CERTIFIED NURSE PRACTITIONER STANDARD CARE ARRANGEMENT

CERTIFIED NURSE PRACTITIONER
STANDARD CARE ARRANGEMENT

This Standard Care Arrangement (“SCA”) is made effective this date, {todaysDate}, by and between Nancy Henceroth-Gatto, DO (individually or collectively the “Collaborating Physicians”), and {name} a licensed Certified Nurse Practitioner (herein the “CNP”). This SCA is entered into pursuant to Ohio Revised Code (“ORC”) §4723.431 and Ohio Administrative Code (“OAC”) §4723-8-04 and serves, in part, as a formal guide to planning and evaluating health care of patients cared for by the CNP.

Background Information

A. The Collaborating Physicians are duly licensed and engaged in the practice of medicine in the State of Ohio (“State”) and specialize in Emergency Medicine.

B. CNP is duly licensed and renders nursing services in Ohio as a registered nurse. CNP has been granted a Certificate of Authority as a certified nurse practitioner by the Ohio State Board of Nursing (the “Board”) noting his/her area of specialization as a Family Nurse Practitioner (FNP) and has been granted a Certificate to Prescribe by the Board.

C. The Collaborating Physicians desire to utilize, and the CNP desires to provide, the services of the CNP through a relationship of the type described by ORC §4723.431 and OAC §4723-8-04 whereby they will collaborate to provide health care services.

The Collaborating Physicians and the CNP (the “Parties”) hereby acknowledge the foregoing Background Information and agree as follows:

§1. Definitions. For purposes of this SCA:

“Board” means the Ohio State Board of Nursing;

“Certificate of Authority” means the certificate issued by the Board and held by a Certified Nurse Practitioner who has fulfilled all requirements of the Board set forth in ORC §4723.41;

“Certificate to Prescribe” means the certificate issued by the Board and held by a Certified Nurse Practitioner who has fulfilled all the requirements of the Board set forth in ORC §4723.48.

“Certified Nurse Practitioner” means a registered nurse who has met the requirements of ORC §4723.41, and who holds a current valid Certificate of Authority issued by the Board under ORC §4723.42;

“Collaboration” or “Collaborating” or “Collaborate” means with respect to a Certified Nurse Practitioner, that a Physician has entered into a Standard Care Arrangement with the nurse and is continuously available to communicate with the Certified Nurse Practitioner either in person, or by radio, telephone, or other form of telecommunication;

“Covering Physician” means, in the event of planned absences of all of the Collaborating Physicians as described in §12 of this SCA, a Physician with whom a Standard Care Arrangement substantially similar to this SCA will be executed, herein the Covering Physician, who meets and accepts the requirements of such SCA and applicable State and federal law (for purposes of this SCA, references to Collaborating Physicians shall include any Covering Physicians performing services in their absence);

“Physician” means an individual holding a certificate issued under ORC Chapter 4731 authorizing the practice of medicine and surgery or osteopathic medicine and surgery, and who is practicing in Ohio;

“Standards of Practice” mean those statements, guidelines, or standards promulgated for a Certified Nurse Practitioner by national professional nursing organizations that emanate from a recognized body of knowledge, and are accepted or adopted by a national certifying organization approved by the Board in accordance with OAC §4723-8-06;

“Standard Care Arrangement” means a written, formal guide for planning and evaluating a patient’s health care that is developed by a collaborating physician and a Certified Nurse Practitioner, and that meets the requirements of ORC §4723.431.

§2. Representations.

(a) CNP’s Representations. CNP represents that: (a) he/she has a valid Certificate of Authority and a Certificate to Prescribe issued by the Board as a Certified Nurse Practitioner in good standing with the Board and in full compliance with the governing laws and regulations of the State; (b) that he/she is not currently under suspension, investigation, or subject to disciplinary action of any kind before any institution of state or federal government; and (c) CNP’s practice and area of specialty are the same or similar to the practice area or specialty of the Collaborating Physicians.

(b) Collaborating Physicians’ Representations. Collaborating Physicians each represent that: (a) they are Physicians duly licensed by the State of Ohio Medical Board and in full compliance with the governing laws and regulations of the State; and (b) they are not currently under suspension, investigation, or subject to disciplinary action of any kind before any institution of state or federal government.

§3. Scope of Practice; CNP Services and Agreement. CNP agrees that he/she will: (a) in accordance with and as limited by ORC §4723.43 and OAC §4723-8-02, provide to patients nursing care with the knowledge and skill obtained from advanced formal education, beyond that required for a registered nurse as specified in ORC § 4723.41, including, but not limited to, (i) preventative and primary care services, acute care and subspecialty care, (ii) assessment of patients, performance of histories and physicals, (iii) planning the care for patients; (iv) implementation of care, including ordering laboratory tests or other diagnostic services, (v) evaluation and revision of care, (vi) special services for which the CNP has been specifically trained, (vii) writing orders for procedures for which the CNP has been specifically trained, (viii) prescribing drugs or therapeutic devices or adjusting dosages of drugs that a patient is currently receiving, (ix) emergency care of patients; (b) work with Collaborating Physicians to incorporate new technology or procedures consistent with the applicable scope of practice as set forth in ORC §4723.43; (c) practice in accordance with the duties, responsibilities, and accountabilities of practice as contained in: (i) State laws and Board rules regulating the practice of nursing, including credentialing requirements and standards, and continuing education requirements; (ii) all applicable Standards of Practice for practice or functions, provided the applicable standards are in accordance with ORC Chapter 4723; (iii) all other applicable federal and State laws and regulations; and (d) at all times during the term of this SCA maintain a Certificate of Authority and a Certificate to Prescribe in good standing with the Board and certification by at least one national certifying body approved by the Board.

§4. Prescriptive Authority. CNP shall only prescribe in accordance with applicable law and the scope of practice of CNP’s Certificate to Prescribe issued by the Board; and CNP shall only prescribe those drugs or devices that are included in the types of drugs and devices listed on the formulary established by the Committee on Prescriptive Governance and approved by the Board annually and attached to this SCA as Addendum I, as may be amended from time to time (see http://www.nursing.ohio.gov). CNP and Collaborating Physicians hereby accept the Board-approved formulary as it may be amended from time to time. Further, the CNP and Collaborating Physicians hereby agree that all drugs/drug categories listed in the "physician initiation OR physician consult" category of the Board-approved formulary, as may be amended from time to time, will be considered physician consult.

(a) CNP’s prescriptive authority shall not exceed the prescriptive authority of the Collaborating Physicians and any restriction to selected drugs or devices within the formulary as may be agreed upon between CNP and Collaborating Physicians from time to time shall be listed in the attached Addendum II to this SCA.

(b) CNP may prescribe a schedule II controlled substance as specified in ORC §3719.06(A)(2), but may not personally furnish samples of controlled substances. CNP may personally furnish to a patient a sample of any drug (except controlled substances) or therapeutic device included in the types of drugs and devices listed on the formulary, except that the amount of the sample furnished shall not exceed a 72-hour supply (unless the minimum available quantity of the sample exceeds a 72-hour supply) and no charge may be imposed for the sample or for furnishing it. CNP must maintain a written record of all drugs and devices personally furnished to any patient.

(c) CNP may prescribe drugs for off-label use if the following criteria are met: (i) the off-label indications must be consistent with the CNP’s scope of practice and clinical specialty or sub-specialty practice, (ii) the drug and off-label indications are included in the attached Addendum III to this SCA, and (iii) the off-label indications are supported by standard clinical practice and literature. The signatures of the CNP and the Collaborating Physicians on this SCA indicate their agreement to the off-label indications stated in Addendum III.

§5. Statutory Standard Care Arrangement Requirements. It is the intent of the Parties that this SCA be in full compliance with the requirements set forth by ORC §§4723.431, OAC §4723-8-04, and all other applicable law or regulations. Any provision deemed, by a court or other State or federal government institution with jurisdiction, to be not in compliance with State or federal law will automatically be amended to conform to applicable law.

§6. Additional Collaborating Physicians. A Standard Care Arrangement shall be entered into with each Collaborating Physician and Covering Physician with whom the CNP collaborates. A new Standard Care Arrangement shall be executed by the CNP when engaging in practice with a different Collaborating Physician.

§7. Notification of the Board. CNP shall notify the Board of the identity of the Collaborating Physicians not later than thirty (30) days after engaging in practice. CNP shall notify the Board of any change in the identity of Collaborating Physicians and of any Covering Physician not later than thirty (30) days after the change takes effect.

§8. CNP Verification of Physicians’ Licensure. Annually, CNP shall verify the licensure and, if applicable, certification status of the Collaborating Physicians and any Covering Physician with whom CNP has entered into a Standard Care Arrangement. Verification of physician licensure and certification status may be performed and documented on behalf of CNP by the P.A. When verification of physician licensure and certification status is completed by the P.A. the CNP must provide documentation of such verification upon the request of the Board.

§9. Referrals to Collaborating Physicians; Direct Evaluation. CNP will immediately refer to a Collaborating Physician any patient exhibiting either, (a) physical or psychological indicators suggestive of new or worsening health conditions that, in the determination of the CNP, could be better managed by the Collaborating Physicians, or (b) health care needs that, in the determination of the CNP, would be better managed by the Collaborating Physicians. CNP will refer to a Collaborating Physician or another physician or specialist, as appropriate, any patient: (a) who requests to see a physician, (b) whose clinical condition is unusual, who is not making satisfactory progress or whose condition is unresponsive to the plan of care, or (c) with complicated diagnoses or multifaceted treatment outside of parameters established by this SCA. Any referral that represents a major change in the direction of the patient’s care shall require consultation with at least one of the Collaborating Physicians prior to initiation. In order to ensure timely and direct evaluation by a physician of patients that receive drug or device prescriptions from CNP, at least one of the Collaborating Physicians or a designated physician colleague shall be available at all times to respond and evaluate a patient. Response time for such evaluations must not exceed four (4) hours from the time CNP requests an evaluation.

§10. CNP Consultation with Physicians. CNP and Collaborating Physicians will render health care services in the same facility in the offices of the P.A. located at location(s) listed in Addendum IV. On a daily basis CNP will be in continuous and direct interaction with one or more of the Collaborating Physicians. In the event that any of the Collaborating Physicians are not physically in the same facility as the CNP, Collaborating Physicians agree that they will, at all times, be available for consultation with the CNP by means of telephone, pager, and/or facsimile. The Parties have exchanged contact information for the purpose of consultation and agree to immediately forward to the Parties updated contact information upon any change in the information previously exchanged.

§11. Consultation for Infant Care. If CNP provides health care services to infants one (1) year of age or younger, at least one of the Collaborating Physicians and CNP will immediately conference regarding each individual patient and the patient’s condition and develop a plan for care of the infant and regular Collaborating Physician visits for the child from birth to age three. Any such plan of care must follow the American Academy of Pediatrics’ or American Academy of Family Physicians’ standards for the schedule and content of well-child visits.

§12. Emergencies and Absences; Continued Coverage. It is the intent of the Parties that at any point in time, at least one of the Collaborating Physicians will be available for consultation with the CNP when the CNP is seeing patients. In the event of an emergency or planned or unplanned absence of the CNP, patients will be seen by another CNP or a Collaborating Physician, and at least one of the Collaborating Physicians will be available for emergency care. In the event of planned absences of all of the Collaborating Physicians, a standard care arrangement substantially similar to this SCA will be executed with a Covering Physician.

§13. Dispute Resolution. Collaborating Physicians and CNP agree to work in good faith to resolve any disputes, including patient treatment, diagnosis, or management disputes, between the Parties through open and professional discussion. The Parties may consult with an uninvolved physician, specialist, or certified nurse practitioner, or refer to current professional literature. If the Parties are unable to resolve any disagreement, the CNP agrees to abide by and follow any final decision made by the Collaborating Physicians.

§14. Review of CNP Referrals. Collaborating Physicians and CNP agree to regularly conference to discuss any and all referrals made by CNP to health care providers other than Collaborating Physicians. Such conferences shall occur regularly, but in no event less than one conference at the end of any sixty (60) day period. Collaborating Physicians agree to monitor all CNP referrals on a continuing basis.

§15. Quality Assurance; Review of Care Outcomes. CNP shall participate in quality assurance processes described herein and as otherwise requested by the Collaborating Physicians. CNP shall immediately provide documentation satisfactory to the Board of such participation upon request of the Board.

(a) Collaborating Physicians shall, on a continuing basis, randomly review a sampling of medical charts and records of patients seen by CNP (including those referred to Collaborating Physicians) in accordance with OAC §4723-8-04(C)(5) and §4723-8-05. Such reviews shall occur regularly, but in no event less than one review at the end of each twelve (12) month period. All charts or records reviewed by the Collaborating Physicians shall be co-signed by the reviewing Collaborating Physician(s).

(b) CNP and Collaborating Physicians will utilize this same process for chart review in accordance with OAC §4723-8-05, if the CNP’s practice includes any direct client care, education, or management.

(c) Collaborating Physicians shall, on a continuing basis, randomly review a sampling of prescriptions written by CNP and CNP’s prescribing patterns in accordance with OAC §4723-8-04(C)(10) and §4723-8-05(E) and ORC §4723.50. Such reviews shall occur regularly, but in no event less than one review at the end of each six (6) month period. During any period in which CNP is prescribing during an ‘externship’ period, such reviews shall be performed on a bi-weekly basis. All prescription records reviewed by the Collaborating Physicians shall be co-signed by the reviewing Collaborating Physician(s).

(d) Subsequent to each chart or record review, a conference shall be held between the CNP and the Collaborating Physicians, or a designated member of a quality assurance committee of an institution, organization, or agency designated by the Collaborating Physicians. Such conference shall include, but not be limited to, a discussion of the results of the chart or record review and identification of client care issues, and, where applicable, whether past plans for improving care delivery have been effectively implemented. The results of the chart or record review and conference shall be used to maintain or improve care delivery, and may be used by CNP as evidence of CNP’s participation in a quality assurance review process upon request of the Board. A patient satisfaction survey will be conducted once at the end of each twelve (12) month period.

§16. SCA Review; Hospital Negotiation. Collaborating Physicians and CNP will annually review, if necessary amend, and re-approve this SCA. If a hospital negotiates this SCA, or amendments hereto, in accordance with ORC §4723.431(D), then this SCA or subsequent amendments shall be developed in accordance with OAC §4723-8-04(C). Review and approval of this SCA by a hospital shall be in accordance with the policies and procedures of the hospital governing body and the bylaws, policies, and procedures of the hospital medical staff.

§17. Employment of CNP. Notwithstanding any employment agreement between the Parties to the contrary, nothing contained in this SCA is intended to create an employment relationship of any kind between the CNP and the Collaborating Physicians and/or the P.A.

§18. Medical Assistance Reimbursement. Reimbursement under any State medical assistance program shall be in accordance with ORC §5111.02(D) and all rules promulgated thereunder. In no case shall reimbursement exceed the payment that the Collaborating Physicians would have received had the Collaborating Physicians provided the entire service. The Parties’ actions pursuant to this SCA will be in full compliance with current State and federal laws governing reimbursement.

§19. SCA Records. The most current copy of this SCA, including all addendums hereto, shall be retained and be available upon request at each site where practice of the CNP occurs. Upon request of the Board, CNP shall immediately provide a current copy of this SCA to the Board.

The foregoing has been accepted and agreed to by the undersigned as of {todaysDate}. 

 

This section will be completed by Dr. Nancy Henceroth-Gatto, DO after review.

Nancy Henceroth-Gatto, DO
NPI: 1164497335
5100 Karl Road, Columbus, OH 43229
(614) 262-5094
provider@helpinghandsfreeclinic.org