Presentation on theme: "APRN PRACTICE UPDATE LAW AND RULE 2014"— Presentation transcript:
1 APRN PRACTICE UPDATE LAW AND RULE 2014 2015 Family Practice Review and Reunion February 21, Douglas Caserta, MSN, FNP-BC, APRN Meets the Category A, hour requirement for Ohio Nursing Law and Rules
2 ObjectivesDiscuss law and rules pertinent to contemporary APRN practice in Ohio including the 2014 updateReview the most recent changes in the Ohio Formulary.Briefly review Schedule II Prescribing and OARRS Law and RuleState 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
3 Law and Rules – Where are they? Title – What is title protection? Review TopicsLaw and Rules – Where are they?Title – What is title protection?Certificate of AuthorityCOA ComponentsScope of PracticeWhat is it?APN Decision Tree –New practice and procedures
4 Review Topics - continued Standard Care Arrangement Collaboration Who signs? Components of the SCA Prescribing Parameters Update Quality Assurance Chart Review: when and who Prescriptive Review: when and who Relicensure – What do I need Primary Source Verification Continuing Education
5 Review Topics – continued Prescribing Principles and StandardsStaying Compliant - ReviewPharmacology HoursLicensure MaintenanceKeeping the BON InformedSCA Key Points – What’s new?Prescriptive Authority – What’s new?Schedule II – Brief ReviewLegislative Updates and Future Initiatives
6 APRN Law and Rules – Where Are They? Ohio Revised Code (ORC) 4723 (Law)Voted and passed by General AssemblySigned by the GovernorThe Nurse Practice Act (ORC 4723)Ohio Administrative Code (OAC) (Rules)Written by the regulatory boards (BON)Cannot conflict with or expand the lawRules assist to implement the lawNursing Rules through (OAC)
7 How Do I Find the APRN Law and Rules APRN State RulesAPRN State LawAPRN Federal LawUnited States Code of regulationsCenter for Medicare and Medicaid Services (CMS)Board of Nursing (BON)Board of Medicine – No direct APRN Authority
8 Title ProtectionProvides legal recognition for practice Unless individuals meet the requirements cannot use the title ORCTies 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 statutesMay still use CRNA, CNM, CNS, CNP
9 Certificate of Authority COA required for APRN to practice: Renews every 2 years with RN license; Must have up to date national certification; primary source verification within 30 days of recertifying, (OAC ) Current national certification: If your national certification lapses by one day, your COA is not active, no grace period, you must cease practice (continuous certification required) At Renewal: submit name and business addresses of collaborating physicians ( ) May place COA on inactive status (Ref OAC)
10 Scope of Practice What is your scope of practice? Scope: defined by national certifying organizations, standards of care, parameters of practiceNO LAUNDRY LIST IN OHIO OF PERMISSABLE SERVICESHBScope: as defined by ORC : 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….”
11 How to determine if a procedure is within my scope? Questions about ScopeHow 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 BONAre APRNs supervised in Ohio?Rarely: APRN CtP – ExternshipCRNAs have supervisory languageMust a Doctor be on site or sign charts? NOException: CtP-E for supervised hours)Must be accessible by telecommunication
12 Standard Care Arrangement SCA ( ) Must have one before you practiceArticulates the APRN & physician collaborating relationshipMust be signed by all collaborators unless it is signed by the “physician’s designated representative” – department director or chairSigned and reviewed once a year (kept on site – don’t send to BON)Must include the PI/PC Arrangement (OAC ) NEW – NEW - NEW
13 Standard Care Arrangement SCA ( ) Must have one before you practice: keep on siteIncludes: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 ( ); - physician must be involveddocument physician licensure yearlyprovisions for in-person physician evaluation if needed.Samples available from OAAPN
14 Standard Care Arrangement Collaborating Physician - Notify the BoardH. 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 effectsee BON site for forms.Schedule II authorityUPDATE SCA FOR PI/PC CATEGORY and PER SCA CATEGORY
15 SCA: Quality Assurance Measures (OAC 4723-8-05) 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 activityChart 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 IIAdditional information on the SCA may be found at the OAAPN website: oaapn.org where an one hour CE on the 2014 SCA is available.
16 Standard Care Arrangement – Clarification of PI/PC BON OAC Formulary: previously listed drugs as PI ( physician initiated) or PC ( physician consultation) or, they were categorized as all PC if noted in SCA Physician Initiated (PI): Means the APRN may continue the medication after the physician has examined the patient in accordance with OAC and initiated therapy. Physician Consult (PC): Means the APRN may initiate and continue the medication after direct communication with the collaborator and documentation of consult in patient record.
17 SCA - Formulary Rule Changes LEGEND and Format Changes: all formulary drugs are now categorized as: “may prescribe,” “physician initiated,” “physician consult” or “may not prescribe.” SCA may also include any additional parameters pertaining to the prescribing of drugs indicated in this column. Effective: APRIL 1, In Accordance with SCA: Means that drugs/drug categories on the formulary under this column, must have the prescribing designations determined jointly by the APRN and CP and specified. See current formulary (9/22/2014).
19 Formulary Legend Changes: SCA Update – “In Accordance with SCA”: *Use general category approval statement to cover all drugs in this column Example of general statement: “The APRN may prescribe all formulary drugs under “in accordance with SCA category”, per the APRN’s and collaborator’s scopes of practice and within acceptable prescribing practices.” *or address each drug individually in SCA Update – “In Accordance with SCA”: *Use individual drug approval statement, PI, PC or may not prescribe
20 Formulary Legend*Off-Label Use: : *May prescribe if supported by current peer review literature (which is accessible by the CTP holder),and noted as the standard of care in the SCA *Compounded Drugs: *Combination Drugs: Each component must be “CTP holder may prescribe” Limited conditions: Components must be FDA approved and listed in formulary as may prescribe. SCA must contain verbiage recognizing the approved compounded drugs; if off label, follow rules
21 Formulary Rule Changes: Schedule II Opioid Analgesics*** All requirements of Section ORC, and more narrow prescribing parameters requiring physician involvement specified in Section 7 of formulary, apply to schedule II Opioid Analgesics SCA must state if initial prescriptions for > 14 day supply require physician initiation or consultation – or are approved by CP for extended initial supply May not change the designation “MAY NOT PRESCRIBE”.
22 Re-licensure – What do I need for my COA? Continuing Education CE LAW and Rule – OAC: 1 hourCategory 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.
23 Re-licensure & COAContinuing Education Requirements: (OAC ) Licensure Renewal: (every 2 years) *24 hrs. for RN renewal (1 hr. nursing law and rule, Category A) *12 hrs. in Pharmacology Save documentation of all CEs for 6 years *Must have some component addressing controlled substances. TOTAL: 36 hours for COA + CTP Renewal Specialty certification every 5 years See certifying organization for specifics
24 Prescribing Principles and Standards Prescriptive AuthorityMust 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 )Within Scope of Practice – congruent with specialty area of physician and APRNMay not prescribe any drug/device that induces an abortionFollow Federal and State LawsSample DrugsSamples within the formularyProvided free of charge, may not repackageNo more than 72 hour supply or smallest packaged amountNo samples of DEA controlled substances( : OAC: ORC)
25 Prescribing Principles and Standards Prescriptive AuthorityStock MedicationsDispense 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 standardsDispensing stock medications by category: antifungals, antibiotics, contraceptives, prenatal vitamins, scabicides; asthma, antihypertensives, DM meds; antilipidemicsOAC: ORC
26 Prescribing Principles and Safety Standards 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 furnishedMust maintain record of all stock drugs and devices personally furnished by the APNPrescribing Standards:Valid prescriber-patient relationshipAssessment/exam, diagnosis, documentCurrent 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
27 Prescribing Principles and Safety Standards Issuance of a Prescription: ( )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 IIMay provide multiple prescriptions for schedule llDEA for scheduled drugsFax: not appropriate for schedule II: exception is LTC and HospiceFollow Hospice Patient prescription format (OAC )All controlled drugs quantity written numerically and alphabetically ( )Formulary Use:Confirm Per SCA preference in SCAFDA and Off-Label Use: in accordance with formulary and consistent with SCAFollow formulary review requirements
28 Board of Medicine: OAC 4731-11-09 Prescribing to persons not seen by the physician/APRN **Not approved, except 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 Prescribing Principles and Safety Standards Approved Delegation of Med Administration/Unlicensed( OAC, ORC)OTC topical medicationsOTC eye drops, ear dropsSuppository medications,Foot soak treatmentsEnemasCtP Externship Requirements for Out of State APRNsAPNs who prescribed in another state within the last 3 yearsIncluded or excluded controlled substancesMust complete 2 hour law and rule course specific to prescribing in Ohio (Follow rules – )
30 Schedule II Brief Review Achieved limited Schedule II Prescriptive Authority – June 2012Changes to SCA and Quality Assurance RequirementsGeneral Pharm CE requirements – 12 pharm hours with some component for controlled substancesIn course objectivesIN COURSE TITLENo specific # of CE required for controlled substancesQuality assurance requiring representative sampling of schedule II drugs if prescribedMust adhere to standards & rules OARRSMust be vigilant as new legislation introduced frequently3 initiatives passed in 2014
31 Prescribing Schedule II Schedule II prescribing outside of approved site list: 1) Only in terminal condition with degree of medical certainty it is terminal, there can be no recovery 2) CP initially prescribed the substance for the patient 3) The amount does not exceed a 24 hour supply (ORC ) These current rules on Schedule II do not apply if the Schedule II drug is written from any of the listed locations NO CONVENIENCE CARE CLINICS EVER
32 Schedule II Brief Review Approved Sites:Hospitals and any entity owned or controlled in whole or part by hospital ORCCounty Home Chapter 5155 ORC etc.Health care facility operated by department of mental health or developmental disabilitiesNursing Home: ORC , or ORCHospice care program ( home, outpatient, inpatient etc.)( ORC)Community Mental Health Facility (ORC )Ambulatory Surgical Facility ORCFree Standing Birthing Center (ORC )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)) ORCHealth Care Office/facility operated by ODH or board of health of city/general district ORCPhysician owned offices/practicesExcludes Convenience Care Clinics
33 Hospice Program or Hospice Facility? Hospice Program – defined under ORC “Hospice care program” is a coordinated program of home, outpatient and inpatient care and services that is operated by a person or public agency and that provides the following care and services to hospice patients, including services as indicated below to hospice patient’s families, through a medically directed interdisciplinary team, under interdisciplinary plans of care established pursuant to section of the ORC, in order to meet the physical, psychological, social, spiritual, and other special needs that are experienced during the final stages of illness, dying, and bereavement.
34 Schedule II Rule Changes Amphetamines: CTP Holder may prescribe with formal established diagnosis Per SCA if no formal diagnosis Opioid Analgesics – Schedule II (NEW) 14 day maximum for initial therapy without PI/PC SCA must indicate amount > 14 day supply per institutional protocol or per PI/PC within SCA “In accordance with SCA”
36 Schedule II Prescribing - Additional Requirements SCA Must Include: *The exact authority to prescribe schedule 2 Example: May prescribe all scheduled drugs per BON formulary: OR May prescribe all schedule II with exception of stimulants: OR May not prescribe schedule II drugs *Quality assurance standards must be inclusive of schedule II drugs, representative sampling review *APRN must follow all of the standards and procedures for the utilization and review of OARRS reports (OAC )
37 Schedule II Prescribing - Additional Requirements *Must have DEA with approval to prescribe 2 and 2N noted on the license to prescribe schedule II *May not prescribe an opioid for the treatment of drug addiction (Federal Law). Problem for neonates with abstinence syndrome
38 APRNS may not prescribe opioids for drug addiction to include neonates
39 Recap: Prescribing Safely Prescribing Rules: According to SCA Scope of practice Formulary requirements Does not exceed your collaborator Valid-patient prescriber relationship No controlled substances – ever for family DEA must have to prescribe II – V drugs No device or substance that induces an abortion Write CtP on all prescriptions Follow OARRS regulations DO NOT furnish a schedule II to anyone DO NOT prescribe anabolic steroids (C-III) ( OAC)
40 OARRS – What YOU Need to Know BON: OAC Standards and Procedures for review of OARRS OARRS: *Is a prescription monitoring program maintained by the Ohio BOP, assists with med management & serves as screening for abuse. *Makes it easy to obtain a chronologic history of patient use of controlled substances ( OAC) *Pharmacy must report on a weekly basis, by pharmacy or prescriber – if personally furnished or dispensed. *Prescriber: May request report if prescriber-patient relationship Must utilize if: *Currently treating or plan on prolonged use 12 weeks or more *Every year at least as well as the first prescription, initial prescribing *If has reason to believe abuse of drugs (list of examples) *Must first review the OARRS report and document review *If you prescribe and review and determine likely abuse, you must document a CP consult before prescribing again. *If the OARRS report is not available – must document in record If you prescribe benzos or opioids - NEW * Hospice patients exempt https://www.ohiopmp.gov/Portal/images/MedBoardArticle.pdf
41 LAW AND RULES PERTINENT TO OHIO CONTEMPORARY APRN PRACTICE - NEW Determination & Pronouncement of Death ( ORC Effective 3/22/2013) CNS, CNP and RN can determine and pronounce death: if respiratory and circulatory functions are not artificially sustained. If individual is in LTC facility; residential care facility, assisted living, county home, If CNP or CNS provides supervision of individual’s care through hospice care program or palliative care, APRN may not complete individual’s death certificate Attending physician must be notified before 24 hrs. has passed.
42 LAW AND RULES PERTINENT TO OHIO CONTEMPORARY APRN PRACTICE - NEW Hospital Admission Authority (ORC ) – effective 5/20/2014 *APRNs with collaboration agreement with hospital staff physician *Hospital privileged and credentialed *Must notify CP prior to admitting patient *No change in APRN scope – APRNs make admission decisions, this simply allows them to write the specific order to admit *Bill is much more restrictive than federal admitting rules – another advancement in practice, Hospital bylaws must allow.
43 New LAWSORC • APRNS may now supervise certified hyperbaric technologists – Effective 9/4/2014.ORC •ALL PRESCRIBERS of Opioids and Benzodiazepines must check OAARS before prescribing - Effective 9/16/2014ORC •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 StartTalking.ohio.gov for sample consent and tipsORC • 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 – EffectiveORC 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 conditionsEffectiveStrategy to repeal started
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 Pink Slip • HB 104 introduced 3/19/13 by Representatives Ruhl & Stautberg; stalled in Senate Civil Justice committee since 12/12/13. • An amendment (G90175) to the bill was sent to Senator Sharon Jones on 7/23/14 for her support. • Amendment includes: A clinical nurse specialist certified as a psychiatric-adult CNS by ANCC; A CNP adult psychiatric-mental health NP by ANCC to be identified amongst those who may “pink slip” Not all APRNs Hope to pass in lame duck!
48 Delegation UpdateHB 301 Introduced 10/16/13 ; passed committee, now in HouseTo 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 drugsCurrently 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 Prescriptive ChangesHydrocodone Combination Products (VICODIN, NORCO)moved from Schedule III to Schedule IIEffective October 6, 2014Tramadol 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
50 BARRIERS TO PRACTICE – FUTURE PERSPECTIVES Full Practice Authority Committee - OAAPN Represents all APRN Associations Seeks Barrier Free Prescribing and Practice and retirement of mandatory collaboration. Research based strategic action RAND Study completed of the economic benefits realized by Ohio with barrier free APRN practice ONLY INITIATIVE for
51 What to do if the board comes knocking. Disciplinary actions on the rise in Ohio.Preventive Action – Most ImportantFollow the rules of practice for Ohio APRNsHave all documents available for review at your work site and up to dateConsult legal counsel – immediatelyDo not call BON before you call your attorneyDon’t represent yourselfKnow your rightsDon’t sign anything
52 Questions?? Douglas Caserta, MSN, FNP-BC, APRN Treasurer OAAPN Member, Full Practice Authority Committee