Nurse Registry Update

Anne MenardHome Care Unit

Bureau of Health Facility Regulation Agency for Health Care Administration

May 6, 2015

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Nurse Registriesas of April 25, 2015

Area Number ofNurse Registries

Currently Licensed 

Number of Applications for New Nurse Registry

Licenses

1 5 12 3 13 30 14 22 35 30 26 48 07 38 18 55 49 148 310 122 311 53 5

TOTAL 554 24

Implementing the 2014 Nurse Registry Law Changes

Based on the law changes:In September, two new survey standards were added to the Nurse Registry State Regulation Set used by Surveyors.

1. G 153 Advise Patient of Independent Contractor quotes 400.506(6)(e), Florida Statutes (F.S.) that requires action by the nurse registry when referring caregivers.

“Upon referral of a registered nurse, licensed practical nurse, certified nursing assistant, companion or homemaker, or home health aide for contract in a private residence or facility, the nurse registry shall advise the patient, the patient ' s family, or any other person acting on behalf of the patient, at the time of the contract for services, that the caregiver referred by the nurse registry is an independent contractor and that it is not the obligation of a nurse registry to monitor, supervise, manage, or train a caregiver referred for contract under this chapter.”

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Implementing the 2014 Nurse Registry Law Changes

2. G 154 Notify Patient and Report Caregiver quotes 400.506(19), F.S that specifies the action required by the nurse registry when a caregiver has violated state laws or has a deficiency in credentials.

“It is not the obligation of a nurse registry to monitor, supervise, manage, or train a registered nurse, licensed practical nurse, certified nursing assistant, companion or homemaker, or home health aide referred for contract under this chapter. In the event of a violation of this chapter or a violation of any other law of this state by a referred registered nurse, licensed practical nurse, certified nursing assistant, companion or homemaker, or home health aide, or a deficiency in credentials which comes to the attention of the nurse registry, the nurse registry shall advise the patient to terminate the referred person's contract, providing the reason for the suggested termination; cease referring the person to other patients or facilities; and, if practice violations are involved, notify the licensing board. This section does not affect or negate any other obligations imposed on a nurse registry under chapter 408.”

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RULE REVISIONS EFFECTIVE MAY 4, 2015

Chapter 59A-18, Florida Administrative Code

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State Rules Revised Effective May 4, 2015

The state rules, Chapter 59A-18, Florida Administrative Code, titled “Nurse Registry Standards and Licensing,” has been revised effective May 4, 2015.

The State Regulation Set for nurse registries has been revised and is effective May 4, 2015. The survey standards in the Regulation Set are verbatim quotes from state laws and rules.

Three (3) survey standards were deleted and revisions were made to 27 other standards based on rule revisions.

A summary of the changes to the standards and a link to the Regulation Set is at:http://ahca.myflorida.com/homecare - select “Nurse Registry,” then see “Survey.”

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59A-18.006 Administrator

• Eliminates the requirement for a full-time administrator -- since the administrator requirements are now at 400.506(18), F.S.

• Adds that an advanced registered nurse practitioner (ARNP) may be an administrator.

• At the time a referral is made, administrator is responsible for making sure that the nurse registry advises the patient and family or other person acting on behalf of the patient that:– (1) the caregiver is an independent contractor

[400.506(6)(e), F.S.]– (2) that RNs are available to make visits for an additional

cost when a home health aide or certified nursing assistant (CNA) is referred. [400.506(6)(c), F.S.]

• Removes the requirement for the administrator to assure the orientation of new independent contractors. (G 160)

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59A-18.005 Registration Policies

• Updates the listing of statutes and rules that the nurse registry provides to independent contractors. May be provided by paper copy, email or other means of electronic communications.

• A screen print from the Department of Health web site is acceptable for verification of licenses for nurses and certifications for CNAs.

• Adds how to report unlicensed nurses and certified nursing assistants to the Department of Health.

• Removes the follow up on complaints.

• Adds that if the complaints are violations of state law, the nurse registry shall take the actions specified in 400.506(19), F.S.

  (G 150, G 251, G 252, G 152 59A-18.005, FAC)

Laws & Rules Given to Independent Contractors

RNs & LPNs:• Rule 59A-18.005 Registration Policies• Rule 59A-18.007 Registered Nurses and Licensed Practical Nurses• Rule 59A-18.011 Medical Plan of Treatment• Rule 59A-18.012 Clinical Records• Rule 59A-18.013 Administration of Biologicals• Sections 400.506, 400.484, 400.462, 400.488, 408.809, and 408.810(5), F.S. with telephone

numbers• Rule 59A-18.018 Emergency Management Plans

CNAs & HH Aides:• Rule 59A-18.005 Registration Policies• Rule 59A-18.005(6) regarding health statements and communicable disease• Rule 59A-18.0081 Certified Nursing Assistant and Home Health Aide• Sections 400.506, 400.484, 400.462, 400.488, 408.809, and 408.810(5), F.S. with telephone

numbers • Rule 59A-18.018 Emergency Management Plans

Homemakers and Companions:• Rule 59A-18.005 Registration Policies• Rule 59A-18.009 Homemakers or Companions• Sections 400.506, 400.484, 400.462, 400.488, 408.809, and 408.810(5), F.S. with telephone

numbers • Rule 59A-18.018 Emergency Management Plans

G 150 59A-18.005(1),FAC

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59A-18.005 Registration PoliciesComplaints

Each nurse registry is still required to have a system for the recording of complaints and actions taken involving individuals they refer.Such records shall be kept in the individual’s registration file or retained in the central files of the nurse registry.

Follow up on complaints has been removed from state rules

If complaints are violations of state law or a deficiency in credentials, the nurse registry shall do the following as shown on the next two slides. G 152 59A-18.005(8), FAC G 154 400.506(19), F.S.

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Notify Patients and Report Caregiver

If there is a violation of state laws or a deficiency in the caregiver’s credentials that the nurse registry becomes aware of, the nurse registry will:

– advise the patient to terminate the referred individual, providing the reason for termination;

– cease to refer the person to other patients or facilities; and,

– if there are practice violations for nurses or CNAs, notify the Department of Health, Board of Nursing by submitting a complaint

G 154 400.506(19), F.S.

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Provide the Complainant with Information on How to Report the Complaint to the Appropriate Entity

(a) Report theft to local law enforcement.

(b) Report abuse, neglect or exploitation to the Central Abuse Hotline 1(800) 962-2873. [415.1034, F.S. requires anyone who knows, or has reasonable cause to suspect that a vulnerable adult has been or is being abused, neglected or exploited to immediately report such knowledge or suspicion to the Hotline.]

(c) Report nurses and CNAs to the Department of Health by completing and submitting the complaint form at http://www.floridahealth.gov/licensing-and-regulation/enforcement/admin-complaint-process/forms.html if there are alleged professional practice violations.

(d) Report other complaints to the AHCA by calling (888) 419-3456 or submitting the on-line complaint form at http://apps.ahca.myflorida.com/hcfc .

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59A-18.005 Registration PoliciesHealth Statements

Health statements are only collected when the independent contractor is first referred. 

Prior to contact with patients or clients, each independent contractor must provide a health statement from a health care professional* dated within the last 6 months, that he or she is free from communicable diseases. The independent contractor will provide this statement to the nurse registry when first referred.

Rule no longer says the statement is based upon an examination. What is done to make this determination is up to the health professional*

*(MD, DO, PA, ARNP, or RN supervised or acting under a protocol signed by a physician).

(G 151 59A-18.005(6), FAC and 400.506(6)(a), F.S.)

59A-18.005 Registration PoliciesContracts with Independent Contractors

The requirement that the contracts with independent contractors provide instructions as to responsibility for the payment of self-employment estimated taxes, and a statement as to the registry's commitment to compliance with civil rights requirements has been removed.

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59A-18.007- Registered Nurse and Licensed Practical Nurse

Assessment of patients served by unlicensed independent contractors has been removed from the rule:(1) “Be responsible for the clinical records for their patients. The clinical

records shall be filed with the nurse registry, for each patient or client to whom they are giving care in the home or place of residence or when they assess the care being provided by non-licensed independent contractors, pursuant to Section 400.506(10)(c),F.S.”

The requirement that the LPN shall be under the direction of a RN or a licensed physician has been removed.

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59A-18.004 Licensure Requirements

Removed:• The 24 hour availability to a nurse by patients receiving

nursing care. • The requirement for an on-call nurse for home health aides

and CNAs. (G 168 has been deleted)

Added: The nurse registry shall provide to the patient or patient’s representative, a list of telephone numbers to be called if a replacement caregiver is needed -- along with local emergency numbers as determined by the nurse registry.

59A-18.004(8)(d), FAC

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59A-18.0081 Home Health Aide Qualifications

For every home health aide registered with the nurse registry since May 4, 2015, a nurse registry shall have on file:

a) A certificate or documentation of successful completion of at least 40 hours of HH aide training from a public vocational technical school or a non-public postsecondary career school licensed by the Commission on Independent Education, Florida Department of Education, or

b) If the training was completed in another state, a certificate of HH aide training from a public vocational technical school or a career education school that is licensed in that state, or

c) LPN or RN licensure in Florida or any other state, or

d) Evidence of completion of LPN or RN training from a public school, college, or university or licensed non-public career education school or college in Florida who are not yet licensed, or

 e) Certification as a CNA.

G 271 59A-18.081(8), FAC 

Nurse Review of Medications if Home Health Aide or CNA Will Assist

If CNA or Home Health Aide assists a patient with self-administered medication, that is routine, regularly scheduled medications [legend & over-the-counter oral dosage forms, topical dosage forms, and topical ophthalmic, otic, & nasal dosage forms, including solutions, suspensions, sprays, and inhalers], there is: -- a documented request by & the written informed

consent of the patient or the patient's surrogate, guardian, or attorney in fact.-- a review of the medications for which assistance is to be provided shall be done by an RN or LPN to ensure the CNA & Aide are able to assist per their training & with the medication prescription – and the medication is not required to be administered by a nurse. If the patient will not consent to a visit by the nurse to review the medications, a written list with the dosage, frequency and route of administration shall be provided by the patient or the patient’s health care surrogate, family member, or person designated by the patient to the home health aide or CNA to have reviewed by the nurse.

G 278 400.488, F.S. 59A-18.0081(14)(d), FAC 18

59A-18.0081 Home Health Aides and CNAs

Who can provide CPR training for home health aides and CNAs:For new independent contractors since May 4, 2015, CPR certification must be from an instructor approved to provide training by the American Red Cross or the American Heart Association.

(G 292 59A-18.0081(11), FAC)

An additional source was added for training on assistance with self-administered medications -- Training by a provider approved by the Florida Board of Nursing. This is in addition to the existing three sources in the rule.

(G 279 59A-18.0081(14)(b), FAC)

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CNAs & Home Health Aides

Documentation of at least 2 hours of training on assistance with self-administered medication from one of the following sources is acceptable:

1. A home health agency (HHA) if the person worked for the HHA

2. An assisted living facility trainer approved by the Department of Elder Affairs

3. A career education school licensed by the Florida Department of Education, Commission for Independent Education

4. A provider approved by the Florida Board of Nursing, Department of Health

G 279 59A-18.0081

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59A-18.0081 Home Health Aides and CNAs

The nurse registry is not obligated to monitor, manage or supervise a certified nursing assistant or home health aide pursuant to Section 400.506(19), F.S.

The nurse registry is not obligated to review patient or client records per Section 400.506(20), F.S., but the nurse registry is not prohibited from reviewing records and may do so.

In the event of violation of Section 400.488, F.S. or other state laws that comes to the attention of the nurse registry, the nurse registry shall take the actions specified in Section 400.506(19), F.S. (This is also stated in other sections of 59A-18.)

59A-18.005(15), FAC

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59A-18.009 Homemakers and Companions

Training of homemakers and companions was removed from state rule.

(G 172 was deleted)

Unusual incidents or changes in the client’s behavior are now reported to the “person(s) designated by the client” – not the nurse registry administration.

Removed the requirement that homemakers and companions “understand the needs” of the clients and be “able to recognize those conditions that need to be reported to the nurse registry office.”

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59A-18.011 Medical Plan of Treatment

“When the delivery of skilled care to a patient in the home is under the direction or supervision of a physician or when a physician, physician’s assistant or advanced registered nurse practitioner is responsible for the medical care of the patient, a medical plan of treatment must be established for each patient receiving care or treatment provided by the licensed nurse in the home or residence.” G 190 59A-18.011(1), FAC

The medical plan of treatment is only for skilled care. Skilled care offered by nurse registries is care provided by nurses. (400.462(28), F.S. defines skilled care.)

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59A-18.012 Clinical Records

The licensed nurse responsible for the delivery of skilled patient care shall maintain a clinical record for each patient receiving nursing services. (59A-18.012, first sentence is revised to make it clear that clinical records are only required for nurses.)

The nurse registry is not obligated to review patient or client records per Section 400.506(20), F.S., but the nurse registry is not prohibited from reviewing records and may do so. (This is also stated in other sections of 59A-18.)

In the event of violation of state law which comes to the attention of the nurse registry, the nurse registry shall take the actions specified in Section 400.506(19), F.S. (This is also stated in other sections of 59A-18.)

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59A-18.017 Supplemental Staffing for Health Care Facilities

(1) “Each nurse registry may provide staffing services as defined in subsection

400.462(29), F.S.” to health care facilities licensed under Chapter 395, F.S., or under Parts I, II, IV, V,

or VI of Chapter 400, F.S., or other business entities on a temporary basis by licensed nurses, home health

aides, and certified nursing assistants.

400.462(29) “ ‘Staffing services’ means services provided to a health care facility, school,

or other business entity on a temporary or school-year basis pursuant to a written

contract by licensed health care personnel and by certified nursing assistants and home

health aides who are employed by, or work under the auspices of, a licensed home

health agency or who are registered with a licensed nurse registry.”

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59A-18.017 Supplemental Staffing for Health Care Facilities

The requirement for an annual performance outcome evaluation from the health care facilities where the independent contractor has provided services has been removed.

Nurse registries still must have a system for recording complaints but the follow up on complaints has been removed.

The nurse registry is not obligated to monitor, manage or supervise a referred independent contractor pursuant to Section 400.506(19), F.S.

In the event of violation of state law which comes to the attention of the nurse registry, the nurse registry shall take the actions specified in Section 400.506(19), F.S.

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59A-18.018 Emergency Management Plans

The Comprehensive Emergency Management Plan form has some changes. The changes do not require nurse registries to revise their emergency management plans.

The updated CEMP form is at the Nurse Registry page of the AHCA web site or at the web site’s main location for emergency management: http://ahca.myflorida.com/MCHQ/Emergency_Activities/index.shtml.

Following are the changes: Page 1 – The law that is quoted, 381.0303(7), F.S., is updated to

conform to current law. The words “Surgeon General” replace “Secretary” for the Department of Health.

Page 4 – Inserted “Safety Liaison” with the item for the primary person in charge during an emergency, as required by 408.821(1), F.S.

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59A-18.018 Emergency Management Plans

Emergency Management Plan form, Section D, item 1, was revised to replace “make every reasonable attempt to assure that all patients needing continuing care will receive it” with specific requirements, based on review comments received from the Chief Attorney at the Joint Administrative Procedures Committee(JAPC) of the Florida Legislature.

“During an emergency, when there is not a mandatory evacuation, some patients registered (pursuant to s. 252.355, F.S.), may decide to stay in their homes, ALF or AFCH. The procedures on how the nurse registry will contact each independent contractor that provides care to the patients needing continuing care to determine whether the independent contractor is still providing the care are described below. If the independent contractor is unable to provide the care and the patient still needs care, the procedure will include how the nurse registry will contact other independent contractors and nurse registries to arrange for care to the patient.:”

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59A-18.018 Emergency Management Plans

Three paragraphs of 59A-18.018 are revised based on JAPC comments to be more specific: (9) “Upon imminent threat of an emergency or disaster” has been replaced with “When a state of emergency has been declared by executive order or proclamation of the Governor, pursuant to Section 252.36(2), F.S.,”(10) Replaced “make reasonable efforts” with “contact the independent contractors it has available for referral.”(11) Replaced “make reasonable attempts” with revised sentence: “The registry shall also contact the patients who need continuing services by calling the patient at home or calling the assisted living facility or adult family care home the patient resides in to determine if the patient still needs services make reasonable attempts to ascertain which patients remaining at home or in their assisted living facility or adult family care home will need services from the registry and which patients have plans to receive care from their family or other persons.

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59A-18.004 Licensure Requirements, Procedures

• The application form is updated. No additional requirements. •The financial ability to operate requirements and form were removed from this rule since they are now in 59A-35.062, the Health Care Licensing Procedures Rule. The requirements have not changed.  •The background screening requirements are removed from this rule since they are now in 408.809, F.S., and must be met by all programs, including nurse registries.  •A satellite office may share administration and is not required to be open for a minimum number of hours like the main office.

•“Satellite office” means a secondary office of the nurse registry established in the same county as the main office pursuant to 400.506(1), F.S. (59A-18.002(13), FAC). The definition in CS/SB 904 will be used instead of this rule if the bill is signed by the Governor.

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CHANGES IN THE NURSE REGISTRY SURVEY PROCESS

Due to the 2014 law changes and the rule chapter revisions

Survey Standards on the Work Done by Caregivers

10 of the survey standards that pertain to the activities of the independent contractor (caregivers) are not cited in the survey report when first found. Nine of the standards pertain to patient care. These are items that the nurse registry would not have known about since they are not required to read records per 2014 state law, 400.506(19), F.S. However, if the deficiency had already come to the attention of the nurse registry, then the deficiency would be cited in the survey report.

Any of the 10 that are found not met, are written in the letter to the nurse registry that is sent with the survey report. Nurse registries are requested to provide a plan of action so that the standard is met on the follow up visit. If it is not met on follow up, the standard is cited on the State 3020 form as is done on surveys.

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Survey Standards on the Work Done by Caregivers

Since the nurse registry was informed by letter, if the standard is not met on the follow up visit, the survey standard will then be cited as a deficiency and appear in the follow up visit report.

The 10 standards are shown on the next page in the “List of Survey Standards in the State Regulation Set”, and are highlighted. The list is at the AHCA web site, http://ahca.myflorida.com/homecare - select “Nurse Registry,” then “Surveys”.

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Survey Standards on the Work Done by Caregivers

G 171 Homemaker Responsibilities

G 173 Companions Responsibilities

G 180 Acceptance of Patients

G 190 Plan of Treatment

G 191 Patient Rights

G 200 Clinical Records

G 225 Administration of Drugs and Biologicals

G 277 CNA and Home Health Aide Responsibilities

G 278 CNA and Home Health Aide Assistance with Medications

G 154 Notify Patient and Report Caregiver Cite as a survey deficiency if the nurse registry informed, such as the arrest of a caregiver for G 154. Write in the letter sent after the survey if it did not come to the attention of the nurse registry.

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Nurse Registry Surveys

From August 12, 2014 to April 26, 201546 initial surveys219 biennial re-licensure surveys 31 complaint surveys 74 follow up surveys

Of the 219 nurse registry re-licensure surveys, 23 of the nurse registries had violations of one or two of the 10 standards based on caregivers’ work. • 18 were written in a letter to the nurse registry but not

cited as deficiencies in the survey report. • 6 were cited as deficiencies in the survey report when first

found by the surveyor.

Example of one of the 10 standards cited when first found

Nurse Registry G 180 Acceptance of Patients Cited on State 3020 form instead of written in letter Family purchased “medication package” for patient that consisted of 2 medication box refills per month by nurse and 2 medication reminders daily/7 days a week by CNA/home health aide. 3 different home health aides were being sent to patient.  Family member contacted the Nurse Registry when they found the patient had pills left in the box several times when they visited. At this point, this came to the attention of the nurse registry.  The Nurse Registry told the complainant the Nurse Registry was not responsible since the Home Health Aides were independent contractors.  

The family member then made a complaint to AHCA. The Field Office made a visit and confirmed

the complaint, citing the Nurse Registry – rather than writing it in a letter for the following

reasons:

1.This violation had already come to the attention of the Nurse Registry.

2.The Nurse Registry ordered and managed the patient’s medications -- had contracted with

the family for a “medication package” and was responsible.

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RENEW YOUR NURSE REGISTRY LICENSE ONLINE

Now available

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Online Licensing

• The Agency for Health Care Administration (AHCA) has implemented its new online licensing system allowing providers the opportunity to renew their license online.

• The new online system allows for the electronic submission of renewal applications along with the ability to upload supporting documentation.

• Additionally, the system will save time and reduce errors by pre-populating data fields and allow for the electronic payment of fees, fines and assessments.

Renew Your Nurse Registry License Online

Step 1: Register -Identify an authorized individual who will access the Online Licensing System on behalf of your nurse registry.

Step 2: Login - After registering, the authorized individual will be redirected to the Online Licensing System.

Step 3: Renew - The license application will appear with most fields filled in for you. Review, add or change information as needed.

Step 4: Payment - After the renewal information has been submitted and verified, you can pay your licensure fees by credit card (currently American Express, Discover, Master Card,), e-check or check through the mail. E-check is only 18 cents – less than the cost of a stamp.

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Registering User Name/ID and Generating a User Agreement

1. See Online Instruction Guide for detailed instructions:http://www.ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Online_Licensure_Info/docs/OL_InstructionGuide.pdf

2. Go to the Portal to register a User Name/ID and Password: https://apps.ahca.myflorida.com/SingleSignOnPortal/Login.aspx?ReturnUrl=%2fSingleSignOnPortal If the person that submitting the licensure renewal application is already registered as a User for the Background Screening System, a new User name and Password is not required. The person can simply login using his/her existing user information.

3. Select the Online Licensing System. A User can select one or multiple facilities across provider types. A separate User Agreement will be created for each licensed nurse registry which must be signed by the Administrator of record for that facility.

4. Send the signed User Agreement(s) to the Agency for approval. You may scan, email, fax, or mail the signed documents.

5. An e-mail will be sent to the approved user confirming that access to the Online Licensing system has been granted. Expect that email confirmation within 2 to 3 business days of the Agency’s receipt of the signed agreement.

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AHCA Home Care Unit Nurse Registry and Home Health Agency

Contact Staff

AREA STAFF CONTACT TELEPHONE

1 Susan Glass (850) 412-4397

2 Edward Barnes (850) 412-4388

3 Ruby Grantham (850) 412-4386

4, 5, 6 Susan Glass (850) 412-4397

7, 8 Edward Barnes (850) 412-4388

9 Patricia Guilford (850) 412-4399

10 Cynthia Thomas (850) 412-4391

11 Pamela Houston (850) 412-4390

AHCA web sites

http://ahca.myflorida.com/homecare -- select “Nurse Registry” – has link to rules and updated State Regulation Set, licensure application, listing of survey standards, summary of changes to survey standards, the emergency management plan format and each county’s plan review contacts, and answers to frequently asked questions

www.FloridaHealthFinder.gov - select “Find Facilities or Providers” (updated nightly) and see Consumer Guides

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