Update
How 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.
Review the State Regulation Set
used by Surveys
• Go to the AHCA web site:
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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
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Nurse Registry Office
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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
3
Nurse Registry Office
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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.
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Nurse Registry Office
• If you set up another office within the county
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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
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Policies & Procedures
Required
1. The selection, documentation, screening and verification of
credentials for each independent contractor referred by the
registry. 59A-18.005(2), FAC (G 251)
2. 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)
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Policies & Procedures
Required
3. 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.
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Policies & Procedures
4. Policy on acceptance of patients & termination of services
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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)
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Policies & Procedures
5. Procedures on the administration of drugs & biologicals (G
225)
6. 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)
7. Emergency Management Plan (G 291)
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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
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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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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 of HH aides
59A-18.005 G 152
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Contractor Registration Folders
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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
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Background Screening
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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)
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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)
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Background Screening
408.809, F.S.
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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.)
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Health Statement
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New independent contractors get statement based on
physical exam within the last 6 months, that they are
free from communicable disease.
TB test not required any more
Statement received by NR prior to contact with
patients
G 151 59A-18.005, 400.506(6)(a), F.S.
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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
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Health Statement
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(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
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Registration folders on contractor
400.506(8), F.S.
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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.
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Keep for 3 years after the date of the last file
entry of patient-related or client-related information.
G 152
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Registration Folders for
Contractors
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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
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Registration Folders
Home Health Aides
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Evidence of completion of a home health aide training
course of at least 40 hours in the topics listed in 59A18.0081(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
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Registration Folders
Certified Nursing Assistants
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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
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Registration Folders
CNAs & Home Health Aides
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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 selfadministration 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)
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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
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Homemaker & Companion
Contractor Folders
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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.
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Other Documents the Surveyor
May Request
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Orientation of new independent contractors
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Resume of administrator & alternate administrator
G 160
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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.
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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
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Supplemental Staffing (cont’d)
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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
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Providing contractors at ALFs
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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.
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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
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Clinical records for patients
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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)
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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 to substantiate the plan of
treatment
G 190
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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;
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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.
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Clinical Records
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(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.
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Patient records
C.N.A. & Home Health Aide
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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.
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Patient records
C.N.A. & Home Health Aide
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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
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Patient records
C.N.A. & Home Health Aide
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If C.N.A. or Aide assists patient with self-administered medication,
that is routine, regularly scheduled medications [legend & over-thecounter 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
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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
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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
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Patient/Client Records
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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
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Homemaker & Companion
client records
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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.
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Patient/Client Records
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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
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Information Given to Patients
1. Independent contractors must inform the patient, caregiver
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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
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Information Given to Patients
2. 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.”
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“To report abuse, neglect, or exploitation, please call
toll-free 1-800-962-2873.”
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“To report suspected Medicaid fraud, please call tollfree 1-866-966-7226” - plus the AHCA description
Medicaid fraud.
408.810(5), F.S.
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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
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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.
400.506(6)(e), F.S. G 153
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Put License Number in Ads
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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.
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Special Needs Registration
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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
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Special Needs Registration
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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 & 296 400.506, F.S. & 59A-18.018)
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Emergency Management Plan
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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 (click on
“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.
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Emergency Management Plan
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Update your plan annually. If county reviewer requests 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) of administrative staff
that are coordinating your emergency response 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-18.018, FAC
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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/Areas
4. If still not resolved, contact Chief of Field Operations, Polly
Weaver (850) 412-4301
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AHCA web sites
http://ahca.myflorida.com/homecare -- select “nurse
registry” – licensing, emergency management plan & each
county’s plan review contacts, state regulation set (survey
standards), answers to frequently asked questions
www.FloridaHealthFinder.com - select “Find Facilities or
Providers” (updated nightly) + see Consumer Guides
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Contact information
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Anne Menard – Anne.Menard@ahca.myflorida.com
Lenora Lowry – Lenora.Lowry@ahca.myflorida.com
(850) 412-4403
Home Care Unit
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