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APRN PRACTICE UPDATE LAW AND RULE 2014.  Discuss law and rules pertinent to contemporary APRN practice in Ohio including the 2014 update  Review the.

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Presentation on theme: "APRN PRACTICE UPDATE LAW AND RULE 2014.  Discuss law and rules pertinent to contemporary APRN practice in Ohio including the 2014 update  Review the."— Presentation transcript:


2  Discuss law and rules pertinent to contemporary APRN practice in Ohio including the 2014 update  Review the most recent changes in the Ohio Formulary.  Briefly review Schedule II Prescribing and OARRS Law and Rule  State the requirements for staying compliant with Ohio’s rules for APRN practice and briefly review what the APRN should do if the “board comes knocking?”  Predict the Legislative and Practice Future for Ohio APRNs 2

3 » Law and Rules – Where are they? » Title – What is title protection? » Certificate of Authority ˃COA Components » Scope of Practice ˃What is it? ˃APN Decision Tree –New practice and procedures 3

4 Review Topics - continued 4

5 » Prescribing Principles and Standards ˃Staying Compliant - Review +Pharmacology Hours +Licensure Maintenance +Keeping the BON Informed +SCA Key Points – What’s new? +Prescriptive Authority – What’s new? » Schedule II – Brief Review » Legislative Updates and Future Initiatives 5

6 Ohio Revised Code (ORC) 4723 (Law)  Voted and passed by General Assembly  Signed by the Governor  The Nurse Practice Act (ORC 4723) Ohio Administrative Code (OAC) (Rules)  Written by the regulatory boards (BON)  Cannot conflict with or expand the law  Rules assist to implement the law  Nursing Rules 4723-1 through 4723-23 (OAC) 6

7 APRN State Rules  APRN State Law  APRN Federal Law United States Code of regulations Center for Medicare and Medicaid Services (CMS) Board of Nursing (BON)  Board of Medicine – No direct APRN Authority  7

8 » Provides legal recognition for practice Unless individuals meet the requirements cannot use the title ORC » Provides legal recognition for practice Unless individuals meet the requirements cannot use the title ORC 4723-8-03 » Ties reimbursement to the title: RNs cannot bill for physician services, APRNs bill for physician services. » Title Change occurred with H.B. 303, 2012: +A.P.N initials changed to A.P.R.N. in all Ohio statutes +May still use CRNA, CNM, CNS, CNP 8

9 Certificate of Authority 9

10 What is your scope of practice? Scope: defined by national certifying organizations, standards of care, parameters of practice NO LAUNDRY LIST IN OHIO OF PERMISSABLE SERVICES HB 303 - 2013 Scope: as defined by ORC 4723.43: CRNPs provide “preventative and primary care services …. OAAPN met with BON and requested they include a CNP scope that was at least consistent with CNS scope that recognizes complexity and illness, not only primary or preventive care. The BON added “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….” 10

11 How to determine if a procedure is within my scope? “Decision-Making Guide for Determining Individual APN Scope of Practice”.. Follow this guideline and ask the BON www.nursing/ Are APRNs supervised in Ohio? Rarely: APRN CtP – Externship CRNAs have supervisory language Must a Doctor be on site or sign charts? NO Exception: CtP-E for supervised hours) Must be accessible by telecommunication 11

12 SCA (4723-8-04) Must have one before you practice  Articulates the APRN & physician collaborating relationship  Must be signed by all collaborators unless it is signed by the “physician’s designated representative” – department director or chair  Signed and reviewed once a year (kept on site – don’t send to BON)  Must include the PI/PC Arrangement (OAC 4723-9-10) NEW – NEW - NEW 12

13 SCA (4723-8-04) Must have one before you practice: keep on site Includes: broad statement of services; description of prescriptive practice; medications designated per SCA; off label use of medications; incorporation of new procedures; referrals; emergency coverage; plans for infant care; dispute settlement; quality assurance process (4723-8-05); - physician must be involved document physician licensure yearly provisions for in-person physician evaluation if needed. Samples available from OAAPN 13

14 Collaborating Physician - Notify the Board  H. B. 303 requires APRN to submit to the BON the name and business address of each of the collaborating physicians/podiatrist no later than 30 days after APRN first engages in practice as an APRN.  Must notify BON of any changes in SCA signatories within 30 days after any change takes effect  see BON site for forms.  Schedule II authority  UPDATE SCA FOR PI/PC CATEGORY and PER SCA CATEGORY 14

15 Is a process for improvement that includes:  QA Committee Members: Must include physician – may use committee, physician component need not take part in all QA activity  Chart Review: regular (once a year minimum and document outcomes and improvement)  Prescriptive review (twice a year minimum and document) inclusive of a representative sampling of schedule II if prescribing schedule II Additional information on the SCA may be found at the OAAPN website: where an one hour CE on the 2014 SCA is available. 15

16 Standard Care Arrangement – Clarification of PI/PC 16

17 SCA - Formulary Rule Changes 17


19 Formulary Legend Changes:

20 Formulary Legend 20

21 Formulary Rule Changes:

22 » CE LAW and Rule 4723-14-03 – OAC: 1 hour Category A, law and rule, must be approved by the Ohio BON or offered by OBN approved provider (every 2 years ) » HB 303, (2012) Ohio APRN may use the CE used for national certification to apply toward CE requirements for renewal of APRN license as RN does if the CE is obtained through a Program approved by the OHIO BON or by a BON approved CE Provider. 22

23 Re-licensure & COA 23

24  Prescriptive Authority  Must have CtP (CtP – E can prescribe when licensed and if meets supervision requirements).  SCA must include prescribing authority of APRN to include off label, Schedule II and per SCA arrangement (OAC 4723-9-10)  Within Scope of Practice – congruent with specialty area of physician and APRN  May not prescribe any drug/device that induces an abortion  Follow Federal and State Laws  Sample Drugs  Samples within the formulary  Provided free of charge, may not repackage  No more than 72 hour supply or smallest packaged amount  No samples of DEA controlled substances  (4723-9-09: 4723-9-08 OAC: 4723.50 ORC) 24

25  Prescriptive Authority  Stock Medications  Dispense or furnish stock medications by site: health department, federally funded primary care clinic, or non profit health care clinic, ( college: student health clinic), maintain safety standards  Dispensing stock medications by category: antifungals, antibiotics, contraceptives, prenatal vitamins, scabicides; asthma, antihypertensives, DM meds; antilipidemics 4723-9-08 OAC: 4723.481 ORC 25

26  Furnishing Standards: ( must be on formulary – no controlled)  Provide directions for Stock Medication use:  Affix label & include: name of APN, name of patient, name and strength of drug: directions for use; date furnished  Must maintain record of all stock drugs and devices personally furnished by the APN  Prescribing Standards:  Valid prescriber-patient relationship +Assessment/exam, diagnosis, document +Current certificate to prescribe, accordance with scope of practice; +No friends or family member (additional rules & no controlled meds); Use DEA if prescribing controlled meds, +According to APRN SCA & most current BON Formulary 26

27  Issuance of a Prescription: (4729-5-30)  Must Have: Date, APRN name, address, title, telephone, same identifiers for patient; drug, quantity, strength, directions for use; refills; CtP on every prescription: no refills for schedule II  May provide multiple prescriptions for schedule ll  DEA for scheduled drugs  Fax: not appropriate for schedule II: exception is LTC and Hospice  Follow Hospice Patient prescription format (OAC 4729-5-15)  All controlled drugs quantity written numerically and alphabetically (4729-5-13)  Formulary Use:  Confirm Per SCA preference in SCA  FDA and Off-Label Use: in accordance with formulary and consistent with SCA  Follow formulary review requirements 27

28 **Not approved, e xcept in institutional settings, on call situations, cross coverage situations, situations involving new patients, protocol situations, situations involving nurses practicing in accordance with standard care arrangements, and hospice settings, as described in paragraphs (D) and (E) of this rule, **A physician shall not prescribe, dispense, or otherwise provide, or cause to be provided, any controlled substance to a person who the physician has never personally physically examined and diagnosed. NOTE: This applies to APRNs.

29  Approved Delegation of Med Administration/Unlicensed (4723-13-05 OAC, 4723.07 ORC)  OTC topical medications  OTC eye drops, ear drops  Suppository medications,  Foot soak treatments  Enemas  CtP Externship Requirements for Out of State APRNs  APNs who prescribed in another state within the last 3 years  Included or excluded controlled substances  Must complete 2 hour law and rule course specific to prescribing in Ohio (Follow rules 4723-9-08 – 4723-9-10) 29

30 Achieved limited Schedule II Prescriptive Authority – June 2012 Changes to SCA and Quality Assurance Requirements  General Pharm CE requirements – 12 pharm hours with some component for controlled substances  In course objectives  IN COURSE TITLE  No specific # of CE required for controlled substances  Quality assurance requiring representative sampling of schedule II drugs if prescribed  Must adhere to standards & rules OARRS  Must be vigilant as new legislation introduced frequently  3 initiatives passed in 2014 30

31 Prescribing Schedule II 31

32  Approved Sites:  Hospitals and any entity owned or controlled in whole or part by hospital ORC 3701.07  County Home Chapter 5155 ORC etc.  Health care facility operated by department of mental health or developmental disabilities  Nursing Home: ORC 3721.02, or 3721.09 ORC  Hospice care program ( home, outpatient, inpatient etc.)(3712.01 ORC)  Community Mental Health Facility (ORC 5122.01)  Ambulatory Surgical Facility 3702.30 ORC  Free Standing Birthing Center (ORC 3702.51)  FQHC or FQHC look a like (defined in section 1905 (1) (2) (B) of SSA 2264, (1989(. 42 U.S.C. 1396d (1)(2)(B)). 3701.047 ORC  Health Care Office/facility operated by ODH or board of health of city/general district 3709.05 ORC  Physician owned offices/practices  Excludes Convenience Care Clinics 32

33 Hospice Program or Hospice Facility? 33

34 Schedule II Rule Changes 34

35 35

36 Schedule II Prescribing - Additional Requirements 36

37 Schedule II Prescribing - Additional Requirements 37

38 38 APRNS may not prescribe opioids for drug addiction to include neonates

39 Recap: Prescribing Safely 39

40 OARRS – What YOU Need to Know 40



43 » ORC 4761.11 APRNS may now supervise certified hyperbaric technologists – Effective 9/4/2014. » ORC 4723.486 ALL PRESCRIBERS of Opioids and Benzodiazepines must check OAARS before prescribing - Effective 9/16/2014 » ORC 3712.062 Requires a licensed hospice care program that provides hospice care and services in a patient's home to establish a written policy & adopt certain practices for preventing the diversion of controlled substances containing opioids – ˃Effective 9/17/2014

44 » ORC 4723-48 Mandatory Consent for Minors who are prescribed Opioids – Effective 9/17/2014 ˃Go to for sample consent and tips » ORC 1751.69 Prohibits health insurance provided by certain insurers from providing less favorable coverage for orally administered cancer medication than for intravenously administered or injected cancer medications – Effective 9-17-2014 » ORC 4730.093 Lyme Disease: a written notice must be given to patients when ordering a test for Lyme disease. Notice is signed by the patient/POA and kept in MR. ˃ Form required to make patients aware of difficulty in diagnosing Lyme disease, as symptoms are often non-specific and found in other conditions ˃ Effective 9-17-2014 ˃Strategy to repeal started 44

45 » ORC 4723.488 Naloxone Prescription to a Non-Patient » Effective March 11, 2014, » APRNs w/ CTP, to personally furnish/ issue naloxone prescription to friend, family member, or other individual in a position to provide assistance to an individual at risk of experiencing an opioid-related overdose; » Grants immunity from criminal or civil liability or professional disciplinary action when acting in good faith; » Requires health care professional to instruct individual to whom the drug is furnished/prescription is issued to summon EMS immediately before or immediately after administering naloxone.

46 » HB 483 Budget Bill had nurse law changes to include: ˃Permits CNPs and CNSs to be added to a list of professionals who may supervise various Chemical Dependency Counselor professionals when treating gambling disorders and various substance abuse disorders. ˃Permits a prescriber to request OARRS information for mother of a newborn or infant patient, for the purpose of providing medical treatment to the newborn or infant after being diagnosed as opioid dependent.

47 Current Legislative Initiatives

48 » HB 301 Introduced 10/16/13 ; passed committee, now in House » To authorize a person not otherwise authorized to do so to administer certain drugs pursuant to delegation by APRN who a CTP. » Requires BON to establish standards and procedures for the delegation of authority to administer drugs » Currently there is no opposition to this bill. » PA association request that we agree to put 301 into 412 and help them get the bill passed in the lame duck session.

49 » Hydrocodone Combination Products (VICODIN, NORCO)moved from Schedule III to Schedule II ˃Effective October 6, 2014 » Tramadol and products containing tramadol moved to Schedule IV controlled substances in Ohio pursuant to a rule adopted by the United States DEA. ˃Effective August 18, 2014


51 Disciplinary actions on the rise in Ohio. Preventive Action – Most Important  Follow the rules of practice for Ohio APRNs  Have all documents available for review at your work site and up to date Consult legal counsel – immediately Do not call BON before you call your attorney  Don’t represent yourself  Know your rights  Don’t sign anything 51

52 Douglas Caserta, MSN, FNP-BC, APRN Treasurer OAAPN Member, Full Practice Authority Committee 937-670-2745 52

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