Unlicensed Personnel Taking Jobs in LTC

[BC Roberts]

Haven’t you heard there is a Nursing shortage.  Well of course I have heard this almost every year I have practiced as a Nurse.  The COVID pandemic has not made things easier and staffing in some areas of nursing have been or are critical. 

Today, I would like to address this particular subject.  I watch for job opportunities frequently and am growing concerned over the job opportunities lost to unlicensed individuals, that used to be offered to Nurses.  Jobs such as Case Managers and MDS Coordinators.  I even saw a facility that wanted to hire a CNA as an infection preventionist in LTC. 

Now, before anyone becomes sympathetic to the fact that staffing may be critical in this area.  I have worked in LTC for quite some time and long before the pandemic, I have seen administration cut staffing to bare bones in the attempt to save money. Bonuses often remained intact for admissions, administrators and CEOs. 

I find myself sympathetic to Residents and families.  I am NOT sympathetic to administration or CEOs/owners. 

I believe that if Nursing Homes had been staffed adequately before the pandemic and better wages were paid at that time, facilities would have fared better or at least not be having the difficulties to the degree it is now. 

CMS is now supposed to be further regulating safe staffing in this area of practice. Hmm, I will watch for further updates on that. 

My questions are these: 

1) Why does CMS not regulate the qualifications of positions in the facility?  Someone once told me; these things are only important if the facility gets caught.  So, if CMS is not looking at these things, will facilities staff positions with qualified people?  Well, I go back to the positions that I have seen listed above. Please don’t get me wrong.  I have seen some really smart people who can do anything.  However, licensing is there for a reason.  A nursing shortage should not allow facilities to staff nursing positions with non-licensed people. This is taking LTC in the wrong direction.  

2) Why are there differing levels of education and qualifications for administrators?  In some states any Bachelor's degree will do.  Some states have required little formal education. Yes, I applaud the facilities that now will only look at individuals with a Master’s degree in Health Administration or Nursing etc.…  Some states require a preceptorship as Administrator in Training, other do not. I just think there should be baseline qualifications set by CMS for this position. After all, this position is supposed to oversee that Residents get appropriate care.  At least there are requirements for DONs.  I personally would like to see at least a BSN prepared nurse for this role, in the future but considering a fair number of facilities run DONs into the ground, I don’t know if this will happen.

3) Why do State BON not go after facilities that put people in positions that they are not qualified for?  The BON in the State that I live in states they only regulate nurses and nursing care. How do you protect the integrity of the nurse scope of practice and protect Residents from improper assessment and care when the Board of Nursing does not want to intervene?

[hppygr8ful, ASN, RN, EMT-I]

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Why do State BON not go after facilities that put people in positions that they are not qualified for?  The BON in the State that I live in states they only regulate nurses and nursing care.

You seem to misunderstand the role of the BON which is to ensure that nurse practice safely and discipline those that don't!

[BC Roberts]

Actually, the BON is supposed to investigate violations of the Nurse Practice act.  The ANA states that 35 states have language in their Nurse Practice Act that restrict the use of title nurse.  "At least 35 states are known to have language in their Nurse Practice Act; either explicit in restricting the use of the title "nurse" to only those who are licensed or implicit language restricting the use of any words implying the individual is a licensed nurse" (ANA 2021).  Would the BON investigate an individual practicing nursing on a lapsed license?  They may not be able to sanction those people that report themselves as nurses when they have neither the education nor the license as a nurse, however, the BON could turn the case over for criminal prosecution to a state's attorney.  In my opinion, allowing facilities to self-regulate what non-licensed individuals can and cannot do, is not the answer. Please see attached case.  It is interesting. Even though the complaint did not seem to go through the BON, they were consulted to testify as to nurse's duties. (People v. Stults 1997 No. 2--96--0946) Link below.

https://law.justia.com/cases/illinois/court-of-appeals-second-appellate-district/1997/2960946.htm

https://www.nursingworld.org/practice-policy/advocacy/state/title-nurse-protection/

 

[PoodleBreath]

The BON sets regulations and defines scope of nurse practice at the various professional levels/degrees, ensures that nursing professionals practice safely, and investigates and disciplines violations of the nurse practice act. They have nothing to do with regulating facilities.

The case referenced about Stults has nothing to do with LTC. She was an individual who represented herself as a pediatric nurse at a pediatric clinic without any credentials. Completely different arena than inpatient bedside nursing care for geriatric medically complex patients.

The BON provided testimony to the State about the nurse practice act and how that defined her scope of practice (she was performing NPA-defined nursing duties without a license).

She was not prosecuted by the BON, she was prosecuted by the State. The clinic physicians were lax about getting her license information, which was on them, but they didn't deliberately hire a non-nurse to handle nursing duties. That was on her.

You bring up a lot of good points about how poorly LTCs are run and how they get away with it - mostly because nursing homes are a billion dollar industry and corporations have lobbying teams in DC to protect their industry, at the expense of our most vulnerable patients and the staff that care for them. 

BON, CMS, the State, the feds, the AG, APS, etc, all handle different areas of health-care and do overlap. But the real issue is about money, corporations, politics, and corruption.

Debates about which agencies are required to do what - and why aren't they doing their jobs - drags us into a quagmire and it's the reason these corporations get away with literal murder. Think bigger, think better.

[BC Roberts]

PoodleBreath,

Hi, in response to comment above to happygra8ful. The point is the BON could do so much more and they do not.  The point is that facilities whether LTC or Hospitals or other settings is that these settings allow non-licensed personnel to take on tasks that require nursing skills (assessment or education etc.)  The point of the case was to identify that even though a state's attorney prosecuted, the BON was still called in to testify as expert witness because they identify legally what nursing skills are.  You are right we should think bigger and better and not get caught up in the details.