Lessons Learned: Compact Investigations & Discipline Valerie Smith, MS, RN, FRE Associate Director Arizona State Board of Nursing

Nurse 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).

More NLC Definitions Home state – party state which is the nurse’s primary state of residence (PSOR) Party state – any state that has adopted this compact Remote state – a party state, other than the home state: where the patient is located recipient of nursing practice located

NLCA Policy No. 5.1 Conducting Investigations Investigations may be conducted either by home state or remote state The party state receiving the initial complaint shall conduct an initial inquiry and open the case if warranted If more than a minor infraction, the party state shall post a Notice of Investigation on Nursys

NLCA 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 state The investigating state shall contact another party state(s) if nurse is known to be practicing or moved to new party state

NLCA 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.

Bird’s-eye view: Complaint investigation process Licensee practicing in a remote state on MSP Complaint allegation received Remote state, home state, or both states Two states mutually determine investigative lead

Investigative Lead Decision Points: Access to witnesses Access to respondent Ability to obtain documentary evidence Public risk involved Ability to timely process case 8

NLCA Policy 5.2: Issuing Subpoenas in Another Party State Compact states will issue subpoenas for other party states as allowed by state law The 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.

NLCA 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 Nursys Removed within 10 days of action

Discipline decision points: Action against license vs. PTP Risk to patient safety Current status of nursing practice Mobility “moving target” Timeliness

Definition: 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).

Definition: 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).

Home 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

Remote State Action Affects only the MSP in the remote state and not the home state license Nurse may practice in another party (remote) state or home state The 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

Multistate 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

Multistate Practice of Licensees Under Discipline or Alternative Program Agreements Obtaining permission Request permission from home state to seek or retain employment in a remote state Permission, if approved, is in writing Home state reviews and determines if employment is consistent with the terms of the order or agreement Request permission from remote state NLCA Policy 5.3

Monitoring 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 working If a violation occurs, the state determining that the violation shall immediately notify the other state The home state and the remote state shall determine which state shall initiate action on the violation The home state and the remote state shall determine if the nurse may continue employment in the remote state The state taking action on the violation shall notify the other state of the final action taken NLCA Policies 5.3 & 5.4

Licensure 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

Licensure 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 residence The 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

Issuing 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 issuance NLCA Policy 3.1 21

Investigative & Discipline Case Scenario Complaint allegation (diversion) received in remote state (AZ); not reported to home state by complainant/employer Remote state and home state case coordinate. Remote state takes lead Case elevated to high priority as new information received impaired on duty; similar complaints in other states, including non-compact 22

Investigative & Discipline Case Example Timelines 1/13/2010 complaint received remote state assigned for initial investigative review 1/28/2010 home state and remote state share information & determine remote state takes lead 2/26/2010 new complaint received by home state re: diversion in a non-compact state Information shared with lead state (remote) 2/26/2010 - Complainant (#2) interviewed & documents requested 23

Investigative & Discipline Case Example Timelines cont ... 3/2/2010: notice of probable summary suspension 3/4/2010: signed consent agreement surrender privilege. Other states of licensure notified (N = 6) 3/17/2010: non-compact state takes action incorporating above information 3/23/2010: home state action incorporating information and action from remote state 1/28/2011 second non-compact state action 24

Investigative & 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

NLC Challenges: Survey Responses Different Board Structures Umbrella vs. independent Authority for investigative and legal staff varies Identifying & establishing key contacts Differences in interpretation rules & policies Knowledge of NLC rules & policies by licensees, Boards, investigative & legal staff varies

NLC Challenges: Survey Responses Mobility of population Difficult to locate, especially those who do not want to be located Time it takes for some states to complete investigation Communication of investigative findings 27

Responding to the Challenges: Enhance Understanding of NLC Educating board, investigative & discipline staff continuous & on-going Develop internal expertise access to policies, data, trends Establish & maintain current contact information networking across state lines

Responding to the Challenges: Enhance Understanding of NLC Education of employers/public Checking current licensure with PSOR and/or Nursys Identifying PSOR and when licensure application is required in new home state Where & how to report alleged violations & misconduct

Responding to the Challenges: Enhance Understanding of NLC Education board, investigative & discipline staff about discipline under the compact Limits of practice within the state under Board disciplinary orders and alternative programs Developing consistency in limiting practice (license vs. contractual or order)

Regulatory Challenges Not New& Not Unique Many of our challenges existed prior and are not unique to the nurse licensure compact mobile population investigative timelines differences between jurisdictions communications before action 31

Advantages Survey Responses Ability to share complaint & investigative information Shared responsibility for patient safety not governed by geographical boundaries Shared commitment to improving our collective ability to protect patients 32

Advantages: Survey Responses Multiple states working together on a priority case to assure patient safety Ability to locate, isolate or limit ability to practice on MSP Reduces duplicative actions Uniform rules applicable to compact states 33

In Summary Communication, cooperation, collaboration & ongoing education are important to the success and understanding of NLC Many of the investigative & discipline challenges are not unique to NCL NLC promotes shared responsibility As nursing practice continues to evolve so does nursing regulation

Questions? Thank you!