Are you considering starting a nurse registry? If so, there are some requirements you need to meet in order to get started.
At InMyTeam, in collaboration with Christina Crumbley – the Chief Executive Officer of Tidal Healthcare Consulting, LLC.- we’ve put together a checklist to make sure you have everything covered.
In this Blog post, you will learn about the application process, allowable services, administrators and staffing requirements, required Policies, Patient Records, main challenges related to contractors, and more.
Important things you need to know Before Applying
Nurse Registry Services
RN, LPN, Certified Nursing Assistants, Home Health Aides, Homemakers, and Companions. Nurse Registries may not provide any therapy services.
ALFs, Hospice, Nursing Home, Adult Day Care, Hospital, Home Health Agency, Private home
- Licensed physician, APRN, RN or individual with training/experience in health service administration and at least 1 year of supervisory experience in health are
- Knowledgeable with AHCA rules of nurse registry
- Written designation of alternate administrator that meets administrator requirements
- Level 2 background screening prior to appointment
- May manage up to 5 registries with identical controlling interests and are located in one agency geographic service area or an immediately contiguous county
Staff requirements and allowable services
- May be employee or Contractor (if acting as Nursing supervisor, all direct care staff must be contractors)
- Responsible to maintain plan of treatment, amendments to the plan, additional order and clinical notes
- Required medication review on clients receiving assistance with self-administered medications, to determine type of assistance to be provided
- If patient refuses visit, a written list with dosage, frequency and route will be provided to be reviewed by the nurse
- Administration of Drugs and Biologicals
- Order dated and signed by MD, APRN, or PA within 30 days
- Limited to allowable services in section 400.506(6)(b)
- Must observe appearance and gross behavior changes in the patient and report changes to the patient’s health care surrogate or other person designated by the patient and the nurse registry or to the responsible facility employee if staffing in a facility
- At this point in time, new Nurse Delegation regulations do not include nurse registries. Only skilled Home Health Agencies.
- Allowed to perform only specific duties as part of 59A-18.009
- Must report any unusual incidents of chagnes in the patient’s or client’s behavior to the person designated by the client
Application Process
Application process timeline
Submit Application
Review Application Checklist before submitting your application, in order to avoid delays.
Notification by AHCA of omissions or errors
30-day notification by AHCA of omissions or errors.
21 days to respond
After receiving the Notification by AHCA of omissions or errors, you only have 21 days to respond and correct.
Survey
Approval of license within 60 days pending survey.
Application Forms
These are the three forms listed in the Agency for Health Care Administration official website:
-Application Checklist Nurse Registry
-Nurse Registry Proof of Financial Ability to Operate
In addition, you can watch this short video that will help you understand how to fill out the Proof of Financial Ability to Operate form:
-Nurse Registry-Introduction to The Proof of Financial Ability to Operate
Company Data
The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA.
You can apply online, by mail, or through a designated CMS contractor. The online application is recommended, because it is generally quicker and easier to track the status.
An employer identification number (EIN) is a nine-digit number assigned by the IRS. It’s used to identify the tax accounts of employers and certain others who have no employees. The IRS uses the number to identify taxpayers who are required to file various business tax returns.
To learn how to apply for an EIN number follow this link: Employer Identification Number (EIN) – How to Apply
- Administrator
- Alternate Administrator
- Registered Nurse
- Chief Financial Officer
Supporting Documents
This refers to the lease, deed of the office.
In addition, you must send notification of satellite office to AHCA prior to opening.
This should be provided by the landlord or Property Management Company. You should also make sure before you buy or lease a local that it has the permits to operate the type f business you’re planning to run.
- Administrator
- Alternate Administrator
- Nurse
- Financial Officer
An authorized representative means a person who is authorized by an applicant or participant to act on their behalf in matters involving the application for assistance or participation in the program.
Each registry is required to prepare and maintain a written emergency plan:
Comprehensive Emergency Management Plan for Nurse Registries, AHCA Form 3110-1017 May 2015
-Review annually
-Report name and personal phone numbers or administrative staff coordination emergency response to county emergency management office and county health department
-Documentation when state of emergency declared of contact with patients needing ongoing care and confirm plan, to include ALFs and Adult family care homes patients to confirm their plans.
Much less start up capital needed than a Licensed Home Health Care Agency.
Survey by AHCA
The Initial survey is announced, follow up surveys are unannounced.
Registries are licensed by AHCA, they do not require Accreditation , therefore, less start up costs.
For additional information, check this link: “Update How to Prepare for a Nurse Registry Survey” by Anne Menard –Home Care Unit, Bureau of Long Term Care Services, Agency for Health Care Administration-
Required Onsite Information
No Quality Assurance/Performance Improvement program requirements.
- Proof special needs registration was sent to emergency management office
- Copy of list of medications and equipment needs for each patient
- Requires license number, including websites
- $100 fine first time, $500 additional times
Office Staffing Requirements
- Posted hours of operation
- Agency must be staffed for 8 consecutive hours between 7am-6pm with at least a clerical person
- Administrator or alternate must be available to the public for 8 consecutive hours between 7am and 6pm in person or phone
- Surveyor to have access to client records within 2 hours
Required Policies
- Availability of nurse -For skilled care vs non-skilled care-
- Grievance Reporting and Resolution
- Providing notice to patients for abuse, neglect, exploitation, complaints and Medicaid Fraud
- Service Termination
- Selection, documentation, screening, and verification of credentials for contractors
- Emergency Management Policy
- Procedure for Informing Patients of Special Needs Registry
- Acceptance of Patients or Clients
- Administration of Drugs and Biologicals
- Office Hours
- Designation of Alternate Administrator
- Patient Rights
- Affirmative Action and Equal Opportunity
- Patient information packet
- Plan of Treatment
- Clinical Record Contents
- Assistance with Self-Administration of Medication
- Job Descriptions
- Contractor Notifications
- Health Screening
- Background Screening
- Coordination of Services for all disciplines
- Supplemental Staffing
- Contractor Registration Folder Contents
After Licensed. Management requirements
Nurse Registries have less requirements to manage compared to a Licensed Home Health Care Agency. When it comes to contractors registration, the checklist includes many less topics than Licensed Home Health. For patient’s record, the nursing assessments require less detailed documentation for admissions.
Contractor Registration Requirements
- Name, address, DOB, SSN, education background, employment history, number and date of license/certification.
- TB test is no longer required
- MD, DO, ARNP, PA or RN supervised by physician or acting under a protocol signed by a physician
Many less topics required compared to home health
- Aides
-Completion of training course for HHA or CNA certificate from a public vocational technical school or licensed non-public career education school
-LPNs and RNs licensed in Florida or another state may work as home health aides, or have completed the training program and are not yet licensed
-Proof of at least 40 hours of home health aide training (Medicare deemed home health agencies are required to have 75 hours of training)
-CNA certification in another state must take written examination
-CPR approved by American Heart Association or American Red Cross
-Assistance with medication training:
- 2-hour training per 59A-8.009(5) F.A.C for home health agency if aide previously worked for agency
- Training certificate per 429.52(6) F.S assisted living facility staff
- Certificate for at least 2 hours of training from a career education school licensed by the Department of Education, Commission for Independent Education
- 2-hour training by a provider approved by the Florida Board of Nursing, Department of Health
- Homemaker/Companion
-Evident of training per 59A-18.009(1)
- Attestation of Compliance with Background Screening Requirements Form
- Nurses
-Rule 59A-18.005, F.A.C., Registration Policies.
-Rule 59A-18.007, F.A.C., Registered Nurses and Licensed Practical Nurses.
-Rule 59A-18.011, F.A.C., Medical Plan of Treatment.
-Rule 59A-18.012, F.A.C., Clinical Records.
-Rule 59A-18.013, F.A.C., Administration of Biologicals.
-Sections 400.506, 408.809, 400.484, 400.462, 400.488 and 408.810(5), F.S., with the telephone numbers referred to in the law.
-Rule 59A-18.018, F.A.C., Emergency Management Plan
- Aides
-Rule 59A-18.005, F.A.C., Registration Policies.
-Rule 59A-18.0081, F.A.C., Certified Nursing Assistant and Home Health Aide.
-Sections 400.506, 408.809, 400.484, 400.462, 400.488 and 408.810(5), F.S., with the telephone numbers referred to in the law.
-Rule 59A-18.018, F.A.C., Emergency Management Plan
- Homemakers and Companions
-Rule 59A-18.009, F.A.C., Homemakers or Companions.
-Sections 400.506, 408.809, 400.484, 400.462 and 408.810(5), F.S., with the telephone numbers referred to in the law.
-Rule 59A-18.018, F.A.C., Emergency Management Plans.
-Rule 59A-18.005, F.A.C., Registration Policies.
Contract Staff
- Economic Realities Test used to determine contractor status
- Nature and degree of employers control over the contractor’s work. Contractors are required to have full control over their work:
-Registries are not allowed to control any function of the contractor. For example, scheduling, requests to report missed visits, requests to complete incident reports, and registry notification of patient’s status.
-Scheduling with patients is the responsibility of the contractor as is providing back up staffing in case of their inability to visit the patient
- Registry is not allowed to dictate dates or times contractor works
- This could be a risk since patients have to approve of staff prior to care
-Contractor should not be required to provide written or oral reports
-Contractor should have full autonomy in how they manage the patient they have a contract with
- Contractor’s opportunity for profit or loss depends on their managerial skills
-Registry must allow the patient to select their contractor and not just schedule staff to a patient
-Rates set by the agency could be seen as a violation for this category
- Contractor’s services require a special skill
-Skilled care meets the qualifications for this element, as does home health aide and/or CNA as they require training and/or certification. Companion care and sitter services may not qualify as there is minimal specialized skills for those services.
- The permanency and duration of working relationship. The longer the relationship, the more contractor status is questioned.
-Long term contractors could be noted as a violation for this category, especially if working with the same client for long periods of time
- The extent in which services are an integral part of the registry’s business. For a contractor, their services are not supposed to be an integral part of the business.
-Providing direct care services is the main reason for a registry making this element difficult to prove.
- The contractor’s investment in equipment or materials and employment of other workers
-Registry is not allowed to provide car stock to contractors or even PPE directly to the contractor. Only allowed to provide PPE directly to the patient.
-Contract agencies with multiple staff meet this requirement since they employ multiple workers.
- Nurse Registry regulations deeming all workers as contractors does not save the agency from following federal law with Fair Labor Standards Act and overtime regulations
-Several nurse registries have been found in violation of federal wage and hour laws
-FLSA allows looking back 2 years – 3 years from the date of compliant for damages
-Registry may be required to pay back taxes, along with fines and penalties if they contractor is seen as being misclassified
- Potential risks for violating IRS Payroll taxes, not providing FMLA leave, unemployment compensation and worker’s compensation even though the Nurse Registry requires all direct care staff to be contractors.
- Registry is not required to carry liability or malpractice insurance, so care provided by the agency is not covered independent of the contractors
-Contractors are not covered by the agency for patient injury, property damages or criminal acts such as theft
-Registry must ensure contractors maintain insurance coverage
-If a patient issue arises, agency is at the mercy of the contractor to settle the issue
-Registry reputation can be affected if issues are not resolved to the patient’s satisfaction
-Registry should have it the contract that the contractor must repay registry for any actions that harmed the business
- Registry is not required to carry worker’s compensation insurance, nor is the contractor
-If a contractor is harmed at a patient’s home, the patient may be held responsible
-If a contractor is harmed at a patient’s home, there is potential for a liability lawsuit with the registry
- New nurse delegation regulations do not apply to Registries
- Staffing:
-Independent contractors are self-employed having no long-term commitment to the registry
-Risk losing contractors to other agencies/registries for any reason along with the patient since they are not allowed to have non-compete implications
- Marketing
-Limits potential clients:
Some patients/clients prefer a home health agency vs a registry since the staff for an agency is covered by an agency’s liability and malpractice insurance.
-Limits potential payers:
Some insurance payers will not credential nurse registries and only allow home health agencies as providers
Managing Contractors
- Registry is only allowed to provide supplies that are billed to the patient
- Registry cannot provide phones or tablets
- Registry is at the mercy of the contractor to provide all required equipment for the patient
- This prevents any training of staff by the registry. Contractors must come trained
- If a new skill is required for the patient and the caregiver is not experienced in it, the registry cannot educate the contractor on the new skill
- A contractor is free to work for other agencies/registries as they choose
- Unable to formally write up contractors
- If any issue arises, the registry can only advise the patient to terminate the referred person’s contract and cease referring the contractor to other patients or facilities
- Registry cannot control how the contractor completes their job
- Prevents registry from assessing the care provided by contractors
- Prevents registry from directing contractor to complete a certain schedule set up by the registry
- Contractors are free to assign work to other contractors within their organization without knowledge by the registry
They are required to find a replacement if they are unable to fulfil their contracted obligation to the patient.
Required Patient Information Dissemination
- Telephone numbers to call if a replacement caregiver is needed
- Local emergency numbers
- Notification that staff are all independent contractors, agency is does not monitor, supervise, manage or train the caregiver
- RNs are available at an addition cost to visit when patient has C.N.A or H.H.A.
- Notification that nurse that communications with MD should update plan of treatment
- Patient Rights per 59A-18.011 (7) F.A.C.
- Complaint Process and agencies to report to with phone numbers: Theft to law enforcement, abuse and neglect to central abuse hotline, Medicaid fraud, nurse/aide complaints to Department of health and how to report them, other complaints to AHCA
- Emergency management plan for Nurse Registries Appendix B
- Copy of list of medication and equipment needs that match list at the registry
Required Patient Records
- Documentation of coordination with case manager for clients under Community Care for the Elderly or Medicaid Waiver programs
- If registered with special needs shelter, proof of providing patient with: List of medications, allergies, name of physician with phone number, name and phone number of patient’s pharmacy, and diagnoses if patient permits.
- Signed within 30 days form initiation of services and reviewed every 2 months
- May be signed by physician, physician assistant, or APRN
- Includes information stated per 59A-18.011 F.A.C
Requires orders with specific protocol signed within 30 days
- Review of Medications by RN or LPN
- Documentation each time patient receives assistance with medication administration
- Caregiver notification of date of termination and reason documented
Supplemental Staffing for Health Care Facilities
- Temporary Staffing
- Written Contract with facility
- All nurse registries may provide staffing services
- Independent contractor must always carry professional license/certification while working at facility
- Complaint process
- Proof of submission of name of person orienting independent contractor for facility
- Supplemental Staffing Contractor File
-Recording and follow up of complaints
-Documentation of notification of facilities if license/certification is restricted
-Name and address of facility contractor staffed with amount of fee charged, title of position and amount of fee received by registry
Assisted Living Facilities
- Require fair market value renumeration for all services provided
- Maintain contracts with ALFs for 5 years
Must provide to surveyor if requested or $5,000 fine
- Fines if care is provided to ALFs without charge:
-$5,000 fine for providing staff and services not at fair market value
-$15,000 fine for providing free staff in return for referrals
-$5,000 fine for remuneration for referrals
What's next?
Medicaid nurse registries are a low-cost model that provides seniors with the necessary assistance for daily living. Medicare does not cover any of these services. Senior citizens and in need of physical therapy or other medical care may utilize a Medicaid home health agency for rehabilitation and medical support as well but will also qualify for rehabilitative services from Medicaid registries. For below market costs, these agencies comprise a large variety of support staff.
Generally, however, home health agencies have been in business for much longer than many nurse registry companies. Because of this, most insurance companies work with them over nurse registries. We recommend you to check our article “Differences between a Licensed Home Health Care Agency and a Nurse Registry” to get some bullet points that will help you make a more informed decision when deciding which model is better for you.
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