1. 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

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

3. Nurse Registry Office
License must be posted in office. (GZ , 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 A (8), FAC

4. 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 (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

5. Policies & Procedures Required
The selection, documentation, screening and verification of credentials for each independent contractor referred by the registry. 59A (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 (5), F.S. (GZ 818)

6. 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 A , FAC

7. 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)

8. 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 A (8), FAC G (19), F.S.

9. 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 (19), F.S.

10. (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) ; [ , 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 if there are alleged professional practice violations.
(d) Report other complaints to the AHCA by calling (888) or submitting the on-line complaint form at .

11. 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 A , FAC G (8)(e), F.S.
G A (11), FAC

12. 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 (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 , September 2013
(GZ , F.S. )

13. 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 , F.S.

14. 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 A (6), FAC (6)(a), F.S.
There is no requirement that this be done annually or biennially.

15. 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 A (6), FAC

16. 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 (8)(10), F.S.

17. 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 (10), F.S.

18. 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 A (8)(10)(11), FAC

19. 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 A (12)

20. 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: call (850)
Current CPR certification from an instructor that is approved to provide training by the American Heart Association or the American Red Cross.
G A (7)(9)(11), FAC

21. 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 (1)(b), F.S., 59A (14)

22. 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 A

23. 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 A ,FAC

24. Staffing Services
(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.

25. 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 A , FAC

26. 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 A , FAC

27. 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 (15)(a), F.S.

28. Evidence that Laws & Rules Are Given to Independent Contractors
RNs & LPNs:
Rule 59A Registration Policies
Rule 59A Registered Nurses and Licensed Practical Nurses
Rule 59A Medical Plan of Treatment
Rule 59A Clinical Records
Rule 59A Administration of Biologicals
Sections , , , , , and (5), F.S. with the telephone numbers
Rule 59A Emergency Management Plans
CNAs & HH Aides:
Rule 59A (6) regarding health statements and communicable disease
Rule 59A Certified Nursing Assistant and Home Health Aide
Homemakers and Companions:
Rule 59A Homemakers or Companions
G A (1),FAC

29. 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 A , FAC G A (3), FAC

30. 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 A , FAC

31. 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 (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

32. 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 A , F.A.C.

33. 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 (20), F.S., but the NR is not prohibited from reviewing records and may do so.
G A , F.A.C.

34. 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 (6), F.S.

35. 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 A , FAC

36. 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 , F.S. and G A , FAC

37. 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 A , FAC

38. 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 A , FAC

39. 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 A , FAC

40. 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 (20), F.S., but the NR is not prohibited from reviewing the records and may do so.
G A , FAC.

41. 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 A , FAC

42. 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 A (7), FAC

43. 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 ”
“To report abuse, neglect, or exploitation, please call toll-free ”
“To report suspected Medicaid fraud, please call toll-free ” - plus the AHCA description Medicaid fraud.
GZ (5),F.S.

44. 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 (6)(c), F.S.

45. 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 (6)(e), F.S.

46. 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
G (4), F.S.

47. 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 (12), , F.S. and 59A , FAC

48. 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 (12), F.S. and 59A )(12)(13), FAC

49. Emergency Management Plan
Have a copy of the emergency management plan
- use required plan format, AHCA Form
Show copy of 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 (Select “Nurse Registry”, scroll down to “emergency management”)
Have copy of any 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 A , F.S, and (12), F.S.

50. Emergency Management Plan
Review and update your plan annually. If county reviewer requests an annual update, then submit it to them (check letter or 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 A , FAC

51. 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
4. If still not resolved, contact Acting Chief of Field Operations, Kim Smoak (850)

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