How to Prepare for a Nurse Registry Survey Anne Menard Home Care Unit Bureau of Health Facility Regulation Agency for Health Care Administration May 2015

Review the State Regulation Set used by Surveyors Go to the AHCA web site: http://ahca.myflorida.com/homecare Select “Nurse Registry”, then “Surveys” Current State Regulation Set is at web site Surveyors may check for compliance with all standards in the set

Nurse Registry Office License must be posted in office. (GZ 803 408.804, F.S.) Must be open for 8 consecutive hours between 7 a.m. & 6 p.m. Monday to Friday, excluding legal & religious holidays Administrator or alternate must be readily available on the premises or by telecommunications. One must come to the office for the survey. A staff person must be at the office to answer the door Surveyor must have access to patient records within 2 hours of arrival. G 174 & G 175 59A-18.004(8), FAC

Nurse Registry Office If you move or set up another office within the county where the office on your license is located, notify AHCA at least 21 days in advance and send $25 fee [59A-35.040(2)(b)] Make space for surveyor to review records Provide list of independent contractors and the patients they are working for Give this week’s schedule of the contractors and the patients they are working for to the surveyor

Policies & Procedures Required The selection, documentation, screening and verification of credentials for each independent contractor referred by the registry. 59A-18.005(2), FAC (G 251) A screen print from the Department of Health web site is acceptable for verification of licenses for nurses and certifications for CNAs. Providing notice to patients of the 3 toll-free numbers for reporting abuse, neglect, exploitation; complaints; & Medicaid fraud. 408.810(5), F.S. (GZ 818)

Policies & Procedures Policy on acceptance of patients & termination of services No patient or client shall be refused service because of age, race, color, sex or national origin When a patient or client is accepted for referrals of independent contractors, there shall be a reasonable expectation that the requested services can be provided adequately & safely in their residence. The registry must refer independent contractors capable of delivering services as defined in a specific medical plan of treatment for a patient or services requested by a client, including all visits; When medical treatments or medications are administered, physician, ARNP or PA orders in writing that are signed & dated shall be included in the clinical record; and When services are to be terminated, the patient or client, or the person designated by the patient or client shall be notified of the date of termination & the reason for termination – include a copy in the patient or client's record. G 180 59A-18.010, FAC

Policies & Procedures Procedures on the administration of drugs & biologicals (G 225) Procedures for informing patients of the special needs registry at intake & assisting in their registration & annual review of registered patients – including registration procedures from each county emergency management office. (G290) Emergency Management Plan (G 291)

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

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.

(a) Report theft to local law enforcement; The nurse registry should provide information on actions that should be taken by the complainant (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 .

Registration Folders for Each Independent Contractor Must contain: 1. Copy of contract with the nurse registry; 2. Evidence of background screening with OK results 3. Affidavit of compliance/will inform of arrests 4. Health statement 5. Application form 6. Proof of current license (nurses) & certification for CNAs & training for HH aides 7. Evidence of a one-time HIV/AIDS training 8. Current CPR certification for home health aides and CNAs G 152 59A-18.005, FAC G 273 400.506(8)(e), F.S. G 272 59A-18.081(11), FAC

Background Screening Level 2 background screening is required every 5 years for all independent contractors, the administrator, the financial officer, the nurse and all other persons working for the nurse registry that may enter a patient’s home or place of residence. 408.809(2), F.S. (GZ 815) Affidavit Every independent contractor attests that he/she qualifies per background screening & will report if arrested for any felony or other disqualifying offense as shown on the form: AHCA 3100-0008, September 2013 (GZ 816 435.05, F.S. )

Background Screening Contractors cannot have a break in service from a position that requires level 2 screening for more than 90 days. Contractors that only had level 1 screening between 1/1/09 and 12/31/11, must get level 2 screening by 7/31/15. GZ 815 408.809, F.S.

Health Statement Each new independent contractor must provide a health statement dated within the last 6 months, that he or she is free from communicable diseases. TB test not required any more Statement is provided to the Nurse Registry when the contractor is first referred G 151 59A-18.005(6), FAC 400.506(6)(a), F.S. There is no requirement that this be done annually or biennially.

Who can give health statements? M.D. or D.O. ARNP, Physician’s assistant or RN supervised by physician or acting under a protocol signed by a physician G 151 59A-18.005(6), FAC

Registration folders on contractors An application form providing the following information: - The name, address, date of birth, & social security number of the applicant. - The educational background & employment history of the applicant. - The number & date of the applicable license or certification. - Information concerning the renewal of the applicable license, registration, or certification. Keep for 3 years after the date of the last file entry of patient-related or client-related information. G 152 400.506(8)(10), F.S.

Registration Folders for Contractors The nurse registry must maintain on file the name and address of the patient or client to whom nurse registry personnel are referred for contract & the amount of the fee received by the nurse registry. G 152 400.506(10), F.S.

Registration Folders Home Health Aides Qualifications For any new home health aides added on or after May 4, 2015, a certificate or an evidence of completion of a home health aide training course from a public vocational technical school or a licensed non-public career education school. An aide that had training in another state must provide a certificate of completion of home health aide training from a public vocational technical school or a career education school that is licensed in that state. Current CPR certification from an instructor that is approved to provide training by the American Heart Association or the American Red Cross. G 271, G 272 59A-18.0081(8)(10)(11), FAC

Registration Folders Home Health Aides Qualifications Evidence of licensure as a licensed practical nurse (LPN) or registered nurse (RN) licensed in Florida or another state. Evidence of completion of LPN or RN training from a public school, college, university or licensed non-public career education school of college in Florida when not yet licensed. G 271 59A-18.0081(12)

Registration Folders Certified Nursing Assistants Florida Department of Health C.N.A. Certification Individuals who earn their CNA certificate in another state must contact the Department of Health about certification by reciprocity: http:floridasnursing.gov/licensing/certified-nursing-assistant-reciprocity/or call (850) 488-0595. Current CPR certification from an instructor that is approved to provide training by the American Heart Association or the American Red Cross. G 277 59A-18.0081 (7)(9)(11), FAC

Registration Folders CNAs & Home Health Aides If they assist with self-administered medication, there is documentation of at least 2 hours of training on: 1. State law & rule requirements re assistance with self-administration of medications in the home, procedures for assisting the resident with self-administration of medication, common medications, recognition of side effects and adverse reactions and procedures to follow when patients appear to be experiencing side effects and adverse reactions. 2. Training must include verification that each CNA & Aide can read the prescription label & any instructions. G 279 400.488(1)(b), F.S., 59A-18.0081(14)

Registration Folders 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

Other Documents the Surveyor May Request Designation in writing of alternate administrator Resume of administrator & alternate administrator. Alternate administrator must meet the same qualifications as the administrator. Must be: a licensed physician, an advanced registered nurse practitioner, a registered nurse, or an individual with training and experience in health service administration and at least one year of supervisory or administrative experience in the health care field. G 160.59A-18.006,FAC

Staffing Services 400.462 (29), F.S. "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.

Supplemental Staffing Individual contractor’s file shall have: Recording of complaints involving individuals they referred to health care facilities or other business entity Documentation of notification of facilities/entities if a licensed or certified individual being referred to the facility is on probation with their professional licensing board or certifying agency or has any other restrictions on their license or certification & information about this. G 253 59A-18.017, FAC

Supplemental Staffing (cont’d) The name and address of facilities to whom the independent contractor is referred for contract, the amount of the fee charged, the title of the position, & the amount of the fee received by the registry. Background screening results that show the person is eligible to work G 253 59A-18.017, FAC

Providing contractors at ALFs Staffing must be at fair market value. ($5,000 fine) Cannot refer contractors for free in exchange for referrals ($15,000 fine) Must be able to provide copies of contracts with ALFs to surveyor when doing staffing ($5,000 fine) G 280 400.506(15)(a), F.S.

Evidence that Laws & Rules Are 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 the telephone numbers Rule 59A-18.018 Emergency Management Plans CNAs & HH Aides: Rule 59A-18.005(6) regarding health statements and communicable disease Rule 59A-18.0081 Certified Nursing Assistant and Home Health Aide Homemakers and Companions: Rule 59A-18.009 Homemakers or Companions G 150 59A-18.005(1),FAC

Clinical records for patients with RNs or LPNs RN & LPN is responsible for records for their patients RN & LPN must maintain the medical plan of treatment with clinical notes The initial medical plan of treatment, any amendments to the plan, any additional order or change in orders, & a copy of the clinical notes must be filed at the office of the nurse registry within 30 days. When staffing at a facility, records are kept at the facility. When medical treatments or medications are administered, the physician, physician’s assistant (PA) or ARNP orders in writing that are signed and dated shall be included in the clinical record; and G 170 59A-18.007, FAC G 180 59A-18.010(3), FAC

Clinical Records Surveyor will check to see if: 1. Plan of treatment has the following content: - Diagnosis - Activities permitted when indicated - Diet when indicated - Medication, treatments & equipment required - Dated signature of physician, PA, ARNP (within 30 days from initiation of services) 2. RN, LPN reviews plan with physician, PA, or ARNP at least every 2 months. 3. Any additional order or change in orders is obtained from the physician, PA, or ARNP. 4. Nursing notes or documentation by the nurse G 190 59A-18.011, FAC

Clinical Records (cont’d) Records for patients receiving nursing services must have the following: (1) Identification sheet containing the patient’s name, address, telephone number, date of birth, sex, and the patient’s designated contact person or guardian; (2) Authorization for release of information, dated and signed by the patient, his/her responsible party, or guardian; (3) Plan of treatment as required in s.400.506 (13), F.S.; (4) Clinical and service notes, signed and dated by the nurse providing the service which shall include: (a) Any assessments by a registered nurse; (b) Progress notes with changes in the person’s condition; (c) Services provided; (d) Observations; and (e) Instructions to the patient and caregiver; G200 59A-18.012

Clinical Records (cont’d) (5) Reports to physicians; (6) Termination summary including; (a) The date of the first and last visit; (b) The reason for termination of services; (c) An evaluation of established goals at time of termination; (d) The condition of the patient at the time of termination of services; and (e) The referral for additional services when the patient requires continuing services; G 200 59A-18.012, F.A.C.

Clinical Records (cont’d) Must be kept for 5 years following the termination of services. Retained records can be stored as hard paper copy, microfilm, computer disks or tapes & must be retrievable for use during unannounced surveys. The NR is not obligated to review patient or client records per 400.506(20), F.S., but the NR is not prohibited from reviewing records and may do so. G 200 59A-18.012, F.A.C.

Patient records C.N.A. & Home Health Aide Document in the patient’s file that the nurse registry has advised the patient, the patient’s family or other person acting on behalf of the patient at the time the contract for services is made that R.N.s are available to make visits to the patient’s home for an additional cost. G 276 400.506(6), F.S.

Patient Records C.N.A. & Home Health Aide The C.N.A. & home health aide must document services provided to the patient on a regular basis. These service logs will be stored by the nurse registry in the client's file. The service logs shall include the name of the patient or client and a listing of the services provided. Must report appearance & behavioral changes in the patient’s health care to the surrogate or other person designated by the patient and to the nurse registry. G 277 59A-18.0081, FAC

Patient Records C.N.A. & Home Health Aide If C.N.A. or 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 a 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. This can be review of a written list with dosage, frequency and route of administration if patient will not consent to a visit by the nurse. Record is documented every time the patient receives assistance with self-administration of medication G 278 400.488, F.S. and G 279 59A-18.0081, FAC

Patient/Client Records Records include: Whether the patient needs assistance in evacuation or sheltering in emergencies because of physical, mental, or sensory Whether the patient has a case manager through the Community Care for the Elderly or other state funded program or Medicaid Waiver programs. If so, verify that the case manager has or will assist the patient with special needs registration and note this in the file. Whether the patient has already has a family member or someone to assist them or whether they need to be registered with the local special needs registry for evacuation assistance and shelter. G 290 59A-18.018, FAC

Patient/Client Records If the patient is to be registered with the special needs registry: Indicate whether there is a family member or someone to take responsibility during an emergency for services normally provided by the independent contractor. Document that the independent contractor has informed patients registered with the special needs registry that special needs shelters are an option of last resort & that services may not be equal to what they have received in their homes. Can show that Appendix B of the Comprehensive Emergency Management Plan for Nurse Registries was given to the patient G 290 59A-18.018, FAC

Patient/Client Records In there is a hurricane or other emergency, when a nurse registry is unable to continue services to special needs patients, the patient’s record must contain documentation of the efforts made by the registry to comply with their emergency management plan. Documentation includes but is not limited to: contacts made to the patient’s family or other person that provides care, if any contacts made to the assisted living facility and adult family care home if applicable; contacts made to local emergency operation centers to obtain assistance in reaching patients and contacts made to other agencies that may be able to provide temporary services G 298 59A-18.018, FAC

Homemaker & Companion Client Records Homemakers & Companions shall be responsible for providing to the client & nurse registry copies of “any documentation that reflects the services provided.” This will be stored by the nurse registry in the client's file. The NR is not obligated to review client records per 400.506(20), F.S., but the NR is not prohibited from reviewing the records and may do so. G 171 59A-18.009, FAC.

Patient/Client Records When services are to be terminated, the patient or client, or the person designated by the patient or client shall be notified of the date of termination and the reason for termination, and these shall be documented in the patient or client's record G 180 59A-18.010, FAC

Information Given to Patients Independent contractors must inform the patient, caregiver or guardian of patient rights: Right to be informed of the medical plan of treatment; Right to participate in the development of the medical plan of treatment; May have a copy of the medical plan of treatment if requested; and That the caregiver being referred is an independent contractor of the registry. G 191 59A-18.011(7), FAC

Information Given to Patients Notice of right to report abuse and make a complaint: "To report a complaint regarding the services you receive, please call toll-free 1-888-419-3456.” “To report abuse, neglect, or exploitation, please call toll-free 1-800-962-2873.” “To report suspected Medicaid fraud, please call toll-free 1-866-966-7226” - plus the AHCA description Medicaid fraud. GZ 818 408.810(5),F.S.

Information Given to Patients 3. For patients that will have a C.N.A. or Home Health Aide, Advise the patient, the patient’s family or other person acting on behalf of the patient at the time the contract for services is made that an R.N.s is available to make visits to the patient’s home for an additional cost. G 276 400.506(6)(c), F.S.

Information Given to Patients 4. When referring a caregiver, the nurse registry must advise the patient, the patient’s family or any other person acting on behalf of the patient that: the caregiver referred is an independent contractor and the nurse registry is not obligated to monitor, supervise, manage or train the caregiver. G 153 400.506(6)(e), F.S.

Put License Number in Ads Make sure the Nurse Registry’s license number is on advertisements and brochures – including web sites $100 fine first time, $500 second or additional time G103 400.506(4), F.S.

Special Needs Registration Show that the Nurse Registry has contacted the emergency management office for each county on their license to find out how patients are registered. Have a procedure for use at intake & on an annual basis, to identify & assist special needs patients with registration. Show the information that you provide to patients who may need to be registered with the special needs registry. Show copies of any information you have sent to county emergency management offices G 290 400.506(12), 252.355, F.S. and 59A-18.018, FAC

Special Needs Registration Show prioritized list of registered special needs patients. List indicates: if the patient is to be transported to a special needs shelter if the patient is receiving skilled nursing services Show copy of the list for each patient of medication & equipment needs (prepared by independent contractor). The list is kept in the patient’s home with a copy at the nurse registry office. G 295 and 296 400.506(12), F.S. and 59A-18.018)(12)(13), FAC

Emergency Management Plan Have a copy of the emergency management plan - use required plan format, AHCA Form 3110-1017 Show copy of email that you have transmitted to the county health department or other plan reviewer in each county on your license - see list of Emergency Management Plan Review Contacts reviewers at http://ahca.myflorida.com/homecare (Select “Nurse Registry”, scroll down to “emergency management”) Have copy of any email response or other acknowledgement that the plan was received. If you got comments on the plan from the reviewer, show that these were addressed. G 291 59A-18.018, F.S, and 400.506(12), F.S.

Emergency Management Plan Review and update your plan annually. If county reviewer requests an annual update, then submit it to them (check letter or email you receive back when your plan is reviewed). Show that you have reported any changes in telephone numbers including after hours numbers and names of administrative staff that are coordinating your emergency response to the emergency management office in each county on your license. If there has been a change of ownership, show that the plan has been reviewed & updated – and that any substantive changes have been reported to the county reviewer. G 292 and 293 59A-18.018, FAC

If you don’t agree with the surveyor 1. Ask the surveyor to show you the survey standard or law, rule 2. Discuss with surveyor at Exit Interview 3. Contact the AHCA Field Office Manager http://ahca.myflorida.com/MCHQ/Field-Office-Info.shtml 4. If still not resolved, contact Acting Chief of Field Operations, Kim Smoak (850) 412-4301

AHCA web sites http://ahca.myflorida.com/homecare -- select “Nurse Registry” – has licensing, emergency management plan & each county’s plan review contacts, state regulation set (survey standards), answers to frequently asked questions www.FloridaHealthFinder.gov - select “Find Facilities or Providers” (updated nightly) and see Consumer Guides