1. Nurse Registry State Regulatory Update
Anne Menard
Home Care Unit
Bureau of Health Facility Regulation
Agency for Health Care Administration
May 9, 2013

2. 458 nurse registries statewide as of 5/2/13
In the past 12 months there were:
71 applications received for new nurse registry licenses
21 nurse registries voluntarily closed
3 applications for new licenses denied
Nurse registries licensed increased by 12% in the past year.

3. Nurse Registries by Area as of May 4, 2013
Area 1 & 2 - NW Florida-Tallahassee/Pensacola – 3 Area 3 - Gainesville area – 26 Area 4 - Jacksonville area – 18 Area 5 & 6 - St.Petersburg-Tampa area – 67 Area 7 - Orlando area – 27 Area 8 - Ft. Myers area – 41 Area 9 - Palm Beach area – 126 Area 10 – Broward County – 105 Area 11 - Miami-Dade area – 45
105 located in Palm Beach County – same for Broward County

4. Nurse Registry Rules 59A-18 Florida Administrative Code
We have drafted some changes to update the rules
due to law changes in , chapter 408, part II, F.S. and its rules, 59A-35
to make improvements to benefit nurse registries
We welcome your input and suggestions
Verbal comments today or call (850)
Written comments to
deadline May 20
Draft changes at Nurse Registry page of AHCA web site ( - select “Nurse Registry”

6. Nurse Registry Draft Rule Revisions Administrator
Draft removes the full-time requirement
59A first sentence
(18) “An administrator may manage only one nurse registry, except that an administrator may manage up to five registries if all five registries have identical controlling interests as defined in s and are located within one agency [AHCA] geographic service area or within an immediately contiguous county.”
Note: State law has authority over the state rule 59A Administrator first sentence.

7. Certified Nursing Assistants(CNAs)
State law requires that persons who work as CNAs have a current certification from the Department of Health. Requires achieving a minimum score on the exam. May or may not have CNA training. [ , Florida Statutes (F.S.)]
Issue:
State law requires that the Nurse Registry ensure that each CNA is “adequately trained to perform the tasks of a home health aide in the home setting.”( (6)(a), F.S.)
Nurse Registries cannot train the CNAs unless licensed by the Department of Education as a career education school

8. Nurse Registry Rules CNAs
Previous suggestion from PCAF for 59A (7) revision:
(7) For every CNA, a nurse registry shall have on file a copy of the person’s State of Florida certification. A CNA certification shall be sufficient to demonstrate that a person is adequately trained to perform the tasks of a home health aide in the home setting, as required in Section , F.S.
Also received a suggestion that a year of work experience in the home setting could be required for a CNA.
Comments?

9. Nurse Registry Rules Home Health Aides
Nurse Registries did not offer home health aides until 1999 when home health aides were added to the nurse registry state law.
There is no licensure or certification of home health aides in Florida law.
The requirements for home health aides to have had 40 hours of training was put in the state rule 59A (8) by AHCA, working with nurse registries at the time. (Rule is quoted in G 271 survey standard.)
1999 law change was initiated by Marc Catalano, President of PCAF, to amend the nurse registry state law.

10. Nurse Registry Draft Rule Revisions Home Health Aides
59A draft:
RNs & LPNs licensed in Florida or another state may work as home health aides.
Persons who have completed nursing training in Florida but are not licensed yet may work as home health aides.

11. Nurse Registry Draft Rules Revisions Homemakers & Companions
Draft proposes to remove the requirement for hiring trained homemakers & companions from 59A

12. Nurse Registry Draft Rule Revisions Registration Policies
Draft changes to 59A :
Updates the listing of laws and rules that the nurse registry provides to independent contractors. These can be provided by paper copy, or other means of electronic communication.
Eliminates the written or oral communications to verify individual licensing with a screen print from the Department of Health web site.
For Health Statements (required in (6)(a), F.S.)- adds the phrase “that could be casually transmitted” as recommended by the Department of Health.
The intent is to protect patients from disease that can be spread by casual contact and not discriminate against persons who can provide safe health care using the universal precautions that are already required for health care work.
For example - HIV is not casually transmitted and can be prevented through the use of universal precautions. HIV itself is not a reason to deny employment. TB can be casually transmitted.

13. Nurse Registry Rules
State law permits another office in the same county as the licensed office.
(1), F.S., says: “….Each operational site of the nurse registry must be licensed, unless there is more than one site within a county. If there is more than one site within a county, only one license per county is required…”
Rule draft calls this a “satellite office” and offers a definition:
59A (13) “Satellite office” means a secondary office established in the same county as the main office, pursuant to (1), F.S.

14. Nurse Registry Proposed Rule Revisions What’s Next?
Receive comments by May 20
Make any changes & draft proposed rules
3. Prepare written justification for revisions & any statements of estimated regulatory cost to go with proposed rules
4. Submit proposed rules for review by Bureau Chief for Health Facility Regulation & Deputy Secretary for approval
5. Submit proposed rules for legal review. Make any changes requested by our attorneys or Deputy General Counsel. Submit back to Bureau Chief & Deputy Secretary for approval.
6. Submit proposed rules to AHCA Secretary and General Counsel for approval.
7. Submit proposed rules to Governor’s Office of Fiscal Accountability and Regulatory Reform
8. Publish proposed rules in Florida Administrative Register offering a public hearing to hear any concerns or objections (

15. Nurse Registry Proposed Rule Revisions What’s Next? (continued)
Post proposed rules from Florida Administrative Register notice at Nurse Registry page of AHCA web site ( - select “Nurse Registry”)
Submit proposed rules to the Joint Administrative Procedures Committee of the Legislature (JAPC).
Hold public hearing and hear concerns. Offer deadline for any written concerns.
Receive comments from legal review by JAPC.
Draft revisions as needed for proposed rules. Prepare Notice of Change for publication in the Florida Administrative Register.
Publish approved Notice of Change & post at Nurse Registry web page.

16. Nurse Registry Proposed Rule Revisions What’s Next? (continued)
Address any other concerns received with Agency attorneys. Publish post any additional change notices.
Submit rules for adoption to Department of State
These summarized steps are from the Administrative Procedures Act, Chapter 120, Florida Statutes and the Department of State Rulemaking Chapter 1-1, Florida Administrative Code.

17. Background Screening
7 nurse registries received survey fines in the past 12 months. 6 of the fines were about background screening:
4 fines were for failure to background screen an independent contractor (GZ 815)
1 fine was for failure to screen 2 contractors
1 fine was for failure to keep evidence of background screening in contractor’s file. (G 152)

18. Background Screening
Definitions in Chapter 435, F.S., Employment Screening: (2), F.S. “Employee” means any person required by law to be screened pursuant to this chapter, including, but not limited to, persons who are contractors, licensees, or volunteers. (3) “Employer” means any person or entity required by law to conduct screening of employees pursuant to this chapter. (4) “Employment” means any activity or service sought to be performed by an employee which requires the employee to be screened pursuant to this chapter.

19. Background Screening Clearinghouse
Implemented January 1, 2013
New web site changes took effect Feb 29
Currently AHCA & Dept of Health are participating – other state agencies in the future:
Department of Children and Families (DCF)
Department of Juvenile Justice (DJJ)
Department of Elder Affairs (DOEA)
Agency for Persons with Disabilities, and (APD)
Vocational Rehabilitation (DOE-VR)
To receive access to the Clearinghouse & begin initiating screenings, you must have registered.

20. Initiating a Clearinghouse Screening
All screenings must be initiated through the Clearinghouse website prior to sending an applicant for fingerprinting
To be entered in the Clearinghouse, a person screened must:
Get level 2 screening & have fingerprints retained by FDLE
Have a photo taken at the time of fingerprinting
Sign a privacy policy

21. Privacy Policy
Applicants must sign a privacy policy in order for their screening to be entered into the Clearinghouse
The privacy policy is available when you initiate screening for the applicant -- at the “Initiate Screening” tab of Clearinghouse web site
Nurse Registries must retain a copy of the privacy policy in the contractor’s personnel file

22. By Initiating Screening through the Clearinghouse, you will:
Enter person’s data only once
Reduce duplicative/unnecessary screening costs – you can use existing screenings at the site
Receive a Florida criminal history report for the person
Be able to track a screening through the entire process & receive notifications
See the status at each stage: Fingerprints submitted, Fingerprints received FDLE, Fingerprints Rejected, Fingerprints Rejected 2nd –NCO requested, etc.
Receive an each time the status is updated, saving you time

23. Employee/Contractor Roster
435.12(2)(c), F.S., requires that you enter initial employment status & any changes in status for each contractor at the Clearinghouse web site within 10 business days
This is within 10 days of:
the date you initiated the screening at the Clearinghouse web site
The date the person is no longer active with your nurse registry -- not on your list of contractors to be referred.

24. Employee/Contractor Roster
Current employees screened since January 1, 2013, who have a photo, retained prints, and a signed privacy policy must be added to the employee roster immediately or their status will change to “Resubmission Required-90-day lapse in employment” & payment will be required for a resubmission

25. Employee/Contractor Roster
Does the 10 days apply to contractors already screened prior to the Clearinghouse going live? No, but adding contractors to your roster will allow you to track them & receive notifications, should an updated status become available.

26. Arrest & Criminal Notifications
Retention of fingerprints will allow the Florida Department of Law Enforcement (FDLE) to report any new arrest/registration information to the specified state agencies
The Agency is receiving arrest/registration notifications from FDLE & manually updating the employee’s eligibility as necessary
What is meant by registration in the context of arrest & criminal notifications?
This is from FDLE’s website about criminal registrations-- a select group of convicted felons, the "worst-of-the-worst", are required to register their residences with law enforcement and a state registry maintained by FDLE , the Career Offender Application for Statewide Tracking (COAST). These offenders, by virtue of their histories of offenses, present a threat to the public and to communities. This registration law will assist law enforcement agencies in timely apprehending a career offender, if a career offender engages again in criminal conduct. Registration is not a punishment, but merely a status.

27. Employee/Contractor Arrests
You must add contractors to your roster to receive arrest and criminal registration notifications
Per section (2)(b), F.S., if a nurse registry (or any employer) becomes aware that a contractor has been arrested for a disqualifying offense, you must remove the contractor from contact with patients or clients.

28. Arrest & Criminal Registration Notifications
Retention of fingerprints when screened will allow the Florida Department of Law Enforcement (FDLE) to report any new arrest/registration information to the specified state agencies
The Agency is receiving arrest/registration notifications from FDLE & manually updating the employee’s eligibility as necessary
What is meant by registration in the context of “arrest & criminal registration notification” ?
Response from Taylor Haddock –

29. Clearinghouse Statistics
From January 1, 2013 to April 30, 2013:
264 individuals arrested AFTER they were screened (rap backs)
64 individuals went from Eligible to Not Eligible for offenses including:
Multiple Grand Thefts
Multiple Batteries and Assaults
Two Sex Offenses
Exploitation of the Elderly

30. Initiating an Agency Review
If an individual has been screened by another specified agency (i.e. DOH) & entered into the Clearinghouse, an AHCA provider must request an agency review on the Clearinghouse website
This will allow AHCA to make an eligibility determination for employment purposes without the provider having to pay for a completely new screening

31. Initiating a Resubmission
The retention of fingerprints (effective for screenings on or after January 1, 2013) provides a cost savings for contractors that are in the Clearinghouse but have had a lapse in employment greater than 90 days
If there has been a 90 day lapse in employment, a contractor would only require a new national criminal history check – a resubmission of the retained fingerprints ($16.50 is FBI national criminal history fee)

32. Initiating a Resubmission
How does the 90 days apply to nurse registries since we do not employ the person?
A nurse registry has a “caregiver”(independent contractor) that is considered “active” and ready to be referred.  The nurse registry would have a registration folder on this caregiver including their background screening results, affidavit of compliance with background screening requirements, health statement, employment verification, individual license or certification, or home health aide training.   This caregiver’s record would be on the active list and could sampled by an AHCA surveyor.  Therefore, even if the caregiver was not referred to any patient by your registry during the 90 day time period, he/she would not have to get re-screened.   If the caregiver also works for other registries or health care agencies, he/she should be listed on their rosters too.

33. Initiating a Resubmission
A new state criminal history search will also be conducted, at no additional charge
A resubmission can be requested and paid for directly through the Clearinghouse website

34. Bulletin Messages
Important updates will be displayed on the home page of the Clearinghouse results website
Regularly check the home page for notifications regarding system outages, new requirements & other information.

35. Background Screening
For help with background screening issues or Clearinghouse web site questions –
Send an to
Call the AHCA Background Screening Unit
(850)
View the web page:

36. Since many nurse registries are enrolled as Medicaid Waiver providers, following is a brief update. Slides were prepared by the AHCA Medicaid office.
Medicaid waivers

37. In 2011, the Florida Legislature created Part IV, Chapter 409, Florida Statutes, directing the Agency to create the Statewide Medicaid Managed Care (SMMC) program.

38. Purpose of the SMMC program
The program is designed to:
emphasize patient centered care, personal responsibility and active patient participation;
provide for fully integrated care through alternative delivery models with access to providers and services through a uniform statewide program; and
implement innovations in reimbursement methodologies, plan quality and plan accountability.
Purpose of the Statewide Medicaid Managed Care program
The program is designed to: emphasize patient centered care, personal responsibility and active patient participation; provide for fully integrated care through alternative delivery models with access to providers and services through a uniform statewide program; and implement innovations in reimbursement methodologies, plan quality and plan accountability.

39. Key Components Statewide Medicaid Managed Care program
Managed Medical Assistance program
Long-term Care
program
Key Components
Statewide Medicaid Managed Care program key components: Managed Medical Assistance Program Long-term Care Managed Care Program

40. Law Provisions
All Medicaid recipients shall receive covered services through the Statewide Medicaid Managed Care program, with few exceptions.
The following recipients are exempt from participation in SMMC:
women who are eligible only for family planning services
women who are eligible only for breast and cervical cancer services
persons who are eligible for emergency Medicaid for aliens
children receiving services in a prescribed pediatric extended care center.
Law Provisions
All Medicaid recipients shall receive covered services through the statewide managed care program, with few exceptions
The following Medicaid recipients are exempt from participation in the statewide managed care program:
Women who are eligible only for family planning services.
Women who are eligible only for breast and cervical cancer services.
Persons who are eligible for emergency Medicaid for aliens.
Children receiving services in a prescribed pediatric extended care center.

41. Law Provisions
The Statewide Medicaid Managed Care program will be implemented statewide.
The State has been divided into 11 regions that coincide with the existing Medicaid areas.
Law Provisions
The Statewide Medicaid Managed Care program will be implemented statewide. The State has been divided into 11 regions that coincide with the existing Medicaid areas.
A provider service network must be capable of providing all covered services to a mandatory Medicaid managed care enrollee or may limit the provision of services to a specific target population based on the age, chronic disease state, or medical condition of the enrollee to whom the network will provide services.

42. Long-term Care Provider Networks
According to s , F.S., managed care plans may limit the providers in their networks based on credentials, quality indicators, and price.
Each selected managed care plan must offer a network contract to all the following providers in the region:
Nursing Homes;
Hospices; and
Aging network service providers that have previously participated in home and community-based waivers.

43. Long-term Care Provider Types
Adult Day Care Center
Food Service Establishment
Nurse Registry
Adult Family Care Home
General Contractor
Older Americans Act Provider
Alarm System Contractor
Health Care Service Pool
Health Care Professional (Nutrition)
Assisted Living Facility
Homemaker/Companion Agency
Nursing Facility
Case Manager/Case Management Agency
Home Health Agency
Occupational Therapist / Aide
Community Care for the Elderly Provider
Home Medical Equipment Company
Pharmacy
Center for Independent Living
Hospice Organization
Physical Therapist
Clinical Social Worker
Independent Provider (Home Adaptations)
Psychologist
Community Mental Health Center
Independent Transportation Provider
Registered Nurse (RN)
Community Transportation Coordinator
Licensed Practical Nurse (LPN)
Respiratory Therapist
Dietician/Nutritionist/Nutrition Counselor
Low-Voltage Contractors, Electrical Contractors
Speech-Language Pathologist
Durable Medical Equipment Provider
Mental Health Counselor
Medication Administration

44. Long-term Care Covered Services

45. LTC Managed Care Plan Awards by Region
Healthcare Plans
American Eldercare, Inc.
Amerigroup Florida, Inc.
Coventry Health Plan
Humana Medical Plan, Inc.
Molina Healthcare of Florida, Inc.
Sunshine State Health Plan
United Healthcare of Florida, Inc. 1 X 2 3 4 5 6 7 8 9 10 11

46. Recipients Required to Enroll
Medicaid recipients living in nursing facilities or enrolled in one of the following programs when the Florida Long-term Care program begins:
the Assisted Living Waiver
the Aged and Disabled Adult Waiver and the Consumer-Directed Care Plus part of this waiver
the Nursing Home Diversion Waiver
the Channeling Services Waiver for Frail Elders
the Frail Elder Program in Miami-Dade County.
Medicaid Recipients Required to Enroll
Medicaid recipients living in nursing facilities or enrolled in one of the following programs when the Florida Long-Term Care Managed Care program begins:
the Assisted Living Waiver;
the Aged and Disabled Adult Waiver or the Consumer-Directed Care Plus part of this waiver;
the Nursing Home Diversion Waiver; and
the Channeling Services Waiver for Frail Elders
Medicaid recipients who are 18 years of age or older who enter a nursing facility after the Florida Long-Term Care Managed Care program begins.
Medicaid recipients age 18 and older who meet nursing facility level of care, but who wish to receive long-term care services in their home or a community setting will be enrolled as space becomes available.

47. Recipients Required to Enroll
Medicaid recipients who are 18 years of age or older who enter a nursing facility after the Florida Long-term Care program begins.
Medicaid recipients age 18 and older who meet nursing facility level of care, but who wish to receive long-term care services in their home or a community setting will be enrolled as space becomes available.
Medicaid Recipients Required to Enroll
Medicaid recipients living in nursing facilities or enrolled in one of the following programs when the Florida Long-Term Care Managed Care program begins:
the Assisted Living Waiver;
the Aged and Disabled Adult Waiver or the Consumer-Directed Care Plus part of this waiver;
the Nursing Home Diversion Waiver; and
the Channeling Services Waiver for Frail Elders
Medicaid recipients who are 18 years of age or older who enter a nursing facility after the Florida Long-Term Care Managed Care program begins.
Medicaid recipients age 18 and older who meet nursing facility level of care, but who wish to receive long-term care services in their home or a community setting will be enrolled as space becomes available.

48. For more information
Visit the Florida Medicaid SMMC website and sign up for program updates at the following address:

49. Emergency Management Plan Updates
Update your plan annually. If county reviewer requests annual update, then submit it to them. (Check letter or you receive back when your plan is reviewed or ask the reviewer. List of county health dept. reviewers is at the Nurse Registry page of the AHCA web site: - select “Nurse Registry) (G 292)
Show that you have reported any changes in telephone numbers (including after hours numbers) of administrative staff that are coordinating your emergency response & changes in these coordinating staff to the emergency management office in each county on your license. (G 292)
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 293)
59A , FAC

50. Companies with both Nurse Registry & Homemaker Companion licenses
There is no need for homemaker companion services registration if you have a nurse registry license.
However, if you have both -- separate your advertising
Have a separate brochure or distinct pages of the brochure & separation of the programs at the web site.
If you have multiple counties for homemaker companion & one county on your nurse registry license – brochures on your nurse registry should only be distributed in the one county.

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

52. Reporting AHCA Complaints
AHCA Contact (888)
Online report Health Care Facility Complaint Form at: ahca.myflorida.com/Complaint
Provide detailed information such as patient/resident names, dates, times of events and where the event occurred
Send copy of advertising if unlicensed activity

53. Contacting AHCA - Call the Field Office Manager or Supervisor
When you have questions about your survey or any standard that was cited as not met
- Call the Field Office Manager or Supervisor
When you have questions about laws, rules, the application form or requirements
1st check - click on “ Nurse Registry” - See Frequently Asked Questions
Then call the Home Care Unit (850)
or, send an to

54. Contact information
Anne Menard – Supervisor, 6 programs
The following staff do nurse registry & home health agency licensing:
Jan Benesh - manager for HHA & NR licensing
Ed Barnes –(Edward.Barnes)
Areas 1 to 8 & all changes of ownership
Lenora Lowry (Lenora.Lowry) – Areas 9 & 10 (Palm Bch area & Broward)
Natarsha Humphries (Natarsha.Humphries)– Area 11 (Dade/Monroe)

55.
See “Find Facilities and Providers” to view licensed nurse registries
Closed nurse registries & other facilities
Inspection reports for each
Can get Excel listings by county & statewide
Updated nightly from licensing data