Standard Care Arrangement

APRN Name Lesley D. Davidson Collaborating Physician Dr. Harold Williams

Specialty/Practice Area: Specialty/Practice Area:
Cardiovascular ICU Cardiovascular ICU

Hospital Address
Mercy- Health Anderson Hospital
7500 State Road.
Cincinnati, OH 45255
Phone number 513-624-4500

The above collaborating physician has an active and unrestricted Ohio license.

RECITALS
WHEREAS, APRN is a registered nurse authorized and duly licensed to practice in the State of
Ohio as a Acute Care Nurse Practitioner, and
WHEREAS, Collaborating Physician is a physician duly licensed in the State of Ohio, specializing
in the practice of Cardiothoracic Surgery, and is qualified by education and experience to
collaborate in that specialty; and
WHEREAS, APRN and Collaborating Physician desire to enter into this Agreement for purposes
of permitting APRN to practice and perform services as an Acute Care Nurse Practitioner, in
collaboration with Collaborating Physician, all in accordance with and in satisfaction of Ohio
Revised Code (ORC) 4723.431, Ohio Administration Code (OAC) 4723-8-04, and such other rules
as may be from time to time adopted by the Ohio Board of Nursing.
Now, THEREFORE, in consideration of the covenants contained herein, the parties hereby agree
as follows:

ARTICLE I
STATEMENT OF SERVICES
Scope. APRN and Collaborating Physician agree to collaborate in providing services to patients
in the manner set forth in this Agreement. APRN may provide to the patients nursing care that
requires knowledge and skill obtained from advanced formal education and clinical
experiences. APRN, in collaboration with Collaborating Physician, may provide cardiothoracic
and vascular and intensive care services within APRN’s specialty, consistent with his or her
education, clinical experience, and certification and in accordance with the provisions of the
ORC 4723.431, and such other rules as may be from time to time adopted by the Ohio Board of
Nursing. Said services shall include, without intending to limit the same: completing detailed
history of present illness, assessment, treatment plan, evaluation, diagnosis, and treatment of
patients, which may include the prescription of medications within the Ohio Prescriptive
Formulary and ordering of and interpreting lab/diagnostic evaluations.
Due to APRN’s scope of practice and training, APRN may also provide care for infants up to the
age of one (1). The American Academy of Pediatrics or the American Academy of Family
Practice Standards of Care for infants up to age one (1) will be followed. The agreed upon
recommendations for Collaborating Physician’s visit for children from birth to age three (3) will
be at the determination of APRN or Collaborating Physician.
ARTICLE II
INCORPORATION OF NEW TECHNOLOGY OR NEW PROCEDURES

APRN will identify and recommend to Collaborating Physician the use of any new technology or
procedures in the conduct of his/her duties in his/her area of specialty. The following may be
utilized as part of this process:
1. Education programs such as continuing education, events, workshops, and
conferences;

2. Preceptorships, fellowships, or internships; and

3. other formally organized educational experiences.

ARTICLE III
QUALITY ASSURANCE PROVISIONS

1. Criteria for Consultation of a Patient. APRN, consistent with his or her education,
clinical experience, and certification, shall determine when consultation with
Collaborating Physician, or another physician, is necessary; provided, however,
notwithstanding the foregoing, that consultation will be sought for each of the following
situations and any others may be deemed appropriate:

(a) Whenever situations arise that go beyond the competence, education, scope of
practice, or experience of APRN;

(b) Whenever a State-reportable incident occurs; or

(c) Whenever a patient, or a patient’s family, request consultation with a physician.

 Consultation may be done by telephone contact, on site case discussion, and/or physical
examination of the patient by Collaborating Physician or another physician. The
consultation and plan of care shall be documented in the patient’s record.

2. Criteria for Referral of a Patient. APRN shall refer a patient to Collaborating Physician,
or another physician, in the following circumstances:

(a) A patient request to see the Collaborating Physician or another physician;

(b) For a patient whose clinical condition is unusual, who is not making satisfactory
progress, or whose condition is unresponsive to the plan of care;

(c) APRN’s license, registration, certification, employment, or clinical privileges are

suspended, revoked, terminated, not renewed, or restricted, such that APRN cannot
independently provide patient care services; or

(d) The appropriate or indicated care to be rendered to a patient exceeds the scope of
APRN’s license, practice, employment, experience, skill, or clinical privileges.

3. Procedure for Regular Review of Referrals to Other Health Professionals and Chart
Review. At least annually, a random selection of patient records will be made by APRN
and Collaborating Physician (or the quality assurance committee of a health care facility
or health care plan) for the purposes of reviewing the care outcomes of APRN patient
referrals and patient charts.

4. Scope of Prescribing Practices. If APRN has a valid and current license to prescribe,
APRN may prescribe drugs and therapeutic devices within his/her knowledge and skill,
consistent with his or her education, clinical experiences, and certification and in
accordance with the provisions of ORC 4723.431, and such other rules as may be from
time to time adopted by the Ohio Board of Nursing. This shall include the ability to
prescribe Schedule II controlled substances pursuant to APRN’s prescriptive authority
under ORC 4723.482 (C) and according to Ohio Law. The APRN shall prescribe from the
most recent version of the formulary approved by the Committee on Prescriptive
Governance (CPG) and available on the Ohio Board of Nursing website:
www.nuring.ohio.gov (“Formulary”). APRN may prescribe any/all Schedule II controlled
substances contained in the Formulary. No Schedule II controlled substances shall be
personally furnished to any patient.

(a) The following Schedule II prescriptions shall not be prescribed to any patient under
thisAgreement:__NA_______________________________________________________
________________________________________________________________________
________________________________________________________________________
__.

(b) All drugs/categories listed in the “In accordance with the SCA” category of the
Formulary shall be prescribed in accordance with Exhibit B or C of this Agreement.

(c) Prescribing Parameters. APRN must prescribe within his or her scope of practice, as
indicated by educational preparation and training:

(i) Off-label Medications and Therapeutic Devices. APRN may prescribe

medications or therapeutic devices for off-label use if the following criteria
are met: (A) the off-label indication(s) must be consistent with APRNS’s scope of
practice and clinical specialty/sub-specialty practice; (B) the drug/device and off-
label indication(s) are included in an attached Exhibit B to this Agreement; (C)
the off-label indications are supported by standard clinical practice and
literature; and (D) the signature of the APRN and Collaborating Physician
indicates agreement to the off-label indication(s) stated in Exhibit B.

(ii) Drugs Prescribed for Compounding. There are very limited conditions under
which APRN may prescribe drugs for compounding. APRN may prescribe drugs
for compounding if all of the following criteria are met: (A) each drug that is to
be part of the compound must be U.S. Food and Drug Administration (FDA)
approved and authorized by the Formulary; (B) if one or more of the drugs is
listed as “in accordance with the SCA,” the APRN must follow the prescribing
designation requirements specified in Exhibit B or C of this Agreement; and (C)
this Agreement must include verbiage that specifies the APRN’s prescribing of
drugs for compounding, the compound, and its indications/use in Exhibit B.

(iii) New Drugs Approved by the FDA. Drugs approved by the FDA but not yet
reviewed and approved by the CPG may be prescribed by the APRN, unless later
disapproved by the CPG, if the following criteria are met: (A) the ability to
prescribe the drug is within that APRN’s scope of practice; (B) the drug type or
subtype is included on the Formulary as one that may be prescribed or may
prescribed “in accordance with the SCA”; and (C) the Collaborating Physician
agreed in this Agreement, as set forth in Exhibit B, that APRN may prescribe
drugs approved by the FDA that meet the criteria of the this paragraph and that
have not yet been reviewed and approved by the CPG.

(iv) Prescribing to Minors. If APRN prescribes drugs to minors, then APRN shall
follow that requirements of ORC 3719.061 before prescribing an opioid analgesic
to a minor.
 (v) Any restrictions to selected drugs within the Formulary, as agreed upon by APRN
and Collaborating Physician, shall be indicated in Exhibit B.

(vi) The signature of APRN and Collaborating Physician on this Agreement implies
acceptance of the Formulary as written, except as restricted by Exhibit B.

(d) OARRS. APRN shall register for and adhere to the requirements of the Ohio Automated
Rx Reporting System (“OARRS”) set forth in ORC 4723.487 and OAC 4723-9-12. APRN
shall not personally furnish or prescribe a reported drug without first reviewing a
patient’s OARRS report if the patient exhibits signs of drug abuse or diversion and shall
not prescribe an opioid analgesic or benzodiazepine to a patient without first reviewing
OARRS as required.

(e) APRN shall ensure that the patient receives timely and direct evaluation by
Collaborating Physician when indicated and shall refer for emergency consultation if
necessary.

(f) Regular Review of Prescriptions. A random selection of patient records will be made by
APRN and Collaborating Physician (or the quality assurance committee of a health care
facility or health care plan, which must include at least one physician) at least semi-
annually for the purposes of reviewing the care outcomes of prescriptions written by
APRN. Such random samples shall be representative of Schedule II controlled substances
prescribed by the APRN.

5. Policy for Coverage of Absences. The parties agree that the Collaboration Physician
must be available to communicate with the APRN by telecommunication at all times. In
the event of a planned or unplanned absence of APRN, scheduled patients will be seen
by another APRN or Collaborating Physician. If this is not possible, an attempt will be
made to contact and reschedule the patients. If the patient requires more immediate
attention or further care, he/she will be directed to the appropriate health care facility
and health care provider.

In the event of a planned or unplanned absence of Collaborating Physician, APRN shall

be notified and Collaborating Physician shall designate a physician colleague to cover in
his/her absence.

6. Policy of Resolution of Clinical Disagreements. Should a disagreement arise between

APRN and Collaborating Physician regarding diagnosis or treatment, one or more of the
following means for resolution shall be followed:
 (a) Consult with an uninvolved physician and/or APRN colleague within the clinical
department;

(b) Refer to current professional literature (journals, research, texts) appropriate to

the area in question; or

(c) Consult with a specialist in the area of question.

Appropriate institutional chain-of-command processes will be adhered to as necessary

or required. In the event that a clinical agreement cannot be reached after following the
above steps, the department medical director, chief of staff, or other mutually
agreeable healthcare provider shall arbitrate.

7. Arrangement Regarding Reimbursement. Current state and federal laws governing

reimbursement and billing shall be adhered to, including those under the medical
assistance program as set forth in ORC 5111.02 (C) and in accordance with any Rules
adopted under ORC 5111.02 (B). In accordance with ORC 4723.28, APRN shall not waive
the payment of all or any part of a deductible or copayment (or advertise as such) that a
patient, pursuant to health insurance policy, contract, or plan that covers such nursing
services, would otherwise be required to pay if the waiver is used as an enticement to a
patient/group of patients to receive health care services from the APRN. However, this
shall not prevent APRN from waiving a fee for an uninsured patient pursuant to
institutional policy.

8. Biennial Licensure Verification. Every two years, APRN shall verify the licensure and, if
applicable, certification status of Collaborating Physician. Verification of physician or
podiatrist licensure and certification status may be obtained online from Ohio e-license
center.

ARTICLE IV
REAFFIRMATION, AMENDMENT, NOTICE, AND FILING

This Agreement shall, from time to time, but not less frequently than once every two
years, be reviewed and reaffirmed or acknowledged by the parties (by affixing their signature
and date on attached Exhibit A or other writing) or, if the circumstances require, amended or
updated, from time to time, to reflect any changes in applicable law, ruled, regulations,
information, identity, or relationship of the parties. APRN agrees to notify the Ohio Board of
Nursing of the identity of each Collaborating Physician or Physicians and their addresses within
thirty (30) days following the Effective Date of this Agreement or any subsequent change
(including any additions or deletions) in the identity of the parties hereto. The most current
copy of the Agreement shall be retained and available upon request at all sites where APRN
practices. APRN shall retain a copy of this Agreement for at least three (3) years after the
Agreement is terminated. Any such reaffirmation or acknowledgement, or any changes or
amendments to this Agreement (including any amendment or restatement thereof) must be
agreed by the parties, in writing, and incorporated as part of this Agreement.

ARTICLE V
TERM AND TERMINATION

1. Term and Termination. This Agreement shall be in full force and effect from the
Effective Date until such time as it is terminated by the occurrence of any one of
the following events:

(a) The mutual written consent of the parties hereto;

(b) Upon thirty (30) days’ prior written notice by either party, with or
without cause; or

(c) Immediately upon written notice by either party in the event of the
suspension, revocation, termination, non-renewal, or restriction of either party’s
license, registration, certification, or clinical privileges.

ARTICLE VI
MISCELLANEOUS

1. Definitions. “Collaborate” shall mean consultation with respect to diagnosis and

treatment of patients and referral of patients as may be necessary or desirable in
recognition of the respective areas of professional licensure, experience, scope
of practice, and clinical expertise of APRN and Collaborating Physician, as
described in this Agreement.

2. Severability. If any provision of this Agreement is or becomes invalid under any

provision of federal, state, or local law, such invalidity shall not affect the validity
or enforceability of any other provision hereof.

3. Entire Agreement. This Agreement sets forth the entire understanding of the
parties with respect to the subject matter hereof, and no amendment, change,
or modification shall be effective unless in writing and in accordance with Article
IV.

4. Applicable Law. This Agreement is made under and shall be governed by and
construed in accordance with the laws of the State of Ohio.
5. Assignment. Neither party may assign this Agreement, and any attempt to assign
this Agreement shall be void.

6. Waiver. The waiver of a breach of any provision of this Agreement by either

party shall not operate or be construed as a waiver of any subsequent breach.
 EXHIBIT A
BIENNIAL REAFFIRMATION AND ACKNOWLEDGEMENT OF STANDARD CARE
ARRANGEMENT

The undersigned Lesley Davidson, a duly licensed and practicing Acute Care Practitioner
in the State of Ohio (“APRN”) in collaboration with the undersigned Harold Williams, a duly
licensed physician in the State of Ohio practicing in the specialty of Cardiothoracic and Vascular
Surgery (“Collaborating Physician”), do hereby this 28th day of March 2018, reaffirm,
acknowledge and agree to be bound by the terms and conditions of a certain Standard Care
Arrangement dated 3/28/18 (the “Agreement”) and previously executed by them in the
capacities hereafter designated. This Exhibit A shall be incorporated and made a part of the
Agreement.

APRN:

Name: Lesley Davidson, RN MSN, ACNP

Specialty: Acute Care Nurse Practitioner-Adult Practice Area: Inpatient Hospital

Address: 7500 State Road Cincinnati, OH 45255

Phone (w): 5-13-624-4029 Phone(c): 937-245-9447 Phone (h): 937-245-9447

Signature: _Lesley Davidson RN, AG-ACNP student_____ Date: _3/28/2018_____

Collaborating Physician:

Name: Harold William, M.D.

Specialty: Cardiovascular and Vascular Surgeon Practice Area: Inpatient and outpatient

Address: 7500 State Road Cincinnati, OH 45255

Phone (w): 513-421-3494 Phone (c): 513-243-7685 Phone (h): 513-965-5407

Signature __________________________ Date _____________________________

 Check box if department chair who is collaborating physician’s designated
representative under OAC 4723-8-04.
EXHIBIT B
PRESCRIBING PARAMETERS

“In Accordance With The Standard Care Arrangement” Drugs

Collaborating Physician or Physician Designee acknowledges and agrees that he or she has
reviewed the complete Formulary set forth by the Ohio Board of Nursing’s Committee on
Prescriptive Governance. All drugs/categories listed in the “In accordance with the SCA”
category of the Formulary
X May be prescribed within the scope of APRN’s specialty and within
Collaborating Physician’s specialty.

May be prescribed within the scope of APRN’s specialty and within Collaborating
Physician’s specialty, subject to the limitations or exclusions found in Exhibit C.

Off-Label Medications or Devices:

Check if APRN cannot prescribe any off-label medications or devices.

Medication/Device FDA Approved Usage Clinically Sanctioned Off-

Label Use

Drugs Prescribed for Compounding

Collaborating Physician or Physician Designee agrees that compounded medications shall be

treated in the following manner
APRN may not prescribe drugs for compounding.

X APRN may prescribe the following drugs for compounding:

Compound Permitted Indication/Use
TCN for intrapleural instillation Pleurodesis
Methylene Blue Cardioplegia
New Drugs Approved by the FDA:

Collaborating Physician or Physician Designee agrees that new drugs approved by the FDA but
not yet reviewed by the CPG shall be treated in the following manner:

X APRN may prescribe drugs approved by the FDA but not yet reviewed by the CPG if
the ability to prescribe the drug is within the APRN’s scope of practice and the drug type
or subtype is included on the Formulary as one that may be prescribed or may be
prescribed “in accordance with the SCA”.

APRN may not prescribe drugs approved by the FDA not yet reviewed and approved
by the CPG.

All drugs and therapeutic devices approved by the FDA and reviewed by the CPG subsequent to
either the date of the initial execution or the most recent review of this Agreement shall follow
the Formulary guidelines of prescribing and this Agreement, and must be consistent with the
APRN’s scope of practice and the practice specialty of the Collaborating Physician.

Provisions for use of drugs previously reviewed by the CPG but approved by the FDA for new
indications subsequent to the date of this Agreement:

All drugs and therapeutic devices approved by the FDA for a new indication and reviewed by
the CPG subsequent to either the date of the initial execution or the most recent review of this
Agreement shall follow the Formulary guidelines of prescribing and this Agreement and must
be consistent with the APRN’s scope of practice and the practice specialty of the Collaborating
Physician.

Formulary Restrictions:

Check if there are no further restrictions to the Formulary.

EXHIBIT C
FORMULARY PARAMETERS

N/A
Mercy Medical Associates Rookwood Cardiac, Vascular and Thoracic Surgeons
4030 Smith Road Cincinnati, OH 45209 Phone: 513-421-3494

IN WITNESS WHEREOF, each of the undersigned has caused this Agreement to be duly executed
in it name and, on its behalf, as of the date first above written.

Physician Name_______________
Specialty____________________
Signature____________________
Date________________________

Physician Name_______________
Specialty____________________
Signature____________________
Date________________________

Physician Name_______________
Specialty____________________
Signature____________________
Date________________________

Physician Name_______________
Specialty____________________
Signature____________________
Date________________________

Physician Name_______________
Specialty____________________
Signature____________________
Date________________________

Physician Name_______________
Specialty____________________
Signature____________________
Date________________________

APRN Name: Lesley Davidson, RN, MSN, ACNP

Specialty Acute Care: Original Date of SCA 4/1/17, renewed March 28, 2018
Signature Lesley Davidson RN, AG-ACNP student_ Date_____3/28/2018_______