Nursing Services

Table Comparing States

Complete Transcript of State Requirements on Nursing Services 

 

Federal Regulations sections & related F-tags F353(a)  Sufficient staff F354(b)  Registered nurse F355(c)  Nursing facilities        (d)  Waiver of requirements

Applicable Federal Regulation: 483.30 Nursing Services 483.20 Resident Assessment 483.25 Quality of Care 483.60 Pharmacy Services 483.75 Administration

Description of Federal Requirements

The Federal regulation, 483.30, which specifically concerns Nursing Services, requires generally that the facility provide services by licensed nurses and other nursing personnel (e.g., nurses’ aides) in sufficient numbers to provide nursing care to all residents in accordance with their care plans.  Licensed nurses include both Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs)

            A facility must have at least one licensed nurse serving on each “tour of duty.”  Further, the facility must designate an RN to be on duty providing direct care for 8 consecutive hours seven hours a week, as well as an RN to serve as director of nurses (DON). The DON may not be counted as the RN on duty in nursing homes with more than 60 beds.  The rule also details circumstances under which both the requirement for an RNs every day and an RN as DON can be waived in rural areas, and the safeguards that must be provided in that case—essentially the facilities with the waivers must provide on-call access to an RN at all times.  

            Our review of Nursing Services in this section is largely limited to State variation in or extension of the actual provisions of 483.30.  Given the centrality of nursing to care in a nursing home, other Federal regulations contain many references to the role and function of licensed nurses in general, RNs in particular, and nurse’s aides.  For example, the Resident Assessment regulation, 483.20, on coordination (h) requires that an RN conduct or coordinate each assessment with the appropriate participation of health professionals, and (i) that an RN sign and certify that the assessment is completed.  Section (k) on comprehensive care plans, states that such plans are prepared by an interdisciplinary team that includes the attending physician, an RN with responsibility for the resident, and other staff from other disciplines as appropriate to the needs, and, if practicable the resident and his/her family or legal representatives.  Thus an RNs have oversight and sign-off responsibility for the assessment and care-planning process; for that reason, those facilities that choose to have a position called MDS Coordinator (which is not federally mandated) usually seek an RN for the role, although they may utilize LVNs or LPNs as part of an MDS Coordination team.   Under Administration (483.75), long sections of the Federal Regulations deal with the competence of nurse’s aides and mandated training for nurse’s aides, and under Quality of Care (483.25) references are made to the roles of nurses in delivering the expected quality of care.

            The DON is mentioned elsewhere in the Federal regulations.  For example, under Pharmacy Services (483.60), the consultant pharmacist must report any irregularities to the attending physician and the DON.  Under Administration (483.75) (q), on quality assessment and assurance, the facility must have a Quality Assurance Committee and the DON is a mandated member.  Finally, under administration, registered nurses and licensed nurses (like all other professionals) must meet any credentialing or licensure requirements of the State where the nursing home is located.

Comparison of State Requirements

General requirements

Typically, state rules reiterate the federal requirement that staffing be adequate to meet residents’ needs.  States may express those general requirements a little more fully than the general federal statement.  For example, Massachusetts requires that all facilities shall provide appropriate, adequate and sufficient nursing services to meet the needs of patients or residents and to assure that preventive measures, treatments, medications, diets, restorative services, activities and related services are carried out, recorded and reviewed.  Further, Massachusetts indicates that nursing care shall be an integral part of total health care and shall emphasize the promotion of health, the prevention and treatment of disease and disability, and the teaching counseling and emotional support of patients.  Similarly, in New York, the facility shall have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility shall assure that each resident receives treatments, medications, diets and other health services in accordance with individual care plans.

            One of the most frequent type of state requirements for nursing services establish specific nursing-staff-to-resident ratios.  Most states have established at least some such ratios; these are described below in another section, See Nursing Services-Staffing Ratios.  Also, states often enunciate of requirements for Directors of Nursing , including role specification; these are described in another section, See Nursing Services-Director of Nursing. 

Some States go beyond federal requirements for nurses without establishing specific ratios.  For example, a licensed nurse may be required for each unit rather than just for each tour of duty.  Some States specify that each floor shall be staffed separately and include licensed personnel. In Arkansas, for example, in multi-story homes, each floor should be staffed as an individual unit. In North Carolina, a multi‑storied facility shall have at least one direct‑care staff member on duty on each patient care floor at all times.  In Wyoming, each nursing station shall be staffed separately and shall have a separate staffing pattern, and in Kansas, the same number of licensed nurses must be employed as nursing units on day shift. South Carolina specifies the maximum size of a nursing unit before extra staff is needed, stating that if a nursing station serves more than forty-four residents, then that station is required to have two licensed nurses on all shifts. Although perhaps it should be self-evident, a number of State rules specify that nursing staff must be awake and dressed when on duty.

            No state actually required permanent assignment of nursing staff to residents, but some language hints at that idea.  For example, in Massachusetts, assignment of nursing staff within a SNCFC shall be made so that each patient is cared for by at least some nursing personnel who are assigned to care for him on a continuing basis.  In New Mexico, not only must there be  sufficient nursing service personnel assigned to care for the specific needs of each resident on each tour of duty, but also that those personnel shall be briefed on the condition and appropriate care of each resident prior to beginning hands-on care of residents.

            In Rhode Island, no nursing staff shall regularly be scheduled for double shifts.  Also Rhode Island requires that at least one individual who is certified in Basic Life Support must be available twenty-four hours a day (24 hrs./day) within the facility. Many states require job descriptions and written policies.  Kansas requires that direct care staff shall wear identification badges to identify name and position.

            A number of States specify that those providing nursing not provide other kinds of services not usually defined as nursing,    Some States simply say that nursing personnel they shall provide nursing services on a “full-time” basis, but others are more specific about tasks that nursing staff should not perform.  For example, in Massachusetts, nursing personnel shall not perform housekeeping, laundry, cooking or other such tasks normally performed by maintenance or other personnel.  In Kansas, nursing personnel must not be routinely assigned housekeeping, laundry or dietary duties. In Michigan, an employee designated as a member of the nursing staff shall not be engaged in providing basic services such as food preparation, housekeeping, laundry, or maintenance services, except in an instance of natural disaster or other emergency reported to and concurred in by the department.  In Wyoming, full-time or part-time members of the nursing staff shall be primarily engaged in providing nursing services and only in rare and exceptional circumstances shall be involved in food preparation, housekeeping, laundry, or maintenance services. When that occurs, proper infection control procedures shall be adhered to at all times.  [NHRegsComments:  Because many facilities have considered creating “universal workers” with broadened job descriptions that can encompass light housekeeping, personal laundry, food preparation, and food service, specific prohibiting language could create a chilling effect, and require waivers of regulation to implement,  The reason for considering the  “universal worker” is to create a more natural life situation for residents and primary, intimate relationships with their caregiving staff, usually at the CNA level.  Sometimes the universal worker idea is combined with household models where residents and their caregivers alike have access to residential-style kitchens and laundries.] 

            Much of the variation relates to specific roles and expected responsibilities of charge nurses, licensed nursing staff, and CNAs.  Sometimes the responsibilities are arrayed according to nursing care and basic hygiene.  Some States have enunciated responsibilities for specific functions such as restorative nursing, drug administration, and the like.  Often the basic care expectations are spelled out in considerable detail, related to matters such as the number of baths, foot and nail care, and the like.  These details are also described under the regulations for Quality of Care,  Rehabilitation Services, and Assessment (which includes Care Planning).  Several States each refers to rules for student nurses, for nurses hired by residents as private duty nurses or sitters, and for advance practice nurses. A few States mention the circumstances under which nurses can and should pronounce death.  Rhode Island, Tennessee, and Oregon all mention the nurse role in discharge planning.  Oregon asked for a post-discharge plan of care to be developed which will assist the resident to adjust to his/her new living environment.  Oddly, the regulation asserts that a post-discharge plan is not required when the resident is discharged to acute care or to the morgue.

[Summarized: August, 2006]
 

Table Comparing States

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Note: If the States in this table are not hyper-linked, their provisions do not appear to address the topic, and therefore, do not alter the Federal Regulatory scope.  The Table summarizes content on Administration by State (with a link to each State's specific language).  Link to a downloadable PDF document containing all State regulation on is at the bottom of the Table.

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Complete Transcript of State Requirements on Nursing Services