category_nursing_services_director_of

Much of the State variation and further specification elaborates on the federal regulation for Directors of Nursing, or the equivalent with another name. Many States have established training or experience requirements or both for those serving as DON; these vary in rigor. Sometimes training must be accomplished within a period of time after employment (thus allowing for promotion from within). Some States specify continuing education for DONS. (States may also have training requirements for licensed nurses or charge nurses, though those are less usual.) Typically the requirements include training in gerontological nursing, long-term care administration, or both.

Some States specify the hours during which DONs must work or the general time period in which their hours will largely fall. Typically these hours must be in the day shift and largely during the weekdays, though a few States require that the DON have hands on experience with all shifts. Often the DON must be a full-time employee, but a few States allow a waiver for the DON role to be shared by two individuals—Illinois has such provisions. Many States have rules governing backup for the DON, or require that the facility appoint an Assistant DON (ADON) under particular circumstances. An ADON may be assigned particular roles, such as staff development. Although the Federal rules permits the DON to also act as charge nurse in facilities under 60 residents, some States establish different and more stringent standards for the DON to be a charge nurse. A few States provide rules for the DON if the nursing home is attached to a hospital.

Almost all States articulate the role of the DON well beyond the federal language. States are similar to each other in the roles they lay out for DONs, though some are more detailed than others, and infinite small variations are found. Commonly the DON is responsible for ensuring that all nursing staff meets standards, that the staffing plans are adequate, that job descriptions are developed, that nursing policies are in place, that in-service training and orientation take place, and that the actual staffing patterns for each unit be documented. DONs are usually also responsible to ensure that supervision of nursing staff occurs. DONs often have roles in quality assurance, infection control, and team operations. DONS are often depicted as responsible for hiring practices and termination of employees. Some of the protocols for DONs include establishing the resident census. Some emphasize budgeting roles of the DON.

A few examples are provided below. Collectively they show variations on the clinical and administrative leadership responsibilities of the DON. Go to the links in the table at the end of this section to review all the descriptions of DON roles.

4In Alabama, where the job description is succinct, the DON shall perform the following duties:

(1) assure that all nurses comply with the requirements of (a) [i.e. individualized care planning] of this section;

(4) maintain records on the number of nurses employed and the hours and weeks of employment;

(5) delegate to a registered nurse the responsibility to plan, assign, supervise, and evaluate the nursing care for each patient;

(6) select and promote nursing personnel based on their qualifications and terminate employees when necessary; and

(7) establish and implement a standard procedure for the safe administration of medications.

4In Oregon, where the duties described are more elaborate, the Director of Nursing Services has the duty to participate in the development of any facility policies that affect the nursing services department, and organize and direct nursing services, which includes as a minimum:

(A) Develop and maintain a nursing service philosophy, objectives, standards of practice, policy and procedure manuals, and job descriptions for each level of nursing service personnel;

(B) Develop and maintain personnel policies of recruitment, orientation, in-service education, supervision, evaluation and termination of nursing service staff;

(C) Develop and maintain policies and procedure for determination of nursing staff's capacity for providing nursing care for any person seeking admission to the facility;

(E) Coordinate nursing service departmental functions and activities with the functions and activities of other departments;

(F) Develop nursing service department budget recommendations and participate with the facility administrator and other department directors in the allocation of funds for the facility;

(G) Participate with the facility administrator and other department directors in development and maintenance of practices and procedures that promote infection control, fire safety, and hazard reduction;

(I) Ensure that only licensed nurses or physicians administer injectable medications;

(J) Ensure adequate nursing services staffing (see OAR 411-086-0100), including development of a written staffing plan; and

(K) Ensure that all nursing staff perform their respective duties in a timely, efficient and professional manner;

a. Participating with the administrator in planning and budgeting for nursing care;

b. Participating in the development and implementation of patient/resident care policies; c. Developing and/or maintaining goals and objectives of nursing service, standards of nursing practice, and nursing policy and procedures manuals;

d. Assisting in the screening and selection of prospective patients/residents in terms of their needs, and the services available in the facility;

e. Observing and evaluating the condition of each patient/resident and developing a written, individualized patient care plan which shall be based upon an assessment of the needs of each patient/resident, and which shall be kept current through review and revision;

f. Recommending to the administrator the numbers and categories of nursing and auxiliary personnel to be employed and participating in their recruitment, selection, training, supervision, evaluation, counseling, discipline, and termination when necessary. Developing written job descriptions for all nursing and auxiliary personnel;

g. Planning and coordinating orientation programs for new nursing and auxiliary personnel, as well as a formal, coordinated in-service education program for all nursing personnel;

h. Making daily rounds of nursing units, assessing each patient/resident, reviewing clinical records, patient/resident care plans, medications, staff assignments and, whenever possible, accompanying physicians when they visit the facility;

i. Preparing daily work schedule for nursing and auxiliary personnel which includes names of employees, professional designation, hours worked, and daily patient census; j. Coordinating the nursing service with related patient/resident care services;

k. Establishing procedures for general nursing care for the cleanliness, comfort, and welfare of the patients/residents;

l. Instructing all personnel in the proper isolation techniques to prevent infection to themselves and the patients/residents; and

m. Delegation of any or all of the Director of Nursing Services duties as appropriate.

1. Developing and maintaining (i) nursing service objectives, (ii) standards of practice, (iii) policy and procedure manuals, and (iv) job descriptions for each level of nursing personnel;

2. Recommending to the administrator the resources needed to carry out nursing service, including but not limited to, equipment and supplies and the number and level of nursing personnel to be employed;

3. Participating in the employment of nursing personnel, including (i) recruitment, (ii) selection, (iii) position assignment, (iv) orientation, (v) in-service education, (vi) supervision, (vii) evaluation, and (viii) termination;

4. Participating with the medical director in developing and implementing policies for resident care;

5. Assuring that the comprehensive plan of care is maintained in conjunction with other disciplines;

6. Coordinating nursing services with other services such as medical, rehabilitative, and social services and the resident activity program;

7. Participating in quality assurance committee meetings to identify issues and to develop and implement appropriate plans of action to correct identified problems;

8. Making daily rounds on resident floors, unless this duty has been delegated to another licensed nurse; and

9. Recommending and coordinating the training needs of nursing staff with the individual responsible for in-service training.

The requirements for the DON can be waived under federal law, and many States provide further detail about the conditions for a Waiver and the kind of coverage needed if a waiver is in place. Several States indicate the kind of search that must be undertaken before a waiver will be approved, and often add that the facility must seek a DON under the prevailing wage. In Indiana, the facility must demonstrate to the satisfaction of the State that the facility has been unable, despite diligent efforts (including offering wages at the community prevailing rate for nursing facilities), to recruit appropriate personnel. ) In Oregon, the facility must show that it has been unable to recruit appropriate personnel despite diligent effort (including offering wages at the community prevailing rate for nursing facilities). In Idaho, the facility must continue to seek a registered nurse at a compensation level at least equal to that prevailing in the community. In Illinois, if the DON position is shared by two RNs, considerable detail is provided for the procedures to acquire a waiver. For example, the State must review written documentation that the facility was unable to obtain the full-time services of a qualified individual to fill this position. Such documentation shall include, but not be limited to: an advertisement that has appeared in a newspaper of general circulation in the area for at least three weeks; the names, addresses and phone numbers of all persons who applied for the position and the reasons why they were not acceptable or would not work full time; and information about the numbers and availability of licensed nurses in the area. The Department will grant approval only when such documentation indicates that there were no qualified applicants who were willing to accept the job on a full-time basis, and the pool of nurses available in the area cannot be expected to produce, in the near future, a qualified person who is willing to work full time.

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 Nursing Services is at the bottom of the Table.

483.30 Nursing Services Director of Nurses
State	Goes Beyond Federal Regulations?	Topics addressed.
Alabama	yes	Echoes federal regulations.
Alaska	yes	duties of DON
Arizona	yes	DON role
Arkansas	yes	DON credentials; DON responsibilities; ADON
California	yes	DON role
Colorado	yes	DON credentials; DON responsibility; ADON
Connecticut	yes	DON roles
Delaware	yes	DON roles
District of Columbia	yes	Education of DON; role of DON; sharing of DON position by two people.
Florida	yes	Echoes federal regulations.
Georgia	yes	DON roles; DON for multiple facilities
Hawaii	no
Idaho	yes	DON duties
Illinois	yes	DON role; DON credentials; DON staffing
Indiana	yes	DON credentials; DON duties
Iowa	yes	Duties of Supervising Nurse; waivers for Supervising Nurse
Kansas	yes	DON authority
Kentucky	no
Louisiana	yes	DON roles; DON for multiple facilities; ADON
Maine	yes	DON credentials; DON roles; DON deployment
Maryland	yes	DON roles; DON relief; DON vacancy;
Massachusetts	yes	DON deployment
Michigan	yes	A nursing home shall not be licensed under this part unless that nursing home has on its staff at least 1 registered nurse with specialized training or relevant experience in the area of gerontology, who shall serve as the director of nursing and who shall be responsible for planning and directing nursing care.
Minnesota	yes	DON credentials; DON role;
Mississippi	yes	DON roles; DON for multiple facilities; ADON
Missouri	no
Montana	yes	DON roles; ADON
Nebraska	yes	ADON in facilities of 180+
Nevada	yes	Credentials of DON
New Hampshire	yes	Credentials of DON
New Jersey	yes	DON credentials
New Mexico	yes	DON duties; DON relief
New York	no
North Carolina	yes	DON role
North Dakota	yes	DON responsibility
Ohio	no
Oklahoma	yes	DON responsibilities; DON deployment
Oregon	yes	DON credentials; DON responsibility; DON backup
Pennsylvania	yes	DON role
Rhode Island	yes	DON credentials; DON role; DON backup
South Carolina	yes	DON backup
South Dakota	yes	DON role
Tennessee	yes	DON roles
Texas	yes	DON responsibilities; Waivers of DON or nurse ratios
Utah	yes	DON role
Vermont	yes	DON responsibility
Virginia	yes	DON role; DON vacancies; no temporary DON for more than 90 days; no agency personnel as DON;
Washington	yes	DON role
West Virginia	yes	DON duty schedule
Wisconsin	yes	DON credentials; DON role
Wyoming	yes	DON roles