Transcript Ohio APN law

Standard Care Agreements (SCA)
Certificate of Authority (COA)
Certificate to Prescribe (CTP)
DEA
Prescriptive Authority
Formulary
State Laws
Adult/Gero NP IV
Jennifer Frost
(modified subsequent authors: Nicolette Black & Rachel Oldham)
(modified, original authors: Erik Anderson, June Mack, & Rebecca Neeley-Rollins)
Practice Agreements
 Ohio
Revised Code (ORC) 4723-8-04
 Agreement between physician/podiatrist
and CNP, CNM, or CNS that needs to be
made before beginning practice
 A complete listing of all components that
should be included in this agreement can
be found at:
http://www.codes.ohio.gov/oac/4723-804
A standard care arrangement shall be in writing and include all of the
following:




1. Signature of all collaborating physicians, date when the
arrangement is executed, and the dates of when reviews shall take
place (including the most recent review).
2. Contact information for the collaborating physician including
phone numbers he/she can be reached at anytime.
3. A well defined scope of practice for the NP, including
procedures, as described in ORC 4723.43, and the practice
expectations for type and expected volume of patients.
4. A description of the scope of prescriptive practice.




5. Periodic review and reapproval of the SCA; review
should occur at least annually.
6. Criteria for referral of a client
by the CNP to a collaborating
physician.
7. Process for chart review (ORC
4723-8-05) and procedure for the
review of CNP initiated referrals
and outcomes.
8. Discussion of the CNP’s yearly
billing and reimbursement.



9. Include an agreement
regarding the medical insurance
reimbursement (i.e. “incident to”
or independent contracting)
(ORC 5111.02).
10. Plan for patient coverage in
CNP or collaborating physician
planned or unplanned absences.
11. Process for resolution of
disputes regarding patient
management.
A new agreement should be initiated when the CNP is employed
at a different setting and collaborates with a different
physician.



A copy of the SCA shall be on file at each site where the CNP practice.
If a collaborating physician enters into a SCA with more than 3 advance
practice nurses who hold certificate to prescribe, the MD shall not
collaborate at the same time with more that 3 of the APN’s
If a CNP is employed by a hospital the negotiation of a SCA must occur,
but may be subject to approval by the medical staff and governing body
of the hospital prior to implementation.
The Ohio Board of Nursing (OBN) must
be informed of the collaborating
physician’s identity within 30 days of
engaging in practice.
COA
Licensed RN
 Verification of National Certification
2013 Approved certifying organizations can be found at
http://www.nursecredentialing.org/Certification/Verify
Certification.aspx (ANCC)
 Completed COA application
 $100 non-refundable fee (Payable to “Treasurer, State
of Ohio”)
 2 x 2 Head shot-less than 1 yr old
 Notarized Affidavit-after application completion
 Verification of graduate degree-Form B must be sent
from school directly to the Board of Nursing
 If not completed in 1 year, application is forfeited
http://www.nursing.ohio.gov/forms.htm#RX

Application forms can be obtained from
http://www.nursing.ohio.gov/forms.htm#RX
• PDF is 7 pages. Pages 1-5 are the application
directions and application
• Make sure there is no missing information;
otherwise, it will be returned to you and the
whole process will be delayed
• Page 6 is Form A and must be completed by
the applicant and sent to the Certifying body
who will send it back to the OBN
• Page 7 is Form B must be filled out by the
applicant, then the educational institution
and sent directly to the OBN
Go to www.nursing.ohio.gov, click on
verification, enter your name, and
“pending” will be displayed until
certification is issued
CTP
 After
certificate of authority is obtained,
the CNP “shall file with the board of
nursing a written application for a
certificate to prescribe.”
 The board of nursing “shall issue a
certificate to prescribe to each
applicant who meets the
requirements…”
Ohio Revised Codes (ORC) 4723.482 & 4723.484


A completed application on a form specified by the board which
includes evidence of having successfully completed the advanced
pharmacology course as set forth in rule 4723-9-03 of the
Administrative Code
Evidence of holding both a current, valid license to practice
nursing as a registered nurse and a current, valid certificate of
authority issued under section 4723.41 of the Revised Code to
practice as a certified nurse-midwife, certified nurse practitioner,
or clinical nurse specialist

Documentation of a collaborative practice with a supervising
physician who has agreed to the practice agreement

An application fee of fifty dollars.
OAC 4723-9-05
 Completion
of 36 contact hours regarding
pharmacokinetics, clinical application, and
the use of medications from a single
provider
 Training in the fiscal, legal, and ethical
implications of prescribing.
 Instruction obtained no longer than 3 years
prior to applying for a CTP-E.
(amended rules in Chapters 4723-8 and 4723-9 ORC)
 Forms
may be accessed from
http://www.nursing.ohio.gov/forms.htm
 Laws, definitions, and
explanations of
application process may be reviewed at
http://codes.ohio.gov/orc/4723
 The
initial certificate to prescribe is an
externship certificate or CTP-E.
 With
a CTP-E the CNP “may obtain
experience in prescribing drugs and
therapeutic devices by participating in an
externship that evaluates the nurse’s
competence, knowledge, and skill in
pharmacokinetic principles and their
clinical application to the specialty being
practiced.”
ORC 4723.48
 During
the externship, the nurse may
prescribe drugs and therapeutic devices
only when one or more physicians are
providing supervision

Supervision is defined as the “oversight of
the prescribing practices of a nurse as a
holder of an externship certificate to
prescribe.”
A
minimum of 1500 hours is required
ORC4723-9-01


500 hours of direct supervision
• “Direct supervision” means the supervising professional is
available on site.
• When the supervising professional is a nurse, the nurse shall
provide no more than 250 hours of supervision
1000 hours of indirect supervision
• “Indirect supervision” means the timely review by a
physician of prescriptions written by and prescribing
practices of a nurse holding an externship certificate to
prescribe
OAC 4723-9-01
 The
 An
CTP-E is issued for one year
extension may be requested if more
time is needed
Once the externship requirements have
been satisfied, Form E may be submitted
to the Board of Nursing with
documentation by the supervising
physician.
On receipt of the new certificate, the
nurse may prescribe drugs and
therapeutic devices in collaboration with
one or more physicians or podiatrists
 Collaboration
or collaborating:
“In the case of a certified nurse
practitioner, a clinical nurse specialist or a
certified nurse-midwife; that a physician has
entered into a standard care arrangement with
the nurse; and is continuously available to
communicate with the nurse either in person, or
by radio, telephone, or other form of
telecommunication.”
ORC 4723.48

Prescription of medications is directed by state formulary
and standard care agreement.

CNP may only prescribe within provider-patient relationship
that must be documented in the patient’s medical record

The APN’s prescriptive authority shall not exceed the
prescriptive authority of the collaborating physician or
podiatrist
ORC 4723-9-09


The amount of the sample furnished shall not exceed a 72
hour supply, except when the minimum available quantity of
the sample is packaged in an amount that is greater than a
72 hour supply – can then furnish the sample in the
packaged amount
If the directions for use are different than stated on the
sample, the nurse has to provide in written format
• The name of the prescribing nurse
• The name of the patient
• Directions for use

Maintain a written record of all drugs and devices
personally furnished by the nurse
ORC 4723-9-08
DEA
 After
CTP has been issued
 May
apply online at
www.deadiversion.usdoj.gov
 Fee
of $551 for 3 years
 Ohio
law allows for NP prescription of
schedule II-V controlled substances.
 The
APN may prescribe a schedule II
controlled substance, but shall not
exceed the prescriptive authority of the
collaborating physician or podiatrist.
ORC 4723.481 & 3719.06
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Substances in this schedule have a high potential for abuse
which may lead to severe psychological or physical
dependence.
Examples of Schedule II narcotics include: hydromorphone
(Dilaudid®), methadone (Dolophine®), meperidine
(Demerol®), oxycodone (OxyContin®, Percocet®), and
fentanyl (Sublimaze®, Duragesic®). Other Schedule II
narcotics include: morphine, opium, and codeine.
Examples of Schedule II stimulants include: amphetamine
(Dexedrine®, Adderall®), methamphetamine (Desoxyn®),
and methylphenidate (Ritalin®).
Other Schedule II substances include: amobarbital,
glutethimide, and pentobarbital
Substitute Senate Bill 83 (SB 83), which
became law on June 8, 2012, expanded the
scope of schedule II prescribing for
Advanced Practice Nurses (APNs) who hold a
certificate to prescribe (CTP), or certificate to
prescribe externship (CTP-E). The Board of
Nursing adopted rules, effective November 5,
2012, implementing the requirements of SB 83
related to continuing education for CTP
holders, and the advanced pharmacology
course of instruction for applicants, related to
schedule II controlled substances.
As of June 8, 2012, a CTP or CTP-E holder who is
practicing in a location specified in the bill is no
longer subject to the 24-hour supply restrictions in
the pre-existing law governing an APN's authority
to prescribe schedule II controlled substances.
However, CTP and CTP-E holders who are not
practicing in one of the specified locations must
follow the restrictions:
 prescribing of schedule II controlled substances
is limited to a 24- hour emergency supply of
medications,
 prescribing to terminally ill patients with respect
to whom the collaborating physician has
previously prescribed the medication.
The locations specified in law are as follows:
(1) A hospital registered with the Department of Health;
(2) An entity owned or controlled, in whole or in part,
by a hospital or by an entity that owns or controls, in
whole or in part, one or more hospitals;
(3) A health care facility operated by the Department
of Mental Health or the Department of Developmental
Disabilities;
(4) A nursing home licensed by the Department of
Health or a political subdivision;
(5) A county home or district home that is certified
under the Medicare or Medicaid program;
(6) A hospice care program;
(7) A community mental health facility;
Locations continued:
(8) An ambulatory surgical facility;
(9) A freestanding birthing center;
(10) A federally qualified health center;
(11) A federally qualified health center look-alike;
(12) A health care office or facility operated by a board of
health or an authority having the duties of a board of
health;
(13) A site where a medical practice is operated, but only
if the practice is comprised of one or more physicians
who are also owners of the practice, the practice is
organized to provide direct patient care, and the APN
providing services at the site has a standard care
arrangement and collaborates with at least one of the
physician owners who practices primarily at that site.
CTP or CTP-E holders are prohibited from prescribing
a schedule II controlled substance from a convenience care
clinic even if the clinic is owned or operated by an entity
specified in the list above, with the exception of prescriptions
limited to a 24-hour supply as set forth in pre-existing law.
 No
controlled substance shall be personally
furnished to any patient.
 Each
written prescription shall be properly
executed, dated, and signed by the
prescriber on the day when issued and shall
bear the full name and address of the
person for whom the controlled substance is
prescribed and the full name, address, and
registry number under the federal drug
abuse control laws of the prescriber.
ORC 3719.06


CTP holders are not required to complete the CE
course prior to prescribing schedule IIs
according to SB 83. However, all CTP holders
must complete the CE no later than August 31,
2013.
Section 4723.482, ORC, requires that a course of
study in Advanced Pharmacology be “planned
classroom and clinical instruction”, not
independent study. The six-hours in schedule II
controlled substances was added by SB 83 to the
Advanced Pharmacology course. It must be part
of planned classroom instruction rather than
independent study.
 The
CE course must meet the Board’s
requirements for continuing education, as
specified in Rule 4723-14-05 (A), OAC. (For
details, go to the Board website at
www.nursing.ohio.gov and click on Law and
Rules.)
A
list of OBN Approvers is located on the
Board web site (click on Continuing
Education). The Board itself will not provide
this CE.
 Developed
by and reviewed/revised
periodically by the Committee on
Prescriptive Governance (CPG)
 Most current formulary and “Formulary
Review/Revision” form available at
http://www.nursing.ohio.gov/Practice.ht
m#AdvancedPractice in the Prescriptive
Authority section
 Newest version is January 14, 2013
1
CNP, 1 CNM, & 1 CNS with prescriptive
authority
 1 RN member of the Ohio Board of
Nursing
 2 physicians who collaborate with an APN
 1 physician certified in Family Practice
 1 physician member of the State Medical
Board
 1 pharmacist member of the Ohio Board
of Pharmacy
 1 clinical pharmacist
 Any
revisions to the formulary are made
by the CPG
 Written recommendations/requests on a
Formulary Review/Revision Form need to
be sent to the board 30 days prior to a
scheduled meeting via email/fax/or mail
 Each meeting focuses on the review of
specific sections of the formulary
 Discuss issues related to prescriptive
authority
 Drug
Recalls
 Warnings and Safety Alerts
 Information for Patients
http://www.fda.gov/oc/oha/default.htm
**Know what you can and cannot prescribe
and if physician initiation or consult is
warranted!
 Can
only prescribe formulary medications
and must be a CTP or CTP-E holder.
 Can
prescribe an approved drug in ANY
form unless exclusion is specified.
 When
prescribing combination medicines,
each component must be in the CTP
formulary.
 Not
OK to RX a new indication until
approved by CPG
 Physician
must have previously
examined/evaluated the patient the
prescription is being written for. The APN
may write the initial prescription after
discussion with the physician.
 APN may start, change, or stop the
medication without further consultation.
 APN
may initiate a medication after
physician communication and must
document it in the patient record.
 Medication
can then be continued,
changed, or stopped by APN without
further physician consultation.
May prescribe as long as:
1)The indication is supported by peerreviewed research from a recognized
body of knowledge. CTP/CTP-E holder
must provide this information if
requested OR
2)Outlined in the SCA and consistent with
the formulary
 Continued
treatment must be reviewed
by the physician at the formulary
directed time.
 SCA
should include the review procedure
and APN must document this in the
patient record.
Initial 30 Day Review:
-Glucocorticoids
-Benzodiazepines: anti-anxiety
-Lithium: also must be PI/PC
-Centrally-acting and combination
muscle relaxants
60 Day Review:
-Atomoxetine: also must be PI/PC
6 Month Review:
-Anti-parkinson agents
 IV
forms of particular drugs that are
identified in the formulary by an asterisk
(* see footnote 1), require holding an
advanced specialty certification as an
Acute Care Nurse Practitioner, Acute
Care Clinical Nurse Specialist, Neonatal
Nurse Practitioner OR non-acute care
CTP holders working in an institutional
setting with PC.
 May
prescribe as an Adult or Adult/Gero APN
without PI/PC
 Many
systemic anti-infectives: PCN,
Quinolones, Flouroquinolones, Tetracyclines,
Macrolides, Spectinomycin, Ketolides,
Rifaximin, Clindamycin Amebicides,
Rimatidine, Zanamivir, Oseltamavir Phosphate
(1) Nutrients and nutritional agents;
(2) Hematological agents;
(3) Endocrine and metabolic agents;
(4) Cardiovascular agents;
(5) Renal and genitourinary agents;
(6) Respiratory agents;
(7) Central nervous system agents;
(8) Gastrointestinal agents;
(9) Anti-infective and systemic agents;
(10) Biologic/immunologic agents;
(11) Dermatologic agents;
(12) Opthalmic and otic agents;
(13) Antineoplastic agents; and
(14) Diagnostic aids.
(15) Other
•
Prescribers may furnish a sample of any drug or
therapeutic device on the formulary with the following
restrictions:
▫ The amount can not exceed a 72-hour supply except when the
minimum quantity of the sample is packaged in an amount
greater than a 72 hour supply [ex, OC]
▫ No charge may be imposed for the sample or furnishing it
▫ Samples of control substances shall not be furnished
•
Prescribers can furnish a complete supply [from
stock]:
▫ Only if employed by a health department, federally funded
comprehensive primary care health clinic, or a nonprofit health
care clinic/program
▫ Categories permitted: ATB, antifungals, scabicides, prenatal
vitamins, contraceptives, and drugs/devices used in the
treatment of HTN, DM, asthma, and dyslipidemia.

If your RN licensure lapses, your COA is revoked; if
your national certification lapses your COA is revoked
… CTP is revoked
• It is a minor misdemeanor to prescribe with a lapsed license
• It is a felony to prescribe without a license

Additional CEU is required to maintain the CTP
• 12 hours of approved advanced pharmacology over hours
needed to maintain RN licensure (24 CEU RN, 1hour OH law)
 Approved Category D [identified with each program]
 Approved CEU activity by an agency which regulates a health care
profession or discipline in OH or another jurisdiction
 CME
• Upon request must provide evidence – audit random
RX
Carolyn Sutter CNP
Primary Care Clinic, Akron OH
Phone ###,
CTP###
DATE_____
Name______________
DOB_______________
Address_____________ Allergies
_______
RX
Dispense____Refills_____
Signature_____________ ______________
DEA#_________________
Lawwriter Ohio Laws and Rules (2012). 4273-8-04: Standard care
arrangement for a certified nurse-midwife, certified nurse practitioner, and
clinical nurse specialist. Retrieved on February 4, 2013 from
http://codes.ohio.gov/oac/4723-8-04
Lawwriter Ohio Laws and Rules.(2012). Apply for certificate to prescribe.
from http://codes.ohio.gov/orc/4723.48
Lawwriter Ohio Laws and Rules. (2012). Standards and procedures for
approval as a certified nurse-midwife, certified nurse practitioner, certified
registered nurse anesthetist, or clinical nurse specialist. Retrieved from
http: //codes.ohio.gov./oac/4723-8-07
Ohio Board of Nursing. (2009). Advanced Practice. Retrieved on February 4,
2013 from http://www.nursing.ohio.gov/Practice.htm#AdvancedPractice
Ohio Board of Nursing. (2013).Forms and Applications. Advanced Practice
Nursing. Certificate of Authority Application Packet. Retrieved on
February 4, 2013 from http://www.nursing.ohio.gov/forms.htm#RX
Ohio Board of Nursing. (2013). Nursing Practice. Advanced Nursing
Practice. Approved National Certifying Organizations. Retrieved from
http://www.nursing.ohio.gov/Practice.htm#AdvancedPractice
 www.oaapn.org
 www.nursing.ohio.gov
 www.deadiversion.usdoj.gov
DOES THE BOARD OF NURSING ISSUE A
DEA NUMBER?
 NO

An application can be found online at
www.deadiversion.usdoj.gov and by clicking on drug
registration
 YES
 PRESCRIBER
NUMBER
SHOULD INCLUDE CTP
YES, BUT ONLY IF:
1) The particular drug appear on the
Formulary as Physician Initiated
2) The patient for the drug is prescribed
has a terminal condition as defined in
ORC 2133.01
3)MD initiated the medication
4)Prescribe less than 24 hour supply
NO.
A NURSE MAY DELEGATE THE
ADMINISTRATION OF ONLY: OTC
TOPICAL MEDICATIONS TO BE APPLIED
INTACT SKIN FOR PURPOSE OF
IMPROVING SKIN CONDITION OR
PROVIDING BARRIER; OTC EYE AND
EAR DROPS; SUPPOSITORY
MEDICATIONS; FOOT SOAK
TREATMENTS, ENEMAS
All CNMs, CNSs and CNPs must have a
SCA.
Only Psychiatric/ Mental Health CNSs
who do not plan on prescribing are
exempt from developing an SCA.
No. The Standard Care Arrangement must
be kept on file at EACH practice site. The
SCA must be available at all times upon
request by the Board of Nursing or other
parties. While the Board of Nursing has
the right to review the SCA at any time for
compliance, it does not need to approve
the Standard Care Arrangement in
advance.
The Formulary is maintained on the Board of
Nursing website in the Nursing Practice
Section. The Committee for Prescriptive
Governance (CPG) meets two to three times
throughout the year to discuss the drugs on the
Formulary. Information regarding meeting
dates may be accessed through the Board’s
website. The Formulary is updated after the
CPG meets. Each CTP holder is responsible for
prescribing in accordance with the most
current version of the Formulary.