Update How to Prepare for a Nurse Registry Survey

1. UpdateHow to Prepare for a Nurse Registry Survey Anne Menard Home Care Unit Bureau of Long Term Care Services Agency for Health Care Administration October 2014 This document will be revised when rule revisions are adopted.

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

3. Nurse Registry Office • 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. 59A-18.004(9), FAC Standard G 174 & G 175

4. Nurse Registry Office • License must be posted • “Each operational site must be licensed unless there is more than 1 site within a county. If there is more than 1 site, only 1 license per county is required. Each operational site must be listed on the license.” (400.509(1), F.S.) Example – Your main office is in West Palm Beach. You can have another office in Palm Beach County – but you would have to get another license to have an office in another county. • If your nurse registry is referring homemakers & companions, there is no need to get a homemaker companion services registration.

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

6. Policies & ProceduresRequired • The selection, documentation, screening and verification of credentials for each independent contractor referred by the registry. 59A-18.005(2), FAC (G 251) • 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)

7. Policies & ProceduresRequired • Availability of a Nurse • 24 hour availability to a nurse, by active patients who are receiving skilled care from licensed nurses referred by the nurse registry. Describe the on-call system whereby designated nursing staff will be available to directly communicate with the patient. • For registries which refer only CNAs or home health aides, written policies & procedures must address the availability of an on-call nurse, during hours of patient service. G 168 59A-18.004 (9), F.A.C.

8. Policies & Procedures 4.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 caregiver shall be notified of the date of termination & the reason for termination – include a copy in the patient or client's record. (G 180)

9. 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)

10. Policies & Procedures 8.Each nurse registry shall establish a system for the recording & follow-up of complaints 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. 59A-18.005(8)(d), FAC

11. 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.

12. Registration Foldersfor 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 of HH aides 59A-18.005 G 152

13. Contractor Registration Folders • Each nurse registry shall, in its contracts with independent contractors, provide instructions as to responsibility for the payment of self-employment estimated taxes, & a statement as to the registry's commitment to compliance with civil rights requirements, pursuant to Chapter 760, F.S. G 152 59A-18.005

14. 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 Recommended Form 3100-0008, September 2013 435.05, F.S. (GZ 816)

15. Background Screening408.809, F.S. • Contractors that had background screening 8/1/2010 or later must have level 2 screening that is OK. Screening is required every 5 years. • 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.)

16. Health Statement • New independent contractors get statement based on physical exam within the last 6 months, that they are free from communicable disease. • TB test notrequired any more • Statement received by NR prior to contact with patients G 151 59A-18.005, 400.506(6)(a), F.S.

17. 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

18. Health Statement (cont’d) • If contractor is later found to have a communicable disease, he/she shall immediately cease to be referred. • If contractor later provides a statement from a health professional that such condition no longer exists, the NR can again refer the contractor to patients. • If contractor refuses to remove him or herself, the NR shall report the person to the county health department. G 151 59A-18.005

19. Registration folderson contractor400.506(8), F.S. • 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

20. 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. 400.506(10), F.S. G 152

21. Registration Folders Home Health Aides • Evidence of completion of a home health aide training course of at least 40 hours in the topics listed in 59A-18.0081(8), FAC; • An aide that had training in another state must provide a copy of the course work & a copy of their training documentation to the nurse registry. If the course work is equivalent to Florida's requirements, the nurse registry may refer the home health aide for contract. • Current CPR certification G 277 59A-18.0081, FAC

22. Registration FoldersCertified Nursing Assistants • Florida Department of Health C.N.A. Certification (removed requirement for evidence that adequately trained in G 271 effective in 6-1-2011) • Individuals who earn their CNA certificate in another state must contact the CNA office in the Board of Nursing at the Department of Health about taking the written examination prior to working as a CNA in Florida. • Current CPR certification G 277 59A-18.0081, FAC

23. 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(12)

24. Registration Folders CNAs & Home Health Aides Training on assistance with self-administered medication from one of the following sources is acceptable: 1. Documentation of 2 hours of training in compliance with subsection 59A-8.0095(5), F.A.C., from a home health agency; 2. A training certificate for 4 hours of training for assisted living facility staff in compliance with subsection 58A-5.0191 (5), F.A.C. 3. A training certificate for at least 2 hours of training from a career education school licensed by the Florida Department of Education, Commission for Independent Education. G 279

25. Homemaker & CompanionContractor Folders • The homemaker or companion has evidence of training in topics related to human development and interpersonal relationships, nutrition, shopping, food storage, used of equipment and supplies, planning and organizing of household tasks and principles of cleanliness and safety. G 172 59A-18.009(1), F.A.C.

26. Other Documents the Surveyor May Request • Orientation of new independent contractors • Resume of administrator & alternate administrator G 160

27. Staffing Services 400.462, F.S. (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.

28. Supplemental Staffing Individual contractor’s file shall have: • Performance outcome evaluation - request from the health care facilities where the individual has provided services. Once a year. • Recording & follow-up 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

29. 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 are OK G 253 59A-18.017

30. 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.

31. Evidence that Laws & Rules are Given to Contractors RNs & LPNs: • 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, F.S. 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 • Sections 400.506, 400.484, 400.462, 400.488, F.S. Homemakers and Companions: • Rule 59A-18.009 Homemakers or Companions • Sections 400.506, 400.484, 400.462, F.S. G 150

32. Clinical records for patients • RN & LPN 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. • If doing staffing at a facility, records are kept at the facility (G 170) • When medical treatments or medications are administered, physician's orders in writing that are signed and dated shall be included in the clinical record; and (G 180)

33. Clinical RecordsSurveyor 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 to substantiate the plan of treatment G 190

34. 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 caregiver or guardian; (2) Authorization for release of information, dated and signed by the patient, caregiver, 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;

35. 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.

36. 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. G 200 59A-18.012, F.A.C.

37. Patient recordsC.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.

38. Patient recordsC.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 patient to the caregiver & the nurse registry G 277 59A-18.0081, FAC

39. Patient recordsC.N.A. & Home Health Aide • If C.N.A. or Aide assists 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, 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 conducted by an RN or LPN to ensure the CNA & Aide are able to assist per their training & with the medication prescription • Record is documented every time the patient receives assistance with self-administration of medication G 278 400.488, F.S. & G 279 59A-18.0081, FAC

40. 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 & 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 G 290 59A-18.018, FAC

41. Patient/Client Records If they are to be registered: • Indicate whether they have 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

42. Patient/Client Records • When a nurse registry is unable to continue services to special needs patients, that 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 caregivers, 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 which may be able to provide temporary services G 298 59A-18.018

43. 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. G 171 59A-18.009, F.A.C.

44. Patient/Client Records • When services are to be terminated, the patient or client, or the caregiver 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

45. 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

46. 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. 408.810(5), F.S.

47. 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 168 59A-18.004(9), FAC

48. 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 contractorand • the nurse registry is not obligated to monitor, supervise, manage or train the caregiver. 400.506(6)(e), F.S. G 153

49. 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 additional times 400.506(4), F.S.

50. 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 & 252.355, F.S. 59A-18.018