MEMORANDUM - Ohio Board of Nursing

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MEMORANDUM To: Board Members Ohio Board of Nursing From: Betsy Houchen Executive Director

Subject: Compact Licensure Date: January 6, 2021 Three memos with attachments are being provided to the Board for discussion about the Compact: (1) General Information; (2) SB 341, Nurse Licensure Compact; and (3) Stakeholder Positions and Questions. We continue to develop materials regarding the financial impact, discipline, and issues/questions. We anticipate providing this additional information to you prior to the meeting.

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MEMORANDUM

To: Board Members Ohio Board of Nursing From: Betsy Houchen Executive Director

Subject: Compact Licensure – Background and General Information Date: January 6, 2021 The Board annually reviews multi-state licensure, also known as Compact licensure or the Nurse Licensure Compact (NLC), to consider the benefits and risks to the citizens of Ohio in relation to the Board’s mission of public protection. Compact/NLC 1998 and 2015 By way of background, the NCSBN Delegate Assembly first adopted NLC model legislation in 1998. The Board considered Compact legislation in 2005 but determined that while multi-state nurse licensure could offer mobility and be advantageous for occupational health nurses, traveling nurses, and employers, the potential risks of harm to the public outweighed the potential benefits. In 2015, due to a concern about national licensure and as a result of additional discussions, the NCSBN Delegate Assembly adopted the Enhanced Nurse Licensure Compact (eNLC) legislation, as attached. The legislation established an Interstate Commission of Nurse Licensure Compact Administrators empowered to “prescribe bylaws or rules to govern its conduct as may be necessary or appropriate to carry out the purposes and exercise the powers of this Compact…” The administrative rules and bylaws are attached. There are currently 34 states in the Compact, as compared to 29 in 2018. A map and list of member states are attached. APRN Compact 2015 and 2020 In addition to the NLC, the Delegate Assembly adopted an APRN Compact. In 2015, the APRN Compact was modified to mirror the eNLC language and in 2020, it was modified to require 2,080 hours of APRN practice in order to be eligible for a multistate license. Ohio is not eligible to join the APRN compact because Ohio does not currently authorize independent practice for APRNs, so the Board will not be reviewing the APRN Compact at this time. For the purpose of providing information to those interested, a copy of the APRN Compact language is attached. Board Position Over the years, the Board has discussed the potential risks if nurses practicing in Ohio have not been held to the same standards that Ohio has deemed important for public safety. Attached are the Board statement and a memorandum (March 22, 2019) that outlines the provisions of the eNLC legislation and areas of concern.

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Nurse Licensure Compact Approved by the May 4, 2015 Special Delegate Assembly

ARTICLE I

Findings and Declaration of Purpose

a. The party states find that:

1. The health and safety of the public are affected by the degree of compliance with and the

effectiveness of enforcement activities related to state nurse licensure laws;

2. Violations of nurse licensure and other laws regulating the practice of nursing may result in injury

or harm to the public;

3. The expanded mobility of nurses and the use of advanced communication technologies as part of

our nation’s health care delivery system require greater coordination and cooperation among

states in the areas of nurse licensure and regulation;

4. New practice modalities and technology make compliance with individual state nurse licensure

laws difficult and complex;

5. The current system of duplicative licensure for nurses practicing in multiple states is cumbersome

and redundant for both nurses and states; and

6. Uniformity of nurse licensure requirements throughout the states promotes public safety and

public health benefits.

b. The general purposes of this Compact are to:

1. Facilitate the states’ responsibility to protect the public’s health and safety;

2. Ensure and encourage the cooperation of party states in the areas of nurse licensure and

regulation;

3. Facilitate the exchange of information between party states in the areas of nurse regulation,

investigation and adverse actions;

4. Promote compliance with the laws governing the practice of nursing in each jurisdiction;

5. Invest all party states with the authority to hold a nurse accountable for meeting all state practice

laws in the state in which the patient is located at the time care is rendered through the mutual

recognition of party state licenses;

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6. Decrease redundancies in the consideration and issuance of nurse licenses; and

7. Provide opportunities for interstate practice by nurses who meet uniform licensure requirements.

ARTICLE II

Definitions

As used in this Compact:

a. “Adverse action” means any administrative, civil, equitable or criminal action permitted by a state’s

laws which is imposed by a licensing board or other authority against a nurse, including actions

against an individual’s license or multistate licensure privilege such as revocation, suspension,

probation, monitoring of the licensee, limitation on the licensee’s practice, or any other encumbrance

on licensure affecting a nurse’s authorization to practice, including issuance of a cease and desist

action.

b. “Alternative program” means a non-disciplinary monitoring program approved by a licensing board.

c. “Coordinated licensure information system” means an integrated process for collecting, storing and

sharing information on nurse licensure and enforcement activities related to nurse licensure laws that

is administered by a nonprofit organization composed of and controlled by licensing boards.

d. “Current significant investigative information” means:

1. Investigative information that a licensing board, after a preliminary inquiry that includes

notification and an opportunity for the nurse to respond, if required by state law, has reason to

believe is not groundless and, if proved true, would indicate more than a minor infraction; or

2. Investigative information that indicates that the nurse represents an immediate threat to public

health and safety regardless of whether the nurse has been notified and had an opportunity to

respond.

e. “Encumbrance” means a revocation or suspension of, or any limitation on, the full and unrestricted

practice of nursing imposed by a licensing board.

f. “Home state” means the party state which is the nurse’s primary state of residence.

g. “Licensing board” means a party state’s regulatory body responsible for issuing nurse licenses.

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h. “Multistate license” means a license to practice as a registered or a licensed practical/vocational

nurse (LPN/VN) issued by a home state licensing board that authorizes the licensed nurse to practice

in all party states under a multistate licensure privilege.

i. “Multistate licensure privilege” means a legal authorization associated with a multistate license

permitting the practice of nursing as either a registered nurse (RN) or LPN/VN in a remote state.

j. “Nurse” means RN or LPN/VN, as those terms are defined by each party state’s practice laws.

k. “Party state” means any state that has adopted this Compact.

l. “Remote state” means a party state, other than the home state.

m. “Single-state license” means a nurse license issued by a party state that authorizes practice only

within the issuing state and does not include a multistate licensure privilege to practice in any other

party state.

n. “State” means a state, territory or possession of the United States and the District of Columbia.

o. “State practice laws” means a party state’s laws, rules and regulations that govern the practice of

nursing, define the scope of nursing practice, and create the methods and grounds for imposing

discipline. “State practice laws” do not include requirements necessary to obtain and retain a license,

except for qualifications or requirements of the home state.

ARTICLE III

General Provisions and Jurisdiction

a. A multistate license to practice registered or licensed practical/vocational nursing issued by a home

state to a resident in that state will be recognized by each party state as authorizing a nurse to

practice as a registered nurse (RN) or as a licensed practical/vocational nurse (LPN/VN), under a

multistate licensure privilege, in each party state.

b. A state must implement procedures for considering the criminal history records of applicants for initial

multistate license or licensure by endorsement. Such procedures shall include the submission of

fingerprints or other biometric-based information by applicants for the purpose of obtaining an

applicant’s criminal history record information from the Federal Bureau of Investigation and the

agency responsible for retaining that state’s criminal records.

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c. Each party state shall require the following for an applicant to obtain or retain a multistate license in

the home state:

1. Meets the home state’s qualifications for licensure or renewal of licensure, as well as, all other

applicable state laws;

2. i. Has graduated or is eligible to graduate from a licensing board-approved RN or LPN/VN

prelicensure education program; or

ii. Has graduated from a foreign RN or LPN/VN prelicensure education program that (a) has been

approved by the authorized accrediting body in the applicable country and (b) has been verified

by an independent credentials review agency to be comparable to a licensing board-approved

prelicensure education program;

3. Has, if a graduate of a foreign prelicensure education program not taught in English or if English

is not the individual’s native language, successfully passed an English proficiency examination

that includes the components of reading, speaking, writing and listening;

4. Has successfully passed an NCLEX-RN® or NCLEX-PN® Examination or recognized

predecessor, as applicable;

5. Is eligible for or holds an active, unencumbered license;

6. Has submitted, in connection with an application for initial licensure or licensure by endorsement,

fingerprints or other biometric data for the purpose of obtaining criminal history record information

from the Federal Bureau of Investigation and the agency responsible for retaining that state’s

criminal records;

7. Has not been convicted or found guilty, or has entered into an agreed disposition, of a felony

offense under applicable state or federal criminal law;

8. Has not been convicted or found guilty, or has entered into an agreed disposition, of a

misdemeanor offense related to the practice of nursing as determined on a case-by-case basis;

9. Is not currently enrolled in an alternative program;

10. Is subject to self-disclosure requirements regarding current participation in an alternative

program; and

11. Has a valid United States Social Security number.

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d. All party states shall be authorized, in accordance with existing state due process law, to take

adverse action against a nurse’s multistate licensure privilege such as revocation, suspension,

probation or any other action that affects a nurse’s authorization to practice under a multistate

licensure privilege, including cease and desist actions. If a party state takes such action, it shall

promptly notify the administrator of the coordinated licensure information system. The administrator

of the coordinated licensure information system shall promptly notify the home state of any such

actions by remote states.

e. A nurse practicing in a party state must comply with the state practice laws of the state in which the

client is located at the time service is provided. The practice of nursing is not limited to patient care,

but shall include all nursing practice as defined by the state practice laws of the party state in which

the client is located. The practice of nursing in a party state under a multistate licensure privilege will

subject a nurse to the jurisdiction of the licensing board, the courts and the laws of the party state in

which the client is located at the time service is provided.

f. Individuals not residing in a party state shall continue to be able to apply for a party state’s single-

state license as provided under the laws of each party state. However, the single-state license

granted to these individuals will not be recognized as granting the privilege to practice nursing in any

other party state. Nothing in this Compact shall affect the requirements established by a party state

for the issuance of a single-state license.

g. Any nurse holding a home state multistate license, on the effective date of this Compact, may retain

and renew the multistate license issued by the nurse’s then-current home state, provided that:

1. A nurse, who changes primary state of residence after this Compact’s effective date, must meet

all applicable Article III.c. requirements to obtain a multistate license from a new home state.

2. A nurse who fails to satisfy the multistate licensure requirements in Article III.c. due to a

disqualifying event occurring after this Compact’s effective date shall be ineligible to retain or

renew a multistate license, and the nurse’s multistate license shall be revoked or deactivated in

accordance with applicable rules adopted by the Interstate Commission of Nurse Licensure

Compact Administrators (“Commission”).

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ARTICLE IV

Applications for Licensure in a Party State

a. Upon application for a multistate license, the licensing board in the issuing party state shall ascertain,

through the coordinated licensure information system, whether the applicant has ever held, or is the

holder of, a license issued by any other state, whether there are any encumbrances on any license or

multistate licensure privilege held by the applicant, whether any adverse action has been taken

against any license or multistate licensure privilege held by the applicant and whether the applicant is

currently participating in an alternative program.

b. A nurse may hold a multistate license, issued by the home state, in only one party state at a time.

c. If a nurse changes primary state of residence by moving between two party states, the nurse must

apply for licensure in the new home state, and the multistate license issued by the prior home state

will be deactivated in accordance with applicable rules adopted by the Commission.

1. The nurse may apply for licensure in advance of a change in primary state of residence.

2. A multistate license shall not be issued by the new home state until the nurse provides

satisfactory evidence of a change in primary state of residence to the new home state and

satisfies all applicable requirements to obtain a multistate license from the new home state.

d. If a nurse changes primary state of residence by moving from a party state to a non-party state, the

multistate license issued by the prior home state will convert to a single-state license, valid only in the

former home state.

ARTICLE V

Additional Authorities Invested in Party State Licensing Boards

a. In addition to the other powers conferred by state law, a licensing board shall have the authority to:

1. Take adverse action against a nurse’s multistate licensure privilege to practice within that party

state.

i. Only the home state shall have the power to take adverse action against a nurse’s license

issued by the home state.

ii. For purposes of taking adverse action, the home state licensing board shall give the same

priority and effect to reported conduct received from a remote state as it would if such

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conduct had occurred within the home state. In so doing, the home state shall apply its own

state laws to determine appropriate action.

2. Issue cease and desist orders or impose an encumbrance on a nurse’s authority to practice

within that party state.

3. Complete any pending investigations of a nurse who changes primary state of residence during

the course of such investigations. The licensing board shall also have the authority to take

appropriate action(s) and shall promptly report the conclusions of such investigations to the

administrator of the coordinated licensure information system. The administrator of the

coordinated licensure information system shall promptly notify the new home state of any such

actions.

4. Issue subpoenas for both hearings and investigations that require the attendance and testimony

of witnesses, as well as, the production of evidence. Subpoenas issued by a licensing board in a

party state for the attendance and testimony of witnesses or the production of evidence from

another party state shall be enforced in the latter state by any court of competent jurisdiction,

according to the practice and procedure of that court applicable to subpoenas issued in

proceedings pending before it. The issuing authority shall pay any witness fees, travel expenses,

mileage and other fees required by the service statutes of the state in which the witnesses or

evidence are located.

5. Obtain and submit, for each nurse licensure applicant, fingerprint or other biometric-based

information to the Federal Bureau of Investigation for criminal background checks, receive the

results of the Federal Bureau of Investigation record search on criminal background checks and

use the results in making licensure decisions.

6. If otherwise permitted by state law, recover from the affected nurse the costs of investigations

and disposition of cases resulting from any adverse action taken against that nurse.

7. Take adverse action based on the factual findings of the remote state, provided that the licensing

board follows its own procedures for taking such adverse action.

b. If adverse action is taken by the home state against a nurse’s multistate license, the nurse’s

multistate licensure privilege to practice in all other party states shall be deactivated until all

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encumbrances have been removed from the multistate license. All home state disciplinary orders

that impose adverse action against a nurse’s multistate license shall include a statement that the

nurse’s multistate licensure privilege is deactivated in all party states during the pendency of the

order.

c. Nothing in this Compact shall override a party state’s decision that participation in an alternative

program may be used in lieu of adverse action. The home state licensing board shall deactivate the

multistate licensure privilege under the multistate license of any nurse for the duration of the nurse’s

participation in an alternative program.

ARTICLE VI

Coordinated Licensure Information System and Exchange of Information

a. All party states shall participate in a coordinated licensure information system of all licensed

registered nurses (RNs) and licensed practical/vocational nurses (LPNs/VNs). This system will

include information on the licensure and disciplinary history of each nurse, as submitted by party

states, to assist in the coordination of nurse licensure and enforcement efforts.

b. The Commission, in consultation with the administrator of the coordinated licensure information

system, shall formulate necessary and proper procedures for the identification, collection and

exchange of information under this Compact.

c. All licensing boards shall promptly report to the coordinated licensure information system any adverse

action, any current significant investigative information, denials of applications (with the reasons for

such denials) and nurse participation in alternative programs known to the licensing board regardless

of whether such participation is deemed nonpublic or confidential under state law.

d. Current significant investigative information and participation in nonpublic or confidential alternative

programs shall be transmitted through the coordinated licensure information system only to party

state licensing boards.

e. Notwithstanding any other provision of law, all party state licensing boards contributing information to

the coordinated licensure information system may designate information that may not be shared with

non-party states or disclosed to other entities or individuals without the express permission of the

contributing state.

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f. Any personally identifiable information obtained from the coordinated licensure information system by

a party state licensing board shall not be shared with non-party states or disclosed to other entities or

individuals except to the extent permitted by the laws of the party state contributing the information.

g. Any information contributed to the coordinated licensure information system that is subsequently

required to be expunged by the laws of the party state contributing that information shall also be

expunged from the coordinated licensure information system.

h. The Compact administrator of each party state shall furnish a uniform data set to the Compact

administrator of each other party state, which shall include, at a minimum:

1. Identifying information;

2. Licensure data;

3. Information related to alternative program participation; and

4. Other information that may facilitate the administration of this Compact, as determined by

Commission rules.

i. The Compact administrator of a party state shall provide all investigative documents and information

requested by another party state.

ARTICLE VII

Establishment of the Interstate Commission of Nurse Licensure Compact Administrators

a. The party states hereby create and establish a joint public entity known as the Interstate Commission

of Nurse Licensure Compact Administrators.

1. The Commission is an instrumentality of the party states.

2. Venue is proper, and judicial proceedings by or against the Commission shall be brought solely

and exclusively, in a court of competent jurisdiction where the principal office of the Commission

is located. The Commission may waive venue and jurisdictional defenses to the extent it adopts

or consents to participate in alternative dispute resolution proceedings.

3. Nothing in this Compact shall be construed to be a waiver of sovereign immunity.

b. Membership, Voting and Meetings

1. Each party state shall have and be limited to one administrator. The head of the state licensing

board or designee shall be the administrator of this Compact for each party state. Any

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administrator may be removed or suspended from office as provided by the law of the state from

which the Administrator is appointed. Any vacancy occurring in the Commission shall be filled in

accordance with the laws of the party state in which the vacancy exists.

2. Each administrator shall be entitled to one (1) vote with regard to the promulgation of rules and

creation of bylaws and shall otherwise have an opportunity to participate in the business and

affairs of the Commission. An administrator shall vote in person or by such other means as

provided in the bylaws. The bylaws may provide for an administrator’s participation in meetings

by telephone or other means of communication.

3. The Commission shall meet at least once during each calendar year. Additional meetings shall

be held as set forth in the bylaws or rules of the commission.

4. All meetings shall be open to the public, and public notice of meetings shall be given in the same

manner as required under the rulemaking provisions in Article VIII.

5. The Commission may convene in a closed, nonpublic meeting if the Commission must discuss:

i. Noncompliance of a party state with its obligations under this Compact;

ii. The employment, compensation, discipline or other personnel matters, practices or

procedures related to specific employees or other matters related to the Commission’s

internal personnel practices and procedures;

iii. Current, threatened or reasonably anticipated litigation;

iv. Negotiation of contracts for the purchase or sale of goods, services or real estate;

v. Accusing any person of a crime or formally censuring any person;

vi. Disclosure of trade secrets or commercial or financial information that is privileged or

confidential;

vii. Disclosure of information of a personal nature where disclosure would constitute a clearly

unwarranted invasion of personal privacy;

viii. Disclosure of investigatory records compiled for law enforcement purposes;

ix. Disclosure of information related to any reports prepared by or on behalf of the Commission

for the purpose of investigation of compliance with this Compact; or

x. Matters specifically exempted from disclosure by federal or state statute.

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6. If a meeting, or portion of a meeting, is closed pursuant to this provision, the Commission’s legal

counsel or designee shall certify that the meeting may be closed and shall reference each

relevant exempting provision. The Commission shall keep minutes that fully and clearly describe

all matters discussed in a meeting and shall provide a full and accurate summary of actions

taken, and the reasons therefor, including a description of the views expressed. All documents

considered in connection with an action shall be identified in such minutes. All minutes and

documents of a closed meeting shall remain under seal, subject to release by a majority vote of

the Commission or order of a court of competent jurisdiction.

c. The Commission shall, by a majority vote of the administrators, prescribe bylaws or rules to govern its

conduct as may be necessary or appropriate to carry out the purposes and exercise the powers of

this Compact, including but not limited to:

1. Establishing the fiscal year of the Commission;

2. Providing reasonable standards and procedures:

i. For the establishment and meetings of other committees; and

ii. Governing any general or specific delegation of any authority or function of the Commission;

3. Providing reasonable procedures for calling and conducting meetings of the Commission, ensuring

reasonable advance notice of all meetings and providing an opportunity for attendance

of such meetings by interested parties, with enumerated exceptions designed to protect the

public’s interest, the privacy of individuals, and proprietary information, including trade secrets.

The Commission may meet in closed session only after a majority of the administrators vote to

close a meeting in whole or in part. As soon as practicable, the Commission must make public a

copy of the vote to close the meeting revealing the vote of each administrator, with no proxy votes

allowed;

4. Establishing the titles, duties and authority and reasonable procedures for the election of the

officers of the Commission;

5. Providing reasonable standards and procedures for the establishment of the personnel policies

and programs of the Commission. Notwithstanding any civil service or other similar laws of any

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party state, the bylaws shall exclusively govern the personnel policies and programs of the

Commission; and

6. Providing a mechanism for winding up the operations of the Commission and the equitable

disposition of any surplus funds that may exist after the termination of this Compact after the

payment or reserving of all of its debts and obligations;

d. The Commission shall publish its bylaws and rules, and any amendments thereto, in a convenient

form on the website of the Commission.

e. The Commission shall maintain its financial records in accordance with the bylaws.

f. The Commission shall meet and take such actions as are consistent with the provisions of this

Compact and the bylaws.

g. The Commission shall have the following powers:

1. To promulgate uniform rules to facilitate and coordinate implementation and administration of this

Compact. The rules shall have the force and effect of law and shall be binding in all party states;

2. To bring and prosecute legal proceedings or actions in the name of the Commission, provided

that the standing of any licensing board to sue or be sued under applicable law shall not be

affected;

3. To purchase and maintain insurance and bonds;

4. To borrow, accept or contract for services of personnel, including, but not limited to, employees of

a party state or nonprofit organizations;

5. To cooperate with other organizations that administer state compacts related to the regulation of

nursing, including but not limited to sharing administrative or staff expenses, office space or other

resources;

6. To hire employees, elect or appoint officers, fix compensation, define duties, grant such

individuals appropriate authority to carry out the purposes of this Compact, and to establish the

Commission’s personnel policies and programs relating to conflicts of interest, qualifications of

personnel and other related personnel matters;

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7. To accept any and all appropriate donations, grants and gifts of money, equipment, supplies,

materials and services, and to receive, utilize and dispose of the same; provided that at all times

the Commission shall avoid any appearance of impropriety or conflict of interest;

8. To lease, purchase, accept appropriate gifts or donations of, or otherwise to own, hold, improve

or use, any property, whether real, personal or mixed; provided that at all times the Commission

shall avoid any appearance of impropriety;

9. To sell, convey, mortgage, pledge, lease, exchange, abandon or otherwise dispose of any

property, whether real, personal or mixed;

10. To establish a budget and make expenditures;

11. To borrow money;

12. To appoint committees, including advisory committees comprised of administrators, state nursing

regulators, state legislators or their representatives, and consumer representatives, and other

such interested persons;

13. To provide and receive information from, and to cooperate with, law enforcement agencies;

14. To adopt and use an official seal; and

15. To perform such other functions as may be necessary or appropriate to achieve the purposes of

this Compact consistent with the state regulation of nurse licensure and practice.

h. Financing of the Commission

1. The Commission shall pay, or provide for the payment of, the reasonable expenses of its

establishment, organization and ongoing activities.

2. The Commission may also levy on and collect an annual assessment from each party state to

cover the cost of its operations, activities and staff in its annual budget as approved each year.

The aggregate annual assessment amount, if any, shall be allocated based upon a formula to be

determined by the Commission, which shall promulgate a rule that is binding upon all party

states.

3. The Commission shall not incur obligations of any kind prior to securing the funds adequate to

meet the same; nor shall the Commission pledge the credit of any of the party states, except by,

and with the authority of, such party state.

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4. The Commission shall keep accurate accounts of all receipts and disbursements. The receipts

and disbursements of the Commission shall be subject to the audit and accounting procedures

established under its bylaws. However, all receipts and disbursements of funds handled by the

Commission shall be audited yearly by a certified or licensed public accountant, and the report of

the audit shall be included in and become part of the annual report of the Commission.

i. Qualified Immunity, Defense and Indemnification

1. The administrators, officers, executive director, employees and representatives of the

Commission shall be immune from suit and liability, either personally or in their official capacity,

for any claim for damage to or loss of property or personal injury or other civil liability caused by

or arising out of any actual or alleged act, error or omission that occurred, or that the person

against whom the claim is made had a reasonable basis for believing occurred, within the scope

of Commission employment, duties or responsibilities; provided that nothing in this paragraph

shall be construed to protect any such person from suit or liability for any damage, loss, injury or

liability caused by the intentional, willful or wanton misconduct of that person.

2. The Commission shall defend any administrator, officer, executive director, employee or

representative of the Commission in any civil action seeking to impose liability arising out of any

actual or alleged act, error or omission that occurred within the scope of Commission

employment, duties or responsibilities, or that the person against whom the claim is made had a

reasonable basis for believing occurred within the scope of Commission employment, duties or

responsibilities; provided that nothing herein shall be construed to prohibit that person from

retaining his or her own counsel; and provided further that the actual or alleged act, error or

omission did not result from that person’s intentional, willful or wanton misconduct.

3. The Commission shall indemnify and hold harmless any administrator, officer, executive director,

employee or representative of the Commission for the amount of any settlement or judgment

obtained against that person arising out of any actual or alleged act, error or omission that

occurred within the scope of Commission employment, duties or responsibilities, or that such

person had a reasonable basis for believing occurred within the scope of Commission

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employment, duties or responsibilities, provided that the actual or alleged act, error or omission

did not result from the intentional, willful or wanton misconduct of that person.

ARTICLE VIII

Rulemaking

a. The Commission shall exercise its rulemaking powers pursuant to the criteria set forth in this Article

and the rules adopted thereunder. Rules and amendments shall become binding as of the date

specified in each rule or amendment and shall have the same force and effect as provisions of this

Compact.

b. Rules or amendments to the rules shall be adopted at a regular or special meeting of the

Commission.

c. Prior to promulgation and adoption of a final rule or rules by the Commission, and at least sixty (60)

days in advance of the meeting at which the rule will be considered and voted upon, the Commission

shall file a notice of proposed rulemaking:

1. On the website of the Commission; and

2. On the website of each licensing board or the publication in which each state would otherwise

publish proposed rules.

d. The notice of proposed rulemaking shall include:

1. The proposed time, date and location of the meeting in which the rule will be considered and

voted upon;

2. The text of the proposed rule or amendment, and the reason for the proposed rule;

3. A request for comments on the proposed rule from any interested person; and

4. The manner in which interested persons may submit notice to the Commission of their intention to

attend the public hearing and any written comments.

e. Prior to adoption of a proposed rule, the Commission shall allow persons to submit written data, facts,

opinions and arguments, which shall be made available to the public.

f. The Commission shall grant an opportunity for a public hearing before it adopts a rule or amendment.

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g. The Commission shall publish the place, time and date of the scheduled public hearing.

1. Hearings shall be conducted in a manner providing each person who wishes to comment a fair

and reasonable opportunity to comment orally or in writing. All hearings will be recorded, and a

copy will be made available upon request.

2. Nothing in this section shall be construed as requiring a separate hearing on each rule. Rules

may be grouped for the convenience of the Commission at hearings required by this section.

h. If no one appears at the public hearing, the Commission may proceed with promulgation of the

proposed rule.

i. Following the scheduled hearing date, or by the close of business on the scheduled hearing date if

the hearing was not held, the Commission shall consider all written and oral comments received.

j. The Commission shall, by majority vote of all administrators, take final action on the proposed rule

and shall determine the effective date of the rule, if any, based on the rulemaking record and the full

text of the rule.

k. Upon determination that an emergency exists, the Commission may consider and adopt an

emergency rule without prior notice, opportunity for comment or hearing, provided that the usual

rulemaking procedures provided in this Compact and in this section shall be retroactively applied to

the rule as soon as reasonably possible, in no event later than ninety (90) days after the effective

date of the rule. For the purposes of this provision, an emergency rule is one that must be adopted

immediately in order to:

1. Meet an imminent threat to public health, safety or welfare;

2. Prevent a loss of Commission or party state funds; or

3. Meet a deadline for the promulgation of an administrative rule that is required by federal law or

rule.

l. The Commission may direct revisions to a previously adopted rule or amendment for purposes of

correcting typographical errors, errors in format, errors in consistency or grammatical errors. Public

notice of any revisions shall be posted on the website of the Commission. The revision shall be

subject to challenge by any person for a period of thirty (30) days after posting. The revision may be

challenged only on grounds that the revision results in a material change to a rule. A challenge shall

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be made in writing, and delivered to the Commission, prior to the end of the notice period. If no

challenge is made, the revision will take effect without further action. If the revision is challenged, the

revision may not take effect without the approval of the Commission.

ARTICLE IX

Oversight, Dispute Resolution and Enforcement

a. Oversight

1. Each party state shall enforce this Compact and take all actions necessary and appropriate to

effectuate this Compact’s purposes and intent.

2. The Commission shall be entitled to receive service of process in any proceeding that may affect

the powers, responsibilities or actions of the Commission, and shall have standing to intervene in

such a proceeding for all purposes. Failure to provide service of process in such proceeding to

the Commission shall render a judgment or order void as to the Commission, this Compact or

promulgated rules.

b. Default, Technical Assistance and Termination

1. If the Commission determines that a party state has defaulted in the performance of its

obligations or responsibilities under this Compact or the promulgated rules, the Commission shall:

i. Provide written notice to the defaulting state and other party states of the nature of the

default, the proposed means of curing the default or any other action to be taken by the

Commission; and

ii. Provide remedial training and specific technical assistance regarding the default.

2. If a state in default fails to cure the default, the defaulting state’s membership in this Compact

may be terminated upon an affirmative vote of a majority of the administrators, and all rights,

privileges and benefits conferred by this Compact may be terminated on the effective date of

termination. A cure of the default does not relieve the offending state of obligations or liabilities

incurred during the period of default.

3. Termination of membership in this Compact shall be imposed only after all other means of

securing compliance have been exhausted. Notice of intent to suspend or terminate shall be

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given by the Commission to the governor of the defaulting state and to the executive officer of the

defaulting state’s licensing board and each of the party states.

4. A state whose membership in this Compact has been terminated is responsible for all

assessments, obligations and liabilities incurred through the effective date of termination,

including obligations that extend beyond the effective date of termination.

5. The Commission shall not bear any costs related to a state that is found to be in default or whose

membership in this Compact has been terminated unless agreed upon in writing between the

Commission and the defaulting state.

6. The defaulting state may appeal the action of the Commission by petitioning the U.S. District

Court for the District of Columbia or the federal district in which the Commission has its principal

offices. The prevailing party shall be awarded all costs of such litigation, including reasonable

attorneys’ fees.

c. Dispute Resolution

1. Upon request by a party state, the Commission shall attempt to resolve disputes related to the

Compact that arise among party states and between party and non-party states.

2. The Commission shall promulgate a rule providing for both mediation and binding dispute

resolution for disputes, as appropriate.

3. In the event the Commission cannot resolve disputes among party states arising under this

Compact:

i. The party states may submit the issues in dispute to an arbitration panel, which will be

comprised of individuals appointed by the Compact administrator in each of the affected party

states and an individual mutually agreed upon by the Compact administrators of all the party

states involved in the dispute.

ii. The decision of a majority of the arbitrators shall be final and binding.

d. Enforcement

1. The Commission, in the reasonable exercise of its discretion, shall enforce the provisions and

rules of this Compact.

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2. By majority vote, the Commission may initiate legal action in the U.S. District Court for the District

of Columbia or the federal district in which the Commission has its principal offices against a party

state that is in default to enforce compliance with the provisions of this Compact and its

promulgated rules and bylaws. The relief sought may include both injunctive relief and damages.

In the event judicial enforcement is necessary, the prevailing party shall be awarded all costs of

such litigation, including reasonable attorneys’ fees.

3. The remedies herein shall not be the exclusive remedies of the Commission. The Commission

may pursue any other remedies available under federal or state law.

ARTICLE X

Effective Date, Withdrawal and Amendment

a. This Compact shall become effective and binding on the earlier of the date of legislative enactment of

this Compact into law by no less than twenty-six (26) states or December 31, 2018. All party states to

this Compact, that also were parties to the prior Nurse Licensure Compact, superseded by this

Compact, (“Prior Compact”), shall be deemed to have withdrawn from said Prior Compact within six

(6) months after the effective date of this Compact.

b. Each party state to this Compact shall continue to recognize a nurse’s multistate licensure privilege to

practice in that party state issued under the Prior Compact until such party state has withdrawn from

the Prior Compact.

c. Any party state may withdraw from this Compact by enacting a statute repealing the same. A party

state’s withdrawal shall not take effect until six (6) months after enactment of the repealing statute.

d. A party state’s withdrawal or termination shall not affect the continuing requirement of the withdrawing

or terminated state’s licensing board to report adverse actions and significant investigations occurring

prior to the effective date of such withdrawal or termination.

e. Nothing contained in this Compact shall be construed to invalidate or prevent any nurse licensure

agreement or other cooperative arrangement between a party state and a non-party state that is

made in accordance with the other provisions of this Compact.

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f. This Compact may be amended by the party states. No amendment to this Compact shall become

effective and binding upon the party states unless and until it is enacted into the laws of all party

states.

g. Representatives of non-party states to this Compact shall be invited to participate in the activities of

the Commission, on a nonvoting basis, prior to the adoption of this Compact by all states.

ARTICLE XI

Construction and Severability

This Compact shall be liberally construed so as to effectuate the purposes thereof. The provisions of this

Compact shall be severable, and if any phrase, clause, sentence or provision of this Compact is declared

to be contrary to the constitution of any party state or of the United States, or if the applicability thereof to

any government, agency, person or circumstance is held invalid, the validity of the remainder of this

Compact and the applicability thereof to any government, agency, person or circumstance shall not be

affected thereby. If this Compact shall be held to be contrary to the constitution of any party state, this

Compact shall remain in full force and effect as to the remaining party states and in full force and effect as

to the party state affected as to all severable matters.

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The Interstate Commission of Nurse Licensure Compact Administrators

Final Rules

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Table of Contents

Section 100. Definitions………………………………………………………………………………………………………..3

Section 200. Coordinated Licensure Information System

201. Uniform Data Set and Levels of Access…….…………………………………………………….4

202. Querying the Coordinated Licensure Information System…………………………….5

Section 300. Implementation

301. Implementation Date…………………………………………………………………………………………5

302. Transition……………………………………………………………………………………………………………5

303. Recognition of New Party States After January 19, 2018…………………………….6

Section 400. Licensure

401. A Party State’s Responsibilities………………………………………………………………………6

402. An Applicant’s Responsibilities……………………………………………………………………….7

403. Change in Primary State of Residence………………………………………………………….8

404. Temporary Permits and Licenses…………………………………………………………………..8

405. Identification of Licenses…………………………………………………………………………………8

406. Credentialing and English Proficiency for Foreign Nurse Graduates………….8

407. Deactivation, Discipline and Revocation………………………………………………………..9

408. Federal Criminal Records ………………………………………………………9

409. Active Duty Military Personnel or their Spouse……………………………….9

Section 500. Administration

501.DuesAssessment……………………………………………………………………………………………..10

502. Dispute Resolution………………………………………………………………………………………….10 503. Compliance and Enforcement…………………………………………………………………..……11

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SECTION 100. DEFINITIONS

(1) "Commission" means the Interstate Commission of Nurse Licensure Compact Administrators.

(2) “Compact” means the Nurse Licensure Compact that became effective on July 20, 2017 and implemented on January 19, 2018.

(3) “Convert” means to change a multistate license to a single-state license if a nurse changes primary state of residence by moving from a party state to a non-party state; or to change a single-state license to a multistate license once any disqualifying events are eliminated.

(4) “Deactivate” means to change the status of a multistate license or privilege to practice.

(5) “Director” means the individual referred to in Article IV of the Interstate Commission of Nurse Licensure Compact Administrators Bylaws.

(6) “Disqualifying Event” means an incident, which results in a person becoming disqualified or ineligible to retain or renew a multistate license. These include but are not limited to the following: any adverse action resulting in an encumbrance, current participation in an alternative program, a misdemeanor offense related to the practice of nursing (which includes, but is not limited to, an agreed disposition), or a felony offense (which includes, but is not limited to, an agreed disposition).

(7) “Independent credentials review agency” means a non-governmental evaluation agency that verifies and certifies that foreign nurse graduates have graduated from nursing programs that are academically equivalent to nursing programs in the United States.

(8) “Licensure” includes the authority to practice nursing granted through the process of examination, endorsement, renewal, reinstatement and/or reactivation.

(9) "Prior Compact" means the Nurse Licensure Compact that was in effect until January 19, 2018.

(10) “Unencumbered license” means a license that authorizes a nurse to engage in the full and unrestricted practice of nursing.

History: Adopted December 12, 2017; effective January 19, 2018.

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SECTION 200. COORDINATED LICENSURE INFORMATION SYSTEM

201. UNIFORM DATA SET AND LEVELS OF ACCESS

(1) The Compact Administrator of each party state shall furnish uniform data to the Coordinated Licensure Information System, which shall consist of the following:

(a) the nurse’s name;

(b) jurisdiction of licensure;

(c) license expiration date;

(d) licensure classification, license number and status;

(e) public emergency and final disciplinary actions, as defined by the contributing state authority;

(f) a change in the status of a disciplinary action or licensure encumbrance;

(g) status of multistate licensure privileges;

(h) current participation by the nurse in an alternative program;

(i) information that is required to be expunged by the laws of a party state;

(j) the applicant or nurse’s United States social security number;

(k) current significant investigative information; and

(l) a correction to a licensee’s data.

(2) The public shall have access to items (1)(a) through (g) and information about a licensee’s participation in an alternative program to the extent allowed by state law.

(3) In the event a nurse asserts that any Coordinated Licensure Information System data is inaccurate, the burden shall be upon the nurse to provide evidence in a manner determined by the party state that substantiates such claim.

(4) A party state shall report the items in the uniform data set to the Coordinated Licensure Information System within fifteen (15) calendar days of the date on which the action is taken.

History: Adopted December 12, 2017; effective January 19, 2018; amended August 14, 2018; effective January 1, 2019.

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202. QUERYING THE COORDINATED LICENSURE INFORMATION SYSTEM

(1) Upon application for multistate licensure, with the exception of renewal by a nurse, a party state shall query the Coordinated Licensure Information System to determine the applicant’s current licensure status, previous disciplinary action(s), current participation in an alternative program, and any current significant investigative information.

(2) Upon discovery that an applicant is under investigation in another party state, the party state in receipt of the nurse licensure application shall contact the investigating party state and may request investigative documents and information.


SECTION 300. IMPLEMENTATION

301. IMPLEMENTATION DATE

The Compact shall be implemented on January 19, 2018.


302. TRANSITION

(1) (a) A nurse who holds a multistate license on the Compact effective date of July 20, 2017, and whose multistate license remains unencumbered on the January 19, 2018 implementation date and who maintains and renews a multistate license is not required to meet the new requirements for a multistate license under the Compact.

(b) A nurse who retained a multistate license pursuant to subsection (a) of this section and subsequently incurs a disqualifying event shall have the multistate license revoked or deactivated pursuant to the laws of the home state.

(c) A nurse whose multistate license is revoked or deactivated may be eligible for a single state license in accordance with the laws of the party state.

(2) A nurse who applies for a multistate license after July 20, 2017, shall be required to meet the requirements of Article III (c) of the Compact.

(3) During the transition period, a licensee who holds a single state license in a Compact state that was not a member of the prior Compact and who also holds a

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multistate license in a party state, may retain the single state license until it lapses, expires or becomes inactive.”

(4) After the implementation date, party states shall not renew or reinstate a single state license if the nurse has a multistate license in another party state.


303. RECOGNITION OF NEW PARTY STATES AFTER JANUARY 19, 2018

(1) All party states shall be notified by the Commission within fifteen (15) calendar days when a new party state enacts the Compact.

(2) The new party state shall establish an implementation date six (6) months from enactment or as specified in the enabling language and shall notify the Director of the date.

(3) Upon implementation, a new state licensee who holds a single state license in a Compact state that was not a member of the prior Compact and holds a multistate license in a party state, may retain the single state license until it lapses, expires or becomes inactive.

(4) At least ninety (90) calendar days prior to the implementation date, all other party states shall notify any active single state licensee with an address in the new party state that the licensee may only hold one multistate license in the primary state of residence. The licensee shall be advised to obtain or maintain a multistate license only from the primary state of residence.

(5) Each party state shall deactivate a multistate license when a new home state issues a multistate license.


SECTION 400. LICENSURE

401. PARTY STATE RESPONSIBILITIES

(1) On all application forms for multistate licensure, a party state shall require, at a minimum:

(a) A declaration of a primary state of residence and

(b) Whether the applicant is a current participant in an alternative program.

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(2) (a) An applicant for licensure who is determined to be ineligible for a multistate license shall be notified by the home state of the qualifications not met.

(b) The home state may issue a single state license pursuant to its laws.

(3) A party state shall not issue a single state license to a nurse who holds a multistate license in another party state.


402. APPLICANT RESPONSIBILITIES

(1) On all application forms for multistate licensure in a party state, an applicant shall declare a primary state of residence.

(2) A nurse who changes primary state of residence to another party state shall apply for a license in the new party state when the nurse declares to be a resident of the state and obtains privileges not ordinarily extended to nonresidents of the state, including but not limited to, those listed in 402 (4) (a) – (e).

(3) A nurse shall not apply for a single state license in a party state while the nurse holds a multistate license in another party state.

(4) A party state may require an applicant to provide evidence of residence in the declared primary state of residence. This evidence may include, but is not limited to, a current:

(a) driver’s license with a home address;

(b) voter registration card with a home address;

(c) federal income tax return with a primary state of residence declaration;

(d) military form no. 2058 (state of legal residence certificate); or

(e) W2 form from the United States government or any bureau, division, or agency thereof, indicating residence.

(5) An applicant who is a citizen of a foreign country, and who is lawfully present in the United States and is applying for multistate licensure in a party state may declare either the applicant’s country of origin or the party state where they are living as the primary state of residence. If the applicant declares the foreign country as the primary state of residence, the party state shall not issue a multistate license, but may issue a single state license if the applicant meets the party state’s licensure requirements.

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(6) An applicant shall disclose current participation in an alternative program to any party state, whether upon initial application or within ten (10) calendar days of enrollment in the program.


403. CHANGE IN PRIMARY STATE OF RESIDENCE

(1) A nurse who changes his or her primary state of residence from one party state to another party state may continue to practice under the existing multistate license while the nurse’s application is processed and a multistate license is issued in the new primary state of residence.

(2) Upon issuance of a new multistate license, the former primary state of residence shall deactivate its multistate license held by the nurse and provide notice to the nurse.

(3) If a party state verifies that a licensee who holds a multistate license changes primary state of residence to a non-party state, the party state shall convert the multistate license to a single state license within fifteen (15) calendar days, and report this conversion to the Coordinated Licensure Information System.


404. TEMPORARY PERMITS AND LICENSES

A temporary permit, license, or similar temporary authorization to practice issued by a party state to an applicant for licensure shall not grant multistate licensure privileges.


405. IDENTIFICATION OF LICENSES

A license issued by a party state shall be clearly identified as either a single state license or a multistate license. History: Adopted December 12, 2017; effective January 19, 2018.

406. CREDENTIALING AND ENGLISH PROFICIENCY FOR FOREIGN NURSE GRADUATES

(1) A party state shall verify that an independent credentials review agency evaluated the credentials of graduates as set forth in Article III (c)(2)ii.

(2) The party state shall verify successful completion of an English proficiency examination for graduates as set forth in Article III (c)(3).

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407. DEACTIVATION, DISCIPLINE AND REVOCATION

A party state shall determine whether a disqualifying event will result in adverse action or deactivation of a multistate license or privilege. Upon deactivation due to a disqualifying event, the home state may issue a single state license.


408. FEDERAL CRIMINAL RECORDS

Communication between a party state and the Commission and communication between party states regarding verification of the nurse’s eligibility for licensure pursuant to the Compact shall not include any Criminal History Record Information (CHRI) received from the Federal Bureau of Investigation relating to a federal criminal records check performed by a member board under Public Law 92-544

History: Adopted August 11, 2020; effective January 1, 2021

409. ACTIVE DUTY MILITARY PERSONNEL OR THEIR SPOUSES

An active duty service member, or the member’s spouse, shall designate a home state where the service member or spouse has a current license in good standing. The service member may retain the home state designation during the period the service member or spouse is on active duty. Subsequent to designating a home state, the service member or spouse shall only change home state through application for licensure in the new state.

History: Adopted August 11, 2020; effective January 1, 2021

SECTION 500. ADMINISTRATION

501. DUES ASSESSMENT

(1) The Commission shall determine the annual assessment to be paid by party states. The assessment formula is a flat fee per party state. The Commission shall provide public notice of any proposed revision to the annual assessment fee at least ninety (90) calendar days prior to the Commission meeting to consider the proposed revision.

(2) The annual assessment shall be due within the Commission’s first fiscal year after the implementation date and annually thereafter.


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502. DISPUTE RESOLUTION.

(1) In the event that two or more party states have a dispute, the parties shall attempt resolution following the steps set out in this rule.

(2) The parties shall first attempt informal resolution. The Compact Administrators in the states involved shall contact each other. Each Compact Administrator shall submit a written statement describing the situation to the other Compact Administrators involved in the dispute. Each Compact Administrator may submit a response. The submission of the statement and the response shall be in a mutually agreed upon time. If the dispute is related to an interpretation of the Compact, the parties shall request assistance from the Executive Committee. If all issues are resolved, no further action is required and all party state Compact Administrators shall be informed of the result. If any issue remains unresolved, the parties shall provide the Compliance Committee with a concise statement of unresolved issue(s) and analysis including references to NLC statutes, rules and any supporting documents. After review by the Compliance Committee, its recommendations will be sent to the parties and the Executive Committee for further review.

History: Subsection (2) Amended August 11, 2020; effective January 1, 2021

(3)(a) A party state that has a dispute with one or more other party states, and informal resolution was unsuccessful, shall attempt mediation. Mediation shall be conducted by a mediator appointed by the Executive Committee from a list of mediators approved by the National Association of Certified Mediators or as agreed to by all parties. If all issues are resolved through mediation, no further action is required. If mediation is unsuccessful, the parties shall submit to binding dispute resolution.

(b) The costs of mediation shall be shared by all party states involved.

(c) All party state Compact Administrators shall be notified of all issues and disputes that rise to the mediation stage in order to comment on those matters and disputes that may impact all party states.

(4)(a) In the event of a dispute between party states that was not resolved through informal resolution or mediation, the party states shall submit to binding dispute resolution. The parties may choose binding dispute resolution either by submitting the question dispute to the Commission for final action or by arbitration.

(b) All party states involved shall agree in order to proceed with arbitration. In the absence of agreement, the matter shall be referred to the Commission for final determination.

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(c) Each party state involved shall be responsible for its own respective expenses, including attorney fees.

(d) The party state Compact Administrators involved in the dispute shall recuse themselves from consideration or voting by the full Commission.

History: Adopted August 14, 2018; effective January 1, 2019.

503. COMPLIANCE AND ENFORCEMENT.

(1) Compliance and enforcement issues shall be initiated by the Executive Committee.

(2) The Executive Committee, through the Director, shall send a written statement to the Compact Administrator in the party state with the alleged non-compliance issue. That Compact Administrator shall respond to the written statement within thirty calendar days.

(3) The Compact Administrator may appear before the Executive Committee at a time and place as designated by the Executive Committee.

(4) The Executive Committee shall make a recommendation to the Commission concerning the issue of non-compliance. History: Adopted August 14, 2018; effective January 1, 2019.

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The Interstate Commission of Nurse Licensure Compact Administrators

By-Laws

Adopted August 3, 2017, Amended August 15, 2017

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INDEX The Interstate Commission of Nurse Licensure Compact Administrators Bylaws (Final Adopted August 3, 2017) Article I - Commission Purpose, Function and Bylaws Section 1. Purpose. Section 2. Functions. Section 3. Bylaws. Article II Membership Article III - Executive Committee Section 1. Section 2: Election and Succession. Section 3. Duties. Section 4. Removal of Executive Committee Members. Section 5. Vacancies Article IV - Commission Personnel Section 1. Duties of the Director. Article V - Meetings of the Commission Section 1. Meetings and Notice. Section 2. Quorum.

Section 3. Voting. Section 4. Procedure. Section 5. Public Participation in Meetings. Article VI - Committees Section 1. Committees. Article VII - Finance Section 1. Fiscal Year. Section 2. Budget. Section 3. Accounting and Audit. Section 4. Costs and Expense Reimbursement. Article VIII - Adoption and Amendment of Bylaws Article IX - Dissolution of the Commission Article X - Affiliation with National Council State Boards of Nursing

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Article I Commission Purpose, Function and Bylaws

Section 1. Purpose. Pursuant to the terms of the Nurse Licensure Compact, (the “Compact”), the Interstate Commission of Nurse Licensure Compact Administrators (the “Commission”) is established as a quasi-governmental and joint public entity of the Party States to fulfill the Compact objectives through a means of joint cooperative action among the Party States. This is accomplished by developing a comprehensive process that facilitates the exchange of information in the areas of licensure and investigative authority of state boards of nursing and providing for mutual recognition of nursing licenses by all Party States, thereby enhancing the portability and mobility of a nursing license and promoting public protection. Section 2. Functions. In pursuit of the fundamental objectives set forth in the Compact, the Commission shall, as necessary or required, exercise all of the powers and fulfill all of the duties delegated to it by the Party States. The Commission’s activities shall include, but are not limited to, the following: the promulgation of rules; enforcement of Commission Rules and Bylaws; provision of dispute resolution; coordination of training and education; and the collection and dissemination of information concerning the activities of the Compact, as provided by the Compact, or as determined by the Commission to be warranted by, and consistent with, the objectives and provisions of the Compact. The provisions of the Compact shall be reasonably and liberally construed to accomplish the purposes and policies of the Compact. Section 3. Bylaws. As required by the Compact, these Bylaws shall govern the management and operations of the Commission. As adopted and subsequently amended, these Bylaws shall remain at all times subject to, and limited by, the terms of the Compact.

Article II

Membership The Commission membership shall be comprised as provided by the Compact. Each Party State shall have and be limited to one voting Compact Administrator. The Compact Administrator shall be the Commissioner of the Party State. Each Party State shall forward the name of its Commissioner to the Chair of the Commission or designee. A Commissioner may designate a person to serve in place of the Commissioner as the Commissioner’s designee with respect to Commission business, including attending Commission meetings and voting. A Commissioner must notify the Chair of the Commission or designee of the scope and duration of the designation, prior to the

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meeting. The Chair of the Commission shall promptly advise the Party State of the need to appoint a new Commissioner whenever a vacancy occurs.

Article III Executive Committee

Section 1. The Commission shall establish an Executive Committee, which shall be empowered to act on behalf of the Commission between Commission meetings, except for rulemaking or amendment of the Compact. The Commission shall determine the procedures, duties and budget of the Executive Committee. The power of the Executive Committee to act on behalf of the Commission shall at all times be subject to any limitations imposed by the Bylaws, Compact or the Commission. The Executive Committee shall consist of the Chair, Vice Chair, and Treasurer of the Commission and three additional members of the Commission. Section 2: Election and Succession. Following formation of the Commission, nominations for candidates for the initial Executive Committee shall be submitted to the Director of the Compact by Party States, which are eligible to vote. The initial and subsequent Executive Committees shall be elected by the Commission by mail or electronic ballot. For all subsequent elections, an Elections Committee shall send a call for nominations at least 50 days prior to the election, shall announce a slate of candidates to the Commission at least 30 days prior to the election, shall announce voting by mail or electronic ballot at least 10 days prior to the election and shall verify and report the results of the election to the Commission on October 1. Any election resulting in a tie vote will be decided by lot. No Commissioner shall be nominated or eligible to serve on the Executive Committee if from a Party State in default of its obligations under the Compact. After the election of the initial Executive Committee, members of the Executive Committee shall serve a term of two years or until a successor is elected. No person shall serve more than two full consecutive terms in the same office. Any candidate for the Executive Committee shall be a Commissioner who has, except for the initial election, previously participated in the meetings of the Commission. The election of the Executive Committee shall be as follows:

1. Chair: After the election of the initial chair, the subsequent chair shall be elected in odd years;

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2. Vice Chair: After the election of the initial vice chair, subsequent vice chair shall be elected in even years;

3. Treasurer: After the election of the initial treasurer, subsequent treasurers shall be elected in even years;

4. Members-at-Large (3 positions): After the election of the initial members-at-large, subsequent members-at-large shall be one member elected in even years; two members elected in odd years.

Section 3. Duties.

The Commission’s officers shall perform all duties of their respective offices as the compact and these Bylaws provide. Their duties shall include, but are not limited to the following: 1. Chair: The Chair shall call and preside at Commission and Executive Committee

meetings; prepare agendas for the meetings; act on Commission’s behalf between Commission meetings.

2. Vice Chair: The Vice Chair shall perform the Chair duties in their absence or at the Chair’s direction. In the event of a vacancy in the Chair’s office, the Vice Chair shall serve until the Commission elects a new Chair.

3. Treasurer: The Treasurer, with the assistance of the Director of the Compact, shall monitor the Commission’s fiscal policies and procedures. If the Commission does not have a Director of the Compact, the Treasurer will also serve as secretary and perform the duties of secretary described in Article IV Section 1 (1).

The Executive Committee shall:

1. Administer the affairs of the Commission in a manner consistent with the Bylaws and purpose of the Commission;

2. Propose budgets, provide fiscal oversight and provide for an annual fiscal review;

3. Propose policies and procedures for consideration by the Commission;

4. Contract for services and monitor contract compliance;

5. Monitor and enforce member compliance with the Compact;

6. Propose standing and ad hoc committees.

7. Approve and maintain its minutes;

8. Perform such other functions as are necessary or appropriate to carry out the purpose of the Commission.

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Section 4. Removal of Executive Committee Members. Any Executive Committee member may be removed from office for good cause by a two-third (2/3rd) majority vote of the Commission. Section 5. Vacancies Upon the resignation, removal, or death of a member of the Executive Committee, such vacancy shall be announced to the Commission by the Chair or designee. An Elections Committee shall send a call for nominations 30 days prior to the election, shall announce a slate of candidates to the Commission 20 days prior to the election, shall announce voting by mail or electronic ballot 10 days prior to the election and shall verify and report the results of the election to the Commission. Any election resulting in a tie vote will be decided by lot. No Commissioner shall be nominated or eligible to serve on the Executive Committee if from a Party State in default of its obligations under the Compact.

Article IV Commission Personnel

Section 1. Duties of the Director. The Commission, through its Executive Committee, may contract for a Director of the Compact. As the Commission’s principal administrator, the Director shall also perform such other duties as may be delegated by the Commission or required by the Compact and the Bylaws, including, but not limited to, the following:

1. Serve at its discretion and act as Secretary to the Commission, but shall not be a Member of the Commission;

2. Hire and supervise such other staff as may be authorized by the Commission;

3. Establish and manage the Commission’s office or offices as determined by the Commission;

4. Recommend general policies and program initiatives for the Commission’s consideration;

5. Recommend for the Commission’s consideration administrative personnel policies governing the recruitment, hiring, management, compensation and dismissal of Commission staff;

6. Implement and monitor administration of all policies, programs, and initiatives adopted by the Commission;

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7. Prepare draft annual budgets for the Commission’s consideration;

8. Monitor the Commission’s financial performance for compliance with approved budgets and policies, and maintain accurate records of the Commission’s financial account(s);

9. Execute contracts on behalf of the Commission as directed;

10. Receive service of process on behalf of the Commission;

11. Prepare and disseminate all required reports and notices directed by the Commission;

12. Assist the members of the Executive Committee in the performance of its duties;

13. Speak on behalf and represent the Commission;

14. In collaboration with legal counsel, ensure the legal integrity of the Commission and

15. Report about policy, regulatory, political, legal or other developments of relevance to the Commission’s operation.

Article V Meetings of the Commission

Section 1. Meetings and Notice. The Commission shall meet face-to-face at least twice a year at a time and place as determined by the Commissioners. Members may participate in meetings by telephone or other means of telecommunication. Special meetings may be scheduled at the discretion of the Chair, or shall be called upon the request of a majority of Commissioners. All Commissioners shall be given notice of Commission meetings at least thirty (30) days prior to the scheduled date. Agendas shall be provided to all Commissioners no later than seven (7) days prior to any meeting of the Commission. If an amendment to an agenda is made after an agenda has been noticed, but forty-eight (48) hours prior to a regular meeting, or twenty-four (24) hours prior to a special meeting, then the agenda is amended upon the posting of the amended agenda. All Commission meetings shall be open to the public, except as set forth in Commission Rules or as otherwise provided by the Compact. Prior public notice shall be as follows: publication of notice of each meeting will be posted at least seven (7) days prior to the

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meeting on the Commission's website or another website designated by the Commission and distribution by e-mail to interested parties who have requested in writing to receive such meeting notices. A meeting may be closed to the public if the Commission determines by a majority vote of the Commissioners that there exists at least one of the conditions for closing a meeting, as provided by the Compact or authorized Rules. Section 2. Quorum. A majority of Commissioners shall constitute a quorum for the transaction of business, except as otherwise required in these Bylaws. The presence of a quorum must be established before any vote of the Commission can be taken. Section 3. Voting. Each Party State is entitled to one vote. A Commissioner shall vote on such member’s own behalf and shall not delegate the vote to another Commissioner, except as permitted by a designation allowed under Article II. Any question submitted for a vote of the Commission shall be determined by a simple majority, except as otherwise required by the Compact or the Bylaws. Section 4. Procedure. The rules contained in the then current edition of Robert’s Rules of Order Newly Revised shall govern the parliamentary procedures of the commission and its committees in all cases not provided for in these Bylaws or in any policies and procedures or any special rules of order which are duly adopted by the Commission. Section 5. Public Participation in Meetings. Upon prior written request to the Commission, any person who desires to present a statement on a matter on the agenda shall be afforded an opportunity to present an oral statement to the Commission at an open meeting. The Chair may, depending on the circumstances, allow any person who desires an opportunity to present a statement on a matter that is on the agenda even in the absence of a prior written request to the Commission. The Chair may limit the time and manner of public statements at any open meeting.

Article VI Committees

Section 1. Committees. The Commission shall establish committees, as it deems necessary, to carry out its objectives which shall include, but not be limited, to:

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1. Rules Committee A Rules Committee shall be established as a standing committee to develop uniform Compact rules for consideration by the Commission and subsequent implementation by the states and to review existing rules and recommend necessary changes to the Commission for consideration.

2. Compliance Committee A Compliance Committee shall be established as a standing committee to monitor a Party State’s compliance with the terms of the Compact and its authorized rules.

3. Elections Committee An Election Committee shall be established as a standing committee to:

a. Inform the Commissioners on the responsibilities of the office; b. Encourage participation by the Commissioners in the elections process; c. Announce nominations deadline and anticipated vacancies of the

Executive Committee of the Commission; d. Communicate with incumbents to determine if they wish to run for re-

election; e. Accept qualified nominees and prepare a slate of candidates for the

election of the officers or members at large of the Executive Committee; f. Present a list of candidates to the Commission including the terms of

office expiration dates; and g. Tally/verify the election results and report to the Commission.

The composition, procedures, duties, budget and tenure of all committees shall be determined through policies approved by the Commission. The Commission may dissolve any committee it determines is no longer needed.

Article VII Finance

Section 1. Fiscal Year. The Commission’s fiscal year shall begin on October 1 and end on September 30. Membership fees in an amount to be determined by the Commission, are payable by October 1 of each year.

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Section 2. Budget. The Commission shall operate on an annual budget cycle and shall, in any given year, adopt budgets for the following fiscal year or years as provided by the Compact. Section 3. Accounting and Audit. The Commission, with the assistance of the Director, shall keep accurate and timely accounts of its internal receipts and disbursements of the Commission funds. The receipts and disbursements of Commission funds are to be audited annually by an independent certified or licensed accountant. The independent audit report shall be made available to the public. Section 4. Costs and Expense Reimbursement. Subject to the availability of budgeted funds and unless otherwise provided by the Commission, Commissioners and Executive Committee shall be reimbursed as allowed by state policy for any actual and necessary expenses incurred pursuant to their attendance at all duly convened meetings of the Commission or its committees as provided by the Compact.

Article VIII Adoption and Amendment of Bylaws

Any Bylaw may be adopted, amended or repealed by a majority vote of the Commissioners, provided that written notice and the full text of the proposed action is provided to all Commissioners at least thirty (30) days prior to the meeting at which the action is to be considered. Failing the required notice, a two-third (2/3rd) majority vote of the Commissioners shall be required for such action.

Article IX Dissolution of the Commission

The Compact shall dissolve effective upon the date of the withdrawal or the termination by default of a Party State, which reduces membership in the Compact to one Party State as provided by the Compact. Upon dissolution, the Compact becomes null and void and shall be of no further force or effect, and the business and affairs of the Commission shall be concluded in an orderly manner and according to applicable law.

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Article X Affiliation with National Council State Boards of Nursing The Commission shall be affiliated with and supported by the National Council of State Boards of Nursing, Inc. (NCSBN). The Commission shall negotiate payment for secretariat services by the NCSBN. Payment for the secretariat services shall be made from the funds collected by NCSBN on behalf of the Commission. Funds contributed by Party States shall be held by NCSBN and disbursed for the benefit of the Commission as decided by the Commission.

44

NH

GUAM

MARIANAISLANDS (MP) AMERICAN

SAMOA (AS)

HAWAII

VIRGIN ISLANDS

ID

AZ

SD

TN

VAMO

DC

FL

OK

WY

AR

MS

KY

ND

NE

WV

GASC

MT

MD

TX

ME

IA

NC

DE

NM

CO

WI

UTKS

LA

IN

AL

NJ

NLC States

NLC States

34 states have enacted the NLC 33 states have implemented the NLC 1 state has partially implemented the NLC

Partial Implementation Currently No Action

*New Jersey is allowing nurses who hold active, unencumbered, multi-state licenses issued by Nurse Licensure Compact member states to practice in New Jersey under their multi-state licenses.

45

NLC Member States

Jurisdiction Date Implemented eNLC Date Withdrawn from Original NLC

1 Alabama 1/01/20 N/A

2 Arizona 1/19/18 1/19/18

3 Arkansas 1/19/18 1/19/18

4 Colorado 1/19/18 7/18/18 5 Delaware 1/19/18 1/19/18

6 Florida 1/19/18 N/A

7 Georgia 1/19/18 N/A

8 Idaho 1/19/18 1/19/18

9 Indiana 7/01/20 N/A

10 Iowa 1/19/18 1/19/18

11 Kansas 7/01/19 N/A

12 Kentucky 1/19/18 1/19/18

13 Louisiana 7/01/19 N/A

14 Maine 1/19/18 1/19/18

15 Maryland 1/19/18 1/19/18

16 Mississippi 1/19/18 1/19/18

17 Missouri 1/19/18 1/19/18

18 Montana 1/19/18 1/19/18

19 Nebraska 1/19/18 1/19/18

20 New Hampshire 1/19/18 1/19/18 21 New Jersey TBD N/A

22 New Mexico 1/19/18 7/18/18

23 North Carolina 1/19/18 1/19/18

24 North Dakota 1/19/18 1/19/18

25 Oklahoma 1/19/18 N/A

26 South Carolina 1/19/18 1/19/18

27 South Dakota 1/19/18 1/19/18

28 Tennessee 1/19/18 1/19/18

29 Texas 1/19/18 1/19/18

30 Utah 1/19/18 1/19/18

31 Virginia 1/19/18 1/19/18

32 West Virginia 1/19/18 N/A

33 Wisconsin 1/19/18 6/11/18

34 Wyoming 1/19/18 N/A

*The original compact dissolved July 18, 2018. RI is no longer a compact state as of 7/18/18. 46

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Advanced Practice Registered Nurse Compact Adopted by NCSBN Delegate Assembly

August 12, 2020

ARTICLE I

Findings and Declaration of Purpose

a. The party states find that:

1. The health and safety of the public are affected by the degree of compliance with APRN licensure

requirements and the effectiveness of enforcement activities related to state APRN licensure

laws;

2. Violations of APRN licensure and other laws regulating the practice of nursing may result in injury

or harm to the public;

3. The expanded mobility of APRNs and the use of advanced communication and intervention

technologies as part of our nation’s health care delivery system require greater coordination and

cooperation among states in the areas of APRN licensure and regulation;

4. New practice modalities and technology make compliance with individual state APRN licensure

laws difficult and complex;

5. The current system of duplicative APRN licensure for APRNs practicing in multiple states is

cumbersome and redundant for healthcare delivery systems, payors, state licensing boards,

regulators and APRNs;

6. Uniformity of APRN licensure requirements throughout the states promotes public safety and

public health benefits as well as providing a mechanism to increase access to care.

b. The general purposes of this Compact are to:

1. Facilitate the states’ responsibility to protect the public’s health and safety;

2. Ensure and encourage the cooperation of party states in the areas of APRN licensure and

regulation, including promotion of uniform licensure requirements;

3. Facilitate the exchange of information between party states in the areas of APRN regulation,

investigation and adverse actions;

4. Promote compliance with the laws governing APRN practice in each jurisdiction;

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5. Invest all party states with the authority to hold an APRN accountable for meeting all state

practice laws in the state in which the patient is located at the time care is rendered through the

mutual recognition of party state privileges to practice;

6. Decrease redundancies in the consideration and issuance of APRN licenses; and

7. Provide opportunities for interstate practice by APRNs who meet uniform licensure requirements.

ARTICLE II

Definitions

As used in this Compact:

a. “Advanced practice registered nurse” or “APRN” means a registered nurse who has gained additional

specialized knowledge, skills and experience through a program of study recognized or defined by

the Interstate Commission of APRN Compact Administrators (“Commission”), and who is licensed to

perform advanced nursing practice. An advanced practice registered nurse is licensed in an APRN

role that is congruent with an APRN educational program, certification, and Commission rules.

b. “Adverse action” means any administrative, civil, equitable or criminal action permitted by a state’s

laws which is imposed by a licensing board or other authority against an APRN, including actions

against an individual’s license or multistate licensure privilege such as revocation, suspension,

probation, monitoring of the licensee, limitation on the licensee’s practice, or any other encumbrance

on licensure affecting an APRN’s authorization to practice, including the issuance of a cease and

desist action.

c. “Alternative program” means a, non-disciplinary monitoring program approved by a licensing board.

d. “APRN licensure” means the regulatory mechanism used by a party state to grant legal authority to

practice as an APRN.

e. “APRN uniform licensure requirements" means the minimum uniform licensure, education

and examination requirements set forth in Article III.b of this Compact.

f. “Coordinated licensure information system” means an integrated process for collecting, storing and

sharing information on APRN licensure and enforcement activities related to APRN licensure laws

that is administered by a nonprofit organization composed of and controlled by licensing boards.

g. “Current significant investigatory information” means:

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1. Investigative information that a licensing board, after a preliminary inquiry that includes notification

and an opportunity for the APRN to respond, if required by state law, has reason to believe is not

groundless and, if proved true, would indicate more than a minor infraction; or

2. Investigative information that indicates that the APRN represents an immediate threat to public

health and safety regardless of whether the APRN has been notified and had an opportunity to

respond.

h. “Encumbrance” means a revocation or suspension of, or any limitation on, the full and unrestricted

practice of nursing imposed by a licensing board in connection with a disciplinary proceeding.

i. “Home state” means the party state that is the APRN’s primary state of residence.

j. ”Licensing board” means a party state’s regulatory body responsible for regulating the practice of

advanced practice registered nursing.

k. “Multistate license” means an APRN license to practice as an APRN issued by a home state licensing

board that authorizes the APRN to practice as an APRN in all party states under a multistate

licensure privilege, in the same role and population focus as the APRN is licensed in the home state.

l. ”Multistate licensure privilege” means a legal authorization associated with an APRN multistate

license that permits an APRN to practice as an APRN in a remote state, in the same role and

population focus as the APRN is licensed in the home state.

m. “Non-controlled prescription drug” means a device or drug that is not a controlled substance and is

prohibited under state or federal law from being dispensed without a prescription. The term includes

a device or drug that bears or is required to bear the legend “Caution: federal law prohibits dispensing

without prescription” or “prescription only” or other legend that complies with federal law.

n. “Party state” means any state that has adopted this Compact.

o. “Population focus” means one of the six population foci of family/individual across the lifespan,

adult-gerontology, pediatrics, neonatal, women’s health/gender-related and psych/mental health.

p. “Prescriptive authority” means the legal authority to prescribe medications and devices as defined by

party state laws.

q. “Remote state” means a party state that is not the home state.

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r. “Role” means one of the four recognized roles of certified registered nurse anesthetists (CRNA),

certified nurse-midwives (CNM), clinical nurse specialists (CNS) and certified nurse practitioners

(CNP).

s. “Single-state license” means an APRN license issued by a party state that authorizes practice only

within the issuing state and does not include a multistate licensure privilege to practice in any other

party state.

t. “State” means a state, territory or possession of the United States and the District of Columbia.

u. “State practice laws” means a party state’s laws, rules, and regulations that govern APRN practice,

define the scope of advanced nursing practice and create the methods and grounds for imposing

discipline except that prescriptive authority shall be treated in accordance with Article III.f and g of

this Compact. “State practice laws” does not include:

1. A party state’s laws, rules, and regulations requiring supervision or collaboration with a healthcare

professional, except for laws, rules, and regulations regarding prescribing controlled substances;

2. the requirements necessary to obtain and retain an APRN license, except for qualifications or

requirements of the home state.

ARTICLE III

General Provisions and Jurisdiction

a. A state must implement procedures for considering the criminal history records of applicants for initial

APRN licensure or APRN licensure by endorsement. Such procedures shall include the submission

of fingerprints or other biometric-based information by APRN applicants for the purpose of obtaining

an applicant’s criminal history record information from the Federal Bureau of Investigation and the

agency responsible for retaining that state’s criminal records.

b. Each party state shall require an applicant to satisfy the following APRN uniform licensure

requirements to obtain or retain a multistate license in the home state:

1. Meets the home state’s qualifications for licensure or renewal of licensure, as well as, all other

applicable state laws;

2. i. Has completed an accredited graduate-level education program that prepares the applicant for

one of the four recognized roles and population foci; or

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ii. Has completed a foreign APRN education program for one of the four recognized roles and

population foci that (a) has been approved by the authorized accrediting body in the applicable

country and (b) has been verified by an independent credentials review agency to be

comparable to a licensing board-approved APRN education program;

3. Has, if a graduate of a foreign APRN education program not taught in English or if English is not

the individual’s native language, successfully passed an English proficiency examination that

includes the components of reading, speaking, writing and listening;

4. Has successfully passed a national certification examination that measures APRN, role and

population-focused competencies and maintains continued competence as evidenced by

recertification in the role and population focus through the national certification program;

5. Holds an active, unencumbered license as a registered nurse and an active, unencumbered

authorization to practice as an APRN;

6. Has successfully passed an NCLEX-RN® examination or recognized predecessor, as

applicable;

7. Has practiced for at least 2,080 hours as an APRN in a role and population focus congruent with

the applicant’s education and training. For purposes of this section, practice shall not include

hours obtained as part of enrollment in an APRN education program;

8. Has submitted, in connection with an application for initial licensure or licensure by

endorsement, fingerprints or other biometric data for the purpose of obtaining criminal history

record information from the Federal Bureau of Investigation and the agency responsible for

retaining that state or, if applicable, foreign country’s criminal records;

9. Has not been convicted or found guilty, or has entered into an agreed disposition, of a felony

offense under applicable state, federal or foreign criminal law.

10. Has not been convicted or found guilty, or has entered into an agreed disposition, of a

misdemeanor offense related to the practice of nursing as determined by factors set forth in

rules adopted by the Commission;

11. Is not currently enrolled in an alternative program;

12. Is subject to self-disclosure requirements regarding current participation in an alternative

program; and

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13. Has a valid United States Social Security number.

c. An APRN issued a multistate license shall be licensed in an approved role and at least one approved

population focus.

d. An APRN multistate license issued by a home state to a resident in that state will be recognized by

each party state as authorizing the APRN to practice as an APRN in each party state, under a

multistate licensure privilege, in the same role and population focus as the APRN is licensed in the

home state.

e. Nothing in this Compact shall affect the requirements established by a party state for the

issuance of a single-state license, except that an individual may apply for a single-state

license, instead of a multistate license, even if otherwise qualified for the multistate license.

However, the failure of such an individual to affirmatively opt for a single state license may

result in the issuance of a multistate license.

f. Issuance of an APRN multistate license shall include prescriptive authority for noncontrolled

prescription drugs.

g. For each state in which an APRN seeks authority to prescribe controlled substances, the APRN shall

satisfy all requirements imposed by such state in granting and/or renewing such authority.

h. An APRN issued a multistate license is authorized to assume responsibility and accountability for

patient care independent of any supervisory or collaborative relationship. This authority may be

exercised in the home state and in any remote state in which the APRN exercises a multistate

licensure privilege.

i. All party states shall be authorized, in accordance with state due process laws, to take adverse action

against an APRN’s multistate licensure privilege such as revocation, suspension, probation or any

other action that affects an APRN’s authorization to practice under a multistate licensure privilege,

including cease and desist actions. If a party state takes such action, it shall promptly notify the

administrator of the coordinated licensure information system. The administrator of the coordinated

licensure information system shall promptly notify the home state of any such actions by remote

states.

j. Except as otherwise expressly provided in this Compact, an APRN practicing in a party state must

comply with the state practice laws of the state in which the client is located at the time service is

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provided. APRN practice is not limited to patient care, but shall include all advanced nursing practice

as defined by the state practice laws of the party state in which the client is located. APRN practice

in a party state under a multistate licensure privilege will subject the APRN to the jurisdiction of the

licensing board, the courts, and the laws of the party state in which the client is located at the time

service is provided.

k. Except as otherwise expressly provided in this Compact, this Compact does not affect additional

requirements imposed by states for advanced practice registered nursing. However, a multistate

licensure privilege to practice registered nursing granted by a party state shall be recognized by

other party states as satisfying any state law requirement for registered nurse licensure as a

precondition for authorization to practice as an APRN in that state.

l. Individuals not residing in a party state shall continue to be able to apply for a party state’s single-

state APRN license as provided under the laws of each party state. However, the single-state license

granted to these individuals will not be recognized as granting the privilege to practice as an APRN in

any other party state.

ARTICLE IV

Applications for APRN Licensure in a Party State

a. Upon application for an APRN multistate license, the licensing board in the issuing party state shall

ascertain, through the coordinated licensure information system, whether the applicant has ever held

or is the holder of a licensed practical/vocational nursing license, a registered nursing license or an

advanced practice registered nurse license issued by any other state, whether there are any

encumbrances on any license or multistate licensure privilege held by the applicant, whether any

adverse action has been taken against any license or multistate licensure privilege held by the

applicant and whether the applicant is currently participating in an alternative program.

b. An APRN may hold a multistate APRN license, issued by the home state, in only one party state at a

time.

c. If an APRN changes primary state of residence by moving between two party states, the APRN must

apply for APRN licensure in the new home state, and the multistate license issued by the prior home

state shall be deactivated in accordance with applicable Commission rules.

1. The APRN may apply for licensure in advance of a change in primary state of residence.

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2. A multistate APRN license shall not be issued by the new home state until the APRN provides

satisfactory evidence of a change in primary state of residence to the new home state and

satisfies all applicable requirements to obtain a multistate APRN license from the new home

state.

d. If an APRN changes primary state of residence by moving from a party state to a non-party state, the

APRN multistate license issued by the prior home state will convert to a single-state license, valid

only in the former home state.

ARTICLE V

Additional Authorities Invested in Party State Licensing Boards

a. In addition to the other powers conferred by state law, a licensing board shall have the authority to:

1. Take adverse action against an APRN’s multistate licensure privilege to practice within that party

state.

i. Only the home state shall have power to take adverse action against an APRN’s license issued

by the home state.

ii. For purposes of taking adverse action, the home state licensing board shall give the same

priority and effect to reported conduct that occurred outside of the home state as it would if

such conduct had occurred within the home state. In so doing, the home state shall apply its

own state laws to determine appropriate action.

2. Issue cease and desist orders or impose an encumbrance on an APRN’s authority to practice

within that party state.

3. Complete any pending investigations of an APRN who changes primary state of residence during

the course of such investigations. The licensing board shall also have the authority to take

appropriate action(s) and shall promptly report the conclusions of such investigations to the

administrator of the coordinated licensure information system. The administrator of the

coordinated licensure information system shall promptly notify the new home state of any such

actions.

4. Issue subpoenas for both hearings and investigations that require the attendance and testimony

of witnesses, as well as, the production of evidence. Subpoenas issued by a party state licensing

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board for the attendance and testimony of witnesses and/or the production of evidence from

another party state shall be enforced in the latter state by any court of competent jurisdiction,

according to that court’s practice and procedure in considering subpoenas issued in its own

proceedings. The issuing licensing board shall pay any witness fees, travel expenses, mileage

and other fees required by the service statutes of the state in which the witnesses and/or

evidence are located.

5. Obtain and submit, for an APRN licensure applicant, fingerprints or other biometric-based

information to the Federal Bureau of Investigation for criminal background checks, receive the

results of the Federal Bureau of Investigation record search on criminal background checks and

use the results in making licensure decisions.

6. If otherwise permitted by state law, recover from the affected APRN the costs of investigations

and disposition of cases resulting from any adverse action taken against that APRN.

7. Take adverse action based on the factual findings of another party state, provided that the

licensing board follows its own procedures for taking such adverse action.

b. If adverse action is taken by a home state against an APRN’s multistate licensure, the privilege to

practice in all other party states under a multistate licensure privilege shall be deactivated until all

encumbrances have been removed from the APRN’s multistate license. All home state disciplinary

orders that impose adverse action against an APRN’s multistate license shall include a statement that

the APRN’s multistate licensure privilege is deactivated in all party states during the pendency of the

order.

c. Nothing in this Compact shall override a party state’s decision that participation in an alternative

program may be used in lieu of adverse action. The home state licensing board shall deactivate the

multistate licensure privilege under the multistate license of any APRN for the duration of the APRN’s

participation in an alternative program.

ARTICLE VI

Coordinated Licensure Information System and Exchange of Information

a. All party states shall participate in a coordinated licensure information system of all APRNs, licensed

registered nurses and licensed practical/vocational nurses. This system will include information on the

licensure and disciplinary history of each APRN, as submitted by party states, to assist in the

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coordinated administration of APRN licensure and enforcement efforts.

b. The Commission, in consultation with the administrator of the coordinated licensure information

system, shall formulate necessary and proper procedures for the identification, collection and

exchange of information under this Compact.

c. All licensing boards shall promptly report to the coordinated licensure information system any

adverse action, any current significant investigative information, denials of applications (with the

reasons for such denials) and APRN participation in alternative programs known to the licensing

board regardless of whether such participation is deemed nonpublic and/or confidential under state

law.

d. Notwithstanding any other provision of law, all party state licensing boards contributing information to

the coordinated licensure information system may designate information that may not be shared with

non-party states or disclosed to other entities or individuals without the express permission of the

contributing state.

e. Any personally identifiable information obtained from the coordinated licensure information system by

a party state licensing board shall not be shared with non-party states or disclosed to other entities or

individuals except to the extent permitted by the laws of the party state contributing the information.

f. Any information contributed to the coordinated licensure information system that is subsequently

required to be expunged by the laws of the party state contributing the information shall be removed

from the coordinated licensure information system.

g. The Compact administrator of each party state shall furnish a uniform data set to the Compact

administrator of each other party state, which shall include, at a minimum:

1. Identifying information;

2. Licensure data;

3. Information related to alternative program participation information; and

4. Other information that may facilitate the administration of this Compact, as determined by

Commission rules.

h. The Compact administrator of a party state shall provide all investigative documents and information

requested by another party state.

ARTICLE VII

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Establishment of the Interstate Commission of APRN Compact Administrators

a. The party states hereby create and establish a joint public agency known as the Interstate

Commission of APRN Compact Administrators.

1. The Commission is an instrumentality of the party states.

2. Venue is proper, and judicial proceedings by or against the Commission shall be brought solely

and exclusively, in a court of competent jurisdiction where the principal office of the Commission

is located. The Commission may waive venue and jurisdictional defenses to the extent it adopts

or consents to participate in alternative dispute resolution proceedings.

3. Nothing in this Compact shall be construed to be a waiver of sovereign immunity.

b. Membership, Voting and Meetings

1. Each party state shall have and be limited to one administrator. The head of the state licensing

board or designee shall be the administrator of this Compact for each party state. Any

administrator may be removed or suspended from office as provided by the law of the state from

which the Administrator is appointed. Any vacancy occurring in the Commission shall be filled in

accordance with the laws of the party state in which the vacancy exists.

2. Each administrator shall be entitled to one (1) vote with regard to the promulgation of rules and

creation of bylaws and shall otherwise have an opportunity to participate in the business and affairs

of the Commission. An administrator shall vote in person or by such other means as provided in

the bylaws. The bylaws may provide for an administrator’s participation in meetings by telephone

or other means of communication.

3. The Commission shall meet at least once during each calendar year. Additional meetings shall be

held as set forth in the bylaws or rules of the commission.

4. All meetings shall be open to the public, and public notice of meetings shall be given in the same

manner as required under the rulemaking provisions in Article VIII.

5. The Commission may convene in a closed, nonpublic meeting if the Commission must discuss:

i. Noncompliance of a party state with its obligations under this Compact;

ii. The employment, compensation, discipline or other personnel matters, practices or

procedures related to specific employees or other matters related to the Commission’s

internal personnel practices and procedures;

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iii. Current, threatened, or reasonably anticipated litigation;

iv. Negotiation of contracts for the purchase or sale of goods, services or real estate;

v. Accusing any person of a crime or formally censuring any person;

vi. Disclosure of trade secrets or commercial or financial information that is privileged or

confidential;

vii. Disclosure of information of a personal nature where disclosure would constitute a clearly

unwarranted invasion of personal privacy;

viii. Disclosure of investigatory records compiled for law enforcement purposes;

ix. Disclosure of information related to any reports prepared by or on behalf of the Commission for

the purpose of investigation of compliance with this Compact; or

x. Matters specifically exempted from disclosure by federal or state statute.

6. If a meeting, or portion of a meeting, is closed pursuant to this provision, the Commission’s legal

counsel or designee shall certify that the meeting may be closed and shall reference each relevant

exempting provision. The Commission shall keep minutes that fully and clearly describe

all matters discussed in a meeting and shall provide a full and accurate summary of actions

taken, and the reasons therefor, including a description of the views expressed. All documents

considered in connection with an action shall be identified in such minutes. All minutes and

documents of a closed meeting shall remain under seal, subject to release by a majority vote of

the Commission or order of a court of competent jurisdiction.

c. The Commission shall, by a majority vote of the administrators, prescribe bylaws or rules to govern its

conduct as may be necessary or appropriate to carry out the purposes and exercise the powers of

this Compact, including but not limited to:

1. Establishing the fiscal year of the Commission;

2. Providing reasonable standards and procedures:

i. For the establishment and meetings of other committees; and

ii. Governing any general or specific delegation of any authority or function of the Commission.

3. Providing reasonable procedures for calling and conducting meetings of the Commission,

ensuring reasonable advance notice of all meetings and providing an opportunity for attendance

of such meetings by interested parties, with enumerated exceptions designed to protect the

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public’s interest, the privacy of individuals, and proprietary information, including trade secrets.

The Commission may meet in closed session only after a majority of the administrators vote to

close a meeting in whole or in part. As soon as practicable, the Commission must make public a

copy of the vote to close the meeting revealing the vote of each administrator, with no proxy votes

allowed;

4. Establishing the titles, duties and authority and reasonable procedures for the election of the

officers of the Commission;

5. Providing reasonable standards and procedures for the establishment of the personnel policies

and programs of the Commission. Notwithstanding any civil service or other similar laws of any

party state, the bylaws shall exclusively govern the personnel policies and programs of the

Commission;

6. Providing a mechanism for winding up the operations of the Commission and the equitable

disposition of any surplus funds that may exist after the termination of this Compact after the

payment and/or reserving of all of its debts and obligations;

d. The Commission shall publish its bylaws and rules, and any amendments thereto, in a convenient

form on the website of the Commission;

e. The Commission shall maintain its financial records in accordance with the bylaws; and

f. The Commission shall meet and take such actions as are consistent with the provisions of this

Compact and the bylaws.

g. The Commission shall have the following powers:

1. To promulgate uniform rules to facilitate and coordinate implementation and administration of this

Compact. The rules shall have the force and effect of law and shall be binding in all party states;

2. To bring and prosecute legal proceedings or actions in the name of the Commission, provided

that the standing of any licensing board to sue or be sued under applicable law shall not be

affected;

3. To purchase and maintain insurance and bonds;

4. To borrow, accept or contract for services of personnel, including but not limited to employees of

a party state or nonprofit organizations;

5. To cooperate with other organizations that administer state compacts related to the regulation of

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nursing, including but not limited to sharing administrative or staff expenses, office space or other

resources;

6. To hire employees, elect or appoint officers, fix compensation, define duties, grant such

individuals appropriate authority to carry out the purposes of this Compact, and to establish the

Commission’s personnel policies and programs relating to conflicts of interest, qualifications of

personnel and other related personnel matters;

7. To accept any and all appropriate donations, grants and gifts of money, equipment, supplies,

materials and services, and to receive, utilize and dispose of the same; provided that at all times

the Commission shall strive to avoid any appearance of impropriety and/or conflict of interest;

8. To lease, purchase, accept appropriate gifts or donations of, or otherwise to own, hold, improve or

use, any property, whether real, personal or mixed; provided that at all times the Commission shall

strive to avoid any appearance of impropriety;

9. To sell convey, mortgage, pledge, lease, exchange, abandon or otherwise dispose of any

property, whether real, personal or mixed;

10. To establish a budget and make expenditures;

11. To borrow money;

12. To appoint committees, including advisory committees comprised of administrators, state nursing

regulators, state legislators or their representatives, and consumer representatives, and other

such interested persons;

13. To issue advisory opinions;

14. To provide and receive information from, and to cooperate with, law enforcement agencies;

15. To adopt and use an official seal; and

16. To perform such other functions as may be necessary or appropriate to achieve the purposes of

this Compact consistent with the state regulation of APRN licensure and practice.

h. Financing of the Commission

1. The Commission shall pay, or provide for the payment of, the reasonable expenses of its

establishment, organization and ongoing activities.

2. The Commission may also levy on and collect an annual assessment from each party state to

cover the cost of its operations, activities and staff in its annual budget as approved each year.

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The aggregate annual assessment amount, if any, shall be allocated based upon a formula to

be determined by the Commission, which shall promulgate a rule that is binding upon all party

states.

3. The Commission shall not incur obligations of any kind prior to securing the funds adequate to

meet the same; nor shall the Commission pledge the credit of any of the party states, except by,

and with the authority of, such party state.

4. The Commission shall keep accurate accounts of all receipts and disbursements. The receipts

and disbursements of the Commission shall be subject to the audit and accounting procedures

established under its bylaws. However, all receipts and disbursements of funds handled by the

Commission shall by audited yearly by a certified or licensed public accountant, and the report of

the audit shall be included in and become part of the annual report of the Commission.

i. Qualified Immunity, Defense, and Indemnification

1. The administrators, officers, executive director, employees and representatives of the

Commission shall be immune from suit and liability, either personally or in their official capacity,

for any claim for damage to or loss of property or personal injury or other civil liability caused by

or arising out of any actual or alleged act, error or omission that occurred, or that the person

against whom the claim is made had a reasonable basis for believing occurred, within the scope

of Commission employment, duties or responsibilities; provided that nothing in this paragraph

shall be construed to protect any such person from suit and/or liability for any damage, loss, injury

or liability caused by the intentional, willful or wanton misconduct of that person.

2. The Commission shall defend any administrator, officer, executive director, employee or

representative of the Commission in any civil action seeking to impose liability arising out of any

actual or alleged act, error or omission that occurred within the scope of Commission

employment, duties or responsibilities, or that the person against whom the claim is made had a

reasonable basis for believing occurred within the scope of Commission employment, duties or

responsibilities; provided that nothing herein shall be construed to prohibit that person from

retaining his or her own counsel; and provided further that the actual or alleged act, error or

omission did not result from that person’s intentional, willful or wanton misconduct.

3. The Commission shall indemnify and hold harmless any administrator, officer, executive director,

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employee or representative of the Commission for the amount of any settlement or judgment

obtained against that person arising out of any actual or alleged act, error or omission that

occurred within the scope of Commission employment, duties or responsibilities, or that such

person had a reasonable basis for believing occurred within the scope of Commission

employment, duties or responsibilities, provided that the actual or alleged act, error or omission

did not result from the intentional, willful or wanton misconduct of that person.

ARTICLE VIII

Rulemaking

a. The Commission shall exercise its rulemaking powers pursuant to the criteria set forth in this Article

and the rules adopted thereunder. Rules and amendments shall become binding as of the date

specified in each rule or amendment and shall have the same force and effect as provisions of this

Compact.

b. Rules or amendments to the rules shall be adopted at a regular or special meeting of the

Commission.

c. Prior to promulgation and adoption of a final rule or rules by the Commission, and at least sixty (60)

days in advance of the meeting at which the rule will be considered and voted upon, the Commission

shall file a notice of proposed rulemaking:

1. On the website of the Commission; and

2. On the website of each licensing board or the publication in which each state would otherwise

publish proposed rules.

d. The notice of proposed rulemaking shall include:

1. The proposed time, date and location of the meeting in which the rule will be considered and

voted upon;

2. The text of the proposed rule or amendment, and the reason for the proposed rule;

3. A request for comments on the proposed rule from any interested person; and

4. The manner in which interested persons may submit notice to the Commission of their intention to

attend the public hearing and any written comments.

e. Prior to adoption of a proposed rule, the Commission shall allow persons to submit written data, facts,

opinions and arguments, which shall be made available to the public.

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f. The Commission shall grant an opportunity for a public hearing before it adopts a rule or amendment.

g. The Commission shall publish the place, time, and date of the scheduled public hearing.

1. Hearings shall be conducted in a manner providing each person who wishes to comment a fair

and reasonable opportunity to comment orally or in writing. All hearings will be recorded, and a

copy will be made available upon request.

2. Nothing in this section shall be construed as requiring a separate hearing on each rule. Rules

may be grouped for the convenience of the Commission at hearings required by this section.

h. If no one appears at the public hearing, the Commission may proceed with promulgation of the

proposed rule.

i. Following the scheduled hearing date, or by the close of business on the scheduled hearing date if

the hearing was not held, the Commission shall consider all written and oral comments received.

j. The Commission shall, by majority vote of all administrators, take final action on the proposed rule

and shall determine the effective date of the rule, if any, based on the rulemaking record and the full

text of the rule.

k. Upon determination that an emergency exists, the Commission may consider and adopt an

emergency rule without prior notice, opportunity for comment, or hearing, provided that the usual

rulemaking procedures provided in this Compact and in this section shall be retroactively applied to

the rule as soon as reasonably possible, in no event later than ninety (90) days after the effective

date of the rule. For the purposes of this provision, an emergency rule is one that must be adopted

immediately in order to:

1. Meet an imminent threat to public health, safety or welfare;

2. Prevent a loss of Commission or party state funds; or

3. Meet a deadline for the promulgation of an administrative rule that is established by federal law or

rule.

l. The Commission may direct revisions to a previously adopted rule or amendment for purposes of

correcting typographical errors, errors in format, errors in consistency or grammatical errors. Public

notice of any revisions shall be posted on the website of the Commission. The revision shall be

subject to challenge by any person for a period of thirty (30) days after posting. The revision may be

challenged only on grounds that the revision results in a material change to a rule. A challenge shall

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be made in writing, and delivered to the Commission, prior to the end of the notice period. If no

challenge is made, the revision will take effect without further action. If the revision is challenged, the

revision may not take effect without the approval of the Commission.

ARTICLE IX

Oversight, Dispute Resolution and Enforcement

a. Oversight

1. Each party state shall enforce this Compact and take all actions necessary and appropriate to

effectuate this Compact’s purposes and intent.

2. The Commission shall be entitled to receive service of process in any proceeding that may affect

the powers, responsibilities or actions of the Commission, and shall have standing to intervene in

such a proceeding for all purposes. Failure to provide service of process to the Commission shall

render a judgment or order void as to the Commission, this Compact or promulgated rules.

b. Default, Technical Assistance and Termination

1. If the Commission determines that a party state has defaulted in the performance of its

obligations or responsibilities under this Compact or the promulgated rules, the Commission shall:

i. Provide written notice to the defaulting state and other party states of the nature of the

default, the proposed means of curing the default and/or any other action to be taken by the

Commission; and

ii. Provide remedial training and specific technical assistance regarding the default.

2. If a state in default fails to cure the default, the defaulting state’s membership in this Compact

may be terminated upon an affirmative vote of a majority of the administrators, and all rights,

privileges and benefits conferred by this Compact may be terminated on the effective date of

termination. A cure of the default does not relieve the offending state of obligations or liabilities

incurred during the period of default.

3. Termination of membership in this Compact shall be imposed only after all other means of

securing compliance have been exhausted. Notice of intent to suspend or terminate shall be

given by the Commission to the governor of the defaulting state and to the executive officer of the

defaulting state’s licensing board, the defaulting state’s licensing board, and each of the party

states.

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4. A state whose membership in this Compact has been terminated is responsible for all

assessments, obligations and liabilities incurred through the effective date of termination,

including obligations that extend beyond the effective date of termination.

5. The Commission shall not bear any costs related to a state that is found to be in default or whose

membership in this Compact has been terminated, unless agreed upon in writing between the

Commission and the defaulting state.

6. The defaulting state may appeal the action of the Commission by petitioning the U.S. District

Court for the District of Columbia or the federal district in which the Commission has its principal

offices. The prevailing party shall be awarded all costs of such litigation, including reasonable

attorneys’ fees.

c. Dispute Resolution

1. Upon request by a party state, the Commission shall attempt to resolve disputes related to the

Compact that arise among party states and between party and non-party states.

2. The Commission shall promulgate a rule providing for both mediation and binding dispute

resolution for disputes, as appropriate.

3. In the event the Commission cannot resolve disputes among party states arising under this

Compact:

i. The party states may submit the issues in dispute to an arbitration panel, which will be

comprised of individuals appointed by the Compact administrator in each of the affected party

states and an individual mutually agreed upon by the Compact administrators of all the party

states involved in the dispute.

ii. The decision of a majority of the arbitrators shall be final and binding.

d. Enforcement

1. The Commission, in the reasonable exercise of its discretion, shall enforce the provisions and

rules of this Compact.

2. By majority vote, the Commission may initiate legal action in the United States District Court for

the District of Columbia or the federal district in which the Commission has its principal offices

against a party state that is in default to enforce compliance with the provisions of this Compact

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and its promulgated rules and bylaws. The relief sought may include both injunctive relief and

damages. In the event judicial enforcement is necessary, the prevailing party shall be awarded all

costs of such litigation, including reasonable attorneys’ fees.

3. The remedies herein shall not be the exclusive remedies of the Commission. The Commission

may pursue any other remedies available under federal or state law.

ARTICLE X

Effective Date, Withdrawal and Amendment

a. This Compact shall come into limited effect at such time as this Compact has been enacted into law

in seven (7) party states for the sole purpose of establishing and convening the Commission to adopt

rules relating to its operation.

b. Any state that joins this Compact subsequent to the Commission’s initial adoption of the APRN

uniform licensure requirements shall be subject to all rules that have been previously adopted by the

Commission.

c. Any party state may withdraw from this Compact by enacting a statute repealing the same. A party

state’s withdrawal shall not take effect until six (6) months after enactment of the repealing statute.

d. A party state’s withdrawal or termination shall not affect the continuing requirement of the withdrawing

or terminated state’s licensing board to report adverse actions and significant investigations occurring

prior to the effective date of such withdrawal or termination.

e. Nothing contained in this Compact shall be construed to invalidate or prevent any APRN licensure

agreement or other cooperative arrangement between a party state and a non-party state that does

not conflict with the provisions of this Compact.

f. This Compact may be amended by the party states. No amendment to this Compact shall become

effective and binding upon any party state until it is enacted into the laws of all party states.

g. Representatives of non-party states to this Compact shall be invited to participate in the activities of

the Commission, on a nonvoting basis, prior to the adoption of this Compact by all states.

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ARTICLE XI

Construction and Severability This Compact shall be liberally construed so as to effectuate the purposes thereof. The provisions of this

Compact shall be severable, and if any phrase, clause, sentence or provision of this Compact is declared

to be contrary to the constitution of any party state or of the United States, or if the applicability thereof to

any government, agency, person or circumstance is held invalid, the validity of the remainder of this

Compact and the applicability thereof to any government, agency, person or circumstance shall not be

affected thereby. If this Compact shall be held to be contrary to the constitution of any party state, this

Compact shall remain in full force and effect as to the remaining party states and in full force and effect as

to the party state affected as to all severable matters.

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Re-issued 4/17/2019

MULTI-STATE NURSE LICENSURE

In 2005, the Ohio Board of Nursing (Board) examined issues and learned about the experience of some Compact states participating in multi-state licensure. Although the Board recognized that multi-state nurse licensure could be advantageous for occupational health nurses, traveling nurses, or employers, the Board discussed that potential risks of harm to the public outweigh the potential benefits. With multi-state licensure, nurses could be practicing in Ohio when they have not been held to the same standards of safe practice that Ohio has deemed important for public safety. For example, Ohio requires criminal records checks for licensure, but not all Compact states had the same requirement. Also, Ohio statute specifies that there are absolute bars to licensure. If an applicant has been convicted of certain crimes such as Murder and Rape, among others, the applicant cannot be considered for licensure in Ohio. The majority of Compact states either do not bar violent felonies, or impose only time-limited, rather than absolute, bars to licensure.

Over the years, the Board reviewed the actual experience of other states and identified the potential impact of multi-state licensure on public safety. We were advised of nurses with multi-state licenses relocating to states as soon as they find themselves under investigation in their home state. While in theory, the home state would immediately report the investigation to the next state, the reality is neither state may learn of the relocation for a significant period of time. Furthermore, not all states had laws like that in Ohio permitting sharing of investigative information with other governmental entities. In addition, when the nurse moves to another state, the home state does not always continue its investigation. This means that Ohio would not receive vital information unless Ohio attempted to conduct an out-of-state investigation and this is not realistic. In fact, it is unclear whether Ohio would have the ability to compel the production of out-of-state documents or witnesses necessary to prepare a case.

On September 16, 2005, the Board voted to delay action seeking the introduction of multi-state compact legislation until such time more information is available to assure that the benefits of multi-state licensure outweigh any risks related to public safety.

Since 2005, the Board has discussed multi-state licensure at numerous meetings and continuously has worked at the national level to address Ohio’s concerns. Annually the Board has discussed the Compact and has reaffirmed its belief that the potential risks of harm to the public outweigh the potential benefits because nurses with multi-state licenses could practice in Ohio without meeting the current statutory and regulatory standards established by the General Assembly and the Board to protect the public. The Board continues to address these issues through the National Council of State Boards of Nursing (NCSBN). NCSBN voted to approve new Compact model legislation, known as the enhanced Nurse License Compact (eNLC). During the NCSBN Annual Meeting in August 2015, an information session for state attorneys, regarding the legal implications of the eNLC, was provided by the Compact Special Counsel and NCSBN Legal Counsel. In January 2018 the eNLC became effective.

The Board reviewed the eNLC to weigh the benefits and potential risks. Concerns regarding the eNLC include (but are not limited to) the following: (i) the eNLC would establish a Commission that would be funded by state revenue, but would not be subject to state transparency requirements (open meetings/open records acts); (ii) the Commission could adopt rules binding on Compact member states without undergoing state rule-making processes; (iii) concern was expressed that state would be ceding their legal authority to a privately operated Commission.

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Further, the Board continues to be concerned about public safety issues due to differences between states that are not addressed in the eNLC, such as mandatory reporting and complaints/investigations. Mandatory reporting is not a requirement for eNLC states as it is in Ohio. Also complaints and investigations are handled differently. For example, some eNLC states require clear and convincing evidence to substantiate a violation of their Nurse Practice Acts. Ohio requires a preponderance of evidence. Because clear and convincing evidence is a higher standard than proof by a preponderance of the evidence, those boards may not investigate complaints that the Ohio Board of Nursing would investigate. The Board is aware of the importance of increasing the mobility of nurses and has implemented an expedited reciprocity process, including issuing temporary permits to work in five-seven business days. The Board recognizes that an adequate and safe nursing workforce is vital during times of emergencies. However, non-membership in the eNLC does not impede the deployment of licensed nurses from other states to Ohio during a disaster, or the deployment of Ohio licensed nurses to declared disaster areas in other states. The Nurse Practice Act, Section 4723.32(G)(7), ORC, allows nurses who hold an active, valid license in another state to come to Ohio in the case of any declared disaster. Further, under Section 4723.32, ORC, providing emergency assistance does not require a nursing license in Ohio. During emergencies in other states, the Board has encouraged and facilitated Ohio participation by Ohio nurses in disaster relief through enrollment in the Medical Reserve Corp (MRC)/Red Cross (ARC). The ARC verifies state licensure status, provides emergency relief training, and organizes deployment by matching a nurse’s area of expertise to the area of need. The ARC has negotiated reciprocal licensing agreements with each state, so if nurses with active, valid licenses in one state are activated through ARC, they are able to practice in other states without having a license to practice in that state. The Board is committed to its mission of public protection, following the laws enacted by the State legislature, and enforcing regulations promulgated for patient safety.

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MEMORANDUM To: Board Members Ohio Board Of Nursing From: Betsy Houchen Executive Director

Subject: New/Enhanced Compact – Areas For Consideration Date: March 22, 2019 The Board’s reviewed and discussed the following areas of concern at the 2015 Board Retreat. The areas of concern are provided annually for review and consideration. Authority of the Interstate Commission Article VII establishes “a joint public entity known as the Interstate Commission of Nurse Licensure Compact Administrators” (Commission) composed of the party states that adopt the new Compact. Article VII also grants powers to the Commission. • Paragraph (b)(1): “Each party state shall have and be limited to one administrator…” • Paragraph (b)(2): “Each administrator shall be entitled to one (1) vote with regard to the

promulgation of rules and creation of bylaws and shall otherwise have an opportunity to participate in the business and affairs of the Commission….”

Þ Consideration: Each member, regardless of the number of licenses regulated, or the amount of fees paid to the Commission, is represented by one person and has one vote.

• Paragraph (g) and (g)(1) “The Commission shall have the following powers: To promulgate

uniform rules to facilitate and coordinate implementation and administration of this Compact. The rules shall have the force and effect of law and shall be binding in all party states.”

Þ Consideration: The Commission will have the power to enact rules that are binding on

each State in the Compact by a simple majority vote. Each State would be subject to administrative rules not passed at the State level.

• Paragraph (a)(2): The Commission will be subject to the laws of the state in which it is

organized, i.e., Illinois.

Þ Consideration: If there is a dispute between Ohio and the Commission or another party state, the matter will be handled in the Illinois court system.

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• Paragraphs (b)(5) and (i): “The Commission may convene in a closed, non-public meeting” for certain reasons; the Commission has immunity/defenses to lawsuits.

Þ Consideration: the Commission is not subject to any independent auditor or legal authority with oversight over its operations or finances, and has immunity/indemnification from lawsuits.

• Paragraph (g)(6): The Commission shall have the following powers: “To hire employees… fix

compensation, define duties…”

• Paragraph (c): “The Commission shall, by a majority vote of the administrators, prescribe bylaws or rules to govern its conduct as may be necessary or appropriate to carry out the purposes and exercise the powers of the Compact, including but not limited to: …providing reasonable standards and procedures: for the establishment and meetings of other committees; and governing any general or specific delegation of any authority or function of the Commission.”

Þ Consideration: The Commission is to be fully staffed and all of its costs will be paid for

by annual assessments on members; the Commission would have exclusive say in how much each member is assessed. At this time, the cost for each party state to support the Commission is unknown.

Many of these provisions may violate the Ohio Constitution, the Ohio Open Meetings Act, the Ohio Ethics Law and other Ohio statutes. The budget impact is uncertain but due to required assessments, it is anticipated that it will not be budget neutral. (See discussion below under Fiscal Implications.) Grandfathering Article III, paragraph (g) specifies that nurses who currently hold a multi-state license would retain their multi-state license. The exceptions would be (1) nurses who change their primary state of residence, must meet the requirements of the new Compact; or (2) a nurse who “fails to meet the multi-state licensure requirements due to a criminal conviction, enrollment in an alternative program, an adverse action or any other event occurring after the Compact’s effective date, shall be ineligible to retain or renew a multi-state license and the nurse’s multi-state license shall be revoked or deactivated in accordance with applicable Commission rules.”

Þ Consideration: Nurses who currently have multi-state license under the old Compact would be grandfathered into the new Compact. Therefore, nurses who never had criminal records checks could hold a multi-state license under the new Compact.

Misdemeanors Article III, paragraph (c)(7) states that for an applicant to obtain or retain a multi-state license in the home state, the individual “has not been convicted or has entered into an agreed disposition, of a misdemeanor offense related to the practice of nursing as determined on a case-by-case basis….”

Þ Consideration: Each State will make its own case-by-case determination about whether to impose discipline for misdemeanors. If the state takes action on a misdemeanor, other party states could take action based on the other State’s action, but if the State where the misdemeanor occurred declines to take action, the Board would not be aware of the misdemeanor.

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Alternative Program for Chemical Dependency (AP) Article III, paragraphs (c)(9) and (10) state that a nurse enrolled in AP cannot obtain or retain a multi-state license and that the nurse is “subject to self-disclosure requirements regarding current participation in an alternative program.” Article V, paragraph (c) states that a party state has authority to place a nurse in an alternative program “in lieu of adverse action.” The paragraph further states that the home state shall deactivate the multi-state license privilege under the multi-state license for the duration of the nurse’s participation in an alternative program.

Þ Consideration: Article V allows each State to place a nurse in AP, however, not all Boards know when nurses are participating in their State’s Alternative Program because, for example, the program is outsourced to a third party. If States do not know their AP participants, those licensees would be able retain multi-state licenses if the licensee did not report their participation to the State.

Uniform Licensure Requirements and Absolute Bars The Uniform Licensure Requirements (ULRs) adopted by NCSBN in 2012, are to be included in the new Compact rules rather than in statute. A copy of the ULRs is attached (Attachment F). The new Compact language and the ULRs do not include absolute bars for licensure, except that the ULRs specify if an “evaluation identifies sexual behaviors of a predatory nature the board of nursing should deny licensure.”

Þ Consideration: The Ohio Nurse Practice Act includes absolute bars for licensure. The following list of crimes that make an individual ineligible for licensure in Ohio, or if already licensed, require an automatic suspension of licensure: aggravated murder, murder, voluntary manslaughter, felonious assault, kidnapping, rape, sexual battery, gross sexual imposition, aggravated arson, aggravated robbery, and aggravated burglary, as defined under Title XXIX [29] of the Ohio Revised Code, or, with regard to offenses committed in other jurisdictions, offenses comparable to the offenses defined in Title XXIX [29] of the Revised Code.

Conviction Language Article III, paragraphs (c)(7) and (8) state that for an applicant to obtain or retain a multi-state license in the home state, the individual “has not been convicted or found guilty, or has entered into an agreed disposition, of a felony offense…and has not been convicted or found guilty, or has entered into an agreed disposition, of a misdemeanor offense related to the practice of nursing….” For felonies and misdemeanors, the Ohio Nurse Practice Act specifies the Board can take action based on a “conviction of, a plea of guilty to, a judicial finding of guilt of, a judicial finding of guilt resulting from a plea of no contest to, or a judicial finding of eligibility for a pretrial diversion or similar program or for intervention in lieu of conviction for, …”

Consideration: The new Compact language, “not been convicted or found guilty, or has entered into an agreed disposition” is too narrow. Under Ohio law, the Board can also take action on judicial findings of eligibility for a pretrial diversion or similar program, or intervention in lieu of conviction. Without these options, the Board would need to base action on the underlying facts which would greatly lengthen the investigative and hearing processes.

Social Security Number Article III, Paragraph (c)(11) specifies that an applicant for a multi-state license would be required to have a social security number. This is not consistent with Ohio law or federal law.

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Conversion of Licenses When Licensee Changes State of Residency Article IV, paragraph (c) states that “If a nurse changes primary state of residence, by moving between two party states, the nurse must apply for licensure in the new home state and the multi-state license issued by the prior home state will be deactivated in accordance with applicable rules adopted by the Commission.” (Emphasis added.) Article IV, paragraph (d) states that “If a nurse changes primary state of residence by moving from a party state to a non-party state, the multi-state license issued by the prior home state will convert to a single state license, valid only in the former home state.” (Emphasis added.)

Þ Consideration: Ohio could not “convert” or “deactivate” a license without affording the licensee due process.

Mandatory Reporting Mandatory reporting is not a requirement in the new Compact. The TERCAP data has shown the importance of mandatory reporting to assure boards of nursing are receiving complaints and preventing unsafe practitioners from moving from employer to employer without the board of nursing knowing about the unsafe practice.

Þ Consideration: Ohio is a mandatory reporting state. Response to Disaster Situations At the 2015 Midyear Meeting, the Compact was cited as being necessary to assure an adequate nursing workforce during disaster situations. However, single state licensure can also effectively address disaster situations. When this question has been presented to the Board, we have responded as follows:

Non-membership in the NLC does not impede the deployment of licensed nurses from other states to Ohio during a disaster, or the deployment of Ohio licensed nurses to declared disaster areas in other states. The Nurse Practice Act, Section 4723.32(G)(7), ORC, allows nurses who hold an active, valid license in another state to come to Ohio in the case of any declared disaster. Further, under Section 4723.32, ORC, providing emergency assistance does not require a nursing license in Ohio. During the aftermath of Hurricane Katrina, the Board encouraged and facilitated Ohio nurses to provide disaster relief by enrolling in the Medical Reserve Corp (MRC)/Red Cross (ARC), Through enrollment, state license status was verified; the deployment of nurses was organized so nurses were matched to the area of need, based on the nurse’s education and experience; and emergency relief training was provided as needed. Also, nurses with active, valid licenses in one state were considered federal employees and did not need a license to practice in the state where they are going. In addition, the ARC has negotiated reciprocal licensing agreements with each state, so if nurses with active, valid licenses in one state are activated through ARC, they are able to practice in other states without having a license to practice in that state.

Sharing of Investigative Information At the 2015 Midyear meeting, it was emphasized that an advantage of the Compact is that states can share investigative information with each other, which they could not do previously as single states.

Þ Consideration: As a single state licensure board, Ohio is authorized to share investigative information with other boards of nursing under the Ohio Nurse Practice Act.

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Effect of Disciplinary Actions in Other Compact States At the 2015 Midyear meeting, it was explained that if the home state takes a disciplinary action against a nurse, that action prevents the nurse from practicing in the remote states and the nurse is issued a single state license. However, if a remote state takes disciplinary action, the discipline is only effective in the remote state that took the action, so the nurse could continue to hold a multi-state license and practice in other Compact states. It was suggested that remote states would check Nursys to determine if other remote states have taken disciplinary actions and then could bootstrap the action taken in the other remote state.

Þ Consideration: If the remote state does not know the nurse is practicing in their state, it is not clear how the remote state would know to check the individual nurse’s license/discipline in Nursys? Perhaps it could be explored so when a nurse is disciplined in a home state or in a remote state, the multi-state license is revoked and the nurse could only be issued a single state license.

Fiscal implications Currently there is a $6,000 annual fee for Compact membership. The fiscal impact will vary from state to state. Ohio would need to conduct a fiscal analysis to determine the impact on loss of licensure fee revenues.

74

MEMORANDUM To: Board Members Ohio Board of Nursing From: Betsy Houchen Executive Director Tom Dilling Public and Governmental Affairs Officer/Liaison

Subject: SB 341, Nurse Licensure Compact (133rd General Assembly) Date: January 6, 2021 The Nurse Licensure Compact, SB 341, was introduced on July 21, 2020 and referred to the Senate Health, Human Services and Medicaid Committee. The Board participated in an interested party meeting with Senator Kristina Roegner, the sponsor of the bill, and continued to meet with the Ohio Organization for Nursing Leadership (OONL), ONA, and NLC staff, all of whom are collecting data and other information in response to Board questions. On December 1, 2020, the Board testified as an interested party in the Senate Health Committee. The Ohio Nurses Association (ONA) testified in opposition at the same Committee Hearing. Proponent testimony was offered by a variety of individuals and groups including the Ohio Hospital Association (OHA), Cleveland Clinic, and Akron Children’s Hospital. On December 9, 2020, SB 341 was passed by the Senate, and it was introduced in the House on December 14 with no action taken. SB 341, the LSC analysis, and Fiscal Note are attached. Also attached are copies of ONA’s and the Board’s testimony provided to the Senate Health, Human Services and Medicaid Committee, as well as the proponent testimony of the organization’s mentioned above. Other compact bills were considered by the 133rd General Assembly and are expected to be introduced and heard again in the 134th General Assembly:

• The Physical Therapy Licensure Compact, SB 272, was passed by the Senate in June of 2020 and informally passed by the House on December 17, 2020.

• SB 258 establishes the multi-jurisdictional psychology compact known as PSYPACT. It was passed by the Senate in May of 2020 and passed by the House on December 17, 2020. This compact provides for the practice of telepsychology and temporary in-person psychology across state boundaries for participating states. The Senate “informally passed” SB 258 on December 28 and 31, 2020 at the end of the General Assembly. The bill does not become law because the Senate adjourned Sine Die.

75

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The Recognized Leader and Advocate for Professional Nursing in Ohio 3760 Ridge Mill Drive Hilliard, OH 43026 614-969-3800 Fax 614-969-3888 www.ohnurses.org

December 1, 2020

Senate Health, Human Services & Medicaid Committee Chairman David Burke 1 Capitol Square Columbus, Ohio 43215

RE: Senate Bill 341 – Nurse Licensure Compact

Good afternoon Chairman Burke, Vice Chair Huffman, Ranking Member Antonio, and Members of the Senate Health, Human Services and Medicaid Committee. Thank you for allowing me to be here today to offer testimony on Senate Bill 341 and Ohio joining the Nurse Licensure Compact. My name is Deb Arms and I am the President of the Ohio Nurses Association (ONA). First, I would like to take the opportunity to thank Senator Roegner for engaging in conversations with the Ohio Nurses Association and bringing together a virtual interested party meeting between ONA, the Ohio Board of Nursing and the National Council of State Boards of Nursing.

As mentioned in Senator Roegner’s sponsor testimony, the Nurse Licensure Compact (Compact) allows

registered nurses and licensed practical nurses to participate in the multi-state licensure compact, which

enables nurses to practice in all Compact states. Currently, thirty-four states have enacted the Enhanced

Nurse Licensure Compact, with five states, including Ohio, having pending legislation.

The former and enhanced Multi-State Nurse Licensure Compact model has been reviewed by the ONA leadership and consideration has been given to the Ohio Board of Nursing’s current position. While ONA remains committed to engaging in all conversations to address factors such as telehealth, cross-border nursing practice, and the Interstate Commission of Nurse Licensure Compact Administrators, we cannot support Senate Bill 341.

What Is the Ohio Board of Nursing’s Position?

While ONA cannot speak on behalf of our regulatory board, we have engaged in many conversations with

the Ohio Board of Nursing regarding Compact licensure over many, many years. In 2005, the Ohio Board

of Nursing (Board) reviewed and examined the multi-state licensure compact and, by Board vote, decided

at that time to “delay action seeking the introduction of interstate compact legislation until such time

more information [was] gathered to assure that the benefits of multi-state licensure outweigh[ed] any

risks related to public safety”. The Board, since its first introduction to multi-state licensure, worked at

the national level to address Ohio’s concerns. To date, not all of Ohio’s concerns have been addressed.

At its April 2019 meeting, the Board updated and reissued its position statement. Per the 2019 statement,

the Board states:

Since 2005, the Board has discussed multi-state licensure at numerous meetings and

continuously has worked at the national level to address Ohio’s concerns. Annually the Board

has discussed the Compact and has reaffirmed its belief that the potential risks of harm to

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the public outweigh the potential benefits because nurses with multi-state licenses

could practice in Ohio without meeting the current statutory and regulatory

standards established by the General Assembly and the Board to protect the public.

The Board continues to address these issues through the National Council of State Boards of

Nursing (NCSBN).

The Board reviewed the eNLC to weigh the benefits and potential risks. Concerns regarding

the eNLC include (but are not limited to) the following:

(i) the eNLC would establish a Commission that would be funded by state revenue, but would

not be subject to state transparency requirements (open meetings/open records acts);

(ii) the Commission could adopt rules binding on Compact member states without undergoing

state rule-making processes;

(iii) concern was expressed that state would be ceding their legal authority to a privately

operated Commission.

Further, the Board continues to be concerned about public safety issues due to differences between states’

licensure laws that are not addressed in the Compact, such as mandatory reporting, complaints and

investigations. Mandatory reporting is not a requirement for all Compact states as it is in Ohio. Also,

complaints and investigations are handled differently. For example, some Compact states require clear

and convincing evidence to substantiate a violation of their Nurse Practice Acts. Ohio requires a

preponderance of evidence. Because clear and convincing evidence is a higher standard of proof than a

preponderance of the evidence, those boards may not investigate complaints that the Ohio Board of

Nursing would investigate.

Why is ONA Concerned About the Compact?

State Sovereignty and Authority of the Interstate Commission-

The Attorneys General in Oklahoma, Indiana, Kansas, Louisiana, and Nebraska have rendered formal

opinions that the multi-state nurse licensure compact interferes with state sovereignty. The Compact

would impose complicated regulatory mechanisms that would allow the joint public entity known as the

Interstate Commission of Nurse Licensure Compact Administrators (Commission), composed of the party

states that adopt the Compact, to promulgate rules that are binding on each state in the Compact by a

simple majority vote. This essentially grants full rule-making authority to the Commission, which is not a

government entity or state agency, nor based in Ohio. This Commission is the equivalent to a professional

association for the state boards of nursing and they do not have authority to pass laws or promulgate

rules.

According to the National Council of State Boards of Nursing, each state would be subject to administrative

rules not passed at the state level. In this way, the Commission is usurping policy-making authority from

the Board and state Legislature. Additionally, the Commission has “enforcement action” authority, which

means that the Commission has the authority to remove any state from the Compact, should a state board

of nursing not adhere to the Compact statute and/or rules. This again, represents an appropriation of

Ohio’s sovereignty.

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Lastly, the Commission would have the opportunity to hold closed, non-public

meetings for certain reasons and would have immunity to lawsuits. Many of these

provisions of the Compact may violate the Ohio Constitution, the Ohio Open Meeting

Act, the Ohio Ethics Law and/or Ohio statute and may potentially create a monopoly system, where NCSBN

holds full national licensure examination and regulatory authority. Some states that have joined the

Compact are witnessing violations of their state’s open public meeting laws. For example, New Mexico

has open meeting laws similar to Ohio’s, and when the New Mexico legislature passed a law requiring that

documents related to the administration of the Compact be released per New Mexico’s public disclosure

laws, the Commission sent a letter threatening New Mexico with legal action.

ONA believes that, by adopting the Compact, the Ohio Board of Nursing and the state would be handing

over significant authority to the Commission, which does not benefit the regulatory board or Ohio nurses.

Regulation, Public Safety, and Disciplinary Action-

The mission of the Ohio Board of Nursing is to actively safeguard the health of the public through the

effective regulation of nursing. However, the Compact would not require that out-of-state nurses be

licensed in the state of Ohio, which means that the Board would no longer review and approve license

applications from out-of-state residents. In addition, the effects of how disciplinary actions would work in

practice in other Compact states are unclear. Because a nurse would have jurisdiction to work in a remote

state without that state’s licensure, it is unclear how that remote state would know to check an individual

nurse’s license and previous disciplinary actions.

During the interested party call I mentioned in my opening remarks, the National Council of State Boards

of Nursing (NCSBN) stated that disciplinary action is two-fold for states who join the Compact. The remote

state Board of Nursing would have authority to discipline a non-Ohio nurse through privilege to practice

restrictions, but only the home state Board of Nursing would have the authority to take action on the

license itself. Thus, the Ohio Board of Nursing would not have the authority to place licensure restrictions

or take action on an out-of-state Compact license. It is unclear how the remote state would stay in

constant contact with each home state’s licensees and how regulators would know what disciplinary

actions have been taken on the license itself, and vice versa.

Additionally, the effects of regulation, licensing and the lack of absolute bars significantly compromises

public safety and place the responsibility for screening licensees onto the employers. Under SB 341,

employers would ultimately be the ones accepting or denying nurses for practice and not the regulatory

Board.

Financial Impact to Ohio Board of Nursing-

According to the Ohio Board of Nursing, there is currently a $6,000 annual fee for Compact membership.

The fiscal impact could vary from state to state and Ohio still needs to conduct a fiscal analysis to

determine the impact on loss of licensure fee revenues. However, the additional expenses and losses

potentially placed on the Board could result in a reduction of services and/or an increase in licensing fees.

For example, the Board of Nursing in Vermont performed a fiscal analysis that showed it could lose a

quarter of its revenue if the state joined the Compact. The Washington state Board of Nursing indicated

that joining the Compact could potentially increase home state license fees to upwards of $200.00.

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Currently, the Ohio Board of Nursing charges $75.00 for initial licensure by

examination and by reciprocity, while the registered nurse license renewal fee is

$65.00 every two years.

Many states that have already joined the Compact offer both a regular home state license and a Compact

license. For the states that have implemented these two licensing options, 12 – 16 percent of nurses have

opted for the Compact license. Preliminary results from a recent ONA member survey on legislative

priorities show that obtaining Compact licensure is not important to Ohio nurses, and joining the Compact

would place undue financial burden on Ohio nurses, while not placing a similar burden on those coming

from out of state.

Voices of Professional Nurse Associations-

The way the Compact shifts power to the Commission, giving it the authority to enact rules that are binding

on each state in the Compact, takes power and authority away from the Ohio Board of Nursing. According

to Compact rules, if there was a dispute between Ohio and the Commission, the matter would be handled

in the Illinois court system, where NCSBN is located, and not in our state’s jurisdiction. ONA believes this

takes influence away from professional associations, like ONA, and does not provide other interested

parties an opportunity to voice opinions, suggestions, or concerns during the promulgation or review of

administrative rules. ONA currently has the valued opportunity to participate in such processes with the

Ohio Board of Nursing and the Ohio General Assembly. We believe that participation is a critical part of

informed policymaking.

The Commission holds four meetings a year, two of which are in Chicago and two of which are in other

various locations across the country. While the meetings are open to the public, it is unclear as to how

the voice of Ohio nurses would be heard at the meetings.

Ohio Already Offers State of Emergency Practice for Out-of-State Nurses-

Supporters of the Compact have stated that Ohio needs to join the Compact to allow nurse mobility during

times of disasters or emergencies. ONA realizes that the ability to mobilize nurses to Ohio during such

emergencies and disasters is critical; however, Ohio already covers this need under Section 4723.32(G)(7)

of the Ohio Revised Code.

This section states the following regarding out-of-state nurses:

(G) The activities of an individual who currently holds a license to practice nursing or equivalent

authorization from another jurisdiction, but only if the individual's activities are limited to those

activities that the same type of nurse may engage in pursuant to a license issued under this chapter,

the individual's authority to practice has not been revoked, the individual is not currently under

suspension or on probation, the individual does not represent the individual as being licensed under

this chapter, and one of the following is the case:

(7) The individual is providing nursing care during any disaster, natural or otherwise, that has been

officially declared to be a disaster by a public announcement issued by an appropriate federal, state,

county, or municipal official;

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While ONA acknowledges the struggles of Ohio hospitals during the current

pandemic, the Compact is not a quick fix to increase the healthcare workforce during

COVID-19. Even if the legislature passed Senate Bill 341 during Lame Duck, the

Compact would take roughly a year and a half to be fully implemented. Therefore, enacting compact

licensure for Ohio is irrelevant and unnecessary when it comes to protecting Ohioans in the case of an

emergency or the current pandemic. Licensed nurses from other states may already practice in Ohio in

these situations without having a multi-state license.

Complexity of Telehealth Services-

ONA understands and appreciates the need for mobility and flexibility for nursing practice in today’s

healthcare environment, as well as the accessibility that telehealth services offer to healthcare

professionals and patients. While telehealth is necessary, the services provided and where they are

provided need to be considered. License jurisdiction and the preeminence of both patient and nurse

location has been long discussed among regulatory boards and nurses throughout the country.

Nurse regulatory boards believe license jurisdiction and practice belongs where the patient is located,

while professional nurses’ associations and nurses believe license jurisdiction and practice should lie

where the nurse is practicing. The Compact has and will always be based on the premise that the practice

of nursing occurs where the patient is located. This fundamental belief that governs the operations of the

compact hold the nurse, patient, and the employer at significant risk.

Based on the ideology that practice follows the patient, a nurse engaging in telehealth must know the

exact location of every patient he/she is providing care to. It also means that any nurse offering telehealth

services should know, understand, and abide by all fifty states’ practice laws and rules. A patient could

theoretically be on vacation in another state or in an entirely different country and it would be the

responsibility of the nurse to know where the patient is located and what the nurse can practice through

telehealth services to be safe and effective in that state. The Compact assumes that scope of practice is

identical in all fifty states and that every nurse working in telehealth is familiar with every state in which

they are practicing. This is neither accurate, nor is it realistic. ONA believes this puts patients, nurses, and

the employers at risk.

Protecting Ohio Nurse Jobs-

The Ohio Nurses Association is committed to protecting nurses across the state through labor

representation and collective bargaining contracts. Part of this representation includes advocating for a

fair contract and protecting nurses’ jobs. Healthcare organizations will lose incentives to come to fair

collective bargaining agreements with Ohio nurses if the licensure Compact is enacted, as it allows out-of-

state nurses to easily replace Ohio nurses who are advocating for safe work environments and fair

compensation. Furthermore, the ONA opposes the Compact because it allows greater opportunities for

out-of-state nurses to work in Ohio facilities in the event of a labor union strike. Not only does this directly

impact the jobs and financial security of our members, the ONA has great concerns about public safety

should an influx of out-of-state nurses, who are not familiar with our state’s Nurse Practice Act, begin

practicing and caring for Ohioans.

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Coupled with the decreased regulatory authority of the Board and the complex

disciplinary processes outlined by NCSBN, the ONA believes the Compact is not in the

best interest of Ohio’s nurses and all Ohioans. Lastly, ONA believes that, as a state,

we should be recruiting and retaining our own nurses. We want nurses to become and/or remain Ohio

residents so that we can build our economy, pay taxes to our state, and lay roots and raise children in our

state, while supporting the nursing workforce.

Due to the concerns addressed in my testimony today, the Ohio Nurses Association believes the Nurse Licensure Compact impedes the Ohio General Assembly and Ohio Board of Nursing’s authority, while also impacting the Ohio nurse workforce into the future. Therefore, the ONA opposes Senate Bill 341 and we respectfully request that this committee oppose the bill as well. Thank you for your time today. I would be happy to answer any questions you may have at this time.

Sincerely,

Deborah Arms, PhD, RN

ONA President

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December 1, 2020 The Honorable Dave Burke Ohio Senate Chair, Senate Health, Human Services and Medicaid Committee Senate Building 1 Capitol Square Ground Floor Columbus, Ohio 43215 Chairman Burke and members of the Senate Health, Human Services and Medicaid Committee: Thank you for the opportunity to provide testimony for Senate Bill 341, sponsored by Senator Kristina Roegner. In 2005, the Ohio Board of Nursing (Board) examined issues and learned about the experience of some Compact states participating in multi-state licensure. Although the Board recognized that multi-state nurse licensure could be advantageous for occupational health nurses, traveling nurses, or employers, the Board discussed that potential risks of harm to the public outweigh the potential benefits. Over the years, the Board reviewed the actual experience of other states and identified the potential impact of multi-state licensure on public safety. We were advised of nurses with multi-state licenses relocating to states as soon as they find themselves under investigation in their home state. While in theory, the home state would immediately report the investigation to the next state, the reality is neither state may learn of the relocation for a significant period of time. Furthermore, not all states had laws like that in Ohio permitting sharing of investigative information with other governmental entities. In addition, when the nurse moves to another state, the home state does not always continue its investigation. This means that Ohio would not receive vital information unless Ohio attempted to conduct an out-of-state investigation and this is not realistic. In fact, it is unclear whether Ohio would have the ability to compel the production of out-of-state documents or witnesses necessary to prepare a case. Annually the Board discusses the Compact and has reaffirmed its belief that the potential risks of harm to the public outweigh the potential benefits because nurses with multi-state licenses could practice in Ohio without meeting the current statutory and regulatory standards established by the General Assembly and the Board to protect the public. The

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Board continues to address these issues through the National Council of State Boards of Nursing (NCSBN). The Board recognizes that an adequate and safe nursing workforce is vital during times of emergencies like the COVID-19 emergency we are fighting today. However, non-membership in the eNLC does not impede the deployment of licensed nurses from other states to Ohio during a disaster, or the deployment of Ohio licensed nurses to declared disaster areas in other states. The Nurse Practice Act, Section 4723.32(G)(7), ORC, allows nurses who hold an active, valid license in another state to practice in Ohio in the case of any declared disaster without being licensed in Ohio

During emergencies in other states, the Board has encouraged and facilitated Ohio participation by Ohio nurses in disaster relief through enrollment in the Medical Reserve Corp (MRC)/Red Cross (ARC). The ARC verifies state licensure status, provides emergency relief training, and organizes deployment by matching a nurse’s area of expertise to the area of need. The ARC has negotiated reciprocal licensing agreements with each state, so if nurses with active, valid licenses in one state are activated through ARC, they are able to practice in other states without having a license to practice in that state.

We are aware that the NCSBN voted to approve new Compact model legislation, known as the enhanced Nurse License Compact (eNLC). During the NCSBN Annual Meeting in August 2015, an information session for state attorneys, regarding the legal implications of the eNLC, was provided by the Compact Special Counsel and NCSBN Legal Counsel. In January 2018 the e NLC became effective.

The Board reviewed the eNLC to weigh the benefits and potential risks. Concerns regarding the eNLC include (but are not limited to) the following: (i) the eNLC established a Commission that would be funded by state revenue but would not be subject to state transparency requirements (open meetings/open records acts); (ii) the Commission could adopt rules binding on Compact member states without undergoing state rule-making processes; (iii) concern was expressed that the state would be ceding their legal authority to a privately operated Commission.

Further, the Board continues to be concerned about public safety issues due to differences between states that are not addressed in the eNLC, such as mandatory reporting and complaints/investigations. Mandatory reporting is not a requirement for eNLC states as it is in Ohio. Also, complaints and investigations are handled differently. For example, some eNLC states require clear and convincing evidence to substantiate a violation of their Nurse Practice Acts. Ohio requires a preponderance of evidence. Because clear and convincing evidence is a higher standard than proof by a preponderance of the evidence, those boards may not investigate complaints that the Ohio Board of Nursing would investigate.

Here is a brief recitation of some of the issues and concerns the Board continues to raise with the NCSBN and NLC with respect to the NLC:

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Authority of the Interstate Commission

Article VII establishes “a joint public entity known as the Interstate Commission of Nurse Licensure Compact Administrators” (Commission) composed of the party states that adopt the new Compact. Article VII also grants powers to the Commission. • Paragraph (b)(1): “Each party state shall have and be limited to one administrator...”

• Paragraph (b)(2): “Each administrator shall be entitled to one (1) vote with regard to

the promulgation of rules and creation of bylaws and shall otherwise have an opportunity to participate in the business and affairs of the Commission....”

® Consideration: Each member, regardless of the number of licenses regulated, or the amount of fees paid to the Commission, is represented by one person and has one vote.

• Paragraph (g) and (g)(1) “The Commission shall have the following powers: To promulgate uniform rules to facilitate and coordinate implementation and administration of this Compact. The rules shall have the force and effect of law and shall be binding in all party states.”

® Consideration: The Commission will have the power to enact rules that are binding on each State in the Compact by a simple majority vote. Each State would be subject to administrative rules not passed at the State level.

• Paragraph (a)(2): The Commission will be subject to the laws of the state in which it is organized, i.e., Illinois. ® Consideration: If there is a dispute between Ohio and the Commission or another

party state, the matter will be handled in the Illinois court system.

• Paragraphs (b)(5) and (i): “The Commission may convene in a closed, non-public meeting” for certain reasons; the Commission has immunity/defenses to lawsuits.

Þ Consideration: The Commission is not subject to any independent auditor or legal authority with oversight over its operations or finances and has immunity/indemnification from lawsuits.

• Paragraph (g)(6): The Commission shall have the following powers: “To hire employees... fix compensation, define duties...”

• Paragraph (c): “The Commission shall, by a majority vote of the administrators, prescribe bylaws or rules to govern its conduct as may be necessary or appropriate to carry out the purposes and exercise the powers of the Compact, including but not limited to: ...providing reasonable standards and procedures: for the establishment

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and meetings of other committees; and governing any general or specific delegation of any authority or function of the Commission.”

® Consideration: The Commission is to be fully staffed and all of its costs will be paid for by annual assessments on members; the Commission would have exclusive say in how much each member is assessed. At this time, the cost for each party state to support the Commission is unknown.

Many of these provisions may violate the Ohio Constitution, the Ohio Open Meetings Act, the Ohio Ethics Law and other Ohio statutes. The budget impact is uncertain but due to required assessments, it is anticipated that it will not be budget neutral.

Mandatory Reporting

Mandatory reporting is not a requirement in the new Compact. The TERCAP data has shown the importance of mandatory reporting to assure boards of nursing are receiving complaints and preventing unsafe practitioners from moving from employer to employer without the board of nursing knowing about the unsafe practice.

® Consideration: Ohio is a mandatory reporting state.

Grandfathering

Article III, paragraph (g) specifies that nurses who currently hold a multi-state license would retain their multi-state license. The exceptions would be (1) nurses who change their primary state of residence, must meet the requirements of the new Compact; or (2) a nurse who “fails to meet the multi-state licensure requirements due to a criminal conviction, enrollment in an alternative program, an adverse action or any other event occurring after the Compact’s effective date, shall be ineligible to retain or renew a multi-state license and the nurse’s multi-state license shall be revoked or deactivated in accordance with applicable Commission rules.”

® Consideration: Nurses who currently have multi-state license under the old Compact would be grandfathered into the new Compact. Therefore, nurses who never had criminal records checks could hold a multi-state license under the new Compact.

Misdemeanors

Article III, paragraph (c)(7) states that for an applicant to obtain or retain a multi-state license in the home state, the individual “has not been convicted or has entered into an agreed disposition, of a misdemeanor offense related to the practice of nursing as determined on a case-by-case basis....”

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® Consideration: Each State will make its own case-by-case determination about whether to impose discipline for misdemeanors. If the state takes action on a misdemeanor, other party states could take action based on the other State’s action, but if the State where the misdemeanor occurred declines to take action, the Board would not be aware of the misdemeanor.

Conversion of Licenses When Licensee Changes State of Residency

Article IV, paragraph (c) states that “If a nurse changes primary state of residence, by moving between two party states, the nurse must apply for licensure in the new home state and the multistate license issued by the prior home state will be deactivated in accordance with applicable rules adopted by the Commission.” (Emphasis added.)

Article IV, paragraph (d) states that “If a nurse changes primary state of residence by moving from a party state to a non-party state, the multi-state license issued by the prior home state will convert to a single state license, valid only in the former home state.” (Emphasis added.)

® Consideration: Ohio could not “convert” or “deactivate” a license without affording the licensee due process.

Effect of Disciplinary Actions in Other Compact States

At the 2015 Midyear meeting, it was explained that if the home state takes a disciplinary action against a nurse, that action prevents the nurse from practicing in the remote states and the nurse is issued a single state license. However, if a remote state takes disciplinary action, the discipline is only effective in the remote state that took the action, so the nurse could continue to hold a multi-state license and practice in other Compact states. It was suggested that remote states would check Nursys to determine if other remote states have taken disciplinary actions and then could bootstrap the action taken in the other remote state.

® Þ Consideration: If the remote state does not know the nurse is practicing in their state, it is not clear how the remote state would know to check the individual nurse’s license/discipline in Nursys? Perhaps it could be explored so when a nurse is disciplined in a home state or in a remote state, the multi-state license must be revoked, and the nurse could only be issued a single state license.

Fiscal implications

Currently there is a $6,000 annual fee for Compact membership. The fiscal impact will vary from state to state. Ohio would need to conduct a fiscal analysis to determine the impact on loss of licensure fee revenues. NCSBN offers states grants of financial

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assistance to help offset the expense of joining and implementing the NLC. The offset is temporary. It is paid for by the NCSBN of which we are a member state. The annual fee is just that—annual—and the offset may not last long.

In addition, each of Ohio’s current 300,000 licensees pay a biennial renewal fee that funds the Board’s operations and mission of public protection. The Board does not receive funds from the General Revenue Fund. The question arises as to why an Ohio licensee pays a fee to the Board, but a compact licensee residing in another state but practicing in Ohio whether as a telehealth nurse or a travelling nurse pays their fee to their home state? And the next question becomes whether that telehealth practice is subject to a tax in Ohio or whether the practitioner’s wages are taxed in Ohio or whether the corporation residing out of state but doing business in Ohio pays any type of fee or tax in this state? What are the fiscal ramifications to the state?

What are the costs of board investigations concerning compact licensees in other states? The costs to adjudication of those matters, including appeals? If an Ohio patient is harmed resulting in lawsuit, what are the costs to the legal process considerations for a matter of care that originated in another state?

Summary

The Board is committed to its mission of public protection, following the laws enacted by the Ohio legislature, and enforcing regulations promulgated for patient safety. The Board has not been dismissive of compact discussions. To the contrary, the Board has engaged in discussions with proponents and interested parties to this matter, including a recent meeting with the bill’s sponsor. The Board will continue to act in good faith in working toward finding a point where benefits outweigh costs in regard to patient safety, public protection and fundamental fairness and equity to Ohio patients and Ohio’s 300,000 nurse licensees and not solely a small and particular segment of that population. If the compact can accomplish these goals, then let’s also assure Ohio’s nursing community that the change can be implemented in a manner that does not unfairly or unnecessarily compromise current licensure and disciplinary practices. We do not believe we are there as yet in being able to safely commit to the Nurse License Compact set forth in SB 341.

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One Perkins Square | Akron, Ohio 44308-1062 | Phone 330-543-1000 | www.akronchildrens.org

Christine Young, MSN, MBA, RN, NEA-BC

Chief Nursing Officer, Akron Children's Hospital

Proponent Testimony, Ohio Senate Bill 341 (SB 341) Ohio Senate Health, Human Services and Medicaid Committee

November 17, 2020

Chairman Burke, Vice-Chair Huffman, Ranking Member Antonio and the members of the Senate Health, Human Services and Medicaid Committee, my name is Christine Young, and I am the Chief Nursing Officer at Akron Children’s Hospital, where I have served since 2012. Thank you for the opportunity to express our hospital’s support and submit proponent testimony for Ohio Senate Bill 341 (SB 341). I would also like to express the appreciation of Akron Children’s Hospital to Senator Kristina Roegner, a member of this committee, for her time, effort and thoughtfulness in drafting this legislation. Akron Children’s Hospital is committed to ensuring that all of our providers, including all of our nurses, are able to provide safe and effective health care services to the patients and families we are privileged to serve. Further, the American Nurses Credentialing Center (ANCC), through the Magnet Recognition Program, has distinguished Akron Children’s with Magnet status for our commitment to nursing excellence and outstanding performance by the entire organization. Less than 7% of U.S. health care organizations (including only 37 children’s hospitals) have achieved Magnet status, and we are proud that Akron Children’s has received continued designation as a Magnet organization in 2007, 2012 and 2016. While providing care in our communities, we know it is crucial for nurses to be able to comply with state licensure laws that cross state lines. The provision of care to patients in states where the nurse is not licensed poses potential legal concerns regarding the nurse’s unlicensed practice in those states. Nurses are faced with a decision to either treat a patient in a state where they are not licensed or to decline providing care to that patient, often after a nurse/patient relationship has been established. This raises potential ethical dilemmas between meeting the need to provide care for a patient and the need to comply with state licensure regulations, which place the nurse, patient and health care organization at risk. This situation occurs frequently as a result of nurses who provide telehealth care, home health, long-distance monitoring of patients, hospital follow-up care and also due to the increased mobility of the nursing workforce across state lines. As outlined in SB 341, the enhanced Nurse Licensure Compact (eNLC) allows registered nurses (RNs) and licensed practical/vocational nurses (LPN/VNs) to have one multistate license in their primary state of residence and to practice in other compact states, while being subject to each state’s practice laws and discipline. Participation in the eNLC facilitates the safe, effective delivery of health care by nurses while reducing the risks of practicing in states where they are not licensed. Further, in catastrophic situations, the ability to quickly mobilize emergency nursing staff is essential. Having expedited access to licensed, qualified and competent nurses that are guaranteed through the eNLC is imperative during these times of crisis. Currently, Ohio is nearly surrounded by states participating in the eNLC. Kentucky, West Virginia and Indiana joined the compact, while Pennsylvania and Michigan have introduced legislation to join the compact. Amid the current coronavirus pandemic, providers are expanding access to care by increasing telehealth technology usage. Nurses are available 24 hours a day to handle telephone coverage, and without endorsement of multistate nursing licensure, the intended use of telehealth services may be limited, which could negatively impact access to care. As one of the largest pediatric health care delivery systems in Ohio, Akron Children’s Hospital has expanded to regions with limited resources in pediatric expertise, and the boundaries where we provide care continue to expand to states outside of Ohio. The nurse compact will support the provision of nursing care to all patients, regardless of the state in which they reside and allow for this to be done efficiently without requiring nurses to hold and maintain multiple nursing licenses. Thank you for the opportunity to share Akron Children’s perspective. I respectfully request that this committee favorably report Ohio Senate Bill 341.

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Senate Bill 341 – Proponent Testimony Senate Health, Human Services, and Medicaid Committee

Meredith Foxx, MSN, MBA, APRN Executive Chief Nursing Officer, Cleveland Clinic

November 17, 2020

Chairman Burke, Vice Chair Huffman, Ranking Member Antonio and members of the Senate Health, Human Services and Medicaid Committee, thank you for the opportunity to provide proponent testimony on Senate Bill 341, which would permit Ohio to enter the national Nurse Licensure Compact (NLC). My name is Meredith Foxx, and I am Executive Chief Nursing Officer at Cleveland Clinic.

Nurses are more critical than ever and Ohio must answer the call to greater care. Ensuring Ohio is competitive nationally to attract and retain nurses to seamlessly deliver care through the Nursing Licensure Compact is a strong next step for our future.

As the largest employer in Ohio, Cleveland Clinic is dedicated to its nurses, which is the health system’s largest caregiver group. The Stanley Shalom Zielony Institute for Nursing Excellence at Cleveland Clinic oversees the practice and education of nearly 23,000 nursing caregivers across inpatient, outpatient, rehabilitation and home care settings. Hospital and surgical nurses provide care for patients in over 4,500 hospital beds and over 225 operating rooms throughout 11 hospitals, 19 family health and surgery centers, and 3 health and wellness centers across northeast Ohio. Cleveland Clinic’s fast-paced, technologically advanced environment allows nurses to learn, grow and remain professionally challenged while shaping their careers. The nurses of Cleveland Clinic have vast experience and diverse expertise. Our nurses work in every setting and can be found in positions of leadership, advanced practice, quality, research, education and more.

With advancements in telehealth in recent years, and with the unprecedented challenges that have resulted from the coronavirus pandemic, Senate Bill 341 would improve patient and would make Ohio more competitive. The Nursing Licensure Compact allows for nurses who are residents of NLC states to practice in other NLC states without having to obtain additional licenses.

Patient care as a whole can benefit from more states joining the NLC. In total, 34 states are currently a part of the NLC, including a majority of the states surrounding Ohio: Indiana, Kentucky, and West Virginia. In addition, legislation is currently pending in six states, including Pennsylvania and Michigan. Ohio joining the NLC will make the state more competitive in retaining and attracting nurses, who otherwise may wish to move to a border state to practice.

Senate Bill 341 is especially beneficial to Cleveland Clinic nurses due to our growing presence in Florida, which is currently a member of the NLC. The Florida region is an integral part of Cleveland Clinic in Ohio, with five hospitals and numerous outpatient centers in Broward, Palm Beach, Martin, St. Lucie and Indian River Counties. Having Ohio join Florida as part of the NLC, would allow our nurses to be portable between the two states to care for patients.

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The need for such mobility is highlighted during the current coronavirus pandemic, where more caregivers may be needed to address growing patient volumes in different parts of the system. Similarly, the NLC will allow the Clinic and other providers to more easily bring traveling nurses into Ohio during times when we need to supplement our own nursing staff.

In addition, when Cleveland Clinic needs to support long distance, virtual care, the NLC will avoid having to require nurses to obtain several licenses to practice. With telehealth as the future of healthcare, this is especially critical.

Again, Cleveland Clinic supports Senate Bill 341 and urges the committee to be supportive as well. We thank the bill sponsor, Senator Kristina Roegner, for being a champion of bills like this that address occupational licensing. Thank you for the opportunity to testify, and I am available to be contacted with any questions you may have.

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James Guliano, MSN, RN, NPD-BC, FACHE Vice President, Quality Programs

Ohio Hospital Association

Proponent Testimony Senate Bill 341

Ohio Senate Health, Human Services and Medicaid Committee November 17, 2020

Chairman Burke, Vice-Chair Huffman, Ranking Member Antonio and members of the Senate Health, Human Services and Medicaid Committee, my name is James Guliano and I serve as Vice President of Quality Programs at the Ohio Hospital Association (OHA). I have been a registered nurse for 34 years and served in past roles holding 24/7/365 accountability for safe, timely provision of hospital patient care services.

Established in 1915, OHA is the nation’s first state-level hospital association. OHA exists to collaborate with member hospitals and health systems to ensure a healthy Ohio. OHA currently represents 240 hospitals and 14 health systems throughout Ohio. OHA members hospitals in 2020 include: 189 acute care hospitals, 23 long-term acute care facilities, 28 psychiatric, rehabilitation, and specialty surgical hospitals, and 10 children’s hospitals. Members include 33 critical access hospitals and 51 teaching hospitals. The association is governed by a 20-member Board of Trustees with representation from small and large hospitals, teaching facilities and health care systems with a committee and task force structure.

Thank you for the opportunity to provide proponent testimony for Senate Bill 341 which would enter Ohio into the enhanced Nurse Licensure Compact, on behalf of the Ohio Hospital Association.

OHA has been in close consultation with the Ohio Organization for Nursing Leadership (OONL), a professional society of OHA, over the past several years and has determined this legislation would positively impact our members’ ability to provide timely care to the patients they serve, both in their own communities and beyond. You will also be hearing testimony from the group’s leadership further outlining the Compact and their supportive position. Through OONL’s thoughtful expertise, and in consultation with OHA’s entire membership, we believe passage of SB 341 would advance our mission to ensure a healthy Ohio. Participation in the Compact would positively impact patients, licensed nurses, and hospitals alike.

Patients who are served by Ohio hospitals but reside in another state (such as in the Ohio boarder states of Michigan, Indiana, Pennsylvania, West Virginia, and Kentucky) would be able to receive nursing services from Ohio licensed nurses for needs such as chronic disease follow-up

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Ohio Hospital Association Proponent Testimony—SB 341

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monitoring, discharge planning and care navigation, to cite a few. Each of these services contribute to optimal patient outcomes and decreasing unnecessary hospital readmissions, while still enabling care for patients in their own community. Interruptions to timely patient care services due to state boundary restrictions lead to fragmentation of care. Promoting continuity of patient care by established health care providers is one of the many benefits that participation in the Compact would afford patients, who are consumers of nursing care.

Licensed Ohio nurses in good standing would be able to practice in other states without delays while awaiting required application processes. Further, OHA supports the changes made to the Nurse Licensure Compact in 2018 to create the Enhanced Nurse Licensure Compact (eNLC). Of note, the eNLC includes standards for licensure which the original compact license lacked. For example, the NLC did not require applicants to undergo state and federal fingerprint-based criminal background checks, whereas the new eNLC does. As Senator Roegner mentioned in her sponsor testimony, the Compact “preserves the regulatory authority of states to protect public health and safety through the current system of state licensure.” Quality care and patient safety are core priorities for OHA and provide the foundation for all we do.

Ohio hospitals would gain an added ability to provide timely care to the communities they serve through Ohio’s participation in the Compact. OHA represents a diverse membership facing many unique and complex challenges. In surveying our member hospitals, we found broad based support for the Compact which demonstrates its potential positive impact on facilities of all kinds including small, rural, urban and academic medical centers. Ohio hospitals having access to practicing nurses with documented and diverse competencies provides an avenue for ensuring continuation of crucial patient care services in Ohio’s diverse patient care settings, such as clinics and ambulatory centers, not just hospitals.

Ongoing preparedness has long been a priority of Ohio hospitals. The COVID-19 pandemic has further underscored the Compact’s necessity. As we address the reality of increased hospital capacity and continued stress on staff and other resources, passage of SB 341 would be a crucial tool in addressing these very difficult situations while providing safe staffing. If Ohio were a member of the eNLC we would be able to supplement our current workforce with other licensed, qualified and competent nurses.

OHA appreciates Senator Roegner’s efforts to bring Ohio in line with its neighboring states in becoming a member of the Compact. We look forward to continuing our work with her to ensure passage of SB 341.

Thank you for your time and consideration of OHA’s support for SB 341. I welcome any questions from the committee.

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Senate Bill 341

Proponent Testimony

Ohio Senate Health, Human Services and Medicaid Committee

November 17, 2020

Chairman Burke, Vice-Chair Huffman, Ranking Member Antonio and members of the Senate

Health, Human Services and Medicaid Committee, we appreciate the opportunity to share our

support on behalf of the Ohio Organization for Nursing Leadership (OONL) for Senate Bill 341

which would enter Ohio in to the enhanced Nurse Licensure Compact.

Due to increasing hospital capacity and needed staffing resources, we regrettably could not join

the committee in-person. Please know that passage of Senate Bill 341 is a top priority for OONL,

and we look forward to continuing our efforts to see its implementation become a reality.

The Ohio Organization for Nursing Leadership is a state organization of nurse leaders serving as

the catalyst for innovative health care in Ohio and the nation. Members of our organization

represent nursing leadership from hospitals and health systems across the state. As the

recognized center of excellence for clinical leadership, OONL is committed to enhancing health

care through education, technology, research, consulting, networking and information sharing.

For further information about OONL, its membership and strategic goals, we have attached a fact

sheet.

Following extensive research and discussion amongst our membership, in August 2019 we

issued the following position statement on the Compact:

The OONL endorses the enhanced Nurse Licensure compact (eNLC) and encourages the

state of Ohio to become a member of this compact.

Our organization is committed to ensuring all nurses are able to provide safe and effective health

care services to all patients. While providing care, it is crucial that nurses are able to comply with

state licensure laws that cross state lines. The provision of care to patients in states in which the

nurse is not licensed potentially poses legal concerns regarding the unlicensed practice in those

states.

Nurses are faced with a decision to treat a patient in a state which they are not licensed, or

decline to provide care to the patient, often after a nurse/patient relationship has been established.

This raises potential questions of patient abandonment and puts the nurse, patient and

organization at risk. Situations in which this occurs frequently include providing telehealth care,

home health, long distance monitoring of patients, hospital follow-up care and the increased

mobility of the nursing workforce across state lines.

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Ohio Organization for Nursing Leadership Proponent Testimony – SB 341

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The enhanced Nurse Licensure Compact (eNLC) allows registered nurses (RNs) and licensed

practical/vocational nurses (LPN/VNs) to have one multistate license in the primary state of

residence (the home state) and practice in other compact states (remote states), while subject to

each state’s practice laws and discipline.

Participation in the eNLC facilitates safe and effective delivery of health care by nurses while

reducing risks of practicing in states where they are not licensed. Further, in catastrophic

situations, the ability to quickly mobilize emergency nursing staff is imperative, as demonstrated

during Hurricane Harvey in Texas in 2017, the 2019 mass casualties shooting incident in Dayton

and presently, the COVID-19 pandemic. Having expedited access to licensed, qualified and

competent nurses that are guaranteed through the eNLC is imperative in these times of crisis.

As of September 2020, 34 states are members of the eNLC. A current map of participating states

can be viewed here: https://www.ncsbn.org/nurse-licensure-compact.htm

Currently, Ohio is nearly surrounded by states participating in the eNLC. Kentucky, West

Virginia and Indiana joined the compact, while Pennsylvania and Michigan have introduced

legislation to join the compact.

Key components of the eNLC have addressed concerns previously noted by the Ohio State Board

of Nursing including: mandatory, finger-print based criminal background checks, and state

boards of nursing retaining jurisdiction over important licensing and discipline matters in their

respective states.

Because the eNLC provides for more robust governance, state boards of nurses retain jurisdiction

over important licensing and disciplinary matter, while at the same time experience a reduction

in administrative burden. State boards of nursing are therefore able to focus their attention where

it matters most: supporting nurses in their profession and protecting patient safety.

It is for these reasons we overwhelmingly support Ohio’s membership in the eNLC.

Of note, OONL has engaged in several meetings and conversations with other interested parties

and remains committed to continuing this open dialogue as SB 341 moves through the legislative

process.

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https://www.ncsbn.org/nurse-licensure-compact.htm

Ohio Organization for Nursing Leadership Proponent Testimony – SB 341

3

We would like to thank Senator Roegner for her work to advance this important legislation and

look forward to building upon our partnership.

Although we could not be with you in-person, we would be happy to answer any questions the

committee may have following its meeting.

Again, thank you for your time and consideration.

Anne Gunther, DNP, RN, NEA-BC

OONL President

Jayne Gmeiner, MSN, RN, NEA-BC

OONL President-Elect

Diane Sprankle MSN, MHA, RN, NE-BC

Diane Sprankle, MSN, MHA, RN, NE-BC

OONL Legislative & Practice, Chair

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Nurse Licensure Compact — Mythvs. FactOct 9, 2020 Topics: Advocacy and policy (/news/advocacy-policy)

This story was published in the Fall 2020 (/washington-nurse/2020/fall) issue of TheWashington Nurse (/washington-nurse) magazine.

This story appears in Asking for an upgrade (/news/2020/asking-for-an-upgrade).

Myth

The Nurse Licen sure Compact (NLC) will improve access to care andhelp with the state’s nursing shortages.

FactBecause a regis tra tion require ment for nurses entering a state undera Compact license is not allowed under the Compact, no data exists toprove that access to care has improved under the NLC. In fact, manystates in the NLC still say they have a nursing shortage.

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Myth

Nurse licen sure is a long and cumber some process for military spouses.

FactWashington state already has expedited licen sure for military spousesand partners seeking a nursing license. The Nursing Commis sion says ittakes about 10 days for processing these licensing requests — and theythen know that a nurse has requested a Washington state license andintends to practice in our state.

Last year, you may have heard us say that we believed the best way tosupport military spouses who want to obtain a Washington nursinglicense is to either waive the $125 appli ca tion fee or waive or reduce the$125 license fee. Then we learned that the Depart ment of Defense (DOD)provides $1,000 to military families when they move to cover incidentalexpenses such as licen sure — so DOD said these fee waivers areunnecessary.

Myth

The NLC will make nurse licen sure faster and easier in the case ofa disaster or public health emergency.

FactUnder RCW 70.15, The Uniform Emergency Volun teer Health Practi tionersAct (https://app.leg.wa.gov/RCW/default.aspx?cite=70.15), health practi -tioners can practice across state borders when an emergency decla ra - 138

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tion is in effect. Health practi tioners, regis tered with a regis tra tionsystem and with a license in good standing in their home state, maypractice in Washington during the emergency decla ra tion. This actapplies to health care practi tioners from out of state and those whoselicenses are inactive.

This act was put into practice at the start of the COVID-19 outbreak. InMarch 2020, over 4,500 health care workers submitted emergencyvolun teer practi tioner appli ca tions. The Depart ment of Health (DOH)maintains a roster of volun teer health care practi tioners practicing underthe emergency decla ra tion. Under the act, DOH has the authority toregulate any matters neces sary to coordi nate the provi sion of healthservices during an emergency, including where a practi tioner works,how long they work and what types of practi tioners can volunteer.

Under the NLC, this type of regis tra tion and regula tion does not exist.

During the COVID-19 pandemic, when preparing for surge capacity,Washington’s Nursing Commis sion issued new licenses within 24 hours.

Addition ally, with the federal State of Emergency decla ra tion, the U.S.Depart ment of Health and Human Services (HHS) declared that healthcare providers may practice across state lines as long as they are ingood standing with their home state license.

In the end, when Washington state did not have as great a surge inspring COVID-19 cases as initially feared, WSNA members were low-censused, furloughed, or experi enced layoffs, while travelers from otherstates stayed on contract. Providers from other states displacedmembers licensed in Washington, who were best equipped in skills andexperi ence to care for patients in our state.

This current public health crisis has proven that being in the NLC wouldbe a moot point in a disaster or a public health emergency — and it hasshown that our state already has the correct systems in place to ensurelicen sure is easy and fast, and that nurses coming into Washington stateare regis tered with the Depart ment of Health so that we know theyare here.

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Myth

The NLC will have no inan cial impact on Washington state.

FactState Boards of Nursing have faced various inan cial loss scenarios whenimple menting the NLC. While states that were early adopters of the NLConly offered a multi-state license, states joining more recently haveoffered the NLC as an option in addition to a regular home state license.So far, many of these states have experi enced an average of 12 – 16% ofnurses opting for the Compact license.

It is imper a tive that states consid ering joining the NLC have a betterunder standing of how such a decision would inan cially impact theirState Board of Nursing and nurse home state licen sure fees. Forexample, Vermont’s Board of Nursing performed a iscal analysis thatshowed it could lose a quarter of its revenue if the state joined the NLC.In Washington state, limited iscal analysis has indicated that joining theNLC could push home state nursing license fees upwards of $200.

Myth

Washington state can amend NLC legis la tion to comply with Washingtonstate laws or to require registration.

Fact140

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States are not allowed to amend NLC legis la tion. The legis la tion must beidentical to NLC legis la tion in all Compact states. The New Mexico Legis -la ture recently passed a bill outside of the NLC legis la tion that wouldrequire nurses entering New Mexico under a Compact license to registerwithin 30 days with the State Board of Nursing. The NLC admin is tra tion — National Council of State Board of Nursing (NCSBN) — sent thema cease and desist order stating that if this clause remains, New Mexicowill be removed from the Compact.

Because of this restric tion, Washington state is unable to make desiredchanges to the Compact to re lect our state’s values, such as addinga regis tra tion require ment or requiring that out-of-state nurses complywith our suicide preven tion training for Washington state nurses.

Quick FactsWhen Washington state did not have as great a surge in springCOVID-19 cases as initially feared, WSNA members were low-censused, furloughed, or experi enced layoffs, while travelers fromother states stayed on contract. Providers from other statesdisplaced members licensed in Washington, who were bestequipped in skills and experi ence to care for patients in our state. Washington state already has expedited licen sure for militaryspouses and partners seeking a nursing license.The Nursing Commis sion would not be able to track who is workingin Washington state under a Compact license for purposes ofdisci pline or workforce planning. Joining the NLC could push home state nursing license feesupwards of $200. Washington state is unable to make desired changes to theCompact to re lect our state’s values. 141

THE NURSING LICENSURE COMPACT AND APRN COMPACT: A BAD OPTION FOR WASHINGTON

I. INTRODUCTION

The National Council of State Boards of Nursing (NCSBN), a private, Chicago-based trade association, has recently proposed revised versions of two previously proposed compacts for multistate nursing practice: a Nursing Licensure Compact (NLC) for registered nurses and licensed practical nurses and an Advanced Practice Registered Nurse (APRN)* Compact.

The NCSBN Compacts are a bad option for Washington, for Washington nurses and for Washington patients. Washington lawmakers should reject them.

NCSBN portrays the Compacts as advancing public protection and access to care, but in fact they would do neither. The NLC and APRN Compacts authorize nurses in party states (states that participate in the compacts) to practice in all other party states. A nurse would hold a “multistate license” from her or his home state (defined as the state of residence) granting privileges to practice in all other party states. Both compacts define the site of a nurse’s practice as the state in which the patient is located at the time services are provided. This would apply not only to nurses who are physically present and providing care to patients in another state; it would also apply to nurses who are providing services through electronic communications. Thus, a nurse might be physically located in Washington but, if providing assessment, advice, counseling or other services via phone or computer to a patient in another state, she or he would be considered to be practicing in that other state.

* APRNs include nurse practitioners, certified nurse- midwives, certified registered nurse anesthetists and clinical nurse specialists – regulated in Washington as Advanced Registered Nurse Practitioners (ARNPs).

NCSBN proposed a prior version of the NLC in 1998 but found limited success in convincing states to adopt it. By 2010, twenty-four states had joined the NLC. In the five years since, one additional state joined. Twenty-five states and the District of Columbia, accounting for almost two-thirds of the U.S. population, declined to adopt it. Among the states rejecting the previous NLC are Washington, Oregon, Nevada, California, New York, Florida and NCSBN’s home state, Illinois. NCSBN’s prior APRN Compact, launched in 2002, was even less successful: it was adopted by only three states and never implemented.

However, since proposing the revised NLC and APRN Compact in 2015, NCBSN has launched an aggressive lobbying effort to convince lawmakers in several states, including Washington, to adopt them.

The Washington State Nurses Association (WSNA) and the American Nurses Association (ANA) are committed to reasonable, efficient regulation of nursing practice across states. But the current NCSBN Compacts pose several serious concerns:

• Despite claims that the Compacts will improve public protection and access to care, they will do neither.

• Instead, they create troubling new complications in regulating nursing practice by imposing unworkable approaches such as defining practice as occurring wherever the patient is located, even when care is provided remotely through electronic communication.

• The APRN Compact will create additional new complications for advanced practice and contains contradictory language regarding

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whether Washington ARNPs will have to practice under physician oversight when practicing out-of-state;

• The Compacts erode Washington state sovereignty by creating powerful and unaccountable new private bureaucracies with significant power over the states.

• The Compacts will impose new but undetermined expenses and likely result in revenue losses that could result in decreased services or increased licensure fees.

• Proponents’ comparisons to existing compacts—such as driver’s license agreements/compacts and the Interstate Medical Licensure Compact—fall short; there are fundamental differences between them and the NCSBN Compacts.

II. THE NCSBN COMPACTS DO NOT IMPROVE PUBLIC PROTECTION

Proponents of the revised NCBSN Compacts argue that they will enhance nursing licensing boards’ ability to protect the public. But the few improvements promised by the Compacts can be accomplished—and, to large extent, have already been accomplished—through less complex, intrusive and overreaching means than adopting the Compacts.

A. The Compacts’ major protections are already in place or pending in Washington

For example, the Compacts call for states’ participation in a coordinated licensing information system. But participation in such a system does not require states to adopt the NCSBN Compacts. In fact, almost all states (including Washington) already participate in the current information system, NURSYS. That system makes information on nurses’ licensure status and discipline history available to the public. (Currently, NURSYS makes information on significant investigations

available only to Compact states. This could be expanded to include other states).

The Compacts require criminal background checks, including fingerprinting or other biometric testing. (The prior versions of the Compacts did not include this requirement). But states can require this without adopting the Compacts. A growing number of states already do. Washington requires federal criminal background checks on out-of-state applicants, and a proposal to require them for all applicants is pending. The Uniform Licensing Requirements put forward by NCSBN in 2011 include this requirement, together with other standards and practices designed to improve public protection. NCSBN has urged all boards of nursing--not just those who participate in the Compacts--to adopt the Uniform Licensing Requirements.

In other words, currently any nurse who wishes to practice in Washington must obtain a Washington license and meet Washington’s standards, which already include screening their licensure history, federal criminal background checks for out-of-state applicants, and are anticipated to include such background checks for all applicants. The Compacts are not needed for any of these measures—these provisions in the Compacts would do nothing to improve public protection in Washington.

B. Despite these protections, important gaps remain

In addition, while criminal background checks and participation in NURSYS are important steps toward protecting the public, they leave some significant gaps that the Compact does not address. States vary in their disciplinary procedures and standards: conduct that would result in investigation and discipline in one state may not do so in another state. Depending on the state in which that conduct occurs, it may not be reported at all. And NURSYS depends on each state board to enter discipline data efficiently—if a state fails to do

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so, other states cannot be notified in a timely manner.

C. The Compacts would allow out-of-state nurses to practice without meeting Washington’s requirements

Although the Compacts require that a nurse practicing in a party state must comply with the state practice laws of the state in which the client is located at the time service is provided, the parameters of this requirement are not made clear.

The NLC allows any nurse with an unencumbered license in her or his home state to practice in other party states. But some states differ in regard to nursing education program requirements, including requirements for supervised clinical experiences. And states vary widely in their requirements for license renewal. For example, in 2011, the Washington State Nursing Care Quality Assurance Commission (NCQAC) adopted continuing competence requirements: Washington nurses must have at least 531 hours of active practice and 45 hours of continuing education every three years. And in 2014, the legislature approved new requirements that RNs, LPNs and most ARNPs—among other health professionals—complete an approved, one-time training of at least 6 hours in suicide assessment, treatment, and management.

The NCSBN Compacts do not directly address continued competence issues, but there is ample reason to believe that Washington’s requirements for continued competence would not apply to out-of-state nurses practicing here if the Compacts are adopted. In a 2012 document regarding the prior version of the NLC, the Nursing License Compact Administrators (NLCA) emphasized that nurses are not held to the continued competence requirements of any state other than their home state—if they are licensed in their home state, they qualify to practice in any other party state1. There is no reason to expect that the language of the current NLC will lead to a different

interpretation. Yet some states have no requirements at all for continued licensure beyond paying a renewal fee. Some have other requirements that may fall short of Washington’s—e.g., having no requirements for recent active nursing practice or no requirements for continuing education. No state other than Washington requires training in assessing, treating and managing suicide.

If Washington adopts the Compacts, we will have ceded our right to determine and enforce the standards for practice that our policy- makers have determined are necessary to ensure safe practice. Why set clear standards for competent practice if they will apply to some nurses practicing in our state but not others?

D. There is no reason to expect the Compacts to improve access to care in Washington

Despite claims that the Compacts will improve access to care, there is no evidence to suggest that they would do so for Washington. Out-of- state nurses who want to practice in Washington are able to do so without significant delay: NCQAC processes endorsement of out-of-state licenses rapidly. Nor is there evidence that the Compacts will increase access to telehealth services (i.e., services provided through electronic communications technologies) in Washington. Further, Washington is a pioneer in authorizing ARNPs to practice without the unnecessary restrictions that have imposed barriers to access in other states. The Compacts would do nothing to promote access to their services.

III. THE COMPACTS CREATE TROUBLING NEW COMPLICATIONS IN REGULATING NURSING PRACTICE

While the Compacts would offer no real improvement in public protection or access, in several respects they would create significant new complications in regulating nursing practice.

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A. Defining practice as taking place in patient’s location is an unworkable approach

The issues sound simple: Nurses are increasingly mobile, but current state-based licensure requires multiple licenses for nurses who practice in more than one state. And the increasing use of electronic communications technologies means that many nurses are practicing across state lines. The Compacts, we are told, will provide a clearer legal basis for their practice.

The NLC and APRN Compact both define nursing practice as taking place in the location where the patient is receiving services. This may be logical when a nurse is providing care while physically present in another state. But when providing care remotely through electronic technologies, it creates significant complications.

Some nurses work in settings such as call centers or advice lines that are set up as “telehealth” practices that primarily use communications technologies to assess, advise and/or counsel patients remotely in their homes. These nurses provide services to patients from multiple states, often in the course of a few hours. Because the Compacts say that practice takes place where the patient is located, these nurses would be expected to be familiar with the practice acts, rules and policies of each of those states.

However, under the Compacts, any use of communications technologies across state lines would be considered interstate practice. When the NLC says “A nurse practicing in a party state must comply with the state practice laws of the state in which the client is located at the time service is provided,” it does not distinguish designated telehealth practices—those in which nurses practice primarily through electronic communications technologies—from settings in which larger numbers of nurses work, such as

outpatient clinics and practices, emergency departments, surgical practices, case management, and other settings or roles in which nurses often have preadmission, post- discharge or ongoing contact with patients.

Some of those patients may reside out of state. And virtually any patient may be out of state or even out of the country temporarily—on vacation, on a business trip, or visiting family. The ubiquitous use of mobile communications devices, such as smart phones, tablets, and laptop computers, means that a nurse may be providing services to a “local” patient who happens to be in another state or country at the time. The nurse may not even be aware that the patient is temporarily out of state.

Consider these scenarios:

An out-of-state patient seeking treatment in Washington: A patient from Eastern Idaho chooses to seek elective surgery at a Spokane hospital. Shortly after discharge, the patient calls to ask questions about follow-up care and speaks to a wound care nurse. Later, the patient alleges that the nurse gave incorrect advice and that the patient suffered complications as a result. Although the patient chose to receive care from Washington providers, the nurse will now need to answer to the Idaho Board of Nursing, and possibly to the Idaho court system as well—in addition to Washington State.

A local patient temporarily out of state: A patient who lives in Olympia is seen in the emergency department of an Olympia hospital. A few days later, while visiting family in Montana, the patient receives a follow-up call on her cell phone from a nurse at the hospital. The patient later alleges that the nurse gave advice that exceeded her scope of practice. The nurse would be considered to be practicing nursing in Montana, perhaps without even knowing it. She would be subject to Montana’s jurisdiction and judged according to Montana’s scope of practice laws.

A nursing faculty member with students who are out of state: Because the Compacts state

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that the site of practice is the location where the client is receiving services, nursing faculty in Washington could find themselves subject to the jurisdiction of other states if they have students who are located in other Compact states, either as residents or visitors. This would apply to faculty who teach on-line courses— and potentially to any course if the faculty member is in contact via email, telephone or the Web with a student who is out of state at the time.

B. Regulating practice while physically out of state does not require a complex new regulatory mechanism

In care that involves the nurse’s physical presence, identifying the site of practice as the location where the patient is receiving services is less complicated, since it is also the site where the nurse is located at the time. However, the limited instances in which a nurse is temporarily located in another state do not warrant a whole new complex regulatory mechanism. Some nurses may practice occasionally in a neighboring state. When “traveling” nurses, who work for agencies that assign nurses to hospitals around the country, require multiple licenses, that detail and expense is generally the responsibility of the nurse’s employing agency. When nurses seek to volunteer assistance following a disaster, states will generally permit out-of-state nurses to practice on a temporary basis.

Of course, a far more common scenario is when a nurse changes residence from one state to another and plans to practice in the new state. Currently that nurse needs to obtain a license in her new state. Under the NCSBN Compacts, this requirement would not change: a nurse who changes her state of residence would still be required to obtain a license in her new home state.

C. The Compacts will mean losing opportunities to ensure that nurses practicing here are familiar with Washington nursing practice

Each state in the U.S. enacts and enforces its own nurse practice act. These practice acts reflect some differences from state to state. As noted earlier, these often include differences in curriculum and clinical experience requirements, especially for basic practice. States differ in standards for delegating tasks or assigning functions to other nursing personnel. They differ with regard to scopes of practice, particularly for licensed practical nurses (LPNs), which has implications not only for out-of-state LPNs practicing in Washington, but also for RNs who work with them.

Requiring nurses to be licensed in Washington before practicing here provides an opportunity to educate them about the specifics of nursing practice and regulation in Washington and to inform them of changes in relevant state legislation, regulation or policy related to nursing practice. If Washington adopts the Compacts, it means that almost any nurse licensed in another party state—literally hundreds of thousands of nurses—would be authorized to practice here without any official notice or any contact at all with the Nursing Care Quality Assurance Commission.

D. The Compacts’ definition of “home state” is confusing and illogical

Under the Compacts, a nurse’s “home state”— the state in which the nurse resides—is the state that issues her or his license. That state authorizes the nurse’s multistate privileges. Thus, a nurse who lives in Oregon or Idaho and commutes into Washington for work could no longer be licensed in Washington. The nurse would instead need to be licensed in her or his state of residence and be authorized by that state to practice in other party states, including Washington. If a nurse who lives and works in Washington moves across the state border while remaining at the same job in Washington, the nurse would need to inactivate her or his Washington license and obtain a license in the new state of residence, even if she or he has no intention of practicing there. A nurse might spend her entire career practicing in

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Washington yet be required to be licensed in another state.

E. The APRN Compact creates additional complications for advanced practice nursing Washington is a pioneer in recognizing the critical role that APRNs play in ensuring access to high quality, affordable health care. Our state has been a model for the rest of the nation in promoting APRNs’ ability to practice to the full extent of their education and training. It is vitally important that we continue to play a leadership role in advanced nursing practice. Unfortunately, adopting the APRN Compact would pose some serious concerns.

The APRN Compact defines APRN as “a registered nurse who has gained additional specialized knowledge, skills and experience through a program of study recognized or defined by the Interstate Commission of APRN Compact Administrators . . . , and who is licensed to perform advanced nursing practice.” In other words, the new Interstate Commission would “recognize or define” educational standards for APRN practice, and Washington would be bound by those standards, which have not yet been determined.

Washington imposes no legal requirements for APRNs to practice under the supervision of or in collaboration with another health professional. The APRN Compact seems at first to be consistent with Washington law when it states that “[a]n APRN issued a multistate license is authorized to assume responsibility and accountability for patient care independent of a supervisory or collaborative relationship with a physician. This authority may be exercised in the home state and in any remote state in which the APRN exercises a multistate licensure privilege.” However, the APRN Compact also states that “[a]n APRN practicing in a party state must comply with the state practice laws of the state in which the client is located at the time service is provided.”

It is not clear how these two provisions can be reconciled. There are still several states in which practice laws require a supervisory or collaborative relationship with a physician. Will Washington APRNs be expected to comply with these requirements? Since APRNs are considered to be practicing in the state where the patient is located, does this mean that even APRNs who are physically located in Washington but providing services remotely will need to comply with a remote state’s requirements for supervision or collaboration? Would a collaborative or supervisory relationship need to be established with a physician in the remote state?

F. Adopting the Compacts could result in significant loss of state revenue

Adopting the NCSBN Compacts would threaten a significant potential loss of revenue for supporting nursing practice and regulation in Washington State. The Nursing Care Quality Assurance Commission is supported by licensing and renewal fees. The Washington Center on Nursing is supported by a surcharge on those fees. Under the Compacts, out-of-state nurses practicing in Washington (including those who commute to Washington to work) would no longer be licensed here; they would be licensed in their states of residence instead, so they would no longer pay fees for licensing and renewal here. (This loss of revenue might be partially offset by fees from Washington residents who practice in other states and would need to be licensed here). In other states, potential loss of licensing revenue has been a major factor in deciding not to adopt the prior NLC. For example, in 2002 the Virginia General Assembly’s Joint Commission on Health Care estimated a total loss of revenue to their Board of Nursing of more than $400,000 biennially if Virginia joined the NLC2. (Virginia subsequently joined, raising their licensing fees for all Virginia- licensed nurses in order to avoid this substantial revenue loss). In 2014, the Kansas Board of Nursing predicted a $376,667 loss of revenue if

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it joined the NLC3 (which it declined to do). A 2013 report to the California board that licenses licensed vocational nurses (equivalent to LPNs in Washington) also noted that joining the NLC would result in a “substantial loss of revenue” to that state’s nursing licensure boards4. There is no mechanism for charging fees to out- of-state licensees practicing in the state in order to recoup these losses. Indiana sought to join the NLC and enacted a provision authorizing a $25 filing fee for out-of-state privileges. Their attempt to join the NLC was rejected and Indiana subsequently repealed the legislation. Today, Indiana remains a non-Compact state. In addition to probably revenue losses, Washington would likely face set-up expenses in joining the Compacts as well as fees to the Interstate Commissions created under the compacts (fees which have yet to be determined). Faced with revenue loss and additional expenses resulting from joining the NCBSN Compacts, the only options would be to reduce services or to increase fees for Washington nurses.

IV. THE COMPACTS WOULD SIGNIFICANTLY ERODE WASHINGTON’S STATE SOVEREIGNTY

A. Interstate compacts are

powerful instruments; adopting them requires careful deliberation and balancing

In the U.S., states regulate health care practice within their borders, in keeping with the basic tenets of federalism. The NCSBN Compacts purport to build on existing state regulatory structures, but they would actually erode states’ powers by superimposing new and complicated regulatory mechanisms that create two powerful and unaccountable “Interstate Commissions,” one for the NLC and one for the APRN Compact.

Interstate compacts are very powerful instruments. They are adopted in statute by participating states, but they also function as

contracts. The provisions of a compact have the force of law. They take precedence over existing laws that may conflict with it. By adopting a compact, the state willingly gives up some of its own autonomy. Clearly, a step like this requires very careful deliberation and balancing—evaluating how much autonomy is surrendered, under what circumstances, and whether the purported benefits justify the risks to the state and its citizens. A careful examination of the NLC and APRN Compact reveals that purported benefits do not justify the risks.

B. The Compacts create unaccountable new private bureaucracies with significant power over participating states

Both the NLC and the APRN Compact create an “Interstate Commission” with broad implementation and enforcement powers, including adopting rules and assessing payments from participating states. Each state would have a representative to the NLC’s Interstate Commission and the APRN Compact’s Interstate Commission. That representative would be the head of the state licensing board or designee, who also serves as the administrator of the Compacts for each party state. (Each state would have one vote on each of the Interstate Commissions, regardless of the state’s population or number of licensees).

The Interstate Commissions’ rules and decisions are binding on all member states. The Compacts include procedures for notice-and- comment rulemaking, although they include no specific length for the comment period. The Compacts also provide for emergency rulemaking, using a notably broad approach to determining when “emergency” rules are needed: it includes not only actions to respond to an imminent threat to public health, safety or welfare, but also to prevent a loss of Commission or party state funds or to meet a deadline for the adoption of an administrative rule that is required by federal law or rule.

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The Interstate Commissions also have the power to adopt budgets and collect annual assessments from each party state to cover the cost of their operations, based on a formula that they will determine. The Commissions can terminate a state for defaulting in the performance of its obligations or responsibilities under the Compacts or Commission rules.

In other words, by adopting the Nurse License Compact and the APRN Compact, Washington would be bound by decisions to adopt rules and to assess payments to fund yet-to-be-determined budgets, based on a yet-to-be-determined formula.

Compounding this problem, there is no oversight or accountability for the Commission’s decisions. While each state’s representative is accountable to her or his own state, the Commissions themselves are accountable to no one. And there is no mechanism to appeal their decisions, with one narrow exception: the right to appeal a decision to terminate a state from the Compact. (And that appeal can only be filed in the U.S. District Court for the District of Columbia or the federal district in which the Commission has its principal offices).

A state can withdraw voluntarily from either Compact only by adopting a new statute to do so, at least six months before withdrawing. The state remains bound by the Compact (and responsible for paying assessments) until then.

C. Washington nurses would be subject to other states’ jurisdiction

As noted earlier, according to the NCBSN Compacts, a nurse who practices in a party state under a multistate licensure privilege will be subject to “the jurisdiction of the licensing board, the courts and the laws of the party state in which the client is located at the time service is provided.” This means that a nurse might be located in Washington and communicating via telephone, computer or other electronic communications technology with a patient in

another state and find herself or himself subject to that state’s licensing board, courts and laws.

Not only could that state revoke the nurse’s privileges to practice there; the Compacts authorize licensing boards in one party state to issue subpoenas for hearings and investigations for attendance and testimony from another party state. So a Washington nurse could be compelled to travel to another state to participate in a hearing or to respond to an investigation for alleged conduct that occurred while she was in Washington providing services remotely. While the Compact does state that the board or court in the other state would pay fees and travel expenses, this does not address the unnecessary disruption and burden involved— let alone the fact that the nurse would be subject to that state’s procedures and standards for investigation and discipline. And this would also represent a new financial burden for states.

Investigation and discipline procedures vary from state to state. While the Compacts say that the home state will apply its own state laws to determine appropriate action to take against a nurse’s license, Washington nurses could still face investigations and hearings in another state based on alleged conduct that occurred in Washington, even if those allegations would not have been sufficient for Washington to take action against the nurse’s license.

And, of course, it would be ironic (to say the least) to think that a nurse might be compelled to make a personal appearance in a distant state because of allegations arising from providing services to a patient in that state remotely via telephone or computer.

The Compact language granting jurisdiction to other states is notably broad: It is not limited to authority over the nurse’s ability to practice nursing. The plain language suggests that this would apply to civil and criminal liability as well.

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V. COMPARISONS TO OTHER COMPACTS FALL SHORT

A. A nursing license is not like a driver’s license

Proponents often draw an analogy between the NCSBN Compacts and driver’s licenses, based on the fact that a driver’s license issued in one state permits the license holder to drive in any other state, subject to motor vehicle laws of the state in which she or he is driving. But this comparison is very limited at best.

Driving in another state invariably means that the driver is physically present in that state. But nursing services are increasingly provided remotely, through electronic communication technologies. In fact, this is a major argument offered for adopting the NCSBN Compacts). This is a fundamental difference between nursing licenses and driver’s licenses.

A driver’s license authorizes an individual to engage in an activity—operating a motor vehicle. A nursing license authorizes an individual to practice a profession. It involves a broad range of cognitive and psychomotor skills and functions based on a specialized body of knowledge acquired through an approved academic program. Also, determining violations of motor vehicle laws is largely based on facts. Penalties are often prescribed in law. Determining violations of nurse practice acts and deciding appropriate penalties often requires evaluating a wide range of circumstances, particularly when a nurse is suspected of practicing incompetently.

B. The Interstate Medical Licensure Compact includes important differences with the NCSBN Compacts

In addition to the NCSBN Compacts, interstate compacts for other health professions have been developed or are being developed. Of these, the Interstate Medical Licensure Compact (IMLC), which addresses interstate licensure and practice of physicians, has drawn the most

attention. It has been adopted by eleven states so far.

Unlike nursing, there are virtually no differences from state to state in the scope of practice for medicine. Furthermore, the IMLC differs from the NCSBN Compacts in several significant ways:

• Rather than granting a multistate license to practice in all other party states, the IMLC still requires a physician to be licensed in each state in which she or he seeks to practice. The IMLC authorizes a physician to apply for an expedited license from that state or states. The board of medicine in that state then evaluates whether the physician is eligible for an expedited license. If granted, the physician is licensed in that state, pays fees to that state and must renew the license periodically.

• Unlike the NCSBN Compacts, which specify that a nursing license is issued in the nurse’s “home state”—i.e., the state of residence—the IMLC provides that a physician has a “state of principal license," which can be the state of residence, a state in which the physician practices at least 25% of the time, or the state of the physician’s employer. The physician may later redesignate another state as the state of principal license.

• The IMLC specifies that physicians must comply with the state’s continuing education requirements in order to renew the license. The NCSBN Compacts do not directly address whether out-of-state nurses will be required to comply with states’ continuing competence rules (such as continuing education) but, as noted earlier, it appears that they will not.

• The IMLC provides that if its Interstate Commission exercises its rulemaking authority in a manner that is beyond the scope of the purposes of the Compact,

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that action “shall be invalid and have no force or effect.” The NCSBN Compacts include no such limitation.

• The IMLC provides that anyone may file a petition for judicial review of any rules adopted by its Interstate Commission. The NCBSN Compacts include no provision for challenging their Interstate Commissions’ rules.

• The IMLC states explicitly that decisions of the actions of its Interstate Commission shall not override existing state authority to regulate the practice of medicine. The NCSBN Compacts contain no similar provision regarding regulation of nursing practice.

VI. THE ALTERNATIVE: FOCUS ON TELEHEALTH Telehealth—delivering services through electronic communication technology—offers great potential for increasing access to care, enhancing patient engagement and experiences of care and reducing costs. Nurses have provided advice, counseling and triage via telephone for many decades; this was never seen as posing regulatory complications. It is the development and proliferation of computer technologies and handheld devices have transformed telehealth practice and raised questions about how best to regulate the interstate use of these technologies.

The NCSBN Compacts represent a flawed attempt to address these regulatory challenges. WSNA agrees that they must be addressed. But doing so does not require adopting a comprehensive change in regulating nursing practice—especially not the broad, complex, cumbersome and inflexible mechanisms proposed by the NCSBN Compacts. Instead, efforts should focus on the discreet issues posed by interstate telehealth practice.

VII. CONCLUSION: ADOPTING THE NCSBN COMPACTS IS A BAD OPTION FOR WASHINGTON Unfortunately, Washington lawmakers who have concerns about any provisions in the NCSBN Compacts have no opportunity to do anything about them at this point: In order to join the NLC and/or the APRN Compact, Washington would have to adopt them as they are, without any substantive changes. The Compacts could be amended later, but that would require every Compact state to enact a new statute to do so.

Thus, the only two options available to Washington are:

• To adopt each Compact as is, despite multiple concerns; or

• To reject the Compacts.

WSNA and the American Nurses Association (ANA) remain committed to finding common ground with NCBSN and others on effective regulatory measures, particularly with regard to interstate telehealth practice, that are workable and realistic, that offer real solutions, and that respect state sovereignty. None of this, unfortunately, describes the NCSBN Compacts. The Compacts are a bad option for Washington. Washington lawmakers should reject them. We can and must work toward better, more effective approaches.

REFERENCES 1 NLCA (2011), Response to ANA Updated NLC Talking Points. Retrieved from https://www.ncsbn.org/4_ANA_TP_Revised_031112.pdf 2 Joint Commission on Health Care (2002). Multi-State Nurse Licensure Compact Study. Retrieved from http://leg2.state.va.us/dls/h&sdocs.nsf/fc86c2b17a1cf388 852570f9006f1299/c5934246b8c2a81585256b650059b2 54/$FILE/RD15_2002.pdf 3 Kansas State Board of Nursing (2014). “Why Kansas Does Not Belong to the Nurse Licensure Compact.” Nursing Newsletter, 27(4): 1-2. Retrieved from http://www.ksbn.org/nursingnewsletter/2014/4qtr2014.pdf 4 Bello-Jones, T. (2013). “Multi - State Licensure Compact for California Nurses.” Retrieved from http://www.bvnpt.ca.gov/pdf/bm11_13/8.pdf

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Asking for an upgradeOct 9, 2020 Topics: Advocacy and policy (/news/advocacy-policy)

This story was published in the Fall 2020 (/washington-nurse/2020/fall) issue of TheWashington Nurse (/washington-nurse) magazine.

WSNA has long opposed the NurseLicen sure Compact for a variety ofreasons — and in 2019, WSNA repre sen ta -tives spent nearly 20 hours meeting withthe members of the Nursing Care QualityAssur ance Commis sion (NCQAC) todiscuss those concerns. In the end, manyof our key concerns remained.

While WSNA opposed a 2020 bill to enterWashington state into the Nurse Licen sure Compact (NLC), we committed to workingwith other states to ask the NLC admin is tra tors to make changes at the national levelthat would address our concerns, which are shared by many states that are, likeWashington state, leaders in health care.

What follows here is:

A letter (https://cdn.wsna.org/assets/site/letter-clc-administrators.pdf?mtime=20201009181604&focal=none) to the NLC admin is tra tors (through theNational Council of State Boards of Nursing) signed by 11 states outlining ourconcerns with the NLC and asking for changesA series of myths vs. facts (https://www.wsna.org/news/2020/nurse-licensure-compact-myth-vs-fact) about the NLCA look at the 10 best and worst health care states and whether they partic i patein the NLC 153

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Until the concerns outlined in the letter to NLCadministrators and in the myths vs. facts areaddressed at the national level, the NLC is nota good option for Washington state.

Letter to the NLC administrators

This is a letter to the NLC admin is tra tors (through the National Council of StateBoards of Nursing) signed by 11 state nurses associ a tions outlining our concerns withthe NLC and asking for changes.

Read the letter (https://cdn.wsna.org/assets/site/letter-clc-administrators.pdf?mtime=20201009181604&focal=none)

NLC Myths vs. Facts (https://www.wsna.org/news/2020/nurse-licensure-compact-myth-vs-fact)

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Top 10 best states for health careThe following states are consid ered the best states for health care as of2019. The ranking is based on health care access, health care quality andpublic health. Data comes from U.S. News & World Report’s Health CareRanking (https://www.usnews.com/news/best-states/rankings/health-care) from August 2020.

Members of the Nurse Licen sure Compact are identi ied.

HawaiiMassa chu settsConnecticutWashingtonRhode Island**New JerseyCaliforniaMaryland (member of compact)Utah (member of compact)Minnesota

**Rhode Island was in the original compact and chose not to join theenhanced compact in 2017.

Top 10 worst states for health careThe following states are consid ered the worst states for health care as of2019. The ranking is based on health care access, health care quality andpublic health. Data comes from U.S. News & World Report’s Health Care 155

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Ranking (https://www.usnews.com/news/best-states/rankings/health-care) from August 2020.

Members of the Nurse Licen sure Compact are identi ied.

Missis sippi (member of compact)Arkansas (member of compact)West Virginia (member of compact)Oklahoma (member of compact)Alabama (member of compact)Louisiana (member of compact)Kentucky (member of compact)Tennessee (member of compact)Wyoming (member of compact)Missouri (member of compact)

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November 19, 2020

Ohio Board of Nursing President Lauralee Krabill 17 S. High Street, Suite 660 Columbus, Ohio 43215 RE: SB 341 – Nurse Licensure Compact Good morning members of the Ohio Board of Nursing and staff. My name is Deb Arms and I am the President of the Ohio Nurses Association. I would like to take this opportunity to thank you for allowing me to speak on behalf of the ONA Board of Directors and members of our association during today’s open forum. For members of the Board who may not be familiar with ONA, we are the recognized leader and advocate for professional nurses and nursing in Ohio. Established in 1904, ONA was founded on the principles of protecting, promoting and advancing the profession of nursing. As an association of nearly 10,000 nurses, ONA strives to improve and protect the health and wellbeing of all Ohio’s citizens. Historically, we have always taken pride in our relationship with the Board of Nursing. I truly believe that both the Board and ONA have worked to strengthen that relationship over the last decade and have always done what we can to prioritize the safety of nurses and patients, while respecting and appreciating our differences. I believe we are always stronger together. The recent introduction of Senate Bill 341, Nurse Licensure Compact, has further emphasized our need to collaborate on efforts to protect Ohio nurses and the public. As I am sure you are well aware, thirty-four states have enacted the Enhanced Nurse Licensure Compact, with five states, including Ohio, having pending legislation. The Nurse Licensure Compact allows registered nurses and licensed practical nurses to participate in multi-state licensure, which enables nurses to practice in all states that have joined the Compact. ONA has examined how this Compact would affect registered nurses in our state if Ohio adopted such licensure. ONA understands that the Board has reviewed and examined the licensure compact and that the Board has, year after year, voted to delay action seeking the introduction of compact licensure until such time more information was gathered to assure that the benefits outweigh any risks related to public safety. I wanted to address the Board today to share ONA’s concerns with Senate Bill 341, but also wanted to personally thank Tom Dilling for working with ONA staff throughout the last several months on the bill’s language. I also wanted to address the Board today to respectfully request that the Board join forces with ONA to formally oppose this bill. The former and enhanced licensure compact, including Senate Bill 341, has been reviewed by the ONA leadership and consideration has been given to the Board’s position. ONA remains committed to engaging in all conversations with respect to the Compact, in order to address the issues facing telehealth, cross-border nursing practice, and the Interstate Commission of Nurse Licensure Compact Administrators. ONA has many concerns about compact licensure, however, we would like to speak to the concerns that we believe directly impacts the Board of Nursing.

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State Sovereignty and Authority of the Interstate Commission- The Attorneys General in Oklahoma, Indiana, Kansas, Louisiana, and Nebraska have rendered formal opinions that the nursing licensure compact interferes with state sovereignty. The Compact would impose complicated regulatory mechanisms that

would allow the joint public entity known as the Interstate Commission of Nurse Licensure Compact Administrators, composed of the party states that adopt the Compact, to promulgate rules that are binding on each state in the Compact by a simple majority vote. This essentially grants full rule-making authority to the Commission, which is not a government entity or state agency, nor are they based in Ohio. According to the National Council State Boards of Nursing, each state would be subject to administrative rules not passed at the state level. Additionally, the Commission has “enforcement action” authority, which means that the Commission has the authority to remove any state from the Compact, should a state board of nursing not adhere to the Compact statute and/or rules. Lastly, the Commission would have the opportunity to hold closed, non-public meetings for certain reasons and would have immunity to lawsuits. Many of the provisions within the Compact may violate the Ohio Constitution, the Ohio Open Meeting Act, the Ohio Ethics Law and/or Ohio statute and may potentially create a monopoly system, where NCSBN holds full national licensure examination and regulatory authority. We believe the Ohio Board of Nursing would be handing over authority to the Commission, which does not benefit our own regulatory board or Ohio nurses. Regulation, Public Safety, and Disciplinary Action- The mission of the Ohio Board of Nursing is to actively safeguard the health of the public through the effective regulation of nursing. The Compact would not require that out-of-state nurses be licensed in the state of Ohio, which means that the Board would no longer review and approve license applications from out-of-state residents. The effects of disciplinary actions in other Compact states are unclear. Because a nurse would have jurisdiction to work in a remote state without that state’s licensure, it is unclear how that remote state would know to check an individual nurse’s license and previous disciplinary actions. During an interested party call between the bill’s sponsor, a representative from NCSBN and staff from ONA and the Board, disciplinary procedure was discussed. NCSBN stated that disciplinary action is two-fold for states who join the Compact. The remote state Board of Nursing would have authority to discipline a non-Ohio nurse through privilege to practice restrictions, but only the home state Board of Nursing would have the authority to take action on the license itself. So, essentially, the Ohio Board of Nursing would not have the authority to place licensure restrictions or take action on an out-of-state Compact license. It is unclear how the remote state would stay in constant contact with each home state’s licensees and what disciplinary actions have been taken on the license itself, and vice versa. Additionally, the effects of regulation, licensing and the lack of absolute bars seriously compromises public safety and places the responsibility onto the employers. Employers would be accepting or denying nurses for practice and not the regulatory Board. Financial Impact to Ohio Board of Nursing- According to documents ONA has reviewed, the Board has stated there would be a $6,000 annual fee for Compact membership. The fiscal impact could vary from state to state and Ohio would need to conduct a fiscal analysis to determine the impact on loss of licensure fee revenues. We believe, however, the additional expenses and losses potentially placed on the Board could result in a reduction of services and/or an increase in licensing fees for Ohio nurses.

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Voice of Professional Nurses Associations and the Open Meeting Act- The shift of power with the Commission having authority to enact rules that are binding on each state in the Compact takes power and authority away from the Ohio Board of Nursing. If there was a dispute between Ohio and the Commission, the matter would be

handled in the Illinois court system, where NCSBN is located, and not in our state’s jurisdiction. We believe this takes influence away from ONA and does not provide other interested parties an opportunity to voice opinions, suggestions, or concerns during the promulgation or review of administrative rules, which we now have the opportunity to participate in with the Board. The Commission holds four meetings a year, two of which are in Chicago and two of which travel the country. While the meetings are open to the public, it is unclear as to how the voice of Ohio nurses would be heard at the meetings. Ohio Offers State of Emergency Practice for Out-of-State Nurses- We have heard time and time again from Compact supporters that Ohio needs to join the Compact to allow nurse mobility during times of disasters or emergencies. ONA realizes that the ability to mobilize nurses to Ohio during such emergencies and disasters is already covered under Section 4723.32(G)(7) of the Ohio Revised Code. Therefore, enacting compact licensure for Ohio is not necessary to protect Ohioans in the case of an emergency. Licensed nurses from other states may practice in Ohio in these situations without having a multi-state license. Having shared ONA’s aforementioned concerns, we believe the Compact impedes the Ohio Board of Nursing’s authority and impacts Ohio nurses’ workforce in the distant future. ONA is primed and ready to oppose Senate Bill 341 and we respectfully request that the Board stand steadfast with us in opposition with the following two asks:

1. We respectfully request that the Board consider testifying in opposition or draft an opposition memorandum to submit to the House and Senate.

2. We respectfully request that the Board consider seeking an Attorney General opinion on whether or not nurse licensure compact interferes with state sovereignty and/or the Ohio Open Meeting Act.

Thank you for your time and consideration. ONA looks forward to continuing our collaborative efforts.

Sincerely,

Deborah Arms, PhD, RN

ONA President

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June 19, 2020 Julia George, MSN, RN, FRE President of the Board of Directors National Council of State Boards of Nursing. 111 East Wacker Drive, Suite 2900 Chicago, IL 60601-4277 Dear Ms. George,

We, the undersigned state nurses associations, are writing to request that the National Council of State Boards of Nursing consider changes to the Nurse Licensure Compact (NLC) that will allow us to understand the impact of the Compact on our states and nationally. We believe such changes are necessary to convince states currently opting out to join the NLC.

Registration Requirement / Data Collection

Proponents of the NLC say that the NLC will improve access to care and help with states’ nursing shortage. However, because a registration requirement for nurses entering a state under a Compact license is not allowed under the Compact, no data exists to prove either of these statements are true. In fact, many states in the NLC still say they have a nursing shortage.

The New Mexico Legislature recently passed a bill outside of the NLC legislation that would require nurses entering New Mexico under a Compact licensure to register within 30 days with the State Board of Nursing. Registration allows a state to know who is practicing within its borders and to track the flow of nurses into the state – helping us understand how and where the NLC is making a difference. For example, is the NLC being used by predominantly by nurses living in border cities? Is the NLC bringing additional nurses into New Mexico? Or are more nurses leaving New Mexico to work across the border in Texas?

These questions are critical for workforce planning and development. They are also important for disciplinary proceedings against a nurse license. If states don’t know who is practicing in a particular jurisdiction, having advance notice of a disciplinary investigation of a nurse for NLC states is no longer useful.

Knowing who is interested in a Compact versus a home state license and where they are practicing is necessary to understanding our national, regional, and state-based nursing workforce. As nursing associations located in states party to the NLC and states that have opted out, we can agree that this is a flaw in the NLC. We ask that NCSBN work to fix this and align the NLC with the registration requirements found in other health profession compacts.

Education Tool for Nurses

Because practice acts vary from state to state, we request that NCSBN create an education tool for nurses practicing under a Compact license to ensure understanding of the biggest differences between Nurse Practice Acts. Because liability of a nurse’s practice and license is based in the state where the patient is, nurses opting for a Compact license need to both understand that this is the case and have a reference tool that calls out major differences and links to each state practice act.

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NURSE LICENSURE COMPACT LETTER TO NCSBN

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For example, some states allow registered nurses to perform conscious sedation using the drug propofol, while others do not. If administered incorrectly, this drug can be deadly – it is widely associated with the death of pop star Michael Jackson. Another example is delegation, where practices vary greatly from state to state. It is in the interest of patient safety to assure that nurses are aware of the Nurse Practice Act in each state in which they are practicing, including major differences.

When the Washington State Nurses Association raised this with its own Nursing Commission (i.e., State Board of Nursing), they were told that NCSBN expects that perhaps they or the American Nurses Association could create such a document. As national administrators of the NLC, who states pay to be party to the Compact, we believe that NCSBN must not abdicate its responsibility to party states and to nurses who pay for a Compact license. We ask that NCSBN undertake this work and provide a date by which such an education tool will be available.

Fiscal Analysis of NLC Impact on State Boards of Nursing

State Boards of Nursing have faced various financial loss scenarios when implementing the NLC.While states that were early adopters of the NLC only offered a multi-state license, states joiningmore recently have offered the NLC as an option in addition to a regular home state license. So far,many of these states have experienced an average of 12 – 16 percent of nurses opting for theCompact license.

It is imperative that states considering joining the NLC have a better understanding of how such adecision would financially impact their State Board of Nursing and nurse home state licensure fees.For example, Vermont’s Board of Nursing performed a fiscal analysis that showed it could lose aquarter of its revenue if the state joined the NLC. In Washington state, limited fiscal analysisprovided has indicated that joining the NLC could push home state nursing license fees upwards of$200.

We ask that NCSBN provide a fiscal analysis of states party to the Compact showing the financialimpact the NLC has had on their State Boards of Nursing and on their state-only license fees.

Transparency of Proceedings and Finance

Many states have open public meeting laws and have strong concerns that the NLC administrativebody conflicts with those statutes. Under the NLC, the national Compact administrators can holdclosed, non-public meetings under certain circumstances. This is concerning given that the NLC isadministered by a non-governmental body of which there is no regulatory oversight and is notbeholden to the public.

When New Mexico tried to align its participation in the NLC with its open public meetings law bypassing a law that would require “[a]ll agendas, minutes, reports, and rulemaking records” of thenational Compact administrative body to be filed with its State Board of Nursing, it received a letter from the Special Counsel of the Interstate Nurse Licensure Compact Administrators Commissionstating that such state laws “are not permitted” and would be cause for legal action or terminationof New Mexico’s participation in the Compact. It is concerning that the national Compactadministrators have power to enact rules that are binding on each state. States should have the

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authority to make those rulemaking records, meeting minutes, associated agendas and reports available to the public.

Additionally, given the revenue loss that State Boards of Nursing experience when joining the NLC, it is important that NCSBN provide financial transparency allowing states to understand how much revenue in multi-state/Compact license fees is collected and how those funds are spent.

We ask that NCSBN provide full transparency of all meetings and documents related to the NLC and its administration to ensure compliance with state laws regarding open public meetings. We ask that NCSBN provide financial transparency allowing states to understand how much revenue in multi-state/Compact license fees NCSBN is collecting to administer the Compact and how those funds are being spent.

Many of our states have spent considerable time and effort attempting to better understand the impact that the NLC is having on nursing shortages, on individual nurses, and on revenue and license fee projections for our respective State Boards of Nursing. Without this information, our states do not have a clear picture of whether the NLC is meeting its intended goals or how it would potentially impact nurses and our State Boards of Nursing.

We look forward to your response.

Sincerely,

Sally Watkins, PhD, RN Jeanine Santelli, PhD, RN, AGPCNP-BC, FAAN Executive Director Executive Director Washington State Nurses Association ANA – New York

Larlene Dunsmuir, DNP, FNP, ANP-BC Debbie White, RN ED of Professional Services President Oregon Nurses Association New Jersey Health Professionals and Allied Employees

Vicky Byrd, MSN, RN, OCN Deb Snell, RN Executive Director President Montana Nurses Association Vermont Federation of Nurses & Health Professionals

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Donna Phillips, BSN, RN Jan Hochadel John Brady, RN Alaska Nurses Association/AFT #1953 President Vice President AFT Connecticut AFT Connecticut

Lisa Ochs Linda McDonald, RN Chief Executive Officer President Ohio Nurses Association United Nurses and Allied Professionals, Rhode Island

Marketa Houskova, DNP, MAIA, BA, RN Executive Director American Nurses Association, California

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MEMORANDUM

To: Board Members Ohio Board of Nursing

From: Betsy Houchen Executive Director

Subject: Nurse Licensure Compact: Fiscal Impact

Date: January 11, 2021

To determine the fiscal impact of joining the Compact, costs need to be identified and the impact on revenues estimated. The following is preliminary information which will require additional review and data to refine and finalize.

Implementation Costs

• Ohio eLicense System modifications – Estimate requested from DAS/OITo Historically, the cost for modifying the system for the HB 216 APRN change from

certification to licensing was about $250,000.

• Administrative and staff time to plan and implement over 12-18 monthso Costs will be determined based on the estimated time for planning and

implementation by the Licensure Supervisor, Program Managers, IT staff, OhioeLicense consultant, etc.; system testing by license staff; training of all licensestaff; Chief Legal Counsel consultation regarding licensing issues and rules;administrative/staff time for development of communications and websitematerials.

Ongoing Costs

• Annual maintenance cost for Ohio eLicense Systemo The number of records in the system will increase based on the MSL licenses

issued. According to the experience of NLC states, NCSBN advises to expect toissue 1% MSL licenses per month and to reach 15-20% MSLs at the end of 24-months.

o Using this estimate, Ohio would issue nearly 3,000 MSLs a month, based on thenumber of active RNs and LPNs in Ohio. An increase in the number of “records”in Ohio eLicense for which DAS/OIT charges the Board an annual maintenancefee will depend on the final configuration of the MSLs in the system.

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• Annual NLC fee – Currently $6,000 but this is an unknown cost in the future.

• Staffingo Because MSLs will increase work of the Licensure Unit, additional staff will be

requested. Current staffing is already inadequate to handle the licensing workloadand especially when any type of additional work is added. Although in the past, wemet outcome measures during peak licensure season, it is difficult and would notbe possible to meet with the addition of a new license type.

Loss of Revenue

Based on data obtained from the Ohio eLicense system, for RNs and LPNs with Compact state addresses, the loss of revenue is estimated to be $1,930,010 over a one-year period. Compact state residents with MSLs would no longer reinstate, reactivate, or renew in Ohio.

For example, Compact nurses are required to renew in their home state/state of residence. Therefore, for nurses with addresses in Compact states who practice in Ohio, it is likely they will have or will obtain MSLs. In these cases, the nurse will renew in their home state and no longer renew in Ohio. Ohio will lose the renewal fees previously paid. The same applies if their license lapses or is made inactive – they will not reinstate or reactivate their license in Ohio and those fees will be lost.

To further examine the impact on revenue, staff requested a Nursys licensure data report for Ohio from NCSBN. NCSBN responded they will provide the report during the week of January 25.

The losses may be offset somewhat by fees for MSL licenses. If higher fees are charged for a MSL, this may provide an offset, however, an increase in license fees would need to be enacted by the General Assembly and is not within the Board’s control.

Summary

This report provides preliminary, initial estimates based on current available data. The estimates will be reviewed, revised, and refined based on additional information from NCSBN and Compact states.

NCSBN has advised Ohio that they have provided financial assistance to states for implementation of the Compact, upon request of the state. Depending on the size of the grant, the request may need to be approved by the NCBSN Board of Directors. The grant would address implementation costs but not ongoing costs or lost revenue.

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MEMORANDUM



Subject: Nurse Licensure Compact: Compliance/Discipline


Board staff will further examine disciplinary issues in light of recent Ohio law changes, discuss these concerns with NLC, and provide additional information at a future Board meeting. Below are the concerns identified previously upon review of the eNLC language.

Conversion of Licenses When Licensee Changes State of Residency Article IV, paragraph (c) states that “If a nurse changes primary state of residence, by moving between two party states, the nurse must apply for licensure in the new home state and the multi-state license issued by the prior home state will be deactivated in accordance with applicable rules adopted by the Commission.” (Emphasis added.)

Article IV, paragraph (d) states that “If a nurse changes primary state of residence by moving from a party state to a non-party state, the multi-state license issued by the prior home state will convert to a single state license, valid only in the former home state.” (Emphasis added.)

Þ Consideration: Ohio could not “convert” or “deactivate” a license without affording the licensee due process.

Effect of Disciplinary Actions in Other Compact States At a NCSBN meeting, it was explained that if the home state takes a disciplinary action against a nurse, that action prevents the nurse from practicing in the remote states and the nurse is issued a single state license. However, if a remote state takes disciplinary action, the discipline is only effective in the remote state that took the action, so the nurse could continue to hold a multi-state license and practice in other Compact states. It was suggested that remote states would check Nursys to determine if other remote states have taken disciplinary actions and then could bootstrap the action taken in the other remote state.

Þ Consideration: If the remote state does not know the nurse is practicing in their state, it is not clear how the remote state would know to check the individual nurse’s license/discipline in Nursys? Perhaps it could be explored so when a nurse is disciplined in a home state or in a remote state, the multi-state license is revoked, and the nurse could only be issued a single state license.

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Alternative Program for Substance Use Disorder (AP) Article III, paragraphs (c)(9) and (10) state that a nurse enrolled in AP cannot obtain or retain a multi-state license and that the nurse is “subject to self-disclosure requirements regarding current participation in an alternative program.”

Article V, paragraph (c) states that a party state has authority to place a nurse in an alternative program “in lieu of adverse action.” The paragraph further states that the home state shall deactivate the multi-state license privilege under the multi-state license for the duration of the nurse’s participation in an alternative program.

Þ Consideration: Article V allows each State to place a nurse in AP, however, not all Boards know when nurses are participating in their State’s Alternative Program because, for example, the program is outsourced to a third party. If States do not know their AP participants, those licensees would be able retain multi-state licenses if the licensee did not report their participation to the State.

Misdemeanors Article III, paragraph (c)(7) states that for an applicant to obtain or retain a multi-state license in the home state, the individual “has not been convicted or has entered into an agreed disposition, of a misdemeanor offense related to the practice of nursing as determined on a case-by-case basis….”

Þ Consideration: Each State will make its own case-by-case determination about whether to impose discipline for misdemeanors. If the state takes action on a misdemeanor, other party states could take action based on the other State’s action, but if the State where the misdemeanor occurred declines to take action, the Board would not be aware of the misdemeanor.

Conviction Language Article III, paragraphs (c)(7) and (8) state that for an applicant to obtain or retain a multi-state license in the home state, the individual “has not been convicted or found guilty, or has entered into an agreed disposition, of a felony offense…and has not been convicted or found guilty, or has entered into an agreed disposition, of a misdemeanor offense related to the practice of nursing….”

For felonies and misdemeanors, the Ohio Nurse Practice Act specifies the Board can take action based on a “conviction of, a plea of guilty to, a judicial finding of guilt of, a judicial finding of guilt resulting from a plea of no contest to, or a judicial finding of eligibility for a pretrial diversion or similar program or for intervention in lieu of conviction for, …”

Þ Consideration: The Compact language, “not been convicted or found guilty, or has entered into an agreed disposition” is too narrow. Under Ohio law, the Board can also take action on judicial findings of eligibility for a pretrial diversion or similar program, or intervention in lieu of conviction. Without these options, the Board would need to base action on the underlying facts which would greatly lengthen the investigative and hearing processes.

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MEMORANDUM



Tom Dilling Public and Governmental Affairs Officer/Liaison

Subject: Nurse Licensure Compact: Summary of Issues


Based on the Compact information presented at the January 2021 Board meeting, the following are identified as areas of concern for discussion:

Lack of Mandatory Reporting Requirement in Compact States Ohio is a mandatory reporting state, but mandatory reporting is not a requirement of the NLC. TERCAP data has shown the importance of mandatory reporting to assure boards of nursing are receiving complaints and preventing unsafe practitioners from moving from employer to employer without boards of nursing knowing about unsafe practice.

• The lack of this requirement in other states impacts Ohio because employers and othersmay not report potential violations. This increases the possibility that nurses with multi-state licenses (MSLs) may not have been reported to their home state board of nursingand these nurses will be practicing in Ohio.

Lack of Continuing Education Requirement on Remote State Law and Rules Ohio requires two hours of continuing education (CE) of Ohio law and rules for nurses seeking reciprocity in Ohio to assure some knowledge of the Ohio Nurse Practice Act and practice requirements. It is designed to promote safe nursing practice in Ohio in compliance with regulatory requirements.

• Under the NLC, nurses are not required to take CE in any remote state in which they arepracticing. Upon discussions with NCSBN, Ohio was advised that this would not beacceptable to include in the NLC legislation. The lack of any requirement to have a basicunderstanding of practice in Ohio for those practicing in Ohio but licensed in their homestate can impact patient safety in Ohio. This prohibition seems inconsistent withrequirements for nursing practice by those licensees who do not hold a Compact license.

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Grandfathering of Nurses Without Criminal Records Checks The Compact language specifies that nurses who held a MSL under the “old” NLC would retain their MSL without obtaining a criminal records check. The exceptions would be (1) nurses who change their primary state of residence, must meet the requirements of the new Compact; or (2) a nurse who “fails to meet the multi-state licensure requirements due to a criminal conviction, enrollment in an alternative program, an adverse action or any other event occurring after the Compact’s effective date, shall be ineligible to retain or renew a multi-state license and the nurse’s multi-state license shall be revoked or deactivated in accordance with applicable Commission rules.”

• Nurses who hold multi-state licenses issued under the old Compact are grandfathered intothe new Compact. Therefore, nurses who never had criminal records checks could hold amulti-state license under the new Compact.

Impact on Nursing Workforce Data NLC legislation does not include requiring nurses with MSLs to register in remote states. States that attempted to include this provision in the Compact legislation have been informed by NLC that they cannot be part of the Compact if this provision is enacted.

• This prevents states from having accurate workforce data. Having correct informationabout nursing workforce is necessary for workforce planning and policy making.

• While HB 341 requires hospitals to report to the Board those nurses working who hold aCompact license, it is questioned whether this reporting would be consistent. Further,based on Ohio nursing workforce data reports, 47% of Ohio nurses are employed byhospitals, and 53% report they work for other types of nursing employers.

Open Meetings Act The Compact language states, “The Commission may convene in a closed, non-public meeting” for certain reasons; the Commission has immunity/defenses to lawsuits. The Commission is not subject to any independent auditor or legal authority with oversight over its operations or finances and has immunity/indemnification from lawsuits.

• This provision may violate the Ohio Open Meetings Act.

Rulemaking Powers of the Commission The Compact language states, “The Commission shall have the following powers: To promulgate uniform rules to facilitate and coordinate implementation and administration of this Compact. The rules shall have the force and effect of law and shall be binding in all party states.” The Commission will have the power to enact rules that are binding on each State in the Compact by a simple majority vote.

• Each State is subject to the majority rule of the Commission. Ohio would have one vote.Each State would be subject to administrative rules not reviewed under the same Stateprocesses as other rules and not passed or reviewed at the State level. This provisionmay violate the Ohio Constitution and possibly federal anti-trust laws requiring “activestate supervision” depending on the rule.

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MEMORANDUM - Ohio Board of Nursing

Documents

Transcript of MEMORANDUM - Ohio Board of Nursing