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IN RE: THE PETITION FOR DECLARATORY STATEMENT OF MARGARET M. WALSH, CNS
STATE OF FLORIDA BOARD OF NURSING
---------------------------·' FINAL ORDER
Final Order No. DOH-13-2183r8 -MQA
FILED DATE- NOV 0 8 2013
THIS CAUSE came before the Board of Nursing (hereinafter Board) pursuant to
§120.565, Florida Statutes, and Rule 28-105, Florida Administrative Code, at a
duly-noticed meeting in Naples, Florida on October 3, 2013, for the purpose of
considering the Petition for Declaratory Statement (attached as Exhibit A) filed on
behalf of MARGARET M. WALSH, CNS (hereinafter Petitioner). Having considered
the petition, the arguments submitted by counsel for Petitioner, and being otherwise
fully advised in the premises, the Board makes the following findings and conclusions.
FINDINGS OF FACT
1. This petition was noticed by the Board in Vol. 39, No. 162, dated August 20,
2013 of the Florida Administrative Weekly.
2. Petitioner, MARGARET M. WALSH, CNS, is a clinical nurse specialist
licensed to practice in the State of Florida, having license number CNS 921131.
3. Section 464.003(7), Florida Statutes, defines "clinical nurse specialist
practice" as the delivery and management of advanced practice nursing care to
individuals or groups, including the ability to assess the health status of individuals and
families using methods appropriate to the population and area of practice and to
diagnose human responses to actual or potential health problems.
4. The practice may include assessing patients with behavioral health
problems, diagnosing using the ICD-9 codes and DSM 5, and treating patients with
psychotherapy.
5. Chapter 464, Florida Statutes, does not require a clinical nurse specialist to
have a protocol with a supervising physician or physician oversight of the nurse's
practice.
CONCLUSIONS OF LAW
1. The Board has jurisdiction over this matter pursuant to Section 120.565,
Florida Statutes, and Rule 28-105, Florida Administrative Code.
2. The petition filed in this cause is in substantial compliance with the provisions
of Section 120.565, Florida Statutes, and Rule 28-105, Florida Administrative Code.
WHEREFORE, the Board hereby finds that under the specific facts of the
petition, as set forth above, a clinical nurse specialist may assess patients with
behavioral health problems, diagnose patients using the ICD-9 codes and DSM 5, and
treat patients with psychotherapy without t~rvision of a physician.
DONE AND ORDERED this J day of ~ '2013.
BOARD OF NURSING
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a true and correct copy of the foregoing Final Order
has been furnished by U.S. Mail to Petitioner MARGARET M. WALSH, CNS, 9959 St.
Moritz Drive, Miramar Lakes FL 33913, and by interoffice mail to Michele Bass,
Paralegal Specialist, Department of Legal Affairs, PL-01 The Capitol, Tallahassee FL
32399-1050 this1 ~ ~ay of t\.lovembe r '2013.
7012 3050 0001 9149 7566 r---.--
C1J~&udu.n DeiJU\Y Agency Cterk
" ~ef'daj .. \/C~·30\r-<-t9 Aug. 31 13 11:128 f!leg Walsh
Margaret Mary Wals , MS, PMHCNS..BC
FILED DEPARTMENT OF HEALTH
DEPUTY CLERK CLERK ~naef Sancfers DATE SEP 0 4 2013
Statement before-the Board ofNursin
REVISED
Petitioner: Margaret ary Walsh, MS, PMHCNS-BC License# CNS 921131
9959 St. Moritz Driv
Fax 239 454 0307
No legal represent •
p.2
Ms. Walsh is seeking e Board's interpretation of Florida Statutes, Nurse Practice Act. Sec:tion
464.003 that as an a anced practice nurse, certified as a Psychiatric I Mental Health Oinical Nurse Specialist, she may d nose human responses to adual or potential behavioral health problems and
implement therapau interventions. She Is seekinsa determination that she would not be outside
her scope of practice s a CNS in maldnc behavioral dlqnosls and treatfna with psychotherapy under
her CNS certification ut physiden oversi&ht or protocol. Ms. Walsh does not prescribe
medication. Shere confirmation that she Is permitted to assess patients with behavioral health
problems, diqnose u 'nc the ICD-9 codes and treat with psychotherapy using the lCD- 9 codes.
Situation:
vldes psychiatric assessment, diagnosis and Individual psychotherapy, couples,
family and group the as a 25 hour a week employee of a Ft. Myers psychiatrist. In this office she is a
member of a multidlsc plinary team of psychiatrist. ARNPs and lMHCs.
In addition to continui her current employment, she wishes to establish an Independent practice as a
CNS rn which she fumi hes individual, couples, family and group therapy services, including diagnosing
behavioral problems. s. Walsh does not do medication management.
Ms. Walsh submitted protocol to the Board of Nursing between herself and Or. Mach lin, a !JSYChiatrist
but was notified on Ap "110, 2013 that a protocol was not required. See attached. Therefore Ms. Walsh
is requesting a declara ion to clarify If it is within her scope of practice as a CNS to deliver mental health
1
Aug 31 13 11:12a· Peg Walsh 239 454-0307 p.3
Margaret Mary Walsh MS, PMHCN5-BC
Precedents
There are two recent eclarations that are relevant:
Feb 3, 2011, (date fro the Final Order document) the Board of Nursing voted to approve a dedaratory
statement for lisa Ma ie Burton, MSN,PMHCNS, ARNP finding that she is able to diagnose human
responses to actual or potential behavioral health problems and implement therapeutic interventions
without entering into S1Jpervisory relationship or a protocol with a physician. It further stated that that
she would not be subj ct to discipline under her ARNP certification for acts performed within the scope of practice of her CNS certification.
eliberatlons of the Board Indicates that the Board undemood that to do her
treatment, she must iasnose using lCD -9 codes, as to all providers of behavioral health services. They
also understood that er treatment as a CNS Is psychotherapv. They took Into consideration that CNSs
can bill Medicare and edicald and must use lCD- 9 codes. It was noted In the transcript that in order
to do their jobs in be vloral health, licensed clinical social workers, licensed mental health counselors
and licensed mar ria and family counselors also must diagnose using lCD -9 in order to treat. The
ey would decide on a case by case basis the issue of advanced practice, certified
lth CNSs providing mental health services without physician oversight.
arc! issued a declaration that it was within the scope of practice for Sharon Van
Fleet, a CNS, whose s eclalty is in psychiatric-mental health nursing, to conduct a psychiatric assessment
of an individual who reatened suicide. The Board unanimously stated It is within the scope of practice
of a CNS to conduct a psychiatric evaluation on an Individual without a protocol or supervising physician.
Meeting Minutes, Flo ida Board of Nursing (October 6-8, 2010).
iningto CNS pradice
Ms. Walsh under stan s that her CNS scope of practice is as follows:
464.003 Definition .-As used in this part, the term:
(6) "Oinical nurse specialist"' means any person licensed in this state to practice professional
nursing and ertlfied in clinical nurse specialist practice.
{7) "Ciinica nurse specialist practice" means the delivery and management of advanced
practice nur ng care to individuals or groups, including the ability to:
(a) Assess health status of Individuals and families using methods appropriate to the
population a d area of practice.
2
Aug 31 13 11:12a Peg Walsh 239 454-0307
(b) uman responses to actual or potential health problems.
(c) Plan for h alth promotion,, disease prevention, and therapeutic intervention In
collaboration "th the patient or client.
p.4
{d) lmpleme t therapeutic interventions based on the nurse specialist's area of expertise
and within th scope of advanced nursing practice, including, 'out not limited to, direct nursing
care, counseli g, teaching, and collaboration with other licensed health care providers.
Certifications:
e health care as necessary and appropriate and evaluate with the patient or
iveness of care.
Ms. Walsh has been rtified as an Adult Psychiatric Mental Healttl CNS by ANCC since well before 1990.
{This is the earliest e that ANCC can confirm.)
are Manager by the National Academy of Certified Care Managers and is a
al Association of Professional Geriatric Care Managers.
She is certified as a x Therapist from American Assodation of Sec Educators, Counselors and
Therapists.
Education In Behavi Health and Psy~herapy:
Ms. Walsh received B.S. in Nursing from Mt St. Mary College in Newburgh NY in 1971, Masters of
Science in Adult Psy iatric /Mental Health Nursing from Adelphi University, Garden City, NY In 19n.
She is a graduate of Y Medical College Program in Sex Therapy, 1979 and a graduate of Florida
Postgraduate Sex Th rapyTrainlng Institute, 2012.
Ms. Walsh has com leted well over 500 hours of continuing education credits related to psychotherapy
and behavioral hea h.
Previous Work Hlst ry:
Prior to coming to F orida 9 years ago, Ms.. Walsh was in private practice in Bayside NY as a solo
practitioner provldl g individual and couples therapy from 1978 to 2004. Her patient census was 10- 20
dients a week. She has never had a malpractice suit or disciplinary hearing or any legal actions against
her as a dinical nur e specialist.
Ms. Walsh has over thirty (30) years of experience in mental health as an advanced practice nurse. In
addition to private ractice, Ms. Walsh also worked as a clinical consultant and trainer for nurses of
Visiting Nurse Servi e of NY (the largest certified Home Health Agency in NVC) and for paraprofessionals
certified by NYS De artment of Heatth and the NYS Department of Social Services. She translated
psychotherapeutic nderstandlngs and interventions into language and techniques that allowed public
3
Aug 31 13 11:13a Peg Walsh 239 454-0307 p.5
Margaret Mary Walsh MS, PMHCNS·BC
health nurses, home alth aides and home attendants to work with "difficult clients". Her publications
In dude:
• Effectively with Physically and Verbally Abusive Elderly Clients and families"
Chapter 10 in Home re Of The Elderly, Sheryl Zang and Judith Albender, lippincott.
• 1992, "Resolv ng The Dilemmas of the Dlflicult to Serve",lnnovatlve strategies and Trainlns
Techniques, National omecaring Coul'lCil- (Monograph) Home Care University of National Association
of Home Care. This wa funded by a grant from the United Hospital Fund.
• 1986, 'The Ch llenge of Mental Health Home Care/' Caring, July, pp. 17-19.
• 1985, "Stress anagement: A Case-Oriented Program for a Home Attendant Agency,"
• 1981, •Role
Ami Sha'ked, Editor,
Rehabllhatlon Nurse-', Chapter 14, Human Sexuality in Rehabilitation Medicine,
illiams & Wilkins.
• 1979, .,.he P ic Health Nurse as Sexual Counselor for Spinal Cord lnjwed Men" in Sexuality
and Disability, 2 {1}, 5 ring.
In 2012, Ms. Walsh wa an adjunct Clinical Instructor at Florida Gulf Coast U niversitv Clinical teaching
Baccalaureate nursing tudents In their clinical rotation at a psychiatric facility. She is contracted to
again function in this r le in the Spring semester of 2014.
In Summary:
Ms. Walsh is seekir~g t e Board's interpretation of Florida Statues, Nurse Practice Act, Section 464.003
that as an advam;ed p ctice nurse, certified as a Psychiatric/ Mental Health Clinical Nurse Specialist, she may diagnose hu n reSpOnses to actual or potential behavioral health problems and implement
therapeutic lnterventl ns. She requests confirmation that her education, certification, training and
experience enable her o assess pat;ents with behavioral health problems, diagnose using the ICD-9
codes and treat with p ychotherapy using the lCD- 9 codes without physician oversight or J')rotocol.
Respectfullv submitted
Margaret Walsh, MS, P
Cf-1-13 4
Aug 31 13 11:13a Peg Walsh
----= To protect promote & ilnllfOie tile ltealt of aJ people il Roridl t'lrough integ stale. county & CQIIliiiiJnity elorts.
,: .··
239 454-0307 p.6
lUck Scott Govemor
.lolm H. An,_ II ••&r MD, FACS S1ate Sutgeon General & Seclalary
VIs loll: To be 1he Heallllielt Stale In llle NaSon
Margaret Mary Walsh 9959 St. Moritz Drive Ft Myers, FL 33913
Dear Ms. Walsh:
April10, 2013
The Board of Nursing s recently received a protocol between you and a supervising physician. Certified nurse speciali ts are not required to send protocols to the Board of Nursing and I will be unable to add it to your practitioner profile as a protocol. I will, however. make sure It is added to your file within our system. If you have any questions, please do not hesitate to contact the Board of Nursing at 850-245-4125.
l"larllla Departrne11t of lth Oivlsion of MeOICal QuaiUV Assurance· ureau of tiCPR '052 Bald Cypress W~. Sin C02 • Tal hassee, Fl323..0!J.3252 Pf.!ONF.: 1850\245-4125 • fAX: {9F.Il} 45.4172
Sincerely,
..----:::.-r-·~· .:.··~*/•'
.-:---.s~an=on Regulatory Specialist I
www.FiorlduH ... h.com TWITIER:HealthyFLA
FACEBOOK:rLDeparlmentDfHealll'l YOUTIJBE: fldoll
Creaied on4J1012013 11:46 AM
· Aug 3t 13 11:13a · Peg Walsh
IN RE: THE PET ION FOR OECLARAT RY STATEMENT OF LISA MARIE BU ON
STATE OF FLORIDA BOARD OF NURSrNG
I
FlfW,ORDER
239 454-0307 p.7
THIS CAU E came before the BOARD OF NURSING (hereinafter Board)
pursuant to § 120. 65, Florida Statutes, and Rule 2&-1 05, Florida Administrative Code,
at a duly-noticed eating in Tampa. Florida on February 3, 2011, for the purpose of
considering the Pe tion for Declaratory Statement (attached as Exhibit A) filed by LISA
MARIE BURTON ( ereinafter Petitioner). Having considered the petition, the
arguments submitt by oounsel for Petitioner, and being otherwise fully advised in the
makes the following findings and conclusions.
FINDINGS OF FACT
was noticed by the Board in Vol. 36, No. 2, dated November 24,
2010 of the Florida mlniStrative Weekly.
2. Petitio er is a licensed registered nurse c•RN"), who Is also dually
credentialed as a ard certified clinical nurse specialist rcNS•) in adult psychiatric
mental health ( . cation number 261~) and a nurse practitioner c·ARNP"}
{cerUflcate number RNP1988612) with national certification in psychiatric menta~
heal1h.
3. Petitio • has practiced as a nurse within the mental heallh field since
1981, as a psychia ARNP sinoe 1995, and as a CNS in adult psychiabic mental
health since 2007 en the oertification was offered in Fbrida. Petitioner currently
· Aug 31 13 11:13a · Peg Walsh 239 454-0307
provides psychia c primay care services as an ARNP in a large multi-specialty
4. Pe · oner has over 25 years of mental health nursing experience with 15
nursing practice utilizing psychotherapy procedures in various
settings. Petition has completed over 300 hours of continuing education credits
related to psycho y and behavioral health. Psychotherapy is within Petitioner's
ed on t'ter Individual education, training and experience.
5. Pe · oner would like to establish a practice as a CNS in which she
fumishes individ , marital, family and group therapy services, including diagnosing
behavioral probl s. Petitioner will not prescribe any medication in this practice.
Medication mana ment wtll be left to the patient's physician or other duly authorized
practitioner.
6. S's scope of practice is defined in §464.003(7), Florida Statutes as
• ... the delivery a management of advanced practice nursing care to individuals or
groups, including abihty to:
a. ss the health status of individuals and families using methods
priate to the population and area of practice.
b. Diag ose human responses to actual or potential health problems.
c. Plan! for healh promotion, disease prevention, and therapeutic
d. lm
of
entlon in collaboration with the patient or client.
ent therapeutic interventions based on the nurse speciaUsl's area
ertise and within the scope of advanced nursl.ng practice, including,
t limited to, direct nursing care, counseling, teaching, and
p.8
Aug _31 13 11:1% Peg Walsh 239 454-0307 p.9
e. Coo inate heafth care as necessary and appropriate and evaluate with
atient or client the effectiveness of care."
7. A nt Petition for Declaratory Statement submitted by Sharon Van
10, requested the Board to decide whether, under its facts, if •it is
within the scope o practice for a CNS whose specialty is in psychiatric-mental health
nursing to conduct a psychiatric assessment of an individual. ... " Sharon Van Aeet,
Petition for Decla tory Statement (July 19, 2010). The Board unanimously stated it is
within the scope of practice of a CNS to conduct a psychtatrtc evaluation on an
individual without a protocol or supervising physician. Meeting Minutes, Florida Board
of Nursing (Octo
8. , Petitioner, along with certification as a CNS Is aso certified as
an ARNP/nurse p~titi· "io1ner. Section 464.012(4)(c){5), Florida Statutes (2010)
(hereinafter rete to as the •ARNP Statute•} provldes that a nurse practitioner may
establish behavi problems and diagnosJs and make treatment recommendations
of established protocoi!Nith a licensed physician.
10. Hence Petitioner is seeking a Declaratory Statement that as a CNS she
may diagnose huma responses 1D actual or potential behavioral health problems
without risking disCi ine under her ARNP certification should she proceed without a
protocol.
11.
within their scope of
stabfished concept that so Jong as a licensee is practicing
ctice, they cannot be found to be practicing outside of the scope
of practice. Petition&l is seeking a detennination that she would not be outside the
· Aug 31' 13 11:14a Peg Walsh 239 454-0307 p.10
making behavior diagnosis under her CNS certifiCation.
CONCLUSIONS OF LAW
has jurisdictJon over this matter pursuant to Section 120.565,
Florida Statutes, a d Rule 28-105, Frorida Administrative Code.
2. The pet· on filed in this cause is in substantial compliance with the provisions
of Section 120.56 , Rorida Statutes, and Rule 28-105, Aorlda Administrative Code.
3. The Boa agrees with Petitioner's analysis of §§464.003(7) and
464.012(4)(c)5, F
to actual or pote
E, the Board hereby finds that under the specific facts of the
above, Petitioner, as a CNS, is able to diagnose human responses
behavioral health problems and Implement therapeutic
interventions witho t entering into a supervisory relationship or a protncol with a
Board finds that Petitioner wilt not be subject to discipline under
her ARNP certifies · n for acts performed within the scope of practice of her CNS
certification. !
CONE AND RDERED this ) ~day of ~ , 2011.
Pursuant to
80~ Joe~ Executive Director for Jessie Colin, RN, PhD, Chair
NOTICE OF APPE&L RiGHTS
ion 120.569, Florida Statutes, the parties are hereby notified
that they may appe this Final Order by fitlng one copy of a notice of appeal with the
t and by ftlilg a firing fee and one copy of a notice of appeal with
··Aug 3113 11:14a Peg Walsh 239 454-0307 p.11
f Appeal within thfrtydays of the date this Final Oltfer is filed.
CERTIFICATE OF SERVICE
I HEREBY RifFY that a true and correct copy of the foregoing Final Order
has been fumis by U.S. Mail to Petitioner LISA MARIE BURTON, c/o Cynthia A.
Mikos. Esquire, 2 S. Rome Avenue, Suite 100, Tampa FL. 33606-1854, and by
interoffice maU to lla Blocker, Department of legal Affairs, Pl-01 The Capitol,
Tallahassee Fl32 99-1050 this2 day of D'ltJ.reA , 2011.
Aug j1 13 11:14a P"eg Walsh 239 454-0307 p.12
os Final Order No. DOH-10ft~ ·MQA
FILED DATE· 10 J ~l'l/0
~~,·-~
JN RE: THE PET ION FOR DECLARAT RY STATEMENT OF SHARON VAN FL ET
STATE OF FLORIDA BOARD OF NURSING
------------+-----------~' FINAbORDER
By: ' ' OJ4tfic
came before the BOARD OF NURSING (hereinafter Board)
pursuant to §120.5 5, Florida Statutes, and Rule 28~105, Florida Administrative Code,
at a duly-noticed m ting in Orlando, Florida on October 8, 2010, for the purpose of
considering the Pet · n for Declaratory Statement (attached as Exhibit A) fifed by
(hereinafter Petitioner). Having considered the petition, the
arguments submi by counsel for Petitioner, and being otherwise fully advised in the
makes the following fllldings and conclusions.
FINDIHGS OF FACT
1. This petiti n was noticed by the Board in Vol. 36, No. 32, dated August 13,
2010 of the Florida ministrative Weekly.
2. Petitioner, SHARON VAN FLEET, is clinical nurse specialist nurse licensed to
practice nursing in e S1ate of Florida, having license number CNS 59176862.
3. Petitioner' specialty is in psychiatry.
4. Petitioner · employed at Moffitt Cancer Center {hereinafter "Moffite).
5. In June of 009, another employee at Moffitt became agitated and threatened
suicide while at work
employee refused voluntary evaluation at an appropriate mental
health facility.
Aug 3f 13 11:15a · Peg Walsh 239 454-<>307
7. The staff t Moffitt did not want the agitated employee to be involuntarily
committed pursuan to the Baker Act.
a. The Chie Nursing OffiCer asked petitioner to examine the agitated employee
to determine if ther: was an alternative, reasonable, safe referral plan.
9. Petitione inquires if it is within the scope of her practice as defined in Section
464.003(3)(c}, now enumbered 464.003(16), Florida Statutes.
CONCLUSIONS OF LAW
has jurisdictiOn over this matter pursuant to Section 120.565,
Florida Statutes, a Rule 28-105, Florida Administrative Code.
2. The petiti n filed in this cause is in substantial ~mpliance with the provisions
of Section 120.565, Florida Statutes, and Rule 28-105, Florida Administrative Code.
3. Section 4 .003(16) defines clinical nurse specialist practice as follows:
(7) "Clinical urse specialist practice" means the delivery and manageme of advanced practice nursing care to individuals or groups, including the ability to:
(a) Assess e health status of individuals and families usfng methods appropriate t the population and area of practice.
(b) Diagno human responses to actual or potential health problems.
(c) Plan for altn promotion, disease prevention, and therapeutic intervention · coJiaboration with the patient or client
(d) lmpleme t therapeutic interventions based on the nurse specialist's area of expe · e and within the scope of advanced nursing practice, including, bu not limited to, direct nursing care, counseling, teaching, and collaborati with other licensed health care providers.
health care as necessary and appropriate and evaluate nt or client the effectiveness of care.
WHEREFO E, the Board hereby finds that under the specifiC facts of the
petition, as set fort above, it is within the scope of practice of a psychiatric clinical
p.13
Aug 3.l 13 11:15a Peg Walsh 239 4~307
nurse specialist to ondud a psychiatric assessment of an individual threatening
suicide. /
DONE AND RDERED this~ / day of
BOARD OF NURSING
ftOTICE OF APPEAL RIQHTJ
Pursuant to ction 120.569. Florida Statutes, the parties are hereby notified
that they may appe I this Final Order by filing one copy of a notice of appeal with the
clerk of the depa nt and by filing a filing fee and one copy of a notice of appeal with
the District Court of peal within thirty days of the date this Final Order is filed.
CERTIFICATE OF SERVICE
I HEREBY C RTIFY that a true and correct copy Qf the foregoing Final Order
has been furnished y U.S. Mall to Petitioner SHARON VAN FLEET, 12902 Magnolia
Drive, Mail stop: N RS ADMIN. Tampa Fl33612-9416, and by interoffice mail to
Marcella Blocker, 0 partment of Legal Affairs, PL-01 the capitol, Tallahassee FL
32399-1050 thia:;l_!_ ray of () cfc,ha,c '201 0.
VanFieetPOS.rtf
p.14
Aug 31 13 11:15a · Peg Walsh 239 454-0307
Florida Bo of Nursing Dtpartment f Health's Agency Clerk's Off tee 4052 Bald C Way. Bin MA02 Tallaba5sce, 'da 32399-1703
Flee&. MS, RN •. PMHCNS-BC, wotlld like 16 petition the. State of Florida ing for a Declaratory Statement reprding The 2009 Flllrlda Slotrdes. Tille
XXXII Re ion of Pro.{nsiolu and Ot%upafit»U, Cluzpttlr 464 N~miltf. Part I. Nurn Practke Act, 'ubseclitm 464.00J.
I am 1be Psyc . atry Clilljcal Nurse Speciatist a1 Moffitt Cancer Center. rn Jane of2009 I was pres by the Chief"Nwsios Off'KCI" to.._ .. an employe~ who becane ~. tb:realeDini cide while at wodc.. The employee was •tin& assistance md was Jefusing to go a vol~ evaluation It aa appropriate menllll halth faeility .
. Earlier, l had n ukeCt to see the employee by a Socill Work su.pei-Yjsor and bad Ur:!icared that my"scopeofpracticc,l w• not allowed toconductdlecxaminalion 1hat would he .WiD such a situation. Our P.sychiaary cotasultation..Jillilon service had been IDd the)' reeomaadcd. a Baler Act. mel J niteratcd this u well. 1l!e suaJCStiOD. or • ch l1ad been rt;jected by sl8fr dempting lo in1enwe with the c:mpJoyce.
. . When 1 home iD Cbe cvc:nin& the CNO bad left a voi" mail messase indicating she needed ro with me. When t returned la.cr call the CNO told me that tbe employee had eft MoftiU aud tbat the CNO wanted fD hPe tb&employee Rlllm to Moffitt the oe JDOl'nios in oRier for me co '"lee" her. I CIIIJ)hui:.rlccl my primary . ovcnid.ing relaied tO my scope of practice, as weD as fXbcr iss=s. ncb. the evidr:nt need file a Babr Act in RCOSJlition tlllt the emplo,YBe was threfiteninJ sukidc yet uawilliog 1 sc:U assistance.,( also spoke to &be reality t11at were I to qn:c: to c:onverse with (or "'sec .. ) employ«, I would not have been allowed, per 1ft) scope of practice, to assess her in a thai woald have diMded the farmatioJJ of a allemldive. reasoaable, saft refl:mU plan. M)' onJy opti~ wuuJd bave bl:a1 to file a Baket Aet. whic:h the CNO did want me to do. expressing disbelief ami disapproval tJIIr I could .ftOt offer more. employee RpOttcdly cornacted peen. pc:csistiD& in mratenina suicide after a left ftiU:.) Thc-CNO DOW contezxls 1hat 1 was "eD:CSSively prcoc:cupiecl" with my scope of ice in siatina that I could not evaluate the cmpiO)'ee~ . . . .
AJ defuu:d inS ion 464.003, para,graJ'h-.. c," '"Ciioical nurse specialist practice' means • the delivery ad ma~~aJCIDCDI of.advanced pracrice nursin& ca.rc ro individuals or BJUUPS, lncladinB the a ity to: . . 1 • Asaas 1be tb 5tabB of individuals aad llmilies us.illa tDCthods appropriate to the papulatiou and of practice. . l~ Diapose. h respoaHS to -=tull orpotea.Ual health problems.
... "" ..... ___ ,_._
.. ..a.......... p -· ... c .... ..c.....
p.15
73144~~----------------~
.. Aug 3,1· 13 11:15a · Peg Walsh 239 454-0307
.3. Plan for th promotion, disease prevention, ancl thenlpeutic i~ntiOD in collabora • witb the patient or dient. 4. Imp therapeutic iatervedtions besed oo the .aurse speei&liat's area of experdae . 8lld within xope of adVIIW<f nunma pract:icc, incluclin& bu1 nollimltecl to, ctircc:t
· marsina ~· cOODSClina, tcachinl. and coUabotation.wilholher licensed balch care providers. . S. Cocmlinat health care u necessary and appropriate and c:val'Uite wi1h the pllient or client the eftl • of caR:."
ording 10 paragraph "'d,'" o{lbe same Sectioa, "Mvaaced ct ~iali.ud Dt8f:*'" 1s defined as: •• .• .in addi~ to rhe practice of professional nursing, tbc
advaoced-level D.\11'8iaa acU ~prod by the board whlch, by virtllc of · iad edUC81ion, lr'IWimg. 11111 experience. 1re appropriat.ely perf'omted by
'stm:d D1D'Se pntelitioner. Widlia the context ofacl.v...:i or specialized the advanced regisrered nune practitioaer may pedilm1 ac1s of mu:sina ·
. treatment of akenslions oftbe health iStatlls. The advaced pnwtitioDCr may also perfoJm acts ofmcdfcal diagnosis and treatmftt. operation which are identified a approved by ajaiut committee .....
ntn.ww~.- speci(ICd by the joint committee. such acts must be performed -andcr the general su sioo. of a practitioner licensed upclet ohapter 4S8 •. Ghapter 459, or chapter %6 within the framework.Qf standing profOCols which identify the medk:al acts to be performed met rhe CODditiODS for· their pedbnDiliO! •..• '"
The scope of p ·ce for both tbe CNS and ARNP arc clearly cldined u delailed .above, evideDcing the "ffereace b=tweeR CNS aDd ARNP p~. Sill<:e the assessmemt of an illdividllal ~suicide mauires a ~biakic dia,anostic naluaaion (a medical evaluation) to · · ne the degree of risk a well as possible cliologic:s undedyina tbe agitation and s ·~idal ideation. such as depression. anxiety, intoxicatioa, wichdrawal stales, or lil)" disorder, in order tD make an appropri~ n:ferral for psychiatric i~tion, Pcdtlooer asks the foil~:
:.;! :¥ a:.. -
Shaion Vm Fl MS, RN. PMHCNS-BC Telephone: (813 74S·.369S Facsimile: (113) ~S·S:S37 (clccttonic:, not paper)
(")~ -r:,=. !! ~~ en ::r,'i I
~3 "" g~ :1 :c::o ;:e::; ~ ~<. c.n ,...,rn r.'\
e:mail: SJwoa. V, [email protected] 12902 Magnolia ·~.Mail Stop: NURS ADMIN, Tampa, Florida.ll612-9416
p.16
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73145'-J--------------~~
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Peg Walsh 239 454-0307
STATE OF FLO~IDA DEPARTMENT OF ~EA~TH
BOARD OF NURSING
Embassy Suites - USS/Busch Gardens 3705 Spectru~ Boulevard
Tampa, Florida 33612
February 4, 2011
Petition for Dec1aratory Statement
In Re: Lisa Marie Burton
p.17
10 MSN, ARNP, Chair, Advanced Practice
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Chair
I:CB OJ' TD M'rORIIBY GEliiBIIAL: 16 L· E NN GUSTAFSON, ESQU RE, Board Counsel
17 PRBSEIIT: CK GARCIA, M.S., R.N., C.C.M., Executive Director
18 BERT J03:JSON OLMSTEAD, Operations Analyst, II
19 LLIAM SPOONER, Regulatory Supervisor/Consultant
20 SECU~ION SBRVICBS PDSBN".r: LLIAM MILLER, ESQUIRE
21 M GAN BLANCHO, ESQUIRE S.ENIKA HARRIS, ESQUIRE
22 A NIE POWEL~, Staff
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ION WIT PRESENT: CE JOHNSON, M.A., ~.S.N, R.N., Director TRIDG~ LIGHTFOOT
CKI::: BOYD
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2
(Whereupon, the proceedings were called to order the
C air, after which the following occurred, to-wit:)
....... MS. GUSTAFSON: rllletMs. Milcos begin.
MS. MIKOS; Good mornins. I'm Cynthia Mikos and I'm here today with Lisa
Burton. Lisa Burton is bo-:h a psychiatrically trained
ARNP and a clinical nurse specialist. And the
question that we provided in the Petition today is
whether Ms. 3urton as a clinical nurse specialist,
according ~o the stat~tory defini~ion of a clinical
nurse specialist and what they do, it says that they
are ab~e to diagnose human responses to act~al
potential health pron:ems as part of their scope of
practice. As an ARNP in the past, the Board's
position has been that a nurse practitioner who makes
a diagnoais of a behavioral diagnosis has to have a
protocol.
So the question here today is CNS' s do not !:ave
protocols and we want to confirm that Ms. Burton is
ab~e to work as a CNS and make a diagnosis without
using the protocol. And Ms. Burton is here to answer
quest~or.s you may have.
DR. COLIN: Board members, any comments or
questions for Ms. Burton? Dr. Danker?
AMERICAN COURT REPORTING (850) 421-0058
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3 DR. DANKER: I just want to make a comment. I
think that ~ot only CNS's but ARNPs and registerec
nurses make diagnoses every day outside of protocols.
DR. COLIN: I would agree that- as you're
working within the title of a CNS, but in the scope
o= practice to diagnose as a nurse, and that there
is not a need for a protocol. The protocol is needed
when you have the - when you are working as an ARNP
and not as a CNS.
D3. DANKE~: Right. Thank you.
MS. MIKOS: It creates an interesting question
and I want to be clear here. If she puts on her
business card that she is a eNS-comma- ARNP, does that
change her - that is her -
DR. COLIN: Those are her credent~als and they
are on her card, but in terms of her work she's working
within the title o£ a CNS. It's kind of like if I
went back to work in a hcspital and when I used to
be ONS-certified that I would have that on my card,
that doesn't maan right now I could go back and be
ONS certified because I haven't renewed my
certification, and I'm not working in that capacity.
I'm working as a trad:..tional everyday RN. So I don't
see that as an issue. I ~hink the cards are really
just fo= credentialing purposes to let people know
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Peg Walsh 239 454-0307 p.20
what your credentials are. 4
It doesn't have anything
to do with the work you do at that point, as I see
it.
DR. McDONOuGH: May I --
DR. COLIN: Yes, Dr. McDonough.
DR. McDONOUGH: I have ser.:..ous doubts about this
contention in tr.is argument. One being ttat the
difference between the authorization granted to
clinical nurse specialists versus advanced
registered nurse practitioners with~n a speciality
is, unless I ~~ mistaken, the clinical nurse
specialist language talks about diagnosing h~an
response to actual or potential health prcble~s.
That is not the same thing as making a diagnosis of
a disease or a condition. That is what is enablec
in the ARNP legislation. What we have here is a
circumstance - if we accept Petitioner's argument,
we're saying that functionally there's absolutely no
difference between an ARNP and psychiatric mental
health nursing and a clinical specialist - a clinical
nurse specialist in psychiatric mental health
nursing, but the Petitioner is asking to be able ~o
under her CNS authority to diagnose and treat in an
individual patient. You can't treat somebody
without making a diagnosis.
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6 MS. MIKOS: If I might fer a momen~, Dr.
:--JcDonough, I apprec:.ate your comment. But I want to
be clear that in the CNS role she will not be
prescribing any medication which will --
DR. McDONOUGH: Yes, counselor, I absolutely
hea~d. I'm not saying prescribir.g medication; I'm
saying treatment. She specifically mentions that
she's going to do psychotherapy en these patients;
is that right?
MS. MIKOS: Yes.
DR. McDONOUGR: Well, that --
MS. MIKOS: But that's well within the role of
a CNS.
DR. McDON08GH: Well, in my view that's
treatment. The issue becomes the diagnosis ahead of
time. You can't treat somebody without a diagnosis.
DR. COLIN: t"lell, it doe:s say in the description
of the CNS role diagnosis human responses to actual
potential health problems, which is what she wo~ld
be doing.
DR. McDONOUGH: Right, except there's a huge
difference between - in my opinio~, between
diagnosing human response and making a diagnosis.
Those are two very different things and I suspect if
we wanted the CNS's to do the same things that the
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7 A::tNPs have done, we would have used the same lar:guage.
We don'~; in the elementary language we do not say
diagnose human response. We say make a diagnosis.
MS. MIKOS: No. It - I'm sorry.
DR. McDONOUGH: Go ahead, counselor; I could be
wrong.
DR. COLIN: Dr. Denker?
DR. DENKER: I have a different perspective on
that. I see it as making a nursing diagnosis which
is different from making a medical diagnosis and
that's the way I would perceive it and pursue-
practicing.
DR. McDONOUGH: ~Yell, I would not disagree with
you, Dr. Denker. The issue is, is t~e nursing
diagnosis goi~g to be justification for providing
psychotherape~tic intervention? I'm saying if you
accept the Petitioner's argu:nent then other than the
prescription of medication, what is the difference
between the role of an ARNP i~ psychiatric mental
health nursing and a clir:ica~ nurse specialist, and
I wo~ld contend ~hat there is none.
DR. COLIN: Dr. Denker?
DR. DENKER: I would like to refer to NANDA
(unintelligible), which are the books that clarify
what nursing diagnosis is, and I would say that that
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Peg Walsh 239 454-0307 p.23
8 falls in the purview of a CNS practice.
DR. COLIN: I wou:d agree with Dr. Denker's
interpretation.
MS. MIKOS: I \V'ant to be clear, though, because
I don't want to have any misunderstanding here, which
is that Ms. Burton wants to be able to use an ICD-9
code so that she may bil~, if you will, for the
services. ~ow a CNS is entitled to bill Medicare,
a CNS is entitled to bill Medicaid, and an ARNP is
entitled to bill Medicare, and an ARNP is entitled
to bill Medicaid.
r-1s. Burton is both of those designaticns. She
has been educated as both of those people, both being
master's programs. So it's well within her scope of
practice and we think (inaudible} to do that,
although the difference here in Florida is that we
see an ARNP has to funct~on under a protocol anri we
do not say that abou~ a CNS. So I don't want any
misunderstanding about what the issue is.
DR. McDONOUGH: Well, although counselor for
the Petitioner has in fact laid out the case exactly
as I would have, the issue here is ~ot that the
Petitioner wants to make a nursing diagnosis.
ICD-9s are not in the nursing diagnosis and wha-: this
Petitioner wants is the ability to make a medical
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Peg Walsh 239 454-0307 p.24
diagnosis using ICD-9 providing therapy and then
billing for it. T.!:at I think is very different than
what has been env-isioned by this bill in the past as
the rule of a CNS.
MS. MIKOS: In regards to this issue in a
previous declarative statenent before Sharon
VanFleet (ph), she asked if she could make an
assessment, not a diagnosis.
DR. McDONOUGH: That's exactly correct. I
think these are two very, very different sit:1ations.
If this request by the Petitioner has been based on
the decla~atory ruling that we made regarding lhe CNS
who applied for a decla=atory ru:ing several months
ago in this Board, it's a very differe~t situation.
That CNS was talking about making an assessment of
a pa~ient who is in crisis, not assigning an ICD-9
code, and providing service and tt-en billing for it
afterwards.
MS. t-UKOS: And just to be clear, I want to give
you the language. I have the language from the nurse
practitioner portion of the ARNP statute to compare.
The language - once again, ignoring CRNAs and
ignoring midwives who have different language. The
language for nurse practitioners is perform any or
all of the following acts within the framework of an
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Peg Walsh 239 454-0307 p.25
established protocol. 10
There a=e four other issues
which I won't bore you with reading, but the fifth
one is establish behavioral problems and diagnosis
and make treatment recommendations. That is the
language for the nurse practitioner.
Now in the past there certainly has been a lot
of discussion about whether a psychiatric nurse
practitioner who's only doing therapy and not
prescribi~g, he didn't have a protocol. But this
Board has gone back and forth bu~ pretty much fallen
down on the side that says we think that means a
protocol because of tnat language in the statute.
And that is the crux o£ why I'm here today. I
understand ~hat the CNS can make an assessme~t, but
a CNS would have - I can't imagine what the role is
if they cannot make the assessment and then draw the
conclusion.
So the differentiation - I understand your
technical question, Dr. McDonough, but I don't - they
are both masters prepared levels, they are both roles
that are able to do ~his under federal law, under
reimbursement crite=ia, and the only potential
impediment is that question, that line, in the
Florida statute. Bt:.t it seems to be countered by the
statutory language in the definition of the CNS t"hi=h
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Peg Walsh 239 454-0307 p.26
11 is why we're here because the defini :.ion of the CNS,
that's also a statutory language, says diagnose-
DR. McDONOUG~: it says diagnose human
response.
MS. MIKOS: I'm sorry, but I think that there's
an interesting question about what that is, but is
not a depression a human response?
DR. COLIN: we:l, it a:so follows that a plan
fer health (inaudible) and therapeutic intervention
and it says i~plement :.herapeu~ic intervention, so
if you are diagnosing human responses, then how do
you plan fo= an intervention? So it follows that
it's within the scope of the CNS practice to be able
to implement these :.hera?eU~ic interventions.
DR. McDONOUGH: Well, I would say in a perfect
world the way I read the s:.atute in real is that the
CNS is perfectly prepared and qualified to provide
the interventional psychotherapy perhaps after that
interventional psychotherapy has been prescribeci by
an ARNP and a diagnosis has been assigned.
MS. MIKOS: I'd like to let- Ms. Burton is way
more trained in this than I am and I'd like to let
her address you for a few moments?
DR. COLIN: Sure.
MS. BURTON: Thank you very, very much all of
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12 you for considering my petition.
The nurse practitioner rule actually has bee~
established - in psychiatry has been established
after the CNS rule. The CNS rule in psych~atry has
a long precedent than the ARNP rule. We just
recently in the last couple of years have an ARNP rule
in psychiatry. Prior to this, there was no ARNP in
psychiatry so we did under a CNS license we've done
both, both medicating and as an ARNP in most states.
The APNA j t.:st published a declaratory respor:se to the
same issue stati~g that CNS's are uniquely trair.ed
in psychiatry. The CNS rule is one of the
forerunners in the advanced practice role of nurses.
So my education and training is cross - overlap
wi~h an ARNP. Yes, I am trained in medicatior.
management clearly, but so much more education just
as a prescriber, and that rule is extrenely impo.ctant
to :ne in mental health. To be able to do therapy with
a patient is as i~portant ~o me, probably more
important ~han prescribing, and I would like the
ability to be able to p!:'ovide therapy to rr.y patients
without the supervision of a :nedical provider,
psychiatrist, dentist, whatever the rule calls for,
and I'm uniquely trained to do that.
DR. CO~:N: DR. DENKER.
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13 DR. DENKER: I think our dilemma is that the
stat~tes and the rules t~at were developed ~eing
relatively new have not - I don't think we've been
faced with this specific question before because the
other case was different, and so I guess i~'s up to
us as a board to come to an agreement of wl::at we think
is appropriate for that practice.
DR. McDONOUGH: Actually, I would agree with
everything that the Petitioner claims. : wo~ld
mention that one of the reasons tha~ the ARNP rule
was developed 2.ater on in psychiatry was specifically
to deal with the issue, in my opinion, of CNS's
diagnosing and mentoring therapy, that this was much
more o= a role - the diagnostic role was much more
the role of the nurse practitioner, and to make that
specialty congruent with the other advanced practice
specia::.ties that have practitioners, such as fam.::.ly
practice and all the other specialities, that's one
of the ~easons why tl:e ARNP rule was i:1 fact developed
for nurses in psychiatric mental healtt nursing.
Now I think anybody who knows me knows that I
am absolutely the top of ~he blind in terms of
independent p~actice for nurses with appropriate
education, and then I am -
DR. COLIN: We couldn't tell that.
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Peg Walsh 239 454-0307 p.29
14 DR. McDONOUGH: Well, I know; it's not- the
light is not well hidden under the bushel in this
particular case, but in this case I think that we have
a circumstance where this particular rule, the ARNP
rule in psych/mental health nursing, was
specifically created in my opinion to address this
issue and what we have here is somebody who has the
ARNP credential and the issue is that the Petitioner,
for wha~ever =eason, does not wan~ to engage in a
protocol relationship to u~ilize the ARNP rule in
psych nursing and instead wishes to make medical
d~agnoses, ICD-9 diagnoses, using her CNS
credential. That's what I have a problem with.
DR. COLIN: Dr. Denker?
DR. DENKER: So I guess we' 11 have to tie it up
soon; so~ebody's going to have to make a motion, but
the way I interpret it is that CNS' s were brought in,
were included under the framework of advanced
practice nurses and they do have the ability to
practice, have independent practices, and I see this
as the neeci to be able to support their practice by
billing, and I still claim that they are practicing
nursing acd not medicir.e. So I would be in support
of it.
MS. KIRKPATRICK: I have a question.
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15 DR. COLIN: Yes.
MS. KIRKPATRICK: Would an ARNP have to have a
protocol to do this?
DR. COLIN: Yes.
MS. KIRKPATR:CK: But the CNS does not have to
have a protoco:?
DR. COLIN: Correct.
DR. DENKER: That's how the regs were writ~en.
MS. GUSTAFSON: Well, the ARNP =ule
specifically mentions performing medical acts in t~'1e
definition.
MS. KIRKPARTICK: Yo~ have to then decide :f
you're doing therapeutic, is that a medical act,
which I guess I would consider that -
DR. COLIN: Well, it says in the CNS scope of
practice implementing therapeutic intervention.
MS. KIRKPATRICK: Is this just in the area of
psychiatric when referring to the CNS, correct?
DR. COLIN: No, the CNS scope of practice is
defined in chapter 4 64 and includes diagnosing human
responses tracked to all potential healtc problems;
and in fact, that line is even wit~ RN's who a=e not
advanced practice nurses, and it goes on to say plan
for health promotion and disease prevention, and
therapeutic intervention in collaboration with the
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Peg Walsh 239 454-0307 p.31
16 patient or the client and implement therapeutic
intervention based on the nurse specialist area of
a expertise within the scope of advanced nursing
practice.
DR. McDONOUGH: If this Board is (inaudible)
making of a diagnosis in the psychiatric mental
healt~ patient is in fact the legitimate practice of
advanced nursing, I'll support tha~ one hundred
percent.
MS. MIKOS: I just want to be clear. You know
that social workers do this, lots of people make these
diagnoses, licensed clinical social workers,
licensed mental health counselors, marriage and
=arr.ily counselors; this is net a domain. This is
really not a question about the domain of doctors
versus advanced practice r.urses. It says mental
health people to do their jobs have to J:;e a~le to say
what they bel:..eve the mental health condition is and
implement the therapeutic intervention.
DR. McDONOUGH: I absolutely agree with that.
My only issue is I think we need to ma~e a clear
statement in the decision that this in fact the
practice of advanced nursing. What I don't wa~t is
us to get into a circumstance where it looks like
we're using an end run around the protocol
AMERICAN COURT rtEPORTING (B50) ~21-00SB
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Peg Walsh 239 4~307 p.32
17 requirement to allow somebody to do sonething without
being associated with the physician. If we say that
the diagnosis of mental health - not diagnosed
response to health problems, the diagnosis, the
assignment of an ICD-9 diagnosis and providing
treatrnen~ is the appropria~e scope of advanced
nursing practice, :'m down with that.
MS. MIKOS: I'd like to limit it to mental ~ealth
issues because I think that mental health issues are
very different, and that is why we're here today
because the people who do the~apy are much, much
broader and this is not medicine.
MS. GUSTAFSON: It will be limited to the
practice of this nurse because -
MS. MIKOS: Right, not for anybody else.
MS. KIRKPARTICK: Tr.at's why I brought up the
question when we're talking about all CNS in our
fields, and- you're talking specifically about this
nurse in psychiatric care.
MS. MIKOS: Correct.
DR. McDONOUGH: And any other n-..Irse who chooses
to request a decla=a~ory rule from this Board can
certa~nly do exactly the same ~hing.
DR. COLIN: Correct.
MS. KIRKPATRICK: O~ay, I'm naki~g a motio~.
AMERICAN COURT REPORTIKG (850) 421-0058
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18 DR. COLIN: You made a motion?
MS. KIRKPATRICK: Yeah. I - yeah. I will
accept the declaratory statement exactly worked ~n
psychiatric, with a CNA specialty to accept her.
DR. COLIN: Fo~ this particular -
MS. KIRKPATRICK: For this individ~al
petitioner, move to accept.
DR. DENKER: Second.
DR. COLIN: Any further discussion? All in
favor? Opposed? None in opposition.
MS. GUSTAPSON: The question t~at was asked is
whether she can diagnose human responses to actual
potential behavioral health problems withoiJt risking
ct:scipline under her ARNP certification should she
proceed without a protocol, and so the answer to that
question is she will not be risking her ARNP license,
she doesn't need a protocol.
DR. COLIN: Correct.
MS. MIKOS: Thank you.
MS. BGRTON: Thank you very, very much for all
the CNS's in Florida.
DR. COLI~: No clapping.
* * * * * (W~ereupon, this co~cludes the excerpted
portion of the record.)
AMERICAN COORT REPORTING (SSO) 421-0058
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19
C E R T I F I C A T E
STATE OF FLORIDA, )
OF WAKULLA,
:, Suzette A. 3ragg, Court Reporter and Notary
State of Florida at Large,
DO HEREBY CERTIFY that the above-entitled and
ered cause was heard as herei~ above set out; that I
authorized to and did transcribe the proceedings of
d matter, and that the foregoing a~d annexed pages,
bered 1 through 18, ~nclusive, comprise a true and
co rect transcription of the proceedings in said cause.
I FURTHER CERTIFY that I am not related to or
em loyed by any of the parties or their counsel, nor have
I ny financial interest in the outcome of this action.
IN WITNESS WHE::\EOF, I have hereunto subscribed
my name and affixed my seal, this 28"h day of May, 2013.
SUZETTE A. BRAGG, Notary ?ublic State of Florida at Large My Commission Expires: 2/21/2017
AMERICAN COURT REPORTING (850) 421-0058
Aug 31 13 11:128 Peg Walsh 239 454-0307 p.1
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to the Board of Nursing for a
pnlfes;slonal education, training and 10 correct the Section of 1he Nwse
~wrhwto Clinical Nurse Specialists
From: Marga ret Walsh, MS. PMHCN5-BC
Pages: 33 pages +cover
Date: 9/1/2013
CC:
UliliiiiOU:Ilii~' a declaration iS for an fndlvrdUaJ. My OfCinal petition for 8 declaration did not 1Jve me. I assumed it was an Issue of scope only. It also referenced the wron1 section of the I have thus rewritten it. C 4 paps)
revised petition. I am also attaching tl'le followlf'11 documents: "'"1'""1~'"'1etter from the Board sayins that a protDcol is not required af a CNS. ( 1 pace)
of the two relevant declarations mentioned In my petition. (10 pages) TrJ•nc,,. .. ;,H> of the Board deliberations on the Petition for Usa Burton. (18 pages)
by cell or email if you need any additional information or have recommendations. a petition before and may not totally understand all that you require.
~~J 9ii>.~ t!tltC!V5 -Be:_ Walsh, MS, PMHCN5-BC
confidentiality This communication and any documents attendin1are meant only for the party to which it is sent. These doc:umeftts ma~•c:Oaaln private and protected health Information under the law. If you are not tile intended recipient, VOU are hereby notified law prohibits your from any clsdosure, gopylns or distributlorl of these documents. If you receive this trans .. lssion In please cal Pet Walsh at U9 454 0307 and destroy the documents.
