1Lessons Learned: Compact Investigations & Discipline Valerie Smith, MS, RN, FREAssociate DirectorArizona State Board of Nursing
2Nurse Licensure Compact (NLC) Definitions “Multistate licensure privilege means current, official authority from a remote state permitting the practice of nursing as either a registered nurse or a licensed practical/vocational nurse in such party state. All party states have the authority, in accordance with existing state due process law, to take actions against the nurse’s privilege such as: revocation, suspension, probation or any other action which affects a nurse’s authorization to practice.”NLC Art. II (h).
3More NLC DefinitionsHome state – party state which is the nurse’s primary state of residence (PSOR)Party state – any state that has adopted this compactRemote state – a party state, other than the home state:where the patient is locatedrecipient of nursing practice located
4NLCA Policy No. 5.1 Conducting Investigations Investigations may be conducted either by home state or remote stateThe party state receiving the initial complaint shall conduct an initial inquiry and open the case if warrantedIf more than a minor infraction, the party state shall post a Notice of Investigation on Nursys
5NLCA Policy No. 5.1 Conducting Investigations Cont .. One state shall take the lead in conducting the investigation, but party state(s) may conduct an investigation simultaneously in collaboration with the lead stateThe investigating state shall contact another party state(s) if nurse is known to be practicing or moved to new party state
6NLCA Policy No. 5.1 Conducting Investigations cont .. Relevant information concerning an investigation which affects more than one party state shall be shared with the state(s) by telephone or written communication within 10 business days of receipt of the information.
7Bird’s-eye view: Complaint investigation process Licensee practicing in a remotestate on MSPComplaint allegation receivedRemote state, home state, or both statesTwo states mutually determine investigative lead
8Investigative Lead Decision Points: Access to witnessesAccess to respondentAbility to obtain documentary evidencePublic risk involvedAbility to timely process case8
9NLCA Policy 5.2: Issuing Subpoenas in Another Party State Compact states will issue subpoenas for other party states as allowed by state lawThe party state needing the documentary evidence shall request in writing that the nurse licensing authority of the state where the incident occurred subpoena the records.
10NLCA Policy 4.3 Current Significant Investigative Information Investigative information that indicates that a nurse represents an immediate threat to public health and safety regardless of whether the nurse has been notified and had an opportunity to respond.Posted in NursysRemoved within 10 days of action
11Discipline decision points: Action against license vs. PTP Risk to patient safetyCurrent status of nursing practiceMobility “moving target”Timeliness
12Definition: Home State Action “… means any administrative, civil, equitable, or criminal action permitted by the home state’s laws…including actions against an individual’s license such as: revocation, suspension, probation or any other action which affects a nurse’s authorization to practice.” NLC Art. II (f).
13Definition: Remote State Action “… any administrative, civil, equitable, or criminal action permitted by a remote state’s laws…including actions against an individual’s multistate privilege to practice in a remote state, and cease and desist and other injunctive or equitable orders issued by remote states or the licensing boards thereof. NLC Art. II (i).
14Home State Action vs. Remote State Action “A remote state may take adverse action affecting the multistate licensure privilege to practice within that party state. However, only the home state shall have the power to impose adverse action against the license issued by the home state.” NLC Art. V (c)Home state action affects ability to practice in all party states
15Remote State ActionAffects only the MSP in the remote state and not the home state licenseNurse may practice in another party (remote) state or home stateThe home state may take adverse action based on the factual findings of the remote state, so long as each state follows its own procedures for imposing such adverse action
16Multistate Practice of Licensees Under Discipline or Alternative Program Agreements “A licensee who is under a disciplinary order or agreement that limits practice or requires monitoring or has an agreement with an alternative program may not work in a remote state without prior written authority of both states.”NLCA Policy 5.3
17Multistate Practice of Licensees Under Discipline or Alternative Program Agreements Obtaining permissionRequest permission from home state to seek or retain employment in a remote statePermission, if approved, is in writingHome state reviews and determines if employment is consistent with the terms of the order or agreementRequest permission from remote stateNLCA Policy 5.3
18Monitoring Multi-State Practice of Nurses under Discipline or in an Alternative Program Nurse shall submit any required reports and adhere to the original order and directives regardless of where workingIf a violation occurs, the state determining that the violation shall immediately notify the other stateThe home state and the remote state shall determine which state shall initiate action on the violationThe home state and the remote state shall determine if the nurse may continue employment in the remote stateThe state taking action on the violation shall notify the other state of the final action takenNLCA Policies 5.3 & 5.4
19Licensure in Another State After Surrender, Revocation, Suspension, or Denial of a License/Privilege …The individual that has a license or privilege to practice which was/is surrendered, revoked, suspended, or denied may be issued a single state license in the current primary state of residence until such time as the individual would be eligible for reinstatement in the prior state(s) of adverse action. Once eligible for licensure in the prior state(s), a multistate license may be issued.NLCA Policy 3.8
20Licensure in Another State after Surrender, Revocation, Suspension, or Denial of a License/Privilege …Information of disciplinary history and Board action(s) shall be made available upon request of the Board in the individual's current primary state of residenceThe current primary state of residence may issue a single state license (see policy 3.1)Each state will notify Nursys…Procedure NLCA Policy 3.8
21Issuing a Single State License When a party state issues a license authorizing practice only in that state and not authorizing practice in other party states (i.e., a single state license), the license shall be clearly marked with words indicating that it is valid only in the state of issuanceNLCA Policy 3.121
22Investigative & Discipline Case Scenario Complaint allegation (diversion) received in remote state (AZ); not reported to home state by complainant/employerRemote state and home state case coordinate. Remote state takes leadCase elevated to high priority as new information receivedimpaired on duty; similar complaints in other states, including non-compact22
23Investigative & Discipline Case Example Timelines1/13/2010 complaint received remote stateassigned for initial investigative review1/28/2010 home state and remote state share information & determine remote state takes lead2/26/2010 new complaint received by home state re: diversion in a non-compact state Information shared with lead state (remote)2/26/ Complainant (#2) interviewed & documents requested23
24Investigative & Discipline Case Example Timelines cont ...3/2/2010: notice of probable summary suspension3/4/2010: signed consent agreement surrender privilege. Other states of licensure notified (N = 6)3/17/2010: non-compact state takes action incorporating above information3/23/2010: home state action incorporating information and action from remote state1/28/2011 second non-compact state action24
25Investigative & Discipline Case Example NLC Article V“…home state shall give same priority and effect to reported conduct received from remote state as it would if such conduct had occurred within the home state.”“The home state may take adverse action based upon the factual findings of the remote state, so long as each state follows its own procedures …”25
26NLC Challenges: Survey Responses Different Board StructuresUmbrella vs. independentAuthority for investigative and legal staff variesIdentifying & establishing key contactsDifferences in interpretation rules & policiesKnowledge of NLC rules & policies by licensees, Boards, investigative & legal staff varies
27NLC Challenges: Survey Responses Mobility of populationDifficult to locate, especially those who do not want to be locatedTime it takes for some states to complete investigationCommunication of investigative findings27
28Responding to the Challenges: Enhance Understanding of NLC Educating board, investigative & discipline staffcontinuous & on-goingDevelop internal expertiseaccess to policies, data, trendsEstablish & maintain current contact informationnetworking across state lines
29Responding to the Challenges: Enhance Understanding of NLC Education of employers/publicChecking current licensure with PSOR and/or NursysIdentifying PSOR and when licensure application is required in new home stateWhere & how to report alleged violations & misconduct
30Responding to the Challenges: Enhance Understanding of NLC Education board, investigative & discipline staff about discipline under the compactLimits of practice within the state under Board disciplinary orders and alternative programsDeveloping consistency in limiting practice (license vs. contractual or order)
31Regulatory Challenges Not New& Not Unique Many of our challenges existed prior and are not unique to the nurse licensure compactmobile populationinvestigative timelinesdifferences between jurisdictionscommunications before action31
32Advantages Survey Responses Ability to share complaint & investigative informationShared responsibility for patient safety not governed by geographical boundariesShared commitment to improving our collective ability to protect patients32
33Advantages: Survey Responses Multiple states working together on a priority case to assure patient safetyAbility to locate, isolate or limit ability to practice on MSPReduces duplicative actionsUniform rules applicable to compact states33
34In SummaryCommunication, cooperation, collaboration & ongoing education are important to the success and understanding of NLCMany of the investigative & discipline challenges are not unique to NCLNLC promotes shared responsibilityAs nursing practice continues to evolve so does nursing regulation