For DON about regulations

KlareRN · May 19, 2007

Hi! All states have their own "state regs" that you have to follow within your state- and EVERYONE has to follow the "federal regs" throughout the US.

Some states have taken some of the federal regs and expanded them or given more specific requirements that you need to follow to be in compliance. Nursing practice is to follow whichever regulation is the strictest because if you don't adhere to the strictest reg; you will get cited during a survey. An annual survey (or complaint survey) can and will "tag" you for state OR federal tags...so you have to follow both.

State tags are sometimes referred to as "it is only a state tag...I'll take it over a federal tag..." But it is still a tag that needs a plan of correction and a revisit for compliance.

If you are the DON in a long term care facility- you should ask your administrator for a copy of the federal and the state regulations so you have them at your fingertips. You should also spend some time with the federal regs (we call it the "watermelon" book because of the color of the cover.) Although alot of it is interpetation- it at least will give you some insight on what you should or should not be doing.

Good luck! :uhoh3:

Daytonite, BSN, RN · May 19, 2007

actually, the way the law works is that you start out with obeying the local laws first. state laws trump local laws. federal laws trump state laws. and, the constitution is the law of the land and trumps everything else. when a proposed law comes before the state assembly, there are legislative law aids whose job is to specifically go through all the different chapters, etc., of the existing california laws to make sure that there isn't any conflicts with any other already existing law before a proposed law gets voted on and passed. if that does happen someone gets into trouble and it gets corrected asap at the next legislative session.

it depends on who is surveying you as to what laws they are looking to see that your facility is following. there are state surveyors; there are cms (medicare) surveyors. they each know both sets of laws. they go by which ever law supercedes the other. where a state law is very specific about something and the federal law is quiet on that particular thing, the state law wins out, or vice versa.

part of the training of a facility administrator is to learn the state and federal laws affecting the running of long term care facilities. your administrator is licensed by the state to do what she does just as we nurses are licensed. one of the things they are tested on in their state board exam and expected to know is these laws. and, if they don't know the specific law, they are expected to know how to find it. having to look up specific laws and regulations is something that nursing schools do not make a big issue out of. we are told about them though.

i have to mention, however, that along with my california license i also hold a nursing license in another state. that state has recently made it a mandatory ceu requirement to take a one hour class on their nursing law to renew our nursing license. i suspect this is being done because so many nurses have never read the nursing law and really have no idea what it actually says other than what they have been told by their instructors in nursing school and learned by word of mouth. contrast that with administrators of healthcare facilities who can almost cite verbatim the laws pertaining to their areas of practice by memory. as healthcare becomes a more litigious and highly regulated industry, learning law by word of mouth is kind of a dangerous thing.

nursbaybie, BSN, RN · May 19, 2007

thanks for your replies. I believe i have found the federal and state laws, but i have no idea where to find the local laws.

the only people that survey our facility is the state, but they are contracted by cms to conduct the surveys according to the cms website and state manual of operations appendix pp (which is a guide for surveyors on how to conduct surveys, how to interpret each federal reg, and what to ask staff and families, etc.)

I just hope I have found the entirity of the laws.

for example, one nurse told me that title 22 is the state law. so i looked up title 22. I did find in division 5, chapter 3 (licensing : SNF respectively) quite a few regs pertaining to snfs including nursing, pharmacy, activities, dietary, etc guidelines) but i wonder are there any other parts of title 22 that also pertain to snfs and are also our regs.

as for federal, most if not all of them are listed in the cms (operations manual) appendix pp as explained above, but i have found the federal regs in fcr 42 social security act.

But what about local laws? anyone know.?

Daytonite, BSN, RN · May 20, 2007

cms often contracts out the surveying of facilities to other professional groups. this is not uncommon. in every state there are usually at least one if not a handful of privately owned "consultant" firms that make a very good living at this. the people who own and work for these companies are former administrators, nurses, doctors, educators and others who worked in management positions of healthcare who know the state and federal laws up, down, backwards and forwards because it's their job to know them. while our orientations are to learn about policies and procedures involved in patient care, theirs are to know these laws and know them like the backs of their hands. the fact is that the laws are not a secret. they are public knowledge and anyone can look them up and read them. the trick is to know where and what to look for so you don't end up wasting time reading everything.

as for any local laws, my guess would be to go to your city hall and talk to someone over there, probably starting in the city attorney's office for help in tracking down any laws pertaining to healthcare facilities in the town, if there are any. i have no idea what the local laws would be where you live. you'd have to find that out.

i'm assuming that you are a new don, is that right? probably your best resources are going to be other dons. there are networks of you guys and professional associations. it would be a good idea to make contact with some of these people to help you get some direction on this. you might ask the administrator how she learned all this stuff as well. i learned about some of it because i am in a health information management (medical records) program and state and federal laws as well as jcaho standards were one of the first things they had us researching. there were no books or manuals. we were told to bring a blank cd or flash drive to class and we downloaded the current hospital jcaho manual on it as well as part 482 of title 42, the cms part that applies to hospitals. our mission, read it, read it all. we had a big written project where we had to find all kinds of information pertaining to 22 healthcare subjects in title 22, title 42 and jcaho to do. mine ended up being 49 pages long.

can i just say something here? ltc is a great place of opportunity. no one would ever get to a don position without years and years of grooming in the acute hospital sector. however, one of the big problems that comes with the opportunities in ltc is that many times they are like sink or swim situations. it really takes a lot of ingenuity, creativity and guts to step up into a don position with no background whatsoever. really, get with a professional organization of dons for some help and guidance. i honestly don't even know what the names of these organizations would be, but i'm betting that your administrator will have a few ideas. i think that you're also going to find that there are classes you can take in healthcare administration that will be of considerable help to you.

nursbaybie, BSN, RN · May 20, 2007

I am not a DON. I am just a staff nurse in LTC, actually treatment nurse, but whatever. Anyway, I am just interested in learning all the regs. As I've stated above, I believe I have actually found what I'm looking for, but I just want to be sure that california state regs under title 22 are just those under division 5, article 3 and that there are no more in any other divisions that i may have overlooked. (either its article 3 or chapter 3, i forget) but i just mean division 5 (licensing of ... ... ...) then the next section that says snfs, then all the subtitles under that.

Then federal regs, for the most part appear to be under 42 cfr, not title 42, but 42 of the code of federal regulations (this is not a title). anyway,

anymore info on local laws for someone residing in santa barbar county would be appreciated, i will check into the reccommended resource. I will also inquire of our administrator for that "rainbow book". sounds fascinating.

thanks again.

TrudyRN · May 20, 2007

actually, the way the law works is that you start out with obeying the local laws first. state laws trump local laws. federal laws trump state laws. and, the constitution is the law of the land and trumps everything else.
i don't believe this is necessarily so, daytonite.
while not a lawyer, i do believe that states are free, for example, to not follow us supreme court decisions. for example, roe v. wade was a federal decision. a state, however, is free to not follow it.
probably the same applies to other federal laws. unless there is money involved. if a state is receiving federal funds, it probably has to follow federal laws regarding the use of those funds. i have heard this said in relation to highway funds and education funds. these are good examples of why we should not take money from others if we can at all survive without it.
there is an area in law called conflict of laws, which might apply here.
to the op: what does your company's legal counsel say? surely they can guide you.

Daytonite, BSN, RN · May 20, 2007

While not a lawyer, I do believe that states are free, for example, to not follow US Supreme Court decisions. For example, Roe v. Wade was a Federal decision. A state, however, is free to not follow it.
Probably the same applies to other Federal laws. UNLESS there is money involved. If a state is receiving Federal funds, it probably has to follow Federal laws regarding the use of those funds. I have heard this said in relation to highway funds and education funds. These are good examples of why we should not take money from others if we can at all survive without it.

Perhaps I was speaking too generally, but I was trying to get a point across. This also points out how complex all these laws can be. With some of these nursing home laws, some states have no state laws referring to specific areas, so what I was meaning was that the next level of governmental law would preside. I'm sorry if I didn't make that clear. Restraints and patient rights might be two areas of law that a state may not address. Title 42, however, does. In any case, if a facility wants to be certified by Medicare so it can accept, treat and bill Medicare for the services it provides, it MUST follow the Title 42 laws. They may also have to observe their own state laws which might be more liberal or more strict, but when a CMS (Medicare) surveyor comes through the facility and sees that Title 42 regulations are not being followed--goodbye Medicare certificate and the privilege to bill for providing service to Medicare patients. Medicare doesn't really care what a state's law is because it has it's own standards it wants to see enforced. Facilities will do what Medicare mandates, however, because for many LTCs Medicare reimbursement is an important source of their bread and butter.

nursbaybie, BSN, RN · May 22, 2007

are you sure you mean title 42 and not cfr 42? I haven't seen any federal "titles" only codes or regs.

thanks

Daytonite, BSN, RN · May 22, 2007

are you sure you mean title 42 and not cfr 42? I haven't seen any federal "titles" only codes or regs.
thanks

All the federal laws are organized into Titles. The entire group of federal laws are referred to as the "code of federal regulations" or cfr for short. Law will be cited as this, for example: "42CFR482" and that means "Title 42 of the Code of Federal Regulations, Part 482 (which is Conditions of Participation for Hospitals)". The title of Title 42 is Public Health.

Here is a link to the Conditions of Participation for LTC on the CMS site. It is contained in 42CFR483. Scroll down the page to the link that says "Title 42--Part 483". It will take you to a page of more links (they break the document up into smaller pages of links because it is so long). I would link into each and then copy and paste the text in them into an open Word document to save it on your computer. It is also easier to search through the text of these documents for specific subjects by using the "Find" (a word or phrase) that is on the Edit menu of your main menu bar.

http://www.cms.hhs.gov/CFCsAndCoPs/14_LTC.asp#TopOfPage

You are going to find some very interesting things in there. One of them is the law that mandates the establishment of state nurse aide registries. There are also some other very interesting links on this page you might want to check out. Have fun reading the law.

Hope this helps you.

RedZeppelinRN · May 30, 2007

Hi you all:

Got a couple of questions. What kind of licensing does an administrator of an LTC have to have? Do they have to be knowledgable about medical education the same as nurses and doctors?

I live in CA. Is it legal for an unlicensed person to be designated as "Assistant Administrator?" If there is no DON or assistant DON may this person or other nurses take on the role of DON, presumably until a properly licensed DON is found.

Is it lawful under the Nurse Practice Act that an unlicensed person take over the supervision of nurses aids, although there are RNs in the facility?

I know of a facility that seems to be living on the edge, reported to the National Registry as causing harm to at least one patient and 2 citations for patient neglect and abuse.

Have you ever read "Patients, Pain & Politics, by Mary Richards Rollings."

Some of you seem to love this type of nursing, others differ in their experiences. I know a big complaint is with cnas. This problem is exactly the same in hospitals that everyone on this thread has reported. I don't know which one would be worse, the hospital or the LTC.

I have taken a refresher course, and almost the first 3 weeks were all about legalities of the nursing profession. Not sure what to do. Any answers would be appreciated.

Daytonite, BSN, RN · May 30, 2007

Hi you all:
Got a couple of questions. What kind of licensing does an administrator of an LTC have to have? Do they have to be knowledgeable about medical education the same as nurses and doctors?

Here is information about the licensing of nursing home administrators in California.

http://www.dhs.ca.gov/lnc/NHAP/default.htm There are links at the lower part of the page to FAQs and other information about licensing.

I live in CA. Is it legal for an unlicensed person to be designated as "Assistant Administrator?" If there is no DON or assistant DON may this person or other nurses take on the role of DON, presumably until a properly licensed DON is found.

I think the term that the state uses would be Administrator-in-Training. I believe that the Assistant Administrator can be a DON because one of the requirements of being a Nursing Home Administrator in California is that you must have an RN (read the FAQs http://www.dhs.ca.gov/lnc/download/NHAP/FAQBecomingNHAdmin.pdf and the other information on the other link I posted for you).

Is it lawful under the Nurse Practice Act that an unlicensed person take over the supervision of nurses aids, although there are RNs in the facility?

Yes, and it depends what they are supervising. Unlicensed persons can supervise healthcare workers as long as they are not supervising the direct patient care. They can supervise with regard to following the rules and regulations of the facility. They cannot delegate specific nursing tasks that are within the realm of a licensed nurse. I've worked in nursing homes where there were LPNs supervising RNs but only where it concerned them as employees not as to their practice as RNs. (An LPN cannot tell an RN to give a patient a medication. That is a delegation authority that the LPN cannot perform upon an RN.) However, there are many nursing home administrators that do not include their RN along with their title as as administrator, so it may not be clear to you at first that the administrator is also an RN.