On July 16, 2015, Governor Kasich signed Senate Bill 110 (“SB110”) into law, which will become effective 90 days after the governor’s signature. SB 110 allows advance practice registered nurses (“APRNs”) to delegate the administration of non-controlled substance drugs and also makes significant changes to rules governing physician assistants (“PAs”). A summary of SB 110’s main components relating to APRN drug administration delegation and PAs follows.
APRN Delegation of the Administration of Drugs
SB 110 allows certain APRNs to delegate the administration of a drug, other than a controlled substance, to an individual not otherwise authorized to administer drugs. However, such delegation is not allowed in hospital inpatient units, emergency departments or ambulatory surgical facilities.
SB 110 adds new Ohio Revised Code sections 4723.48(C) and 4723.489, which allow clinical nurse specialists, certified nurse practitioners and certified nurse-midwives to delegate the administration of a drug (other than a controlled substance) to a person not otherwise authorized to administer the drug, so long as the following steps are taken:
- Prior to the delegation, the APRN assesses the patient and determines that the drug is appropriate for the patient.
- The APRN determines that the person to whom he/she will be delegating has completed education based on a recognized body of knowledge regarding drug administration and demonstrates the ability to administer the drug safely.
ORC §4723.489 allows a person not otherwise authorized to administer a drug to administer the drug to a specified patient, so long as the following conditions are met:
- An APRN who is a clinical nurse specialist, certified nurse-midwife or certified nurse practitioner and holds a certificate to prescribe delegates the administration of the drug.
- The drug is listed in the formulary established by the Board of Nursing and under ORC §4723.50 and is not a controlled substance or to be administered intravenously.
- The drug is to be administered at a location other than a hospital inpatient care unit, a hospital emergency department, a freestanding emergency department or an ambulatory surgical facility.
- The person has completed education based on a recognized body of knowledge regarding drug administration and demonstrates the ability to administer the drug safely.
- The person's employer has given the APRN access to documentation showing that the person has successfully completed the requisite education mentioned above and demonstrates the ability to administer the drug safely.
- The APRN is physically present at the location where the drug is administered.
Lastly, SB 110 requires the Ohio Board of Nursing to adopt rules establishing standards and procedures for APRN delegation of the authority to administer drugs.
Below is a summary some of SB110’s major changes to the PA rules.
- For PAs practicing outside a health care facility (defined in ORC §4730.01 as a hospital registered with the Ohio Department of Health, a licensed ambulatory surgical facility and any other facility designated by the Medical Board pursuant to ORC §4730.08), there is no longer a requirement that the supervising physician have a Medical Board-approved physician supervisory plan and that the PA practice under this plan. However, supervision agreements are still required. For PAs practicing outside of a health care facility, the supervision agreement must include the following:
- Responsibilities to be fulfilled by the supervising physician.
- Responsibilities to be fulfilled by the PA.
- Any limitations on the responsibilities to be fulfilled by the PA.
- Circumstances under which the PA is required to refer a patient to the supervising physician.
- If the supervising physician elects to designate other physicians to act as alternate supervising physicians, the names, business addresses and business phone numbers of such physicians.
- Supervision agreements for PAs practicing within a healthcare facility still must require the PA to practice in accordance with the policies of the healthcare facility.
- All supervision agreements must clearly state that the physician is legally responsible and assumes legal liability for the services provided by the PA.
- In lieu of the now eliminated supervisory plan, SB 110 requires the supervising physician to submit a copy of each supervision agreement to the board and gives the board discretion to review it at any time for compliance and for verification of licensure of the supervising physician and the PA. The supervision agreement becomes effective five business days after being submitted, unless the board notifies the supervising physician that the agreement is non-compliant.
- Supervising physicians can amend an active supervision agreement to add one or more PAs.
- The supervision agreement must be kept in the records maintained by the supervising physician.
- Under SB 110, PAs can perform any services authorized by the supervising physician that are a part of the physician’s “normal course of practice and expertise.” A “service” is defined as a medical activity that requires training in the diagnosis, treatment or prevention of disease. If the supervising physician gives authorization and the services are within his/her normal course of practice and expertise, a PA can do any of the following:
- Order diagnosis, therapeutic and other medical services.
- Prescribe physical therapy or refer a patient to physical therapy.
- Order occupational therapy or refer a patient to occupational therapy.
- Identify and comply with a DNR order.
- Determine and pronounce death.
- Assist in surgery.
- If the PA has been granted physician-delegated prescriptive authority, order, prescribe and personally furnish and administer drugs and medical devises.
- Perform any other services that are part of the supervising physician’s normal course of practice and expertise.
- The services a PA can perform at a health care facility are limited to those authorized by the health care facility. The health care facility cannot authorize the PA to perform services prohibited under ORC §4730.
- SB 110 eliminates the current law requiring the board to approve “special services” that can be performed by the PA. Special services were the services not listed in the Ohio Revised Code or designated by Medical Board rule that a PA can be authorized to perform. Instead, the new requirements set forth above will govern, and the PA can perform other services that are part of the physician’s normal course of practice and expertise.
- PAs can delegate the performance of a task to implement a patient’s plan of care and may delegate the administration of a drug, so long as the requirements below are met. In order to delegate, the PA must be physically present where the task is performed or the drug is administered. In addition, prior to delegating a task or administration of a drug, the PA must determine that it is appropriate for the patient and that the person to whom the delegation is to be made can safely perform the task.
- A PA can delegate the administration of a drug, so long as the following requirements are met:
- The PA has been granted physician-delegated prescriptive authority.
- The drug is included in the formulary established under division (A) of ORC 4730.39.
- The drug is not a controlled substance.
- The drug will not be administered intravenously.
- The drug will not be administered in a hospital inpatient unit, a hospital emergency department, a freestanding emergency department or an ambulatory surgical facility.
- SB110 eliminates the certificate to prescribe and provisional certificate concepts. Instead, a PA who holds a valid prescriber number issued by the board is authorized to prescribe and personally furnish drugs and therapeutic devices in the exercise of physician-delegated prescriptive authority. (SB110 doesn’t indicate how a prescriber number is obtained from the board.)
- SB110 specifies that a PA’s first 500 hours of physician-delegated prescriptive authority must be under on-site supervision of a physician. This requirement is waived if a PA had prescriptive authority in another state and practiced with that authority for at least 1000 hours.
- The supervising physician is required to keep a record of the PA’s completion of the supervised hours.
- PAs will now have a “license” instead of a certificate of practice issued by the state Medical Board.
- The old law specified that a supervising physician could authorize a PA to practice in any setting within which the supervising physician routinely practiced. SB110 replaces this requirement and provides instead that a PA may practice in any setting within which the supervising physician has supervision, control and direction of the PA.
- SB 110 eliminates the old law requiring the supervising physician to be in a location of not more than 60 minutes travel time form the PA’s location. Instead, the supervising physician must now be a distance from the location where the physician is practicing that “reasonably allows the physician to assure proper care of patients.”
- Physicians are still allowed to enter into supervision agreements with any number of PAs but may now supervise up to three PAs at any one time. This was increased from two under the old law.
- Grounds for discipline of a PA now include revocation, suspension, restriction, reduction or termination of clinical privileges by the U.S. Department of Defense or Veterans Affairs, or the termination or suspension of a DEA license, and having a certification by the national commission on certification of PAs lapse or be suspended or revoked.