following:

(1) A certified registered nurse anesthetist;

(2) A clinical nurse specialist;

(3) A certified nurse-midwife;

(4) A certified nurse practitioner.

(B) "Collaboration" or "collaborating" means:

(1) In the case of a certified nurse practitioner or a clinical nurse specialist, that a podiatrist orphysician has entered into a standard care arrangement with the nurse and is continuouslyavailable to communicate with the clinical nurse specialist or certified nurse practitioner either inperson, or by electronic communication ;

(2) In the case of a certified nurse-midwife, that a physician has entered into a standard carearrangement with the nurse and is continuously available to communicate with the nurse either inperson, or by electronic communication. .

(C) "Dentist" means an individual holding a license issued under Chapter 4715. of the RevisedCode to practice dentistry, and who is practicing in Ohio.

(D) "Physician" means an individual holding a certificate issued under Chapter 4731. of the RevisedCode authorizing the practice of medicine and surgery or osteopathic medicine and surgery, andwho is practicing in Ohio.

(E) "Podiatrist" means an individual holding a certificate issued under Chapter 4731. of the RevisedCode authorizing the practice of podiatric medicine, and who is practicing in Ohio.

(F) "Practice of nursing as an advanced practice registered nurse" means providing to individualsand groups nursing care that requires knowledge and skill obtained from advanced formaleducation, training and clinical experience. Such nursing care includes the care described insection 4723.43 of the Revised Code.

http://codes.ohio.gov/oac/4723-8-01v1

http://codes.ohio.gov/orc/4723.43

(G) "Nursing specialty" means a specialty in practice as a certified registered nurse anesthetist,clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner.

(H) "Standard care arrangement" means a written, formal guide for planning and evaluating apatient's health care that is developed by a collaborating physician or podiatrist and a certifiednurse-midwife, certified nurse practitioner, or clinical nurse specialist, and that meets therequirements of section 4723.431 of the Revised Code and this chapter.

(I) "Supervision" means that a certified registered nurse anesthetist is under the direction of apodiatrist, a dentist, or a physician, and, when administering anesthesia, the certified registerednurse anesthetist is in the immediate presence of the podiatrist, dentist, or physician.

4723-8-02 Standards of practice.

(A) An advanced practice registered nurse shall provide to patients nursing care that requiresknowledge 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 of the RevisedCode and this chapter.

(B) Except as otherwise precluded by law or rule, each advanced practice registered nurse shallpractice in accordance with the following:

(1) The advanced practice registered nurse's education and clinical experience;

(2) The advanced practice registered nurse's national certification as provided insection 4723.41 of the Revised Code; and

(3) Chapter 4723. of the Revised Code and rules adopted under that chapter.

(C) Only a certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist holdinga current valid license as an advanced practice registered nurse may prescribe drugs.

(D) Each certified nurse-midwife, certified nurse practitioner, and clinical nurse specialist shallutilize and incorporate into the nurse's practice, knowledge of Chapter 4731. of the Revised Codeand rules adopted under that chapter that govern the practice of the nurse's collaborating physicianor podiatrist. Each certified registered nurse anesthetist shall utilize and incorporate into thenurse's practice, knowledge of Chapters 4715. and 4731. of the Revised Code and rules adoptedunder these chapters that govern the practice of the nurse's supervising podiatrist, dentist, orphysician.

(E) Nothing in this rule precludes an advanced practice registered nurse from practicing as aregistered nurse in accordance with section 4723.01 of the Revised Code and the rules of theboard.

4723-8-03 Title protection.

(A) Only a person who holds a current valid license to practice as an advanced practice registerednurse issued in accordance with sections 4723.41, 4723.42 and 4723.482 of the Revised Code andthis chapter may use the following titles or initials if designated to do so:












(1) Certified nurse-midwife, or A.P.R.N.-C.N.M., , if the individual is authorized to practice inaccordance with division (A) of section 4723.43 of the Revised Code;

(2) Clinical nurse specialist, or A.P.R.N.-C.N.S., , if the individual is authorized to practice inaccordance with division (D) of section 4723.43 of the Revised Code;

(3) Certified nurse practitioner, or A.P.R.N.-C.N.P., , if the individual is authorized to practice underdivision (C) of section 4723.43 of the Revised Code;

(4) Certified registered nurse anesthetist or A.P.R.N.-C.R.N.A., if the individual is authorized topractice in accordance with division (B) of section 4723.43 of the Revised Code; or

(5) Advanced practice registered nurse or A.P.R.N. if the individual is authorized to practice underdivision (A) to division (D) of section 4723.43 of the Revised Code.

(B) Only a person who holds a current valid advanced practice registered nurse license issued inaccordance with sections 4723.41, 4723.42 and 4723.482 of the Revised Code and this chapter topractice as a certified nurse-midwife, certified nurse practitioner, certified registered nurseanesthetist, or clinical nurse specialist shall:

(1) Practice in accordance with section 4723.43 of the Revised Code and this chapter as a certifiednurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nursespecialist;

(2) Hold themselves out as being a certified nurse-midwife, certified nurse practitioner, certifiedregistered nurse anesthetist, clinical nurse specialist, or advanced practice registered nurse;

(3) Use any title or initials implying that the person is a certified nurse-midwife, certified nursepractitioner, certified registered nurse anesthetist, clinical nurse specialist, or advanced practiceregistered nurse authorized to practice in accordance with section 4723.03 of the Revised Codeand paragraph (A) of this rule.

(C) At all times when an advanced practice registered nurse is providing direct care to a patientwithin the nurse's respective scope of practice, each certified nurse-midwife, certified nursepractitioner, certified registered nurse anesthetist, or clinical nurse specialist shall display andidentify the applicable title and designation as set forth in this rule.

(D) No person who is not authorized to do so shall knowingly prescribe or personally furnish drugsor therapeutic devices without holding a current valid license to practice nursing as an advancedpractice registered nurse issued under Chapter 4723. of the Revised Code and being designatedas a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner according tosection 4723.42 of the Revised Code.

4723-8-04 Standard care arrangement for a certified nurse-midwife, certified nurse practitioner, and clinical nurse specialist.

(A) Prior to engaging in practice, a standard care arrangement shall be entered into with eachphysician or podiatrist with whom the certified nurse-midwife, certified nurse practitioner, orclinical nurse specialist collaborates.















(1) The standard care arrangement shall be revised to reflect the addition or deletion of a physicianor podiatrist with whom the nurse collaborates within that employment setting. Under thesecircumstances, a new standard care arrangement is not necessary.

(2) A new standard care arrangement shall be executed when

(a) tThe nurse is employed at a different or additional organization or practice and setting

(b) and eEngages in practice with a different collaborating physician or podiatrist outsideof the primary employing organization.

(3) A new standard care arrangement is not necessary during any time period in which theGovernor of the State of Ohio declares a state of emergency, and, the nurse is re-assigned within the employing organization.

(B) A certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist engaged inthe practice of the nurse's specialty, shall enter into a written standard care arrangement with oneor more collaborating physicians or podiatrists whose practice is the same or similar to the nurse'spractice. In accordance with division (D) of section 4723.431 of the Revised Code, a clinical nursespecialist whose nursing specialty is mental health or psychiatric mental health, as determined bythe board, must enter into a standard care arrangement with a collaborating physician whopractices in one of the following specialties:

(1) A specialty that is the same or similar to the nurse's specialty;

(2) Pediatrics; or

(3) Primary care or family practice.

(C) The standard care arrangement shall include at least:

(1) The signatures of each nurse, and each collaborating physician, or the physician's designatedrepresentative, or each podiatrist with whom the certified nurse-midwife, certified nursepractitioner, or clinical nurse specialist primarily collaborates indicating review of and agreementto abide by the terms of the standard care arrangement. For purposes of this rule, a physician'sdesignated representative means a physician who serves as the department or unit director orchair, within the same institution, organization or facility department or unit, and within the samepractice specialty, that the nurse practices, and with respect to whom the physician has executeda legal authorization to enter collaborating agreements on the physician's behalf;

(2) The date when the arrangement is initially executed;

(3) The date of the most recent review of the arrangement;

(4) The complete name, specialty and practice area, business address, and business phone numberor number at which the individual can be reached at any time for:

(a) Each collaborating physician or podiatrist with whom the certified nurse-midwife, certified nursepractitioner, or clinical nurse specialist primarily collaborates and who is a party to the standardcare arrangement; and


(b) Each certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist who is aparty to the standard care arrangement;

(c) Except when the standard care arrangement is signed by the designated physicianrepresentative as defined in 4723-8-4(C)(1)

5) A statement of services offered by the certified nurse-midwife, certified nurse practitioner, orclinical nurse specialist consistent with section 4723.43 of the Revised Code and this chapter,including a description of the scope of prescriptive practice.

(6) A plan for incorporation of new technology or procedures consistent with the applicable scopeof practice as set forth in section 4723.43 of the Revised Code and this chapter;

(7) Quality assurance provisions, including at least:

(a) When modification is made to the body of the standard care arrangement, Every two years,review and reapproval of the standard care arrangement is required. The standard carearrangement shall be reviewed at least every two years. Each nurse who is a party to thearrangement and at least one collaborating physician or podiatrist shall sign and date the biennialreview of the standard care arrangement;

(b) Criteria for referral of a patient by the certified nurse-midwife, certified nurse practitioner, orclinical nurse specialist to a collaborating physician or podiatrist, including, for the certified nurse-midwife, a plan for referral of breech or face presentation or any other abnormal condition identifiedas such in the standard care arrangement;

(c) A process for the certified nurse-midwife, certified nurse practitioner, or clinical nurse specialistto obtain consultation from a physician or podiatrist; and

(d) A process for chart review in accordance with rule 4723-8-05 of the Administrative Code if thenurse's practice includes any direct patient care,. education, or management;

(8) A plan for coverage of patients in instances of emergency or planned absences of either thecertified nurse-midwife, certified nurse practitioner, or clinical nurse specialist, or the collaboratingphysician or podiatrist;

(9) A process for resolution of disagreements regarding matters of patient management; and

(10) An arrangement regarding reimbursement under the medical assistance program as set forthin Chapter 5162. of the Revised Code and in accordance with any rules adopted under division (B)of section 5164.02 of the Revised Code .

(11) Regarding the prescribing component of the clinical nurse specialist, certified nurse-midwife,or certified nurse practitioner's practice , the following quality assurance provisions shall includeat least:

(a) Provisions to ensure timely direct, personal evaluation of the patient with a collaboratingphysician or the physician's designee when indicated;

(b) Additional pPrescribing parameters for drugs or therapeutic devices when indicated, including:



http://codes.ohio.gov/oac/4723-8-05

(i) Provisions for use of drugs with non-food and drug administration (FDA) approved indications;

(ii) Provisions for use of drugs approved by the FDA and reviewed by the committee on prescriptivegovernance subsequent to the date of the standard care arrangement;

(iii) Provisions for use of drugs previously reviewed by the committee on prescriptive governancebut approved by the FDA for new indications subsequent to the date of the standard carearrangement;

(iv) Provisions for the use of schedule II controlled substances;

(v) If the nurse is prescribing to minors, as defined in division (A) of section 3719.061 of theRevised Code, provisions for complying with section 3719.061 of the Revised Code whenprescribing an opioid analgesic to a minor; and

(vi) Provisions for obtaining and reviewing OARRS reports, and engaging in physician consultationand patient care consistent with section 4723.487 of the Revised Code and rule 4723-9-12 of theAdministrative Code.

(c) A procedure for the nurse and the collaborating physician, or a designated member of a qualityassurance committee, composed of at least one physician, of the institution, organization, oragency where the nurse has practiced during the period covered by the review, to conduct aperiodic review, at least semiannually, of:

(i) A representative sample of prescriptions written by the nurse;

(ii) A representative sample of schedule II prescriptions written by the nurse; and

(d) Provisions to ensure that the nurse is meeting all the requirements of rule 4723-9-12 of theAdministrative Code related to review of a patient's OARRS report, consultation with thecollaborating physician prior to prescribing based on the OARRS report and signs of drug abuse ordiversion as set forth in rule 4723-9-12 of the Administrative Code, and documentation of receiptand assessment of OARRS report information in the patient's record.

(12) Quality assurance standards consistent with rule 4723-8-05 of the Administrative Code.

(D) The most current copy of the standard care arrangement, and any legal authorization signedby a physician according to paragraph (C)(1) of this rule, shall be retained on file by the nurse'semployer . Upon request of the board, the certified nurse-midwife, certified nurse practitioner, orclinical nurse specialist shall immediately provide a copy of the standard care arrangement to theboard.

(E) Copies of previously effective standard care arrangements shall be retained by the nurse forthree years and provided to the board upon request.

(F) When a hospital negotiates a standard care arrangement in accordance with division (F) ofsection 4723.431 of the Revised Code and this chapter, the standard care arrangement shall bedeveloped in accordance with paragraph (C) of this rule. Review and approval of the standard carearrangement shall be in accordance with the policies and procedures of the hospital governingbody and the bylaws, policies, and procedures of the hospital medical staff.







(G) A certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist shall notifythe board of the identity of a collaborating physician or podiatrist not later than thirty days afterengaging in practice.

(H) A certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist shall notifythe board of any change in the name and business address of a collaborating physician or podiatristnot later than thirty days after the change takes effect , except as provided in division (E) ofsection 4723.431 of the Revised Code.

4723-8-05 Quality assurance standards.

(A) An advanced practice registered nurse shall comply with all continuing education requirementsfor registered nurse license renewal and advanced practice registered nurse license renewal setforth in division (C) of section 4723.24 of the Revised Code and national certification requirementsset forth in sections 4723.41 and 4723.42 of the Revised Code and this chapter.

(B) The certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist and thecollaborating physician or podiatrist shall jointly review each effective standard care arrangementat least once every two years. Such review shall be documented with the date and signature ofeach nurse who is party to the arrangement and at least one collaborating physician or podiatrist.

(C) Each certified nurse-midwife, certified nurse practitioner, and clinical nurse specialist who is aparty to a standard care arrangement shall comply with all quality assurance provisions of thestandard care arrangement in accordance with this chapter. Failure to provide, enter into, or topractice in accordance with a standard care arrangement may result in disciplinary action inaccordance with section 4723.28 of the Revised Code.

(D) Each practicing certified nurse-midwife, certified nurse practitioner, and clinical nurse specialistwho is a party to a standard care arrangement shall participate in a quality assurance process andshall immediately provide documentation satisfactory to the board of such participation uponrequest of the board. The quality assurance process shall include at a minimum:

(1) Periodic random chart review which includes prescribing patterns and Schedule II prescribing,if indicated, at least annually by a collaborating or supervising physician, podiatrist, dentist, or adesignated member of a quality assurance committee, composed of at least one physician, of theinstitution, organization, or agency where the nurse has practiced. during the period covered bythe review , including a procedure for periodic review, at least semi-annually, of prescriptionswritten and prescribing patterns for the advanced practice registered nurse ;

(2) Subsequent to each chart review, a conference shall be held between a collaborating orsupervising physician, podiatrist, dentist, or a designated member of a quality assurancecommittee of the institution, organization, or agency and the advanced practice registered nurse;and

(3) A process for patient evaluation of care.

(E) Documentation of participation in an ongoing, systematic quality assurance process at aninstitution, organization, or agency shall satisfy the requirements of paragraph (D) of this rule,provided there is a plan to utilize the results of the quality assurance process to maintain orimprove care delivery.

(F) Every two years, each certified nurse-midwife, certified nurse practitioner, and clinical nursespecialist shall verify the licensure status of each collaborating physician or podiatrist with whom







the nurse has an effective standard care arrangement. Verification of licensure status may be obtained online from the Ohio e-license center. The nurse shall document that such verification was obtained.

(G) The board may audit, review or investigate, at any time, whether an advanced practiceregistered nurse has complied with the quality assurance standards set forth in this rule.

4723-8-06 National certifying organizations.

(A) To be approved by the board, a national certifying organization shall meet all of therequirements set forth in division (A) of section 4723.46 of the Revised Code.

(B) Annually at a time specified by the board, the board shall provide to each national nursingcertifying organization approved by the board for the prior year a form, locatedat http://www.nursing.ohio.gov/forms.htm (revised 2015), for the organization to submit to theboard attesting that the organization has met and continues to meet all the requirements containedin section 4723.46 of the Revised Code. The board shall verify compliance of each national nursingcertifying organization with the criteria contained in section 4723.46 of the Revised Code. No laterthan January thirtieth of each year, the board shall publish a list of approved national certifyingorganizations that meet these requirements. The board may approve additional national nursingcertifying organizations or discontinue approval of a national nursing certifying organization basedon criteria in section 4723.46 of the Revised Code. At the discretion of the board, it maydiscontinue approval of a national certifying organization for failure of the organization to returnto the board the form indicating compliance with the requirements of section 4723.46 of theRevised Code.

4723-8-08 Advanced practice registered nurse license renewal; notification of national recertification.

[Comment: Information regarding the availability and effective date of the materials incorporated by reference in this rule can be found in paragraph (G) of rule 4723-1-03 of the Administrative Code.]

(A) To renew a current valid license to practice as an advanced practice registered nurse, a licenseeshall:

(1) Submit a "Certified Registered Nurse Anesthetist Renewal Application," "Certified Nurse MidwifeRenewal Application," "Certified Nurse Practitioner Renewal Application," and/or "Clinical NurseSpecialist Renewal Application," that includes:

(a) Except as provided in paragraph (A)(2) of this rule, documentation satisfactory to the boardthat the licensee has maintained certification in the nursing specialty with a national certifyingorganization as required by division (B) of section 4723.42 of the Revised Code;

(b) Documentation satisfactory to the board of completion of continuing education required bydivision (C)(2) of section 4723.24 of the Revised Code and rule 4723-8-10 of the AdministrativeCode;

(c) A list of the names and business addresses of the holder's current collaborating physicians andpodiatrists, if the nurse is a clinical nurse specialist, certified nurse-midwife, or certified nursepractitioner; and



http://www.nursing.ohio.gov/forms.htm











(d) The renewal fee set forth in division (A)(8) of section 4723.08 of the Revised Code. If acompleted renewal application is not renewed online by September fifteenth of odd numberedyears, in order to renew the applicant shall pay a late processing fee of fifty dollars in accordancewith division (A)(10) of section 4723.08 of the Revised Code. The late processing fee is in additionto the renewal fee specified in division (A) (8) of section 4723.08 of the Revised Code, and is inaddition to any late processing fee imposed with respect to renewal of the applicant's registerednurse license; and

(2) A clinical nurse specialist, originally issued a certificate of authority on or before December 31,2000 in accordance with division (C) of section 4723.41 of the Revised Code, as that divisionexisted prior to March 20, 2013, is not required to provide documentation of having maintainedcertification in the holder's specialty, but shall submit documentation satisfactory to the board ofcompletion of continuing education in compliance with paragraph (E) of rule 4723-8-10 of theAdministrative Code.

(B) A renewed advanced practice registered nurse license is subject to renewal in odd-numberedyears. When an advanced practice registered nurse license is first issued by the board on or afterJuly first of an odd numbered year, that license shall be current through the thirty-first of Octoberof the next odd-numbered year.

(C) The board shall provide access to an on-line application to each holder of a current validadvanced practice registered nurse license for renewal of the license, except when the board isaware that an individual is ineligible for renewal for any reason, including those reasons specifiedin section 4723.24 of the Revised Code. Failure of the licensee to receive an application for renewalfrom the board does not excuse the licensee from the requirements of Chapter 4723. of the RevisedCode and this chapter.

(D) Within thirty days of recertification by the applicable national certifying organization, anadvanced practice registered nurse shall request that the national certifying organization provide,directly to the board, satisfactory documentation of recertification to the board. This requirementdoes not apply to a clinical nurse specialist, originally issued a certificate of authority on or beforeDecember 31, 2000 in accordance with division (C) of section 4723.41 of the Revised Code, asthat division existed prior to March 20, 2013.

(E) An advanced practice registered nurse who fails to maintain certification or recertification bythe applicable national certifying organization approved by the Board according tosection 4723.46 of the Revised Code, may be subject to disciplinary action in accordance withsection 4723.28 of the Revised Code. This requirement does not apply to a clinical nurse specialist,originally issued a certificate of authority on or before December 31, 2000 in accordance withdivision (C) of section 4723.41 of the Revised Code, as that division existed prior to March 20,2013.

(F) A clinical nurse specialist, originally issued a certificate of authority on or before December 31,2000 in accordance with division (C) of section 4723.41 of the Revised Code, as that divisionexisted prior to March 20, 2013, who fails to complete the continuing nursing education requiredby division (B) of section 4723.42 of the Revised Code and rule 4723-8-10 of the AdministrativeCode, may be subject to disciplinary action in accordance with section 4723.28 of the RevisedCode.

(G) A holder of a current valid advanced practice registered nurse license who does not intend topractice as a certified nurse-midwife, certified nurse practitioner, certified registered nurseanesthetist, or clinical nurse specialist in Ohio may request that the license be placed on inactivestatus at any time, by submitting a written statement to the board or electronic request askingthat the certificate be placed on inactive status.















(H) While on inactive status a nurse shall not represent or imply to the public that the nurse isauthorized to practice as a certified nurse-midwife, certified nurse practitioner, certified registerednurse anesthetist, or clinical nurse specialist or use the titles or designations established bysection 4723.03 of the Revised Code and rule 4723-8-03 of the Administrative Code.

(I) An inactive or lapsed advanced practice registered nurse license may be reactivated orreinstated by:

(1) Submitting an "Advanced Practice Registered Nurse Reactivation and ReinstatementApplication"; and

(2) Payment of the applicable fees set forth in section 4723.08 of the Revised Code.

(3) By executive order by the governor during a state emergency with fees waived.

(J) An advanced practice registered nurse who is a service member or veteran, as defined inrule 4723-2-01 of the Administrative Code, or who is the spouse or surviving spouse of a servicemember or veteran, may be eligible for a waiver of the late application fee and the reinstatementfee according to rule 4723-2-03 of the Administrative Code.

4723-8-09 Advanced practice registered nurse license for a certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist practicing in another jurisdiction.

[Comment: Information regarding the availability and effective date of the materials incorporated by reference in this rule can be found in paragraph (G) of rule 4723-1-03 of the Administrative Code.]

A certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist who is practicing in another jurisdiction may apply for an advanced practice registered nurse license to practice in Ohio if the nurse meets the requirements for licensure set forth in section 4723.41 of the Revised Code and this chapter. An applicant from another jurisdiction shall:

(A) Submit a completed "Advanced Practice Registered Nurse License Application," ; and

(B) Submit the applicable fee.

4723-8-10 Continuing education requirements.

(A) Each registered nurse who obtains continuing nursing education in the nurse's area of practicefor the purpose of obtaining or maintaining a national certification may use those continuingeducation hours to satisfy the continuing education requirements for renewal of a license topractice as a registered nurse and advanced practice registered nurse set forth in this rule,section 4723.24 of the Revised Code and Chapter 4723-14 of the Administrative Code, if thecontinuing education meets the requirements of Chapter 4723-14 of the Administrative Code.














(B) An advanced practice registered nurse who holds an active license shall complete continuingnursing education as follows in order to renew the license:

(1) Twenty-four contact hours of continuing nursing education;

(2) For advanced practice registered nurses designated as a clinical nurse specialist, certifiednurse-midwife or certified nurse practitioner, at least twelve hours of the education must be inadvanced pharmacology and must have been provided by an accredited institution recognized bythe board, including any provider referenced in paragraph (E) of rule 4723-9-01 of theAdministrative Code;

(3) For the first period of renewal immediately following the initial issuance of the advancedpractice registered nurse license by the board, a licensee is not required to complete any contacthours of continuing education;

(4) For purposes of fulfilling the twenty-four hours of continuing education required for renewal,an advanced practice registered nurse may satisfy up to eight hours by providing health careservices as a volunteer if the following requirements are met:

(a) The licensee provides the health care services to an indigent and uninsured person as definedin section 2305.234 of the Revised Code;

(b) The health care provided is advanced practice registered nursing, as defined in division (P) ofsection 4723.01 of the Revised Code and is within the designated specialty scope of practice of theadvanced practice registered nurse providing the services as set forth in section 4723.43 of theRevised Code;

(c) The health care services provided are provided as a volunteer, as that term is defined insection 2305.234 of the Revised Code;

(d) The licensee satisfies the requirements of section 2305.234 of the Revised Code to qualify forthe immunity from liability granted under that section;

(e) One hour of continuing education may be awarded for each sixty minutes documented as spentproviding health care services as a volunteer;

(f) The advanced practice registered nurse obtains, and maintains for a period of six years followingthe date the health care services are provided, a signed statement from a person at the healthcare facility or location where the health care services were performed indicating:

(i) The date and time period the licensee performed the health care services;

(ii) That the recipient of the health care services was indigent and uninsured as defined insection 2305.234 of the Revised Code; and

(iii) That the licensee provided the health care services as a volunteer as defined insection 2305.234 of the Revised Code.

(C) An advanced practice registered nurse who earns more than the number of hours required bythis rule during a single renewal period cannot apply the extra hours to meet future renewal periodcontinuing education requirements.









(D) The waiver option discussed in rule 4723-14-03 of the Administrative Code, for purposes ofregistered nurse or licensed practical nurse continuing nursing education, does not apply to theadvanced practice registered nurse continuing education requirements set forth in this rule.

(E) A clinical nurse specialist, originally issued a certificate of authority on or before December 31,2000 in accordance with division (C) of section 4723.41 of the Revised Code, as that divisionexisted prior to March 20, 2013, who is not certified by a national nursing certifying organizationapproved by the board shall obtain twelve contact hours of continuing nursing education in additionto the twenty-four hours required every two years for renewal of a license to practice nursing asa registered nurse and the twenty-four hours required for renewal of a license to practice as anadvanced practice registered nurse. For the purposes of complying with this rule:

(1) The additional hours shall be in programs that are targeted to advanced practice registerednurses in the nurse's area of practice or in relevant programs from other health care disciplines;

(2) The continuing education activity must meet the requirements of Chapter 4723-14 of theAdministrative Code; and

(3) The clinical nurse specialist cannot use the waiver option contained in rule 4723-14-03 of theAdministrative Code for the additional twelve contact hours of continuing nursing educationrequired by this paragraph.

4723-8-11 Youth concussion assessment and clearance.

(A) For purposes of this rule:

(1) "Interscholastic athletics" means an athletic activity, that is an interscholastic extracurricularactivity as defined in section 3313.535 of the Revised Code, that a school or school districtsponsors or participates in and that includes participants from more than one school or schooldistrict.

(2) "Youth" means an individual between the ages of four and nineteen who participated in youthsports organization or interscholastic athletics and was removed from practice or competition underdivision (D) of section 3707.511 of the Revised Code or division (D) of section 3313.539 of theRevised Code, based on exhibiting signs, symptoms or behaviors consistent with having sustaineda concussion or head injury while participating in practice or competition.

(3) "Youth sports organization" has the same meaning as in section 3707.51 of the Revised Codeand means a public or nonpublic entity that organizes an athletic activity in which the athletes arenot more than nineteen years of age and are required to pay a fee to participate in the athleticactivity or whose cost to participate is sponsored by a business or nonprofit organization.

(4) "Consensus Statement" means the "Consensus Statement on Concussion in Sport- the 5thInternational Conference on Concussion in Sport held in Berlin, October 2016 ."

(B) An advanced practice registered nurse clinical nurse specialist or certified nurse practitionermay assess and clear a youth to return to practice or competition if all of the following requirementsare met:

(1) The advanced practice registered nurse's designation specialty must includes care andtreatment of patients aged four through nineteen years of age and the nurse must collaborate witha physician whose practice includes this age group;









(2) The advanced practice registered nurse has completed education and training in the detectionof concussion, its clinical features, assessment techniques, and the principles of safe return to playprotocols consistent with the " Consensus Statement";

(3) The advanced practice registered nurse has maintained competency and completed continuingeducation in the detection of concussion, its clinical features, assessment techniques, and theprinciples of safe return to play protocols consistent with the " Consensus Statement"; and

(4) The nurse uses the medical clearance return to play after suspected concussion form locatedat: http://www.nursing.ohio.gov/forms.htm (2015).

4834-5367-3921, v. 14849-2824-3135, v. 1

http://www.nursing.ohio.gov/forms.htm

Exhibit B

Chapter 4723-9 Prescriptive Authority


For purposes of this chapter the following definitions shall apply:

(A) "Collaboration or collaborating" means in the case of an advanced practice registered nursewith the designation of certified nurse practitioner, a clinical nurse specialist or a certifiednurse-midwife, that a physician has entered into a standard care arrangement with thenurse and is continuously available to communicate with the nurse either in person, or byelectronic communication

(B) "Consultation" means the discussion or communication between a clinical nurse specialist,certified nurse-midwife, or certified nurse practitioner with a physician prior to initiating theprescription for a drug. The consultation relative to drug therapy shall be documented in thepatient's record and shall include the consulting physician's name and the date the consultationtook place

(C) "Controlled substance" means a drug, compound, mixture, preparation, or substance includedin schedule I, II, III, IV, or V pursuant to the provisions of Chapter 3719. of the Revised Code.

(D) "Contact hour" means a minimum of sixty minutes of continuing education. For credit hoursearned on an academic quarter system, one credit hour is equivalent to ten contact hours. Forcredit hours earned on an academic trimester system, one credit hour is equivalent to twelvecontact hours. For credit hours earned on an academic semester system, one credit hour isequivalent to fifteen contact hours.

(E) "Course of study" means an advanced level instructional program in pharmacology required bysection 4723.482 of the Revised Code for advanced practice registered nursing licensure, that iseither:

(1) Offered by an accredited educational institution acceptable to the board. Accredited educationalinstitutions acceptable to the board include programs that are required to obtain approval,authorization, or accreditation from one of the following:

(a) The Ohio board of regents under section 3333.07 of the Revised Code;

(b) The Ohio department of education under section 3313.90 of the Revised Code;

(c) The Ohio state board of career colleges and schools under section 3332.05 of the Revised Code;

(d) The higher learning commission of the north central association of colleges and schools;

(e) The accrediting council for independent colleges and schools; or

(f) Any other national or regional post-secondary education accreditation entity recognized by theboard; or

(2) A continuing education course that meets the requirements of Chapter 4723-14 of theAdministrative Code.

(F) "Dangerous drug' has the same meaning as in section 4729.01 of the Revised Code.

(G) "Jurisdiction" means any state, territory, or political subdivision of the United States in whicha board or legal approving authority regulates nurse licensure and nursing practice and maintainsmembership in the national council of state boards of nursing.

(H) "Physician" means an individual who holds a current valid license to practice medicine andsurgery, osteopathic medicine and surgery, or podiatric medicine and surgery issued by the Ohiostate medical board, or, in the case of applicants who hold a current valid certificate of authorityto prescribe drugs and therapeutic devices from another jurisdiction, or who have been employedby the United States government and authorized to prescribe in conjunction with that employment,the physician's license may be issued by another jurisdiction as defined in this chapter.

(I) "Sample drug" has the same meaning as in section 2925.01 of the Revised Code.

(J) "Types of drugs" means therapeutic drug class.

4723-9-02 Requirements for a course of study in advanced pharmacology.

(A) To be acceptable to the board, a course of study shall meet the following requirements:

(1) Be a minimum of forty-five contact hours in length and include content which ensures sufficientpreparation for the safe and effective prescribing of drugs and therapeutic devices;

(2) Include content which is specific to the participant's nursing specialty and which includes all ofthe following:

(a) A minimum of thirty-six hours of training, obtained from a single provider, in:

(i) Pharmacokinetic principles and clinical application; and

(ii) Principles of the use of drugs and therapeutic devices in the prevention of illness andmaintenance of health;

(b) The fiscal and ethical implications of prescribing drugs and therapeutic devices;

(c) The state and federal laws that apply to the authority to prescribe;

(d) Instruction that is specific to schedule II controlled substances, including instruction in all ofthe following:

(i) Indications and contraindications for the use of schedule II controlled substances in drugtherapies, including risk, evaluation and mitigation strategies for the use of opiates in themanagement of pain (acute, sub-acute and chronic) treatment of chronic pain for non-terminal

conditions, and the need for periodic assessment and documentation of the patient's functional status;

(ii) The most recent guidelines and recommendations for pain management therapies andeducation, as established by state and national organizations such as the Ohio pain initiative, theAmerican pain society, the governor's cabinet opiate action team (GCOAT), and the United Statesfood and drug administration (FDA), and the centers for disease control (CDC

(iii) The most recent guidelines and recommendations for stimulant therapies utilized in themanagement of attention-deficit or hyperactivity disorder, as adopted by state and nationalorganizations. such as the American academy of pediatrics;

(iv) Fiscal and ethical implications of prescribing schedule II controlled substances;

(v) State and federal laws that apply to the authority to prescribe schedule II controlledsubstances, including state medical board of Ohio rules governing controlled substances and thetreatment of chronic pain, and Ohio state board of pharmacy rules governing the manner ofissuance of a prescription, and rules set forth in Chapters 4723-1 to 4723-27 of the AdministrativeCode;

(vi) Prevention of abuse and diversion of schedule II controlled substances, including identificationof the risk of abuse, addiction and diversion, recognition of abuse, addiction and diversion, typesof assistance available for prevention of abuse, addiction and diversion, the use of the Ohioautomated rx reporting system (OARRS), including standards and procedures for OARRS accessand review established in section 4729.75 of the Revised Code and rule 4723-9-12 of theAdministrative Code, and other methods of establishing safeguards against abuse and diversion;and

(e) Instruction specific to schedule II controlled substances as set forth in paragraph (A)(2)(d) ofthis rule may be integrated with areas of instruction required by paragraphs (A)(2)(a), (A)(2)(b)and (A)(2)(c) of this rule.

(3) Include a process for interaction of the participants with instructional personnel;

(4) Include a process for evaluating the participants' learning of the content required by this rule.that may include :

(a) Successful completion of case studies or written assignments;

(b) Successful completion of a comprehensive written examination or a series of sequentialexaminations completed by topic area;

(c) A mechanism to assure the security of the evaluation process; and

(5) May be provided online, but must be faculty-directed or independent study and, as defined inrule 4723-14-01 of the Administrative Code, is offered by either an accredited educationalinstitution acceptable to the board or a continuing education course that meets the requirementsof Chapter 4723-14 of the Administrative Code.

02/01/2011, 11/05/2012, 02/01/2016, 04/01/2017

4723-9-03 Completing a course of study in advanced pharmacology.

Applicants seeking an advanced practice registered nurse license, with designation as a clinical nurse specialist, certified nurse practitioner, or certified nurse-midwife, who do not meet the requirements set forth in division (C) of section 4723.482 of the Revised Code, shall complete, within the five years immediately preceding the application, a course of study, as defined in rule 4723-9-01 of the Administrative Code, that meets the requirements of rule 4723-9-02 of the Administrative Code.

4723-9-08 Safety standards for personally furnishing drugs and therapeutic devices.

(A) An advanced practice registered nurse who has the designation of a clinical nurse specialist,certified nurse-midwife, or certified nurse practitioner who holds a current, valid advanced practiceregistered nurse license issued by the board may personally furnish to a patient a drug ortherapeutic device, whether as a sample drug or a complete or partial supply, only if the followingrequirements are met:

(1) The drug or therapeutic device is not excluded by the formulary, locatedat http://www.nursing.ohio.gov/Practice-Prescribing.htm(effective 2017) , established accordingto rule 4723-9-10 of the Administrative Code;

(2) If the drug furnished is a controlled substance, the requirements of section 4729.291 of theRevised Code are met, including limiting the amount of the controlled substance to a seventy-twohour supply, and, in any thirty-day period, not personally furnishing to or for patients, taken as awhole, an amount that exceeds two thousand five hundred dosage units;

(3) If the drug furnished is a dangerous drug, other than a sample drug, the nurse affixes labelingto the container as specified in rule 4729-5-17 of the Administrative Code;

(4) The nurse complies with rule 4723-9-12 of the Administrative Code regarding standards andprocedures for review of OARRS reports;

(5) The nurse maintains a written record of all drugs and therapeutic devices personally furnishedby the nurse as required by rule 4729-5-17 of the Administrative Code; and

(6) The nurse maintains current knowledge of and complies with all applicable state and federallaws or rules related to personally furnishing drugs and therapeutic devices.

(B) An advanced practice registered nurse with a designation of a clinical nurse specialist, certifiednurse-midwife, or certified nurse practitioner who holds a current, valid advanced practiceregistered nurse license issued by the board may personally furnish to a patient a sample drugonly if, in addition to the requirements set forth in paragraph (A) of this rule, the followingrequirements are met:

(1) The sample drug is furnished in compliance with section 3719.81 of the Revised Code, includingbut not but limited to the requirement that the sample be provided free of charge; and

(2) If the sample is a dangerous drug, the requirements of rule 4729-5-17 of the AdministrativeCode are met.

(C) Notwithstanding the requirements of this rule, an advanced practice registered nurse with thedesignation of clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner whoholds a current, valid advanced practice registered nurse license issued by the board maypersonally furnish a supply of naloxone according to section 4723.488 of the Revised Code.

(D) Notwithstanding the requirements of this rule, an advanced practice registered nurse with thedesignation of clinical nurse specialist, certified nurse- midwife, or certified nurse practitioner whoholds a current, valid advanced practice registered nurse license may personally furnish a completeor partial supply of a drug to treat chlamydia, gonorrhea, or trichomoniasis as specified insection 4723.4810 of the Revised Code.

4723-9-10 Formulary; standards of prescribing for advanced practice registered nurses designated as clinical nurse specialists, certified nurse-midwives, or certified nurse practitioners.

(A) Definitions; for purposes of this rule and interpretation of the formulary set forth in paragraph(B) of this rule :

(1) "Acute pain" means pain that normally fades with healing, is related to tissue damage,significantly alters a patient's typical function, and is expected to be time-limited and not morethan six weeks in duration.

(2) "Chronic pain" means pain that has persisted after reasonable medical efforts have been madeto relieve it and continues either episodically or continuously for twelve or more weeks followinginitial onset of pain. It may be the result of an underlying medical disease or condition, injury,medical treatment, inflammation, or unknown cause. "Chronic pain" does not include painassociated with a terminal condition or with a progressive disease that, in the normal course ofprogression, may reasonably be expected to result in a terminal condition.

(3) "Extended-release or long-acting opioid analgesic" means an opioid analgesic that:

(a) Has United States food and drug administration approved labeling indicating that it is anextended-release or controlled release formulation;

(b) Is administered via a transdermal route; or

(c) Contains methadone.

(4) "Family member" means a spouse, parent, child, sibling or other individual with respect towhom an advanced practice registered nurse's personal or emotional involvement may render theadvanced practice registered nurse unable to exercise detached professional judgment in reachingdiagnostic or therapeutic decisions.

(5) "Hospice care program" has the same meaning as in section 3712.01 of the Revised Code.

(6) "ICD-10-CM medical diagnosis code" means the disease code in the most current internationalclassification of diseases, clinical modifications published by the United States department of healthand human services.

(7) "Opioid analgesic" has the same meaning as in section 3719.01 of the Revised Code, andmeans a controlled substance that has analgesic pharmacological activity at the opioid receptorsof the central nervous system, including but not limited to the following drugs and their varyingsalt forms or chemical congeners: buprenorphine, butorphanol, codeine (including acetaminophenand other combination products), dihydrocodeine, fentanyl, hydrocodone (includingacetaminophen combination products), hydromorphone, meperidine, methadone, morphinesulfate, oxycodone (including acetaminophen, aspirin, and other combination products),oxymorphone, tapentadol, and tramadol.

(8) "Medication therapy management" has the same meaning as in rules adopted by agency 4729of the Administrative Code.

(9) "Minor" has the same meaning as in section 3719.061 of the Revised Code.

(10) "Morphine equivalent daily dose (MED)" means a conversion of various opioid analgesics to amorphine equivalent dose by the use of accepted conversion tables provided by the state board ofpharmacy at: https://www.ohiopmp.gov/MED_Calculator.aspx (effective 2017).

(11) "Palliative care" has the same meaning as in section 3712.01 of the Revised Code.

(12) "Sub-acute pain" means pain that has persisted after reasonable medical efforts have beenmade to relieve it and continues either episodically or continuously for more than six weeks butless than twelve weeks following initial onset of pain. It may be the result of an underlying medicaldisease or condition, injury, medical or surgical treatment, inflammation, or unknown cause.

(13) "Terminal condition" means an irreversible, incurable, and untreatable condition caused bydisease, illness, or injury from which, to a reasonable degree of medical certainty as determinedin accordance with reasonable medical standards by a physician who has examined the patient,both of the following apply:

(a) There can be no recovery;

(b) Death is likely to occur within a relatively short time if life-sustaining treatment is notadministered.

(B) Exclusionary Formulary. An advanced practice registered nurse who has a designation as acertified nurse practitioner, clinical nurse specialist or certified nurse midwife shall not prescribe orfurnish any drug or device in violation of federal or Ohio law, or rules adopted by the board,including this rule. The prescriptive authority of an advanced practice registered nurse who has adesignation as a certified nurse practitioner, clinical nurse specialist and certified nurse midwifeshall not exceed the prescriptive authority of the collaborating physician or podiatrist.

(C) The committee on prescriptive governance shall review the exclusionary formulary at leasttwice a year, and submit the recommended exclusionary formulary to the board. After reviewinga formulary submitted by the committee, the board may either adopt the formulary as a rule orask the committee to reconsider and resubmit the formulary. The board shall not adopt any rulethat does not conform to a formulary developed by the committee. ONLY IF CPG HAS BEENSUNSETTED

(D) An advanced practice registered nurse with a designation of clinical nurse specialist, certifiednurse-midwife, or certified nurse practitioner may prescribe any drug or therapeutic device in anyform or route of administration if:

(1) The ability to prescribe the drug or therapeutic device is within the scope of practice in theadvanced practice registered nurse's specialty area;designation;

(2) The prescription is consistent with the terms of a standard care arrangement entered into witha collaborating physician;

(3) The prescription would not exceed the prescriptive authority of the collaborating physician,including restrictions imposed on the physician's practice by action of the United States drugenforcement administration or the state medical board, or by the state medical board rules,including but not limited to rule 4731-11-09 of the Administrative Code;

(4) The individual drug or subtype or therapeutic device is not one excluded by the exclusionaryformulary set forth in paragraph (B) of this rule

(5) The prescription meets the requirements of state and federal law, including but not limited tothis rule, and all prescription issuance rules adopted by agency 4729 of the Administrative Code;

(6) A valid prescriber-patient relationship exists. This relationship may include, but is not limitedto:

(a) Obtaining a relevant history of the patient;

(b) Conducting a physical or mental examination of the patient;

(c) Rendering a diagnosis;

(d) Prescribing medication;

(e) Consulting with the collaborating physician when necessary; and

(f) Documenting these steps in the patient's medical records;

(7) Notwithstanding paragraph (D)(6) of this rule, a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner may prescribe or personally furnish a drug according tosection 4723.4810 of the Revised Code to not more than a total of two individuals who are sexualpartners of the advanced practice registered nurse's patient.

(8) If the patient is a family member, acceptable and prevailing standards of safe nursing carerequire that the advanced practice registered nurse maintain detached professional judgment. Theadvanced practice registered nurse shall not prescribe to a family member unless:

(a) The advanced practice registered nurse is able to exercise detached professional judgment inreaching diagnostic or therapeutic decisions;

(b) The prescription is documented in the patient's record.

(9) Controlled substances. For drugs that are a controlled substance:

(a) The advanced practice registered nurse has obtained a United States drug enforcementadministration registration, except if not required to do so as provided in rules adopted by agency4729 of the Administrative Code, and indicates the number on the prescription;

(b) The prescription indicates the ICD-10-CM medical diagnosis code of the primary disease orcondition that the controlled substance is being used to treat. The code shall, at minimum, includethe first four alphanumeric characters of the ICD-10 CM medical diagnosis code, sometimesreferred to as the category and etiology (ex. M165);

(c) The prescription indicates the days' supply of the controlled substance prescription.

(d) The patient is not a family member; and

(e) The advanced practice registered nurse shall not self-prescribe a controlled substance.

(E) Schedule II controlled substances. Except as provided in paragraph (F) of this rule, anadvanced practice registered nurse who has a designation of clinical nurse specialist, certifiednurse-midwife, or certified nurse practitioner may prescribe a schedule II controlled substanceonly in situations where all of the following apply:

(1) A patient has a terminal condition;

(2) A physician initially prescribed the substance for the patient; and

(3) The prescription is for a quantity that does not exceed the amount necessary for the patient'suse in a single, seventy-two hour period.

(F) Subject to the requirements set forth in paragraphs (G), (L), and (K) of this rule, a clinicalnurse specialist, certified nurse-midwife, or certified nurse practitioner may prescribe a scheduleII controlled substance, if not excluded by the exclusionary formulary set forth in paragraph (B)of this rule, if the advanced practice registered nurse issues the prescription to the patient fromany of the following locations:

(1) A hospital registered under section 3701.07 of the Revised Code;

(2) An entity owned or controlled, in whole or in part, by a hospital or by an entity that owns orcontrols, in whole or in part, one or more hospitals;

(3) A health care facility operated by the department of mental health or the department ofdevelopmental disabilities;

(4) A nursing home licensed under section 3721.02 of the Revised Code or by a political subdivisioncertified under section 3721.09 of the Revised Code;

(5) A county home or district home operated under Chapter 5155. of the Revised Code that iscertified under the medicare or medicaid program;

(6) A hospice care program;

(7) A community mental health agency, as defined in section 5122.01 of the Revised Code;

(8) An ambulatory surgical facility, as defined in section 3702.30 of the Revised Code;

(9) A freestanding birthing center, as defined in section 3702.141 of the Revised Code;

(10) A federally qualified health center, as defined in section 3701.047 of the Revised Code;

(11) A federally qualified health center look-alike, as defined in section 3701.047 of the RevisedCode;

(12) A health care office or facility operated by the board of health of a city or general healthdistrict or the authority having the duties of a board of health under section 3709.05 of the RevisedCode;

(13) A site where a medical practice is operated, but only if the practice is comprised of one ormore physicians who also are owners of the practice; the practice is organized to provide directpatient care; and the clinical nurse specialist, certified nurse-midwife, or certified nurse practitionerproviding services at the site has a standard care arrangement and collaborates with at least oneof the physician owners who practices primarily at that site; or

(14) A residential care facility, as defined in section 3721.01 of the Revised Code.

(G) An advanced practice registered nurse who has a designation as clinical nurse specialist,certified nurse-midwife, or certified nurse practitioner shall not issue to a patient a prescription fora schedule II controlled substance from a convenience care clinic even if the clinic is owned oroperated by an entity specified in paragraph (F) of this rule.

(H) Acute pain. For the treatment of acute pain, an advanced practice registered nurse who has adesignation as clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner shallcomply with the following:

(1) Extended-release or long-acting opioid analgesics shall not be prescribed for the treatment ofacute pain;

(2) Before prescribing an opioid analgesic, the advanced practice registered nurse shall firstconsider non-opioid treatment options. If opioid analgesic medications are required as determinedby history and physical examination, the prescription should be for the minimum quantity andpotency needed to treat the expected duration of pain, with a presumption that a three-day supplyor less is frequently sufficient;

(3) In all circumstances where opioid analgesics are prescribed for acute pain:

(a) Except as provided in paragraph (H)(3)(a)(iii) of this rule, the duration of the first opioidanalgesic prescription for the treatment of an episode of acute pain shall be:

(i) For adults, not more than a seven-day supply with no refills;

(ii) For minors, not more than a five-day supply with no refills. As set forth in section 4723.481 ofthe Revised Code, the advanced practice registered nurse shall comply with section 3719.061 ofthe Revised Code, including but not limited to obtaining the parent or guardian's written consentprior to prescribing an opioid analgesic to a minor;

(iii) The seven-day limit for adults and five-day limit for minors may be exceeded for pain that isexpected to persist for longer than seven days based on the pathology causing the pain. In thiscircumstance, the reason that the limits are being exceeded and the reason that a non-opioidanalgesic medication was not appropriate to treat the patient's condition shall be documented inthe patient's medical record; and

(iv) If a patient is intolerant of or allergic to an opioid medication initially prescribed, a prescriptionfor a different opioid medication may be issued at any time during the initial seven-day or five-day

dosing period, and the new prescription shall be subject to the requirements of this rule. The patient's intolerance or allergy shall be documented in the patient's medical record, and the patient advised to safely dispose of the unused medication;

(b) The patient, or a minor's parent or guardian, shall be advised of the benefits and risks of theopioid analgesic, including the potential for addiction, and the advice shall be documented in thepatient's medical record; and

(c) The total morphine equivalent dose (MED) of a prescription for opioid analgesics for treatmentof acute pain shall not exceed an average of thirty MED per day, except when:

(i) The circumstances set forth in paragraph (A)(3)(c) of rule 4731-11-13 of the AdministrativeCode exist; and

(ii) The patient's treating physician has entered a standard care arrangement with the advancedpractice registered nurse that states the understanding of the physician as to when the advancedpractice registered nurse may exceed the thirty MED average, and when the advanced practiceregistered nurse must consult with the physician prior to exceeding the thirty MED average. Thestandard care arrangement in this circumstance must comply with rule 4731-11-13 of theAdministrative Code, and the advanced practice registered nurse must document in the patient'srecord the reason for exceeding the thirty MED average and the reason it is the lowest doseconsistent with the patient's medical condition.

(I) The requirements of paragraph (H) of this rule apply to treatment of acute pain, and do notapply when an opioid analgesic is prescribed:

(1) To a patient in a hospice care ;

(2) To a patient who is receiving palliative care;

(3) To a patient who has been diagnosed with a terminal condition, as that term is defined inparagraph (A) of this rule; or

(4) To a patient who has cancer or a condition associated with the individual's cancer or history ofcancer.

(J) The requirements of paragraph (H) of this rule do not apply to:

(1) Prescriptions for opioid analgesics for the treatment of opioid addiction utilizing a controlledsubstance that is approved by the FDA for opioid detoxification or maintenance treatment; or

(2) Inpatient prescriptions as defined in rules adopted by agency 4729 of the Administrative Code.

(K) Sub-acute and chronic pain. As specified in section 4723.481 of the Revised Code, fortreatment of sub-acute and chronic pain, an advanced practice registered nurse who has adesignation as clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner shallprescribe in a manner not exceeding the prescriptive authority of the collaborating physician orpodiatrist. Prescribing parameters specifically include, but are not limited to, the followingrequirements set forth in rule 4731-11-14 of the Administrative Code:

(1) Prior to treating, or continuing to treat sub-acute or chronic pain with an opioid analgesic, theadvanced practice registered nurse shall first consider and document non-medication options. Ifopioid analgesic medications are required as determined by a history and physical examination,

the advanced practice registered nurse shall prescribe the minimum quantity and potency needed to treat the expected duration of pain and improve the patient's ability to function;

(2) Before prescribing an opioid analgesic for sub-acute or chronic pain, the advanced practiceregistered nurse shall complete or update and document in the patient record assessment activitiesto assure the appropriateness and safety of the medication, as required by rule 4731-11-14 of theAdministrative Code, including but not limited to:

(a) Completing an OARRS check in compliance with rule 4723-9-12 of the Administrative Code;

(b) Offering the patient a prescription for naloxone if the following circumstances exist:

(i) The patient has a prior history of opioid overdose;

(ii) The patient is co-prescribed a benzodiazepine, sedative hypnotic drug, carisprodal, tramadol,or gabapentin;

(iii) The patient has a concurrent substance use disorder; or

(iv) The dosage exceeds eighty MED as discussed in paragraph (K)(5) of this rule;

(c) The advanced practice registered nurse shall consider offering the patient a prescription fornaloxone if the dosage exceeds fifty MED as discussed in paragraph (K)(4) of this rule.

(3) During the course of treatment with an opioid analgesic at doses below the average of fiftyMED per day, the advanced practice registered nurse shall provide periodic follow-up assessmentand documentation of the patient's functional status, the patient's progress toward treatmentobjectives, indicators of possible addiction, drug abuse or diversion, and any adverse drug effects.

(4) Fifty MED. Prior to increasing the opioid dosage to a daily average of fifty MED or greater, theadvanced practice registered nurse shall complete and document in the patient record the activitiesand information set forth in rule 4731-11-14 of the Administrative Code, including but not limitedto the following:

(a) Review and update the assessment completed in paragraph (K)(2) of this rule if needed. Theadvanced practice registered nurse may rely on an appropriate assessment completed within areasonable time if the advanced practice registered nurse is satisfied that he or she may rely onthat information for purposes of meeting the requirements of Chapter 4723-8 and Chapter 4723-9 of the Administrative Code;

(b) Except when the patient was prescribed an average daily dosage that exceeded fifty MEDbefore the effective date of this rule, document consideration of:

(i) Consultation with a specialist in the area of the body affected by the pain;

(ii) Consultation with a pain management specialist;

(iii) Obtaining a medication therapy management review by a pharmacist;

(iv) Consultation with a specialist in addiction medicine or addiction psychiatry, if aberrantbehaviors indicating medication misuse or substance use disorder are noted;

(c) The advanced practice registered nurse shall consider offering the patient a prescription fornaloxone if the dosage exceeds fifty MED as discussed in paragraph (K)(4) of this rule;

(d) During the course of treatment with an opioid analgesic at doses at or above the average offifty MED per day, the advanced practice registered nurse shall complete and document in thepatient record all of the information and activities required by rule 4731-11-14 of theAdministrative Code not less than every three months.

(5) Eighty MED. Prior to increasing the opioid dosage to a daily average of eighty MED or greater,the advanced practice registered nurse shall complete and document in the patient record theactivities and information set forth in rule 4731-11-14 of the Administrative Code, including butnot limited to the following:

(a) A written pain management agreement shall be entered with the patient that outlines theadvanced practice registered nurse's and patient's responsibilities during treatment, which requiresthe patient or patient guardian's agreement to all of the provisions set forth in rule 4731-11-14 ofthe Administrative Code;

(b) The advanced practice registered nurse shall offer the patient a prescription for naloxone;

(c) Except when the patient was prescribed an average daily dosage that exceeded eighty MEDbefore the effective date of this rule, the advanced practice registered nurse shall obtain at leastone of the following based upon the patient's clinical presentation:

(i) Consultation with a specialist in the area of the body affected by the pain;

(ii) Consultation with a pain management specialist;

(iii) A medication therapy management review by a pharmacist; or

(iv) Consultation with a specialist in addiction medicine or addiction psychiatry, if aberrantbehaviors indicating medication misuse or substance use disorder are noted.

(6) One hundred twenty MED. The advanced practice registered nurse shall not prescribe a dosagethat exceeds an average of one hundred twenty MED per day. This prohibition shall not apply underthe following circumstances:

(a) The advanced practice registered nurse holds national certification by a national certifyingorganization approved according to section 4723.46 of the Revised Code in:

(i) Pain management;

(ii) Hospice and palliative care;

(iii) Oncology; or

(iv) Hematology;

(b) The advanced practice registered nurse has received a written recommendation for a dosageexceeding an average of one hundred twenty MED per day from a board certified pain medicinephysician, aor board certified hospice and palliative care physician, or a board certified oncologyor hematology physician, who based the recommendation on a face-to-face visit and examination

of the patient. The advanced practice registered nurse shall maintain the written recommendation in the patient's record; or

(c) The patient was receiving an average daily dose of one hundred twenty MED or more prior tothe effective date of this rule. However, prior to escalating the patient's dose, the advancedpractice registered nurse shall receive a written recommendation as set forth in paragraph(K)(6)(b) of this rule.

(7) The requirements of paragraph (K) of this rule do not apply when an opioid analgesic isprescribed:

(a) To a patient in hospice care ;

(b) To an patient who has terminal cancer or another terminal condition, as that term is definedin paragraph (A) of this rule; or

(c) As an inpatient prescription as defined in rules adopted by agency 4729 of the AdministrativeCode.

(L) Drugs approved by the FDA but not yet reviewed and approved by the committee onprescriptive governance may be prescribed, unless later disapproved by the committee onprescriptive governance, if: ONLY IF CPG HAS BEEN SUNSETTED

(1) The drug type or subtype is not excluded on the formulary set forth in paragraph (B)of thisrule ; and

(2) The collaborating physician has agreed in the standard care arrangement that the advancedpractice registered nurse may prescribe drugs approved by the FDA, that meet the criteria setforth in paragraphs (L)(1) and (L)(2) of this rule, that have not yet been reviewed and approvedby the committee on prescriptive governance.

(M) As specified in section 4723.44 of the Revised Code, an advanced practice registered nursewho has a designation as clinical nurse specialist, certified nurse-midwife, or certified nursepractitioner shall not prescribe any drug or device to perform or induce an abortion.

(N) As specified in section 4723.488 of the Revised Code, notwithstanding the requirements of thisrule, an advanced practice registered nurse who has a designation as clinical nurse specialist,certified nurse-midwife, or certified nurse practitioner may prescribe or personally furnishnaloxone.

(O) The requirements of paragraph (D)(9)(c) of this rule apply to prescriptions for products thatcontain gabapentin.

4723-9-11 Course in Ohio law governing drugs and prescriptive authority.

(A) All applicants seeking an advanced practice registered nurse license who practiced or arepracticing as a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner inanother jurisdiction or as an employee of the United States government, in accordance withdivision (C) of section 4723.482 of the Revised Code, are required to complete a course ofinstruction in the laws of this state that govern drugs and prescriptive authority. To meet thisrequirement, the course of instruction must:

(1) Include content and instruction on rules 4723-9-08, 4723-9-10, and 4723-9-12 of theAdministrative Code, and other state, or federal laws that apply to the authority to prescribeschedule II controlled substances;

(2) Include content and instruction concerning the indications and contraindications for the use ofopioids and benzodiazepines in drug therapies, and alternatives to opioid therapies in themanagement of acute and chronic pain, including the guidelines issued by the governor's cabinetopiate action team (GCOAT);

(3) Be approved by the board, or by an OBN approver as defined in rule 4723-14-01 of theAdministrative Code, or offered by an OBN approved provider unit, as defined in rule 4723-14-01 of the Administrative Code that is headquartered in the state of Ohio; and

(4) Be at minimum two hours in length.

(B) Applicants must submit documentation of successful completion to the board in the form of anoriginal certificate, issued by the provider of the course of instruction that includes:

(1) Name of the attendee;

(2) Title of the program;

(3) Date of the program;

(4) Name and address of the provider and OBN approver number, if applicable; and

(5) Verification of completion of at least two hours of instruction, each of sixty minutes in duration.

4723-9-12 Standards and procedures for review of OARRS.

(A) Definitions; for purposes of this rule:

(1) "APRN" means a clinical nurse specialist, certified nurse-midwife, or certified nurse practitionerwho holds a current, valid license as an advanced practice registered nurse issued by the board.

(2) "Delegate" means an authorized representative who is registered to obtain an OARRS reporton behalf of an APRN.

(3) "OARRS" means the Ohio automated RX reporting system established and maintainedaccording to section 4729.75 of the Revised Code.

(4) "OARRS report" means a report of information related to a specified patient generated by thedrug database established maintained by the state board of pharmacy pursuant tosection 4729.75 of the Revised Code.

(5) "Reported drugs" means all drugs listed in rule 4729-37-02 of the Administrative Code that arerequired to be reported to the drug database established and maintained according tosection 4729.75 of the Revised Code, including controlled substance schedules II, III, IV and V.

(B) Standards of care: in addition to the requirements set forth in rule 4723-9-08 and rule 4723-9-10 of the Administrative Code, accepted and prevailing standards of care require that whenprescribing or personally furnishing a reported drug, an APRN shall takeng into account the

potential for abuse of the reported drug, the possibility that the reported drug may lead to dependence, the possibility the patient will obtain the reported drug for a nontherapeutic use or distribute it to other persons, and the potential existence of an illicit market for the reported drug. When considering these circumstances in the course of determining whether to prescribe or personally furnish a reported drug to a patient, the APRN shall use sound clinical judgment and consider obtaining and reviewing an OARRS report, consistent with the requirements of this rule.

(C) Red flags: an APRN shall obtain and review an OARRS report when any of the following redflags pertain to the patient:

(1) Selling prescription drugs;

(2) Forging or altering a prescription;

(3) Stealing or borrowing reported drugs;

(4) Increasing the dosage of reported drugs in amounts that exceed the prescribed amount;

(5) Suffering an overdose, intentional or nonintentional;

(6) Having a drug screen result that is inconsistent with the treatment plan or refusing toparticipate in a drug screen;

(7) Having been arrested, convicted, or received diversion, or intervention in lieu of conviction fora drug-related offense while under the APRN's care;

(8) Receiving reported drugs from multiple prescribers, without clinical basis;

(9) Traveling with a group of other patients to the APRN's office, where all or most of the patientsrequest controlled substances prescriptions;

(10) Traveling an extended distance or from out of state to the APRN's office;

(11) Having a family member, friend, law enforcement officer or health care professional expressconcern related to the patient's use of illegal or reported drugs;

(12) A known history of chemical abuse or dependency;

(13) Appearing impaired or overly sedated during an office visit or examination;

(14) Requesting reported drugs by specific name, street name, color, or identifying marks;

(15) Frequently requesting early refills of reported drugs;

(16) Frequently losing prescriptions for reported drugs;

(17) A history of illegal drug use;

(18) Sharing reported drugs with another person; or

(19) Recurring visits to non-coordinated sites of care, such as emergency departments, urgentcare facilities, or walk-in clinics to obtain reported drugs.

(D) OARRS review; opioid analgesics and benzodiazepines.

Except as provided in paragraph (G) of this rule, an APRN shall:

(1) Obtain and review an OARRS report before initially prescribing to a patient a reported drugthat is an opioid analgesic or benzodiazepine;

(2) Obtain and review an OARRS report when prescribing opioid analgesics for the treatment ofsub-acute and chronic pain as set forth in rule 4723-9-10 of the Administrative Code;

(3) If the patient continues to receive opioid analgesics or benzodiazepines for more than ninetydays after the initial report is requested, the APRN shall obtain and review OARRS reports for thepatient at intervals not exceeding ninety days, determined according to the date the initial requestwas made, and until the course of treatment has ended; and

(4) In obtaining and reviewing OARRS reports, comply with paragraph (F) of this rule.

(E) OARRS review; reported drugs that are not opioid analgesics or benzodiazepines.

Except as provided in paragraph (G) of this rule, an APRN shall:

(1) Obtain and review an OARRS report following a course of treatment for a period of more thanninety days if the treatment includes the prescribing or personally furnishing of reported drugsthat are not opioid analgesics or benzodiazepines;

(2) Obtain and review an OARRS report at least annually thereafter until the course of treatmentutilizing these reported drugs has ended; and

(3) In obtaining and reviewing OARRS reports, comply with paragraph (F) of this rule.

(F) OARRS reports; time period; adjoining state: for purposes of paragraphs (C), (D), and (E) ofthis rule:

(1) OARRS reports may be requested by the APRN's delegate but must be personally reviewed bythe APRN;

(2) Receipt and assessment of the OARRS report information, including consultation with thecollaborating physician that occurred based on the OARRS report information or as required byparagraph (H) of this rule, shall be documented in the patient record;

(3) Initial reports requested shall cover at least twelve months immediately preceding the date ofthe request;

(4) If the APRN practices in a county of this state that adjoins another state, the APRN or theAPRN's delegate shall also request a report of any information available in the drug database thatpertains to prescriptions issued or drugs furnished to the patient in the state adjoining the county;and

(5) If an OARRS report regarding the patient is not available, the APRN shall document in thepatient's record the reason that the report is not available and any efforts made in follow-up toobtain the requested information.

(G) OARRS report exceptions: an APRN shall not be required to review and assess an OARRS reportwhen prescribing or personally furnishing a reported drug under the following circumstances,unless the APRN believes or has reason to believe that the patient may be abusing or divertingreported drugs:

(1) The reported drug is prescribed or personally furnished to a hospice patient in a hospice careprogram as those terms are defined in section 3712.01 of the Revised Code ;

(2) The reported drug is prescribed or personally furnished to a patient who has been diagnosedwith terminal cancer or another terminal condition, as defined in section 2133.01 of the RevisedCode;

(3) The reported drug is prescribed for administration in a hospital, nursing home, or residentialcare facility;

(4) The reported drug is prescribed or personally furnished in an amount indicated for a period notto exceed seven days; or

(5) The reported drug is prescribed for treatment of non-terminal cancer or another conditionassociated with non-terminal cancer, except if prescribed for sub-acute or chronic pain and anOARRS report review is required by rule 4723-9-10 of the Administrative Code.

(H) Physician consultation: an APRN who prescribes or personally furnishes a reported drug to apatient following review of an OARRS report under paragraph (C), (D), or (E) of this rule, anddetermines, based on the OARRS report or red flags described in paragraph (C) of this rule thatthe patient may be abusing or diverting reported drugs, shall first consult with their collaboratinga physician prior to personally furnishing or prescribing a reported drug at the patient's next visit.

(1) Consultation shall include and result in:

(a) Review and documentation of the reasons why the APRN believes or has reason to believe thatthe patient may be abusing or diverting drugs;

(b) Review and documentation of the patient's progress toward treatment objectives over thecourse of treatment; and

(c) Review and documentation of the functional status of the patient, including activities for dailyliving, adverse effects, analgesia and aberrant behavior over the course of treatment.

(2) Consultation may include and result in:

(a) Utilization of a patient treatment agreement that includes more frequent and periodic reviewof OARRS reports, more frequent office visits, different treatment options, drug screens, use ofone pharmacy, use of one provider for the prescription or personally furnishing of reported drugs,and consequences for non-compliance with the terms of the agreement. The patient treatmentagreement shall be maintained as part of the patient record; and

(b) Consultation with or referral to a substance use disorder specialist.

4723-9-13 Medication-assisted treatment.

(A) Definitions; for purposes of this rule and interpretation of the formulary set forth in rule 4723-9-10 of the Administrative Code :

(1) "Community addiction services provider" has the same meaning as in section 5119.01 of theRevised Code.

(2) "Community mental health services provider" has the same meaning as in section 5119.01 ofthe Revised Code.

(3) "Controlled substance," "schedule III," "schedule IV," and "schedule V" have the samemeanings as in section 3719.01 of the Revised Code.

(4) "FDA" means the United States food and drug administration.

(5) "Induction phase" means the phase of opioid treatment during which maintenance medicationdosage levels are adjusted until a patient attains stabilization.

(6) "Medication-assisted treatment" means alcohol or drug addiction services that are accompaniedby medication that has been approved by the United States food and drug administration for thetreatment of substance use disorder, prevention of relapse of substance use disorder, or both.

(7) "Office-based opioid treatment" or "OBOT" means medication-assisted treatment of opioiddependence or addiction utilizing controlled substances, in a private office or public sector clinicthat is not otherwise regulated, by practitioners who are authorized to prescribe outpatient suppliesof medications approved by the FDA for the treatment of opioid addiction or prevention of relapse.OBOT includes treatment with all controlled substance medications approved by the FDA for suchtreatment. OBOT does not include treatment that occurs in the following settings:

(a) A state or local correctional facility, as defined in section 5163.45 of the Revised Code;

(b) A hospital, as defined in section 3727.01 of the Revised Code;

(c) A provider certified to provide residential and inpatient substance use disorder services,including withdrawal management, by the Ohio department of mental health and addictionservices;

(d) An opioid treatment program certified by SAMHSA and accredited by an independent, SAMHSA-approved accrediting body; or

(e) A youth services facility, as defined in section 103.75 of the Revised Code.

(8) "OARRS" means the "Ohio Automated RX Reporting System" drug database established andmaintained pursuant to section 4729.75 of the Revised Code.

(9) "Qualified behavioral healthcare provider" means the following who is practicing within thescope of professional licensure:

(a) A medical doctor or doctor of osteopathic medicine and surgery who holds board certificationin addiction medicine or addiction psychiatry, or a psychiatrist, licensed under Chapter 4731. ofthe Revised Code;

(b) A licensed independent chemical dependency counselor-clinical supervisor, licensedindependent chemical dependency counselor, licensed chemical dependency counselor III, licensedchemical dependency counselor II, or licensed chemical dependency counselor assistant licensedunder Chapter 4758. of the Revised Code;

(c) A professional clinical counselor, licensed professional counselor, licensed independent socialworker, licensed social worker, or marriage and family therapist, licensed under Chapter 4757. ofthe Revised Code;

(d) An advanced practice registered nurse licensed as a clinical nurse specialist or certified nursepractitioner licensed by the board, who holds national certification in psychiatric mental health, orclinical nurse specialist who was not required to obtain national certification according tosection 4723.41 of the Revised Code, and whose specialty is psychiatric mental health; or

(e) A psychologist, as defined in division (A) of section 4732.01 of the Revised Code, licensedunder Chapter 4732. of the Revised Code; or

(f) An advanced practice registered nurse licensed by the board who holds additional certificationas a certified addictions registered nurse-advanced practice issued by the addictions nursingcertification board.

Nothing in paragraph (A)(9) of this rule shall be construed to prohibit an advanced practice registered nurse who collaborates with a physician licensed under Chapter 4731. of the Revised Code and certified as an addiction psychiatrist, addictionologist, or psychiatrist, from providing services within the normal course of practice and expertise of the collaborating physician, including addiction services, other mental health services, and prescriptive services in compliance with Ohio and federal law and rules.

(10) "SAMHSA" means the United States substance abuse and mental health servicesadministration.

(11) "Stabilization phase" means the medical and psychosocial process of assisting the patientthrough acute intoxication and withdrawal management to the attainment of a medically stable,fully supported substance-free state, which may include the use of medications.

(B) An advanced practice registered nurse who has a designations as clinical nurse specialist,certified nurse midwife or certified nurse practitioner who holds a current valid advanced practiceregistered nurse license may provide medication-assisted treatment, including prescribingcontrolled substances in schedule III, IV or V, if the advanced practice registered nurse clinicalnurse specialist, certified nurse midwife or certified nurse practitioner:

(1) Complies with section 3719.064 of the Revised Code, and all federal and state laws andregulations governing the prescribing of the medication, including but not limited to incorporatinginto the advanced practice registered nurse's practice knowledge of Chapter 4729. of the RevisedCode, and Chapter 4731. of the Revised Code and rules adopted under that Chapter that governthe practice of the advanced practice registered nurse's collaborating physician;

(2) Completes at least eight hours of continuing nursing education in each renewal period relatedto substance abuse and addiction. Courses completed in compliance with this requirement shall beaccepted toward meeting the continuing education requirements for biennial renewal of theadvanced practice registered nurse license; and

(3) Only provides medication-assisted treatment if the treatment is within the collaboratingphysician's normal course of practice and expertise.

(C) In addition to the requirements for medication-assisted treatment set forth in paragraph (B)of this rule, an advanced practice registered nurse who has a designation as clinical nurse specialist, certified nurse-midwife or certified nurse practitioner may provide OBOT under the followingcircumstances:

(1) The standard care arrangement statement of services offered includes OBOT;

(2) The advanced practice registered nurse performs, or confirms the completion of, anddocuments a patient assessment that includes all of the following:

(a) A comprehensive medical and psychiatric history;

(b) A brief mental status history;

(c) Substance abuse history;





(h) Review of patient's prescription information in OARRS;



(k) Testing for hepatitis C;

(l) Consideration of screening for tuberculosis and sexually-transmitted diseases in patients withknown risk factors.

(m) For other than the toxicology tests for drugs and alcohol, appropriate history, substance abusehistory, and pregnancy test, the advanced practice registered nurse may satisfy the assessmentrequirements by reviewing records from a physical examination and laboratory testing of thepatient that was conducted within a reasonable period of time prior to the visit.

(n) If any part of the assessment cannot be completed prior to the initiation of OBOT, the advancedpractice registered nurse shall document the reasons in the medical record.

(3) The advanced practice registered nurse establishes and documents a treatment plan thatincludes all of the following:

(a) The advanced practice registered nurse's rationale for selection of the specific drug to be usedin the medication-assisted treatment;

(b) Patient education;

(c) The patient's written, informed consent;

(d) Random urine-drug screens or oral fluid drug testing;

(e) A signed treatment agreement with the patient that outlines the responsibilities of the patientand the advanced practice registered nurse;

(f) A plan for psychosocial treatment as discussed in paragraph (C)(5) of this rule;

(4) The advanced practice registered nurse shall provide OBOT in accordance with an acceptabletreatment protocol for assessment, induction, stabilization, maintenance and tapering. Acceptableprotocols are any of the following:

(a) SAMSHA treatment improvement protocol publications for medication-assisted treatmentavailable from the SAMSHA website at: https://store.samhsa.gov ;

(b) "National Practice Guideline for the Use of Medications in the Treatment of Addiction InvolvingOpioid Use," approved by the American society of addiction medicine in 2015, and available fromthe website of the American society of addiction medicine athttps://www.asam.org/. .

(5) Except if the advanced practice registered nurse is a qualified behavior healthcare provider,the advanced practice registered nurse shall refer and work jointly with a qualified behavioralhealthcare provider, community mental health services provider, or community addiction servicesprovider to determine the optimal type and intensity of psychosocial treatment for the patient anddocument the treatment plan in the patient record.

(a) The treatment shall at minimum include a psychosocial needs assessment, supportivecounseling, links to existing family supports, and referral to community services;

(b) The treatment shall include at least one of the following interventions:

(i) Cognitive behavioral treatment;

(ii) Community reinforcement approach;

(iii) Contingency management/motivational incentives; or

(iv) Behavioral couples counseling;

(c) The treatment plan shall include a structure for renegotiation of the treatment plan if the patientdoes not adhere to the original plan.

(6) When clinically appropriate and if the patient refuses treatment from a qualified behavioralhealthcare provider, community mental health services provider, or community addiction servicesprovider, the advanced practice registered nurse shall ensure that the OBOT treatment planrequires the patient to participate in a twelve step program or appropriate self-help recoveryprogram. If the patient is required to participate in a twelve step program or self-help recoveryprogram, the advanced practice registered nurse shall require the patient to providedocumentation of on-going participation in the program.

(7) If the advanced practice registered nurse refers the patient to a qualified behavioral healthservice provider, community addiction services provider, or community mental health servicesprovider, the advanced practice registered nurse shall document the referral and the advancedpractice registered nurse's meaningful interactions with the provider in the patient record.

(8) The advanced practice registered nurse shall offer the patient a prescription for a naloxone kit.

(a) The advanced practice registered nurse shall ensure that the patient receives instruction onthe kit's use including, but not limited to, recognizing the signs and symptoms of overdose andcalling 911 in an overdose situation.

(b) The advanced practice registered nurse shall offer the patient a new prescription for naloxoneupon expiration or use of the old kit.

(c) The advanced practice registered nurse shall be exempt from this requirement if the patientrefuses the prescription. If the patient refuses the prescription the advanced practice registerednurse shall provide the patient with information on where to obtain a kit without a prescription.

(9) If the advanced practice registered nurse provides OBOT using buprenorphine products, thefollowing additional requirements must be met:

(a) The provision shall comply with the FDA approved "Risk Evaluation and Mitigation Strategy"for buprenorphine products, which can be found on FDA website at the followingaddress:https://www.accessdata.fda.gov/scripts/cder/rems/index.cfm. With the exception ofthose conditions listed in paragraph (C)(9)(b) of this rule, the advanced practice registered nursewho treats an opioid use disorder with a buprenorphine product shall only prescribebuprenorphine/naloxone combination products for use in OBOT.

(b) The advanced practice registered nurse shall prescribe buprenorphine without naloxone(buprenorphine mono-product) only in the following situations, and shall fully document theevidence for the decision to use buprenorphine mono-product in the patient's record:

(i) When the patient is pregnant or breast-feeding;

(ii) When converting the patient from buprenorphine mono-product to a buprenorphine/naloxonecombination product ;

(iii) In formulations other than tablet or film form for indications approved by the FDA;

(iv) For withdrawal management when a buprenorphine/naloxone combination product iscontraindicated, with the contraindication documented in the patient record; or

(v) When the patient has an allergy to or intolerance of a buprenorphine/naloxone combinationproduct , after explaining to the patient the difference between an allergic reaction and symptomsof opioid withdrawal precipitated by buprenorphine or naloxone, and with documentation includedin the patient record.

(c) Due to a higher risk of fatal overdose when buprenorphine is prescribed with other opioids,benzodiazepines, sedative hypnotics, carisoprodol, and tramadol, the advanced practice registerednurse shall only co-prescribe these substances when it is medically necessary , and only if:

(i) The advanced practice registered nurse verifies the diagnosis for which the patient is receivingthe other drug and coordinates care with the prescriber for the other drug, including whether it is

possible to taper the drug to discontinuation. If the advanced practice registered nurse prescribing buprenorphine is the prescriber of the other drug, the advanced practice registered nurse shall taper the other drug to discontinuation if it is safe to do so. The advanced practice registered nurse shall educate the patient about the serious risks of the combined use; and

(ii) The advanced practice registered nurse documents progress in achieving the tapering plan inthe patient record.

(d) During the induction phase, the advanced practice registered nurse shall not prescribe a dosagethat exceeds the recommendation in the FDA approved labeling, except for medically indicatedcircumstances as documented in the patient record. The advanced practice registered nurse shallsee the patient at least once per week during this phase.

(e) During the stabilization phase, when using any oral formulation of buprenorphine, the advancedpractice registered nurse shall increase the daily dosage of buprenorphine in safe and effectiveincrements to achieve the lowest dose that avoids intoxication, withdrawal, or significant drugcraving.

(i) During the first ninety days of treatment, the advanced practice registered nurse shall prescribeno more than a two-week supply of the buprenorphine product containing naloxone.

(ii) Starting with the ninety-first day of treatment and until the completion of twelve months oftreatment, the advanced practice registered nurse shall prescribe no more than a thirty-day supplyof the buprenorphine product containing naloxone.

(f) The advanced practice registered nurse shall take steps to reduce the chances of buprenorphinediversion by using the lowest effective dose, appropriate frequency of office visits, pill counts, andchecks of OARRS. The advanced practice registered nurse shall also require urine drug screens,serum medication levels, or oral fluid testing at least twice per quarter for the first year oftreatment and at least once per quarter thereafter.

(g) When using any oral formulation of buprenorphine, the advanced practice registered nurseshall document in the patient record the rationale for prescribed doses exceeding sixteenmilligrams of buprenorphine per day. The advanced practice registered nurse shall not prescribe adose of buprenorphine exceeding twenty-four milligrams per day.

(h) The advanced practice registered nurse shall incorporate relapse prevention strategies intocounseling or assure that they are addressed by a qualified behavioral healthcare provider whohas the education and experience to provide substance abuse counseling.

(i) The advanced practice registered nurse may treat a patient using the administration ofextended-release, injectable, or implanted buprenorphine under the following circumstances:

(i) The advanced practice registered nurse strictly complies with any required risk evaluation andmitigation strategy program for the drug;

(ii) The advanced practice registered nurse shall prescribe an extended-release buprenorphineproduct strictly in accordance with the FDA's approved labeling for the drug's use;

(iii) The advanced practice registered nurse documents in the patient record the rationale for theuse of the extended-release product; and

(iv) The advanced practice registered nurse who orders or prescribes extended-release, injectable,or implanted buprenorphine product shall administer the drug, or require it to be administered byanother Ohio licensed health care provider acting in accordance with the scope of their professionallicense.

(10) If the clinical nurse specialist or certified nurse practitioner is using naltrexone to treat opioiduse disorder, the advanced practice registered nurse shall comply with the following additionalrequirements:

(a) Prior to treating a patient with naltrexone, the advanced practice registered nurse shall informthe patient about the risk of opioid overdose if the patient ceases naltrexone and then uses opioids.The advanced practice registered nurse shall take measures to ensure that the patient isadequately detoxified from opioids and is no longer physically dependent prior to treatment withnaltrexone;

(b) The advanced practice registered nurse shall use oral naltrexone only for treatment of patientswho can be closely supervised and who are highly motivated;

(i) The dosage regime shall strictly comply with the FDA approved labeling for naltrexonehydrochloride tablets;

(ii) The patient shall be encouraged to have a support person assist with the administration of themedication and supervise the medication. Examples of a support person are a family member,close friend, or employer;

(c) The advanced practice registered nurse shall require urine drug screens, serum medicationlevels or oral fluid testing at least every three months for the first year of treatment and at leastevery six months thereafter;

(d) The advanced practice registered nurse shall incorporate relapse prevention strategies intocounseling or assure that they are addressed by a qualified behavioral healthcare or mental healthservices provider who has education and experience to provide substance abuse counseling.

(e) The advanced practice registered nurse may treat a patient with extended-release naltrexonefor opioid dependence or for co-occurring opioid and alcohol use disorders.

(i) The advanced practice registered nurse should consider treatment with extended-releasenaltrexone for patients who have issues with treatment adherence;

(ii) The injection dosage shall strictly comply with FDA labeling for extended-release naltrexone;and

(iii) The advanced practice registered nurse shall incorporate relapse prevention strategies intocounseling or assure that they are addressed by a qualified behavioral healthcare provider ormental health services provider who has the education and experience to provide substance abusecounseling.

4838-2781-8689, v. 1

BMD Brennan Manna Diamond

LISTEN. SOLVE. EMPOWER.

P: 330 253.5060 F: 330 .:s�.i977 W: brndl!c...:cn1

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November 19, 2019

Holly Fischer, Chief Legal Counsel

Ohio Board of Nursing

17 S. High Street, Suite 660

Columbus, Ohio 43215-3466

SENT VIA EMAIL ONLY TO [email protected] and [email protected]

RE: Comments to Proposed Rules

Dear Ms. Fischer:

As general counsel for the Ohio Association of Advanced Practice Nurses ("OAAPN"),

we respectfully submit these comments regarding certain proposed rule changes that will

be the subject of a public hearing scheduled for November 20, 2019. Thank you to the

Ohio Board of Nursing for the opportunity to submit these comments.

1. OAC 4723-9-10 ("Formulary; standards of prescribing for advanced practice

registered nurses designated as clinical nurse specialists, certified nurse-midwives,

or certified nurse practitioners")

Under the proposed changes to OAC 4723-9-10(K)(6)(a) [currently subsection M.6], the

Board of Nursing proposes to add oncology and hematology to the list of national

certifications an APRN could hold and then be permitted to prescribe in excess of an

average 120 MED per day. As an initial matter, OAAPN would like to state that it is

unaware of any national board certification for APRNs in hematology. As such, it may

make sense to remove hematology from the list of APRN board certifications in Section

(K)(6)(a).

Next, we respectfully suggest that OAC 4723-9-10(K)(6)(b) be revised to allow an

APRN to follow a written recommendation of a "board certified oncology or hematology

physician" to prescribe in excess of an average 120 MED per day. The current language

Exhibit C

only allows the written recommendation to come from a "board certified pain medicine

physician or board certified hospice and palliative care physician." Adding "board

certified oncology or hematology physician" to the list of approved physicians who may

provide the written recommendation would keep the language consistent with the intent

stated in the previous section (6)(a) which would allow for the care of oncology or

hematology patients.

Thank you again for the opportunity to comment on these rules.

Sincerely,

Jeana M. Singleton

CC: Joscelyn Greaves, OAAPN President

Thursday, July 2, 2020 at 11:16:40 AM Eastern Daylight Time

Subject: FW: Comments regarding Rule 4723-9-10 "Exhibit C"Date: Thursday, July 2, 2020 at 11:16:11 AM Eastern Daylight TimeFrom: Sunderman, Chantelle

From: Fischer, Holly <[email protected]>Sent: Thursday, July 2, 2020 9:31 AMTo: Jeana Singleton <[email protected]>; [email protected] <[email protected]>Cc: [email protected] <[email protected]>; Emrich, Lisa<[email protected]>Subject: Comments regarding Rule 4723-9-10 "Exhibit C" Ms. Singleton, Regarding this rule comment (your leXer from November 2019 /labeled Exhibit C), as you may recallwe discussed the raTonale for not making the proposed change last year. I've copied my email to youbelow. Is there a reason at this Tme to propose this change in light of the informaTon I provided you? Holly R. Fischer, J.D. Chief Legal Counsel Ohio Board of Nursing 17 S. High Street, Suite 660 Columbus, Ohio 43215> >> > This communicaTon is intended only for use by the individual or enTty to whom it is addressed. It may contain informaTon that isprivileged, confidenTal, and exempt from disclosure under the State and/or Federal law. If the reader of this message is not the intendedrecipient you are noTfied that any disseminaTon, distribuTon, or copying of this communicaTon is strictly prohibited. If you receive thiscommunicaTon in error, please noTfy the sender immediately by telephone, and return the original message to the above address.> >> >> > In order to help contain the spread of the coronavirus (COVID-19), the Ohio Board of Nursing has closedits offices to the general public and Board staff will be working remotely unTl further noTce. Please beadvised that it may take longer than usual to receive a response.> >> > If you need to contact the Board for any reason, please use the Contact Us at www.nursing.ohio.gov. Amember of our staff will reply to your email as soon as possible.> >> > Thank you for your paTence and understanding during this public health event. For updated informaTonabout COVID-19, visit www.coronavirus.ohio.gov or call 1-833-4-ASK-ODH.

From: Fischer, Holly <[email protected]>

https://gcc01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.nursing.ohio.gov%2F&data=02%7C01%7CHFischer%40nursing.ohio.gov%7Caa53f5bdc5c94247969b08d7cc43614c%7C50f8fcc494d84f0784eb36ed57c7c8a2%7C0%7C0%7C637202462077365506&sdata=Wp1rFHiL%2FQl8Ppnxgp8tG7%2BtHAwrf04BMkirHEcvPIs%3D&reserved=0

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From: Fischer, Holly <[email protected]>Sent: Wednesday, November 20, 2019 7:06 AMTo: Jeana Singleton <[email protected]>Cc: Sharpnack, Patricia <[email protected]>; Erin Keels <[email protected]>Subject: Re: Comments to Proposed Rules Ms. Singleton,

Here is some addiTonal informaTon for you to consider, if you are preparing tesTmony for the hearing today:

The official names of the APRN cerTficaTons are: “Advanced Oncology CerTfied Nurse PracTToner” and“Advanced Oncology CerTfied Clinical Nurse Specialist.” These are by the Oncology Nursing CerTficaTonCorp. PracTce within these cerTficaTons includes treaTng disorders of the blood/bone marrow, etc. Thusthe pracTce has been generally referred to as “hematology/oncology.” Thank you again for sending your suggesTons.

Holly

Holly R. Fischer, J.D.Chief Legal CounselOhio Board of Nursing17 S. High Street, Suite 660Columbus, Ohio 43215Direct: (614) 995-4934

This communicaTon is intended only for use by the individual or enTty to whom it is addressed. It maycontain informaTon that is privileged, confidenTal, and exempt from disclosure under the State and/orFederal law. If the reader of this message is not the intended recipient you are noTfied that anydisseminaTon, distribuTon, or copying of this communicaTon is strictly prohibited. If you receive thiscommunicaTon in error, please noTfy the sender immediately by telephone, and return the original messageto the above address.

>> <Comments to Proposed Rules 2019.11.19.pdf>> > > > > >

Jeana M. Singleton Partner P: 330-253-2001 F: 330-253-2012 E: [email protected] July 2, 2020 Ohio Board of Nursing 17 S. High Street, Suite 660 Columbus, Ohio 43215-3466 SENT VIA EMAIL ONLY TO [email protected] RE: Additional Comments for 5-Year Rule Review (OAC 4723-9 and OAC 4723-10) To Whom It May Concern: As general counsel for the Ohio Association of Advanced Practice Nurses ("OAAPN"), we respectfully submit these additional comments regarding certain proposed rule changes that will be the subject of a public hearing scheduled for November 2020. In particular, this letter provides additional explanation for the rationale behind the proposed revisions to OAC 4723-9 and OAC 4723-10 that OAAPN submitted on June 30, 2020. Thank you to the Ohio Board of Nursing for the opportunity to submit these additional comments.

1. OAC 4723-8-04(B)(7)(a) – The two -year standard care arrangement (“SCA”) review has become an administrative burden to manage especially in large institutions. A recommendation for the SCA to be reviewed and signed only when there has been a change to its content is offered. Meaningful changes would include but not be limited to law and rule modifications.

2. OAC 4723-8-04(B)(7)(d) – If an advanced practice registered nurse (“APRN”) is not engaged in clinical practice and practices in a role in education or management, a chart review should not be necessary.

3. OAC 4723-8-04(B)(10) – Having an arrangement for reimbursement under the medical assistance program is obsolete. APRNs, who accept patients with Medicaid as a single

payer, are credentialled providers with Medicaid and accept Medicaid’s reimbursement dispersion.

4. OAC 4723-8-04(B)(11)(b) – This suggestion modifies prescriptive practice review which deletes statements on FDA approved or pending approval parameters. If the pending legislation is passed, the Committee for Prescriptive Governance (“CPG”) will be sunsetted. Since H.B. 216 passed with authority for an exclusionary formulary, the need to have an outside body recommending what new FDA drugs may be prescribed by an APRN is redundant.

5. OAC 4723-8-04(B)(11)(c) – APRNs are required to meet at least annually with the collaborating physician for a clinical review of performance by observation and documentation review which incorporates prescriptive practice. Rules for additional quality assurance provisions on prescriptive practice made after Schedule 2 authority was granted in 2012 are no longer necessary. There are mechanisms in place to thwart inappropriate controlled substance prescriptions, such as OAARS.

6. OAC 4723-8-05(F) – Having the APRN check the collaborating physician’s licensure every two years and document it is superfluous. Institutions have medical staff offices which perform this task for credentialing. Smaller practices have practice or billing managers keep track of all licensure information for reimbursement credentialing.

7. OAC 4723–9-02(A)(2)(d)(iii) – Listing specific organizations negates other organizations with guidelines. Stimulants for ADHD are given for adult-onset with guidelines from neurology and psychiatric organizations. Keeping non-specific state and national organizations should suffice.

Thank you again for the opportunity to submit these additional comments.

Sincerely,

Jeana M. Singleton

CC: Joscelyn Greaves – OAAPN President

4829-8484-1153, v. 1

Jeana M. Singleton Partner P: 330-253-2001 F: 330-253-2012 E: [email protected]

July 2, 2020 APRN Advisory Committee Ohio Board of Nursing 17 S. High Street, Suite 660 Columbus, Ohio 43215-3466 SENT VIA EMAIL ONLY TO [email protected] RE: Comments to Proposed Detox Rules – OAC 4723-9-14 To Whom It May Concern: As general counsel for the Ohio Association of Advanced Practice Nurses ("OAAPN"), we respectfully submit these comments regarding the proposed rule OAC 4723-9-14 that will be discussed at the APRN Advisory Committee meeting on July 6, 2020. Thank you for the opportunity to submit these comments. 1. OAC 4723-9-14(B)(1) Providing withdrawal management with a collaborating physician is not always possible. For example, the Advanced Practice Registered Nurse ("APRN") may have a standard care arrangement ("SCA") with a collaborating physician who provides withdrawal management services, but that physician may not be the physician with whom the APRN is working in the office. Under that situation, the APRN would be able to work with the physician in the office and still have a collaborating physician available under the SCA if necessary. As such, we recommend that this provision be simplified to state the following:

(B)… (1) Has a standard care arrangement with a physician who provides withdrawal management as part of the physician's normal course of practice.

2. OAC 4723-9-14(C)(1) It is overly burdensome to require an APRN to provide written information (and to document such information in the chart) on "all drugs approved by the FDA for use in medication-assisted treatment including withdrawal management." It is not always possible to have written information readily available on all of these drugs. Additionally, who is providing the content for this literature? Furthermore, this seems to indicate that the APRN is responsible for documenting all of the information provided in the patient chart. Does this mean that the APRN must copy and paste all of this documentation into the chart after the visit summary? OAAPN respectfully requests that this provision be revised to state the following:

(C)… (1) Verbally provide the patient with information regarding drugs used in medication-assisted treatment drug therapy including withdrawal management. The advanced practice registered nurse shall document in the patient's record that such discussion occurred.

3. OAC 4723-9-14(E)(1)(a) We respectfully request that this condition be deleted. Many patients do not have access to a "positive and helpful support network." Unfortunately, given the nature of the disease, many patients suffering from addictions have ruined their friendships, family relationships, and traditional support systems. Rebuilding a support network after sobriety is incredibly difficult for many patients. Additionally, this definition also leaves much room for interpretation and may be difficult to enforce consistently given that there may be a wide range of what individual providers consider "positive" or "helpful." 4. OAC 4723-9-14(E)(1)(c) We respectfully request that this condition be deleted. While the OAARS system has helped with preventing drug diversion, it is still often very difficult for the APRN to be able to quantify the likelihood of medication diversion. Additionally, a potential for diversion should not limit a patient's access to care. 5. OAC 4723-9-14(E)(4)(i), (j), (k), and (l)

OAAPN respectfully suggests that these provisions be adjusted to simply require the APRN to offer these tests rather than require the APRN to administer them. If a patient refuses to be tested for these conditions, they should not be denied access to care for their addiction. 6. OAC 4723-9-14(E)(7) Standards for addiction treatment have already been established by current laws and rules. As such, OAAPN requests that this provision be revised to simply refer back to the guidelines set forth in OAC 4723-9-13 for medication-assisted treatment. 7. OAC 4723-9-14(E)(9) It is important to acknowledge that for many APRNs practicing in the addiction treatment space, a large portion of their practice is treating patients with polysubstance abuse disorders. Very few of their patients will have only one drug addiction. As such, OAAPN respectfully requests that the last portion of this provision be deleted so that an APRN is not required to confer with their collaborating physician prior to prescribing a buprenorphine/naloxone combination product to the patient. This requirement places an unnecessary burden upon the APRN and collaborating physician; ultimately, the APRN has the ability (and should be given the right) to determine when a collaborating physician consult is necessary. 8. OAC 4723-9-14(E)(10) OAAPN respectfully requests that provision be revised to allow for adjunctive drugs used for medication assisted therapy. As such, we suggest the following language.

(E)… (10) A drug, excluding methadone, that is used for alleviation of

withdrawal symptoms, including but not limited to adjunctive drugs. 9. OAC 4723-9-14(E)(10)(c)(i) We respectfully request that the timeframes be removed from this provision. APRNs are trained to provide these treatments and must have the ability to do what is best for their patients. It is possible that a patient is in full withdrawal prior to these timeframes and will need treated. 10. OAC 4723-9-14(E)(11)(a) While it may be important that the patient know how to use a naloxone kit for treating others, it is

unlikely that the patient will be able to administer a naloxone kit on themselves. Such instructions can also be a lengthy process to make sure all involved are appropriately trained. As such, we suggest that it might be more effective to adjust this provision to allow trained staff (which may or may not be the APRN) to educate the patient and their family or friends. 11. OAC 4723-9-14(F)(1), (3), and (5) Paragraph (1) is redundant of Section (E)(1)(a) and should be deleted. Additionally, please see Comment #3 above. We also request that Paragraphs (3) and (5) be deleted. As previous discussed in Comment #7 above, many addiction patients suffer from polysubstance dependence and should not be denied the APRN's care. Additionally, addiction is commonly accompanied by comorbid or psychiatric disorder conditions. It is within the APRNs scope of practice to treat these complex patients, and the patients should not be denied access to care. Thank you again for the opportunity to comment on these rules. Sincerely,

Jeana M. Singleton CC: Joscelyn Greaves, OAAPN President

MEMORANDUM To: Advisory Committee on Advanced Practice Registered Nursing From: Tom Dilling, Public and Governmental Affairs Officer/Liaison Betsy Houchen, Executive Director Subject: Legislation, 133rd General Assembly Update Date: June 29, 2020

HB 177, Standard Care Arrangements HB 177 was introduced April 9, 2019, proposing to eliminate the standard care arrangements entered into by advanced practice registered nurses and collaborating physicians or podiatrists; prohibit physician prescribing of schedule II controlled substances in convenience care clinics; and remove physician oversight of a CNP, CNS, or CNM (APRN) granting clearance for a concussed student to return to play or practice in a sport, consistent with other parts of the bill. The bill has had six hearings in the House Health Committee. The Committee most recently heard HB 177 on January 28, 2020, at which time they accepted a second substitute version of the bill. Generally, the most recent Sub HB 177 grants those APRNs who submit documentation of having completed 2,000 clinical practice hours or twelve months of clinical practice under a standard care arrangement with a collaborating practitioner, the option to practice without the arrangement and collaborating practitioner, if they so choose. Following the effective date of the bill, those APRN applicants who have not yet completed 2,000 clinical practice hours or twelve months of clinical practice with one or more physician or podiatric collaborating practitioners or an APRN not practicing under a standard care arrangement must document sufficient hours or twelve months of collaborative practice to be eligible to practice without a standard care arrangement. The most recent substitute bill also modifies restrictions on certified nurse-midwives; and modifies restrictions on APRNs assessing and clearing a concussed youth athlete. HB 197, Omnibus Measures on Coronavirus HB 197 was introduced originally as tax code corrections bill on April 11, 2019. In March 2020 it was substantially amended and became the vehicle to continue essential operations of state government and maintain the continuity of the state tax code in response to the declared pandemic and global health emergency related to COVID-19, to make appropriations, and to declare an emergency. The bill became effective on March 27, 2020. Temporary Nursing Licenses HB 197 suspends, for the period of the COVID-19 emergency, the requirement that an applicant for licensure by examination have passed the national standardized licensure examination approved by the Ohio Board of Nursing (Board). The law authorizes the Board to issue licenses to practice as a RN or LPN to applicants who meet the remaining legal requirements, including

completing a Board-approved nursing education program and criminal records check. The license will be valid until whichever of the following dates occurs first: (1) the date that is ninety days after December 1, 2020; (2) the date that is ninety days after the duration of the period of the emergency declared by Executive Order 2020-01D. Extended License Deadlines HB 197 authorizes the following: Licenses or other similar authority expiring during the period of the emergency declared by Executive Order 2020-01D on March 9, 2020 will remain valid until the earlier of either 90-days after the date the emergency ends or December 1, 2020 unless revoked, suspended, or otherwise subject to discipline or limitations. If a person is required by law to take an action to maintain the validity of a license during the period of the emergency declared by Executive Order 2020-01D on March 9, 2020, the person must take that action not later than the sooner of either 90-days after the date the emergency ends or December 1, 2020. CRNA Practice Prior to the enactment of HB 197, CRNAs lacked authority to select and order drugs; whereas other advanced practice registered nurse (APRN) designations are authorized to prescribe or furnish most drugs and therapeutic devices as part of the APRN license. HB 197, however, permits a CRNA to select, order, and administer drugs, treatments, or intravenous (IV) fluids for conditions related to the administration of anesthesia. This may occur as necessary for patient management and care and only during the time period that begins on a patient’s admission to a health care facility for a surgery or procedure and ends with the patient’s discharge from recovery. When a CRNA selects, orders, and administers a drug or treatment or IV fluids, the CRNA and the supervising practitioner must both be physically present at the health care facility. In addition, the CRNA must indicate the administration in the patient’s medical or electronic health record. HB 197 also requires the facility to have adopted a written policy. Under HB 197, the written policy must be developed by the health care facility’s medical, nursing, and pharmacy directors. It also must establish standards and procedures to be followed by CRNAs when ordering and evaluating diagnostic tests; selecting, ordering, and administering drugs, treatments, and IV fluids; and directing RNs, LPNs, and respiratory therapists to administer drugs, treatments, and IV fluids or provide supportive care. HB 197 further provides that it does not authorize a CRNA to prescribe a drug for use outside the facility or other setting where the nurse provides anesthesia care. HB 197 authorizes a CRNA to direct RNs, LPNs, and respiratory therapists to do the following as necessary for patient management and care:

1. Administer drugs, treatments, and IV fluids for the treatment of conditions related to administration of anesthesia;

2. Provide supportive care, including monitoring vital signs, conducting electrocardiograms, and administering IV fluids.

However, a CRNA may direct such actions only during the time period that begins on the patient’s admission to the facility for a surgery or procedure and ends on the patient’s discharge from recovery and in accordance with the facility’s required policy. HB 197 also requires the CRNA and supervising practitioner to both be present at the facility when the CRNA directs the actions. When a CRNA selects, orders, and administers a drug or treatment or IV fluids, the CRNA and the supervising practitioner must both be physically present at the health care facility. In addition, the CRNA must indicate the administration in the patient’s medical or electronic health record. HB 197 also requires the facility to have adopted a written policy.

In addition to the changes in a CRNA’s practice described above, HB 197 permits a CRNA to do the following:

1. Perform and document evaluations and assessments, which may include ordering and evaluating one or more diagnostic tests for conditions related to the administration of anesthesia;

2. Obtain informed consent for anesthesia care; and 3. Perform postanesthetic preparation and evaluation. (Prior to HB 197, Ohio law referred

only to the authority to perform post-anesthesia care.) In the event a CRNA performs and documents evaluations and assessments, the act requires both the CRNA and supervising practitioner to be present at the health care facility. It also requires the CRNA to indicate those evaluations and assessments in the patient’s medical or electronic health record. HB 197 continues provisions specifying that a CRNA is authorized to perform anesthesia induction, maintenance, and emergence in the immediate presence of a supervising practitioner. Public Meetings and Hearings HB 197 establishes a policy for public meetings and hearings for use during the period of emergency declared by Executive Order 2020-01D only, but not beyond December 1, 2020. The law authorizes a public body, during the state of emergency declared by Executive Order 2020-01D, but not beyond December 1, 2020, to hold and attend meetings and hearings by means of teleconference, video conference, or any other similar electronic technology. For this purpose, “public body” and “meeting” have the meanings defined in Ohio Open Meetings Law. “Hearing” includes an administrative hearing, hearing held in compliance with the Administrative Procedure Act, or any other hearing at which a person may present written or oral testimony on a matter before a public body. HB 224, Nurse Anesthetists HB 224 provisions regarding the practice of certified registered nurse anesthetists were amended into HB 197 and became effective on March 27, 2020. Please see the analysis of HB 197 in this legislative report for details. HB 611, Medicaid Coverage-Doula Services HB 611 was introduced on April 28, 2020 related to Medicaid coverage of doula services. The bill requires the Medicaid Director shall establish a state doula registry. A substitute version of the bill was accepted by the House Insurance Committee on June 9, 2020. As used in the bill, "Doula services" mean physical, emotional, or educational support provided during the prenatal, childbirth, and postpartum periods, other than such support that is considered to be medical, midwifery, or clinical in nature. "Doula services" include all of the following: (a) Prenatal and postpartum visits; (b) Birth support and time spent on call in reasonable anticipation of a birth; (c) Communications between a doula and a pregnant woman or a pregnant woman's support person, including through telephone, electronic, or other means; (d) Connecting a pregnant woman or woman capable of becoming pregnant with nonprofit organizations that provide assistance in locating available health and social services; (e) Time spent on related administrative tasks such as documentation. To be eligible for payments under the Medicaid program's coverage of doula services, a doula must submit proof that the doula has a current, valid certificate issued by a doula certification organization to the satisfaction of the Medicaid Director. "Doula certification organization" means an entity that is nationally or internationally recognized for training and certifying doulas and whose educational curriculum meets the

requirements set forth in this bill. The doula must also complete at least 24 hours of in-person classroom instruction and training in certain subject matter. The substitute version of the bill creates an Ohio doula advisory board in the Ohio Department of Medicaid. It also adds recognition as a doula certification organization for a “black-led, community based public health organization” that has been approved by the Ohio doula advisory board. SB 303, Pharmacist Consult Agreements HB 203, Mobile Dental Facilities SB 303 was introduced on April 20, 2020 to expand the list of professionals who may enter into consult agreements with pharmacists. The Senate unanimously passed the bill on May 6, 2020. The bill was referred to House Health on May 12, 2020. The bill has had one hearing in House Health Committee. Portions of SB 303 (Huffman, Manning) including provisions related to consult agreements were amended on the Senate Floor into HB 203 (Lipps) on May 20, 2020. Sen. Steve Huffman (R-Tipp City), joint sponsor of SB 303 and a physician, said SB 303 would expand the list of clinical professionals with whom pharmacists can have consult agreements to manage chronic conditions to include nurse practitioners, nurse midwives, clinical nurse specialists and physician assistants. The bill proposes that practitioners still be required to have a relationship with each patient in a consult agreement and be in a supervising or standard care arrangement with a supervising or collaborating physician. Current Ohio law allows pharmacists to enter into consult agreements with physicians to manage drug therapies for patients with chronic health conditions, such as hypertension or diabetes. These consult agreements are patient specific, last two years with the option to renew and may be terminated upon request of any of the three parties involved (pharmacist, physician, or patient). HB 673, Business Operation, Education Completion HB 673 was introduced on May 26, 2020 and was heard in the House State and Local Government Committee. A substitute bill was accepted and reported out of Committee on June 9, 2020. The Bill passed the House on June 10, 2020 but was amended on the floor. The Board testified as an interested party to the bill. HB 197 of the 133rd General Assembly initially provided a temporary suspension to the requirement that an applicant pass a nurse license examination to receive a license to practice as a registered nurse or licensed practical nurse. This temporary authorization was apparently due in part to closure of testing sites because of COVID-19. The testing sites have already re-opened, though not to full capacity. HB 197 licenses are full licenses issued after receipt of a criminal records check and a Program Completion Letter by which nursing education programs attest that the applicants completed the education program requirements. HB 673 proposes that the Board “recognize any hours” nurses who work on an HB 197 temporary license accumulate on the job and count them toward “any outstanding clinical hours” required to take the NCLEX licensing examination. The Board questions why this language is considered necessary. Nurses who obtained the temporary license created by HB 197 are required to complete their “clinical education” prior to being issued a license under HB 197. The NCLEX examination does not require a certain number of clinical hours for a nursing graduate to be eligible to take the exam. Moreover, the number of hours of “clinical education” that a nursing license applicant took to graduate is not used by the Board to determine eligibility for a license to practice nursing. At this point, there is no further reason to count clinical hours of a licensee’s

education by the nursing program or the Board. It remains unclear how this language benefits any party to the bill. In addition, as stated previously, HB 197 of the 133rd General Assembly initially provided a temporary suspension to the requirement that an applicant pass the NCLEX to practice as a registered nurse or licensed practical nurse. The bill specifies an end date of July 1, 2021, rather than being tied to the end of the emergency declared by Executive Order 2020-01D. The Board recognizes that authorizing nursing licensure on a temporary basis prior to passing the NCLEX was a unique legislative grant based on a lack of available testing sites during COVID-19 and an expectation that hospitals would be inundated with patients shortly after passage of HB 197. Extending the date to July 1, 2021 does not appear to be related to either of these factors. Because NCLEX testing is a core aspect of assuring entry-level safe nursing practice and there has been no showing of a need for an extension of the NCLEX exception, the Board would prefer the July 1, 2021 date be removed from the bill. The Ohio Nurses Association opposes the July 1, 2021 exception date. On the House floor language was added to the bill specifying that having taken and failed the NCLEX exam makes an individual ineligible to hold a temporary nursing license granted under HB 197 authorization. To be eligible for the license, the bill specifies that an individual must not have (1) previously taken and failed the licensure examination, (2) been convicted of, pleaded guilty to, or had a judicial finding of guilt for, any felony, or (3) failed a drug test, as determined by the Nursing Board. HB 679, Telehealth Service Requirements HB 679 was introduced on May 26, 2020 and heard in the House Insurance Committee. The bill establishes and modifies requirements regarding the provision of telehealth services. A substitute version of the bill was accepted and reported out of Committee on June 9, 2020. The bill was passed by the House on June 10, 2020. SB 305, Telemedicine During Emergency SB 305 was introduced on April 29, 2020. The bill proposes to require health plan insurers to cover telemedicine during a state of emergency and to declare a state of emergency. The Bill had its first hearing on May 27, 2020 in the Senate Insurance and Financial Institutions Committee. _______________________ 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. Additional information and details related to the content and status of various state and federal law changes during the COVID-19 state of emergency, including HB 197 provisions mentioned in this legislative report may be found at www.nursing.ohio.gov under the header NOTICE.

https://www.legislature.ohio.gov/legislation/search

http://www.nursing.ohio.gov/

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APRN Licensure and Practice in Ohio DRAFT 6/22/2020

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. Ohio Revised Code Chapter 4723. (NPA) 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. APRN Consensus Model The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education (APRN Consensus Model) (2008) is not an Ohio law or rule, however, it is included here for reference as the 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, 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. The Board’s Advisory Committee on Advanced Practice Registered Nursing recommended to the Board, and the Board agreed, that the APRN Consensus Model would 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. Designations of APRNs in Ohio The NPA recognizes four “designations” of APRNs in Ohio: Certified Registered Nurse Anesthetist (CRNA); Certified Nurse-Midwife (CNM); Clinical Nurse Specialist (CNS); and 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.


http://nursing.ohio.gov/wp-content/uploads/2019/08/Consensus_Model_for_APRN_Regulation_July_2008_5.2.pdf

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• An earned masters or doctoral degree with a major in a nursing specialty or in a related field that qualifies the nurse to sit for the certification examination of a national certifying organization approved by the Board.

• 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.

• 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.

• 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

• 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 colloborating 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.

• 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 Resulting National Certifications Issued by the Board Approved National Certifying Organization

http://codes.ohio.gov/orc/4723.46v1


https://nursing.ohio.gov/wp-content/uploads/2020/02/2020-BOARD-APPROVED-NATIONAL-CERTIFYING-ORGANIZATIONS.pdf


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• 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 Defines APRN Designation’s 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: 4723.481; 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.

CRNA Scope of Practice, Sections 4723.433, 4723.434, and 4723.435 and 4723.43(B), ORC

• 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 preanesthetic preparation and evaluation, postanesthesia 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 of a patient’s admission for surgery or a procedure until patient discharge, a CRNA under the conditions established in Section 4723.434, ORC, (effective March 27, 2020) may provide orders to registered nurses, licensed practical nurses and respiratory therapists to administer medications and treatments to the patient. In addition consistent with Section 4723.433, ORC, (effective March 27, 2020) the CRNA may direct registered nurses, licensed practical nurses and respiratory therapists to provide patient monitoring, and the administration of drugs, treatments and IV fluids when the CRNA is engaging in clinical support functions.

• 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.







http://codes.ohio.gov/oac/4723-9



https://www.nbcrna.com/initial-certification

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• 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.

• 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 the Medical Practice Act, 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 Population Foci Certification Examinations for CNSs (Each CNS certification validates condition ranges from wellness through acute care)

• Adult-Gerontology (AACN; ANCC)

• Pediatrics (AACN)

• Neonatal (AACN) 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 within the nurse’s nursing specialty, consistent with the nurse’s education and 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 the Medical Practice Act, 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

https://www.amcbmidwife.org/amcb-certification

https://www.aacn.org/certification/advanced-practice

https://www.nursingworld.org/our-certifications/

https://www.aanpcert.org/certifications

https://www.aacn.org/certification/advanced-practice

https://www.nursingworld.org/our-certifications/

https://www.nccwebsite.org/

https://www.pncb.org/

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Currently Available Population Foci 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 both acute care and primary care. (APRN Consensus Model, 2008; 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 Rule 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 in the nursing specialty, SCA, and standards of practice.

• 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.

• Rule 4723-9-13, OAC, establishes requirements for APRNs who provide medication assisted treatment, including additional requirements regarding the qualifications of the physician with whom the APRN may enter into a SCA.

• 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.

https://www.pharmacy.ohio.gov/


https://www.dea.gov/

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• 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.

Standard Care Arrangements CNSs or 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 pursuant to Rule 4723-9-13, OAC, medication-assisted treatment must be “within the collaborating physician's normal course of practice and expertise.” Rule 4723-9-13(B)(3), OAC.

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

• SCAs must be reviewed every two years and the review must be documented by the APRN and at least one collaborating physician or podiatrist by signature and date.

• 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

• APRN scope of practice for each designation 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.

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.



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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.

• 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. These types of subspecialties are not themselves regulated by the Board of Nursing, other than all APRN practice must be consistent with the standards of practice.

Below are FAQs related to the NPA and administrative rules for APRNs. SCA FAQs Q: I plan to practice as an 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.


http://codes.ohio.gov/orc/4731

http://codes.ohio.gov/oac/4731

http://codes.ohio.gov/oac/4731

http://codes.ohio.gov/orc/4715


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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. Please note that if an APRN is engaged in medication assisted treatment (MAT), additional requirements apply, as discussed below. See 4723.481(B), ORC, and 4723-9-13(B), OAC.

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 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 may enter into a SCA. There is a limit on the number of APRNs with whom a collaborating physician may collaborate “at the same time in the prescribing component of their practices.” Section 4723.431(A), ORC.

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.

Section 4723.481, ORC and Chapter 4723-9, OAC, authorize CNMs, CNSs, and CNPs to prescribe drugs or therapeutic devices consistent with the designation’s defined scope; 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.

https://nursing.ohio.gov/practice-resources/prescribing-resources/

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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(C)(5), OAC1. 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 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, etc.

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.”

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?

1 A currently proposed revision to this rule would redesignate the reference to: 4723-8-04(D)(5), OAC.



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A: In addition to the scope of practice for each APRN designation specified in Sections 4723.43 and 4723.433, 4723.434, and 4723.435, ORC, that define the parameters of practice, Section 4723.151(B), ORC, states that the prohibitions from the practice of medicine and surgery in Section 4723.151(A), ORC, do not prohibit a CRNA, CNM, CNS, or a CNP from practicing within the APRN’s scope of practice as defined in Section 4723.43, ORC.

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 patients for women's health issues. The NCC 2020 Candidate Guide Women’s Health Care Practitioner 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?

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.

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.


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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, postanesthesia care, and clinical support functions, consistent with the nurse's education and certification, and in accordance with rules adopted by the board.” Section 4723.43(A), ORC. New law effective March 27, 2020 also expanded CRNAs authority to provide orders in certain circumstances for the administration of drugs and intravenous fluids to their patients in health care facilities where they 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 is a RN, and may administer drugs as a RN, in accordance with Section 4723.01(B)(5), pursuant to a specific current order from an authorized provider who is acting within the course of the individual’s professional practice (e.g., a physician, or an APRN-CNP). 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

http://nursing.ohio.gov/wp-content/uploads/2019/10/10.2019-APRN-Decision-Model-2019-1.pdf

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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 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 or facility 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, it then would be a requirement.

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.

13

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.

Links to relevant law and rules sections: http://codes.ohio.gov/orc/4723.43 (Scope)

http://codes.ohio.gov/orc/4723.433v1 (CRNA) http://codes.ohio.gov/orc/4723.434v1 (CRNA) http://codes.ohio.gov/orc/4723.435v1 (CRNA) http://codes.ohio.gov/orc/4723.431 (SCA) http://codes.ohio.gov/orc/4723.151 (Scope) http://codes.ohio.gov/orc/4723.481 (Prescribing) http://codes.ohio.gov/oac/4723-8 (SCA, standards) http://codes.ohio.gov/oac/4723-9 (Prescribing)










Material on use of the title “Doctor.” This memorandum provides background information to assist the APRN Advisory Committee in its review and discussion of the use of the title “doctor” by APRNs. This Agenda topic was requested by the Committee at its March 2020 meeting. Below is an example of a Board staff response to questions received about the use of titles, academic credentials, etc. The response references administrative rules adopted by the Board, and law. Relevant excerpts of cited rules and law are included below. The full text of each is also attached. In addition, the response mentions that law and rules of other entities may also impact the use of a title. The most notable is Section 4731.34, Ohio Revised Code (ORC), also attached. Informal staff advisory response to questions regarding use of titles, academic credentials, etc.:

Law and rules enforced by the Board require APRNs to display and identify their applicable licensure to patients when providing direct patient care. They also 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. 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, Ohio Administrative Code (OAC), says in part, “(B) 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. This informal staff advisory opinion is limited to questions arising under the Nurse Practice Act, Chapter 4723, ORC, and the rules adopted thereunder, and does not purport to interpret other laws or rules.

Excerpt, Ohio Revised Code Section 4723.03 Unlicensed practice. …. (E) No person shall use the titles or initials "graduate nurse," "G.N.," "professional nurse," "P.N.," "graduate practical nurse," "G.P.N.," "practical nurse," "P.N.," "trained nurse," "T.N.," or any other statement, title, or initials that would imply or represent to the public that the person is authorized to practice nursing in this state, except as follows: …. (3) A person licensed under this chapter to practice nursing as an advanced practice registered nurse and designated as a certified registered nurse anesthetist may use that title or the initials "A.P.R.N.-C.R.N.A." ; (4) A person licensed under this chapter to practice nursing as an advanced practice registered nurse and designated as a clinical nurse specialist may use that title or the initials "A.P.R.N.-C.N.S." ; (5) A person licensed under this chapter to practice nursing as an advanced practice registered nurse and designated as a certified nurse-midwife may use that title or the initials "A.P.R.N.-C.N.M." ; (6) A person licensed under this chapter to practice nursing as an advanced practice registered nurse and designated as a certified nurse practitioner may use that title or the initials "A.P.R.N.-C.N.P." ; (7) A person licensed under this chapter to practice nursing as an advanced practice registered nurse may use the title "advanced practice registered nurse" or the initials "A.P.R.N. …. Excerpt, Ohio Administrative Code Rule 4723-4-06 Standards of nursing practice promoting patient safety. (A) At all times when a licensed nurse is providing direct nursing care to a patient the licensed nurse shall display the applicable title or initials set forth in division (C) of section 4723.03 of the Revised Code to identify the nurse's relevant licensure as a registered nurse or as a licensed practical nurse. (B) 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 division (C) of section 4723.03 of the Revised Code 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 division (E) of section 4723.03 of the Revised Code 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. ….




Excerpt, Ohio Administrative Code Rule 4723-8-03 Title protection. (A) Only a person who holds a current valid license to practice as an advanced practice registered nurse issued in accordance with sections 4723.41, 4723.42 and 4723.482 of the Revised Code and this chapter may use the following titles or initials if designated to do so: (1) Certified nurse-midwife, or A.P.R.N.-C.N.M., , if the individual is authorized to practice in accordance with division (A) of section 4723.43 of the Revised Code; (2) Clinical nurse specialist, or A.P.R.N.-C.N.S., , if the individual is authorized to practice in accordance with division (D) of section 4723.43 of the Revised Code; (3) Certified nurse practitioner, or A.P.R.N.-C.N.P., , if the individual is authorized to practice under division (C) of section 4723.43 of the Revised Code; (4) Certified registered nurse anesthetist or A.P.R.N.-C.R.N.A., if the individual is authorized to practice in accordance with division (B) of section 4723.43 of the Revised Code; or (5) Advanced practice registered nurse or A.P.R.N. if the individual is authorized to practice under division (A) to division (D) of section 4723.43 of the Revised Code. …. (C) At all times when an advanced practice registered nurse is providing direct care to a patient within the nurse's respective scope of practice, each certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist shall display and identify the applicable title and designation as set forth in this rule. ….

4723.03 Unlicensed practice.

(A) No person shall engage in the practice of nursing as a registered nurse, represent the person as being a registered nurse, or use the title "registered nurse," theinitials "R.N.," or any other title implying that the person is a registered nurse, for a fee, salary, or other consideration, or as a volunteer, without holding a current,valid license as a registered nurse under this chapter.

(B) No person shall knowingly do any of the following without holding a current, valid license to practice nursing as an advanced practice registered nurse issuedunder this chapter:

(1) Engage in the practice of nursing as an advanced practice registered nurse;

(2) Represent the person as being an advanced practice registered nurse;

(3) Use the title "advanced practice registered nurse," the initials "A.P.R.N.," or any other title implying that the person is an advanced practice registered nurse, for afee, salary, or other consideration, or as a volunteer.

(C) No person who is not otherwise authorized to do so shall knowingly prescribe or personally furnish drugs or therapeutic devices without holding a current, validlicense to practice nursing as an advanced practice registered nurse issued under this chapter and being designated as a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner under section 4723.42 of the Revised Code;

(D) No person shall engage in the practice of nursing as a licensed practical nurse, represent the person as being a licensed practical nurse, or use the title "licensedpractical nurse," the initials "L.P.N.," or any other title implying that the person is a licensed practical nurse, for a fee, salary, or other consideration, or as a volunteer,without holding a current, valid license as a practical nurse under this chapter.

(E) No person shall use the titles or initials "graduate nurse," "G.N.," "professional nurse," "P.N.," "graduate practical nurse," "G.P.N.," "practical nurse," "P.N.,""trained nurse," "T.N.," or any other statement, title, or initials that would imply or represent to the public that the person is authorized to practice nursing in this state,except as follows:

(1) A person licensed under this chapter to practice nursing as a registered nurse may use that title and the initials "R.N.";

(2) A person licensed under this chapter to practice nursing as a licensed practical nurse may use that title and the initials "L.P.N.";

(3) A person licensed under this chapter to practice nursing as an advanced practice registered nurse and designated as a certified registered nurse anesthetist may usethat title or the initials "A.P.R.N.-C.R.N.A." ;

(4) A person licensed under this chapter to practice nursing as an advanced practice registered nurse and designated as a clinical nurse specialist may use that title orthe initials "A.P.R.N.-C.N.S." ;

(5) A person licensed under this chapter to practice nursing as an advanced practice registered nurse and designated as a certified nurse-midwife may use that title orthe initials "A.P.R.N.-C.N.M." ;

(6) A person licensed under this chapter to practice nursing as an advanced practice registered nurse and designated as a certified nurse practitioner may use that titleor the initials "A.P.R.N.-C.N.P." ;

(7) A person licensed under this chapter to practice nursing as an advanced practice registered nurse may use the title "advanced practice registered nurse" or theinitials "A.P.R.N.

(F) No person shall employ a person not licensed as a registered nurse under this chapter to engage in the practice of nursing as a registered nurse.

No person shall knowingly employ a person not licensed as an advanced practice registered nurse under this chapter to engage in the practice of nursing as anadvanced practice registered nurse.

No person shall employ a person not licensed as a practical nurse under this chapter to engage in the practice of nursing as a licensed practical nurse.

(G) No person shall sell or fraudulently obtain or furnish any nursing diploma, license, certificate, renewal, or record, or aid or abet such acts.

Amended by 131st General Assembly File No. TBD, HB 216, §1, eff. 4/6/2017.

Amended by 129th General AssemblyFile No.194, HB 303, §1, eff. 3/20/2013.

Effective Date: 04-10-2001; 04-07-2005


4723-4-06 Standards of nursing practice promoting patient safety.

(A) At all times when a licensed nurse is providing direct nursing care to a patient the licensed nurse shall display the applicable title or initials set forth in division(C) of section 4723.03 of the Revised Code to identify the nurse's relevant licensure as a registered nurse or as a licensed practical nurse.

(B) At all times when a certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist is providing direct nursingcare to a patient, the nurse shall display the applicable title or initials set forth in division (C) of section 4723.03 of the Revised Code to identify relevant approvaleither 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 anyform of telecommunication, the licensed nurse shall identify to each patient or health care provider the nurse's title or initials set forth in division (E) of section4723.03 of the Revised Code 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.

(D) A licensed nurse shall delegate a nursing task, including medication administration, only in accordance with Chapter 4723-13, 4723-23, 4723-26, or 4723-27 ofthe Administrative Code.

(E) A licensed nurse shall, in a complete, accurate, and timely manner, report and document nursing assessments or observations, the care provided by the nurse forthe patient, and the patient's response to that care.

(F) A licensed nurse shall, in an accurate and timely manner, report to the appropriate practitioner errors in or deviations from the current valid order.

(G) A licensed nurse shall not falsify, or conceal by any method, any patient record or any other document prepared or utilized in the course of, or in conjunction with,nursing practice. This includes, but is not limited to, case management documents or reports or time records, reports, and other documents related to billing fornursing services.

(H) A licensed nurse shall implement measures to promote a safe environment for each patient.

(I) A licensed nurse shall delineate, establish, and maintain professional boundaries with each patient.

(J) At all times when a licensed nurse is providing direct nursing care to a patient the licensed nurse shall:

(1) Provide privacy during examination or treatment and in the care of personal or bodily needs; and

(2) Treat each patient with courtesy, respect, and with full recognition of dignity and individuality.

(K) A licensed nurse shall not:

(1) Engage in behavior that causes or may cause physical, verbal, mental, or emotional abuse to a patient;

(2) Engage in behavior toward a patient that may reasonably be interpreted as physical, verbal, mental, or emotional abuse.

(L) A licensed nurse shall not misappropriate a patient's property or:

(1) Engage in behavior to seek or obtain personal gain at the patient's expense;

(2) Engage in behavior that may reasonably be interpreted as behavior to seek or obtain personal gain at the patient's expense;

(3) Engage in behavior that constitutes inappropriate involvement in the patient's personal relationships or financial matters; or

(4) Engage in behavior that may reasonably be interpreted as inappropriate involvement in the patient's personal relationships or financial matters.

For the purpose of this paragraph, the patient is always presumed incapable of giving free, full, or informed consent to the behaviors by the nurse set forth in thisparagraph.

(M) A licensed nurse shall not:

(1) Engage in sexual conduct with a patient;

(2) Engage in conduct in the course of practice that may reasonably be interpreted as sexual;

(3) Engage in any verbal behavior that is seductive or sexually demeaning to a patient; or

(4) Engage in verbal behavior that may reasonably be interpreted as seductive, or sexually demeaning to a patient.

For the purpose of this paragraph, the patient is always presumed incapable of giving free, full, or informed consent to sexual activity with the nurse.

(N) A licensed nurse, when functioning in an administrative role, shall verify that each nurse, dialysis technician, or medication aide under the nurse administratorhas:




(1) A current valid license to practice nursing in Ohio or a current valid certificate to practice as a dialysis technician or medication aide in Ohio; and

(2) If applicable, other documents of approval or certification as required by the board.

(O) When nursing practice, as set forth in section 4723.01 of the Revised Code, is supervised or evaluated:

(1) Only a registered nurse shall supervise or evaluate the practice of nursing, as set forth in Chapter 4723. of the Revised Code and the rules of the board, performedby other registered nurses and licensed practical nurses; or

(2) In matters other than the practice of nursing, a non-nursing supervisor may evaluate a nurse employee.

(3) Supervision or evaluation by a registered nurse does not require that the registered nurse be present on-site on a routine basis, but at minimum:

(a) Supervision requires that the registered nurse be continuously available through some form of telecommunication with the supervised nurse, and take all actionnecessary, including but not limited to conducting periodic on-site visits, to insure that the supervised nurse is practicing in accordance with acceptable and prevailingstandards of safe nursing care as set forth in Chapter 4723. of the Revised Code and the rules of the board; and

(b) Evaluation requires that the registered nurse conduct periodic on-site visits sufficient to enable the evaluating nurse to evaluate the evaluated nurse's performance.

Nothing in this paragraph shall be construed to authorize a licensed practical nurse to practice without direction, as required by division (F) of section 4723.01 of theRevised Code.

Nothing in this paragraph shall be construed to prohibit a licensed practical nurse from participating in activities that contribute to the delivery of patient care services.Such participation may include, but is not limited to, scheduling of coverage for nursing services and observation and documentation by a licensed practical nurseregarding care provided by assistive personnel.

(P) A licensed nurse shall not make any false, misleading, or deceptive statements, or submit or cause to be submitted any false, misleading or deceptive information,or documentation to:

(1) The board or any representative of the board;

(2) Current employers;

(3) Prospective employers when applying for positions requiring a nursing license;

(4) Facilities in which, or organizations for whom, the nurse is working a temporary, agency, or locus tenens assignment;

(5) Other members of the patient's health care team; or

(6) Law enforcement personnel.

(Q) For purposes of paragraphs (I), (J), (K), (L), and (M) of this rule, a nurse shall not use social media, texting, emailing, or other forms of communication with, orabout a patient, for non-health care purposes or for purposes other than fulfilling the nurse's assigned job responsibilities.

Effective: 2/1/2019Five Year Review (FYR) Dates: 10/22/2018 and 10/16/2023Promulgated Under: 119.03 Statutory Authority: ORC 4723.07 Rule Amplifies: ORC 4723.28 Prior Effective Dates: 12/01/1995, 04/01/1997, 04/01/1999, 02/01/2002, 02/01/2003, 02/01/2004, 02/01/2009, 02/01/2014, 02/01/2015






4723-8-03 Title protection.

(A) Only a person who holds a current valid license to practice as an advanced practice registered nurse issued in accordance with sections 4723.41, 4723.42 and4723.482 of the Revised Code and this chapter may use the following titles or initials if designated to do so:

(1) Certified nurse-midwife, or A.P.R.N.-C.N.M., , if the individual is authorized to practice in accordance with division (A) of section 4723.43 of the Revised Code;

(2) Clinical nurse specialist, or A.P.R.N.-C.N.S., , if the individual is authorized to practice in accordance with division (D) of section 4723.43 of the Revised Code;

(3) Certified nurse practitioner, or A.P.R.N.-C.N.P., , if the individual is authorized to practice under division (C) of section 4723.43 of the Revised Code;

(4) Certified registered nurse anesthetist or A.P.R.N.-C.R.N.A., if the individual is authorized to practice in accordance with division (B) of section 4723.43 of theRevised Code; or

(5) Advanced practice registered nurse or A.P.R.N. if the individual is authorized to practice under division (A) to division (D) of section 4723.43 of the RevisedCode.

(B) Only a person who holds a current valid advanced practice registered nurse license issued in accordance with sections 4723.41, 4723.42 and 4723.482 of theRevised Code and this chapter to practice as a certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialistshall:

(1) Practice in accordance with section 4723.43 of the Revised Code and this chapter as a certified nurse-midwife, certified nurse practitioner, certified registerednurse anesthetist, or clinical nurse specialist;

(2) Hold themselves out as being a certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, clinical nurse specialist, or advancedpractice registered nurse;

(3) Use any title or initials implying that the person is a certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, clinical nursespecialist, or advanced practice registered nurse authorized to practice in accordance with section 4723.03 of the Revised Code and paragraph (A) of this rule.

(C) At all times when an advanced practice registered nurse is providing direct care to a patient within the nurse's respective scope of practice, each certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist shall display and identify the applicable title and designation asset forth in this rule.

(D) No person who is not authorized to do so shall knowingly prescribe or personally furnish drugs or therapeutic devices without holding a current valid license topractice nursing as an advanced practice registered nurse issued under Chapter 4723. of the Revised Code and being designated as a clinical nurse specialist, certifiednurse-midwife, or certified nurse practitioner according to section 4723.42 of the Revised Code.

Effective: 1/1/2018Five Year Review (FYR) Dates: 10/15/2020Promulgated Under: 119.03 Statutory Authority: 4723.07 Rule Amplifies: 4723.44 Prior Effective Dates: 04/01/1997, 02/01/2004, 04/01/2006, 11/05/2012, 02/01/2014


















4731.34 Unauthorized practice.

(A) A person shall be regarded as practicing medicine and surgery, osteopathic medicine and surgery, or podiatric medicine and surgery, within the meaning of thischapter, who does any of the following:

(1) Uses the words or letters, "Dr.," "Doctor," "M.D.," "physician," "D.O.," "D.P.M.," or any other title in connection with the person's name in any way thatrepresents the person as engaged in the practice of medicine and surgery, osteopathic medicine and surgery, or podiatric medicine and surgery, in any of its branches;

(2) Advertises, solicits, or represents in any way that the person is practicing medicine and surgery, osteopathic medicine and surgery, or podiatric medicine andsurgery, in any of its branches;

(3) In person or, regardless of the person's location, through the use of any communication, including oral, written, or electronic communication, does any of thefollowing:

(a) Examines or diagnoses for compensation of any kind, direct or indirect;

(b) Prescribes, advises, recommends, administers, or dispenses for compensation of any kind, direct or indirect, a drug or medicine, appliance, mold or cast,application, operation, or treatment, of whatever nature, for the cure or relief of a wound, fracture or bodily injury, infirmity, or disease.

(B) The treatment of human ills through prayer alone by a practitioner of the Christian Science church, in accordance with the tenets and creed of such church, shallnot be regarded as the practice of medicine, provided that sanitary and public health laws shall be complied with, no practices shall be used that may be dangerous ordetrimental to life or health, and no person shall be denied the benefits of accepted medical and surgical practices.

(C) The use of words, letters, or titles in any connection or under any circumstances as to induce the belief that the person who uses them is engaged in the practice ofmedicine and surgery, osteopathic medicine and surgery, or podiatric medicine and surgery, in any of its branches, is prima-facie evidence of the intent of such personto represent the person as engaged in the practice of medicine and surgery, osteopathic medicine and surgery, or podiatric medicine and surgery, in any of its branches.

Effective Date: 04-10-2001 .

Sample of Email Questions Received

Q: I have a question about the scope of practice applicable to nurse practitioners and clinical nursing specialists in Ohio in light of recent changes to the Medicare and Medicaid home health certification and related regulations promulgated by the Secretary of HHS pursuant to the Coronavirus Aid, Relief, and Economic Security (CARES) Act. We understand that these changes allow licensed nurse practitioners, and clinical nursing specialists to (i) certify the need for home health services, and (ii) order home health services, provided that such practitioners are able to do so under state law. We are unable to identify Ohio laws, rules, or other guidance that prohibits these practitioners from engaging in certification and ordering of home health services. Could you please confirm whether such activities are within the scope of practice of nurse practitioners and clinical nursing specialists in Ohio?

A: Nothing in Ohio law and rule enforced by the Board of Nursing prohibits an APRN, acting within their scope and consistent with standards of practice, from ordering or overseeing a patient's home care. However, law and rule enforced by the Board does not address billing. CMS (or a private insurer or other payor) may impose certain requirements for home health care certification or re-certification. That would be based on the payor’s law and rule or policies and not based on the Ohio Nurse Practice Act. If you have any question about billing, you will want to contact the particular insurer/payor, to determine if they have published guidance about billing for particular practices. Q: I am licensed as an ARN-CNP in (Colorado, Arizona, West Virginia) and writing on behalf of the University Student Wellness Center. Our Wellness Center is run and staffed with family/adult nurse practitioners and psych-mental health nurse practitioners. We would like to know if, UNRELATED TO COVID-19, Ohio law and rule allows for our nurse practitioners to provide telehealth visits and prescribe medication to a student who is established with our clinic and is temporarily in Ohio (such as the student is home in Ohio for holiday break, summer break, etc.)? A: The practice of nursing occurs where the patient is located at the time. During the declared COVID-19 emergency, nurses who are licensed elsewhere are permitted under Section 4723.32(G)(7), ORC, to practice in Ohio, without being licensed in Ohio. See the statement on nurse mobility at https://nursing.ohio.gov/wp-content/uploads/2020/03/OBN-Statement-Nurses-and-COVID-19.pdf This exemption from state licensure is only in effect as long as the declared state of emergency is in effect. Individuals practicing as APRNs (-CNP, -CNM, or -CNS) in the state of Ohio are required to practice pursuant to a standard care arrangement (SCA) entered into with a physician or podiatrist who is authorized to practice in Ohio, as required under Section 4723.431, ORC. http://codes.ohio.gov/orc/4723.431 http://codes.ohio.gov/oac/4723-8-04v1 In the absence of a declared emergency, to practice as an APRN in Ohio, an individual must either be licensed to practice in Ohio, or, meet one of the limited, specific exemptions in Section 4723.32, ORC, which can be accessed here: http://codes.ohio.gov/orc/4723.32


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, OAC, 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 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. Added by 129th General Assembly, eff. 3/22/2013. (Emphasis added.) Q: I am seeking information related to the authority of Ohio CNPs to procure testosterone hormone pellets, a Schedule 3 controlled substances. I have reviewed Ohio Rule 4723-9, OAC, “Prescriptive Authority” but found no specific guidance regarding the procurement of controlled substances by CNPs. A: Law and rule enforced by the Board of Nursing governing APRN prescribing and personally furnishing of drugs include Section 4723.481, ORC, and Chapter 4723-9, OAC. The purchase, storage, maintenance, and dispensing of drugs is primarily governed by law and rule enforced by the Board of Pharmacy. https://www.pharmacy.ohio.gov/




Q: May an APRN-CNP interpret EEGs and EMGs? A: The statutory scope of practice for an APRN-CNP, defined in Section 4723.43(C), ORC, authorizes the APRN-CNP to provide preventive and primary care services, provide services for acute illnesses, and evaluate and promote patient wellness within the nurse's nursing specialty, consistent with the nurse's education and certification, and in accordance with rules adopted by the board. There is no prohibition on an APRN-CNP interpreting a diagnostic test if doing so is consistent with their national certification, and, it may be performed consistent with standards of care including consideration of the APRN’s knowledge, skills, and ability, as well as the clinical circumstances, etc., Chapter 4723-4, OAC. The APRN Decision Making Model, available on the Board website under Practice, can assist APRNs in determining whether performance of a specific procedure, task, or activity is consistent with standards of safe patient care, including whether it is appropriate to perform based on the individual APRN’s knowledge, skills, and abilities, and, clinical circumstances. Also, as APRNs add new procedures, they will want to review their SCAs to update the statement of services offered, as appropriate. Rule 4723-8-04, OAC. June 2020

Documents

AGENDA Advisory Committee on ... - Ohio Board of Nursing€¦ · Advisory Committee on Advanced Practice Registered Nursing July 6, 2020 10:00 a.m. to 2:30 p.m. Via Virtual Conference