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

2. 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).

3. 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

4. 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

5. 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

6. 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.

7. 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

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

9. 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.

10. 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

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

12. 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).

13. 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).

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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/ Complainant (#2) interviewed & documents requested 23

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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)

31. 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

32. 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

33. 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

34. 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

35. Questions?
Thank you!