A performance audit of the Arizona Board of Examiners of Nursing Care Institution Administrators

              STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
A PERFORMANCE AUDIT
OF THE
) I ARIZONA BOARD OF EXAMINERS
OF NURSING CARE INSTITUTION ADMINISTRATORS
MAY 1983
A REPORT TO THE
ARIZONA STATE LEGISLATURE
REPORT 83- 1 1
DOUGLAS R. NORTON. CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
May 31, 1983
Members of the Arizona Legislature
The Honorable Bruce Babbitt, Governor
Dr. Theodore H. Koff, President
Board of Examiners of Nursing Care Institution Administrators
Transmitted herewith is a report of the Auditor General, A Performance
Audit of the Board of Examiners of Nursing Care Institution
Administrators. This report is in response to a January 18, 1982,
resolution of the Joint Legislative Oversight Committee. The performance
audit was conducted as a part of the Sunset Review set forth in A. R. S.
$ 541- 2351 through 41- 2379.
The blue pages present a summary of the report; a response from the Board
of Examiners of Nursing Care Institution Administrators is found on the
yellow pages.
My staff and I will be pleased to discuss or clarify items in the report.
Respectfully submitted,
~ o u ~ Rg. sNo rton
Auditor General
Staff : William Thomson
Steve H. Thacker
Martha L. Bradley
Karen C. Holloway
Enclosure
1 1 1 WEST MONROE SUITE 600 PHOENIX. ARIZONA 85003 ( 602) 255- 4385
OFFICE OF THE AUDITOR GENERAL
A PERFORMANCE AUDIT OF THE
ARIZONA BOARD OF EXAMINERS OF
NURSING CARE INSTITUTION ADMINISTRATORS
A REPORT TO THE
ARIZONA STATE LEGISLATURE
REPORT 83- 11
SUMMARY
INTRODUCTION AND BACKGROUND
SUNSET FACTORS
FINDINGS
FINDING I
TABLE OF CONTENTS
S t a t e r e g u l a t i o n of nursing care i n s t i t u t i o n
a d m i n i s t r a t o r s should continue.
CONCLUSION
FINDING I1
The Board should obtain and u t i l i z e Department of
Health Services' information t o strengthen the Board's
regulatory a b i l i t y .
CONCLUSION
RECOMMENDATIONS
OTHER PERTINENT INFORMATION
Page
i
1
5
LIST OF TABLES
TABLE 1 - Board Revenues and Expenditures f o r
F i s c a l Years 1981- 82 through 1983- 84
TABLE 2 - Board Compositions and Locations i n 16 S t a t e s
The Office of the Auditor General has conducted a performance a u d i t of the
Arizona Board of Examiners of Nursing Care I n s t i t u t i o n Administrators
( NCIA) i n response t o a January 18, 1982, r e s o l u t i o n of the J o i n t
L e g i s l a t i v e Oversight Committee. This performance a u d i t was conducted a s a
part of the Sunset review s e t f o r t h i n Arizona Revised S t a t u t e s ( A. R. S.)
§ § 41- 2351 through 41- 2379.
The Arizona Board of Examiners of Nursing Care I n s t i t u t i o n Administrators
( NCIA Board o r " Board") was created i n 1975 by A. R. S. $ 36- 446 e t seq as
part of Federal requirements t o receive Medicaid funding i n Arizona
( pursuant t o T i t l e XIX of t h e S o c i a l Security Act). The goal of the Board
is t o l i c e n s e competent and q u a l i f i e d people who w i l l 1 ) administer nursing
care f a c i l i t i e s i n accordance with the s t a t u t e s governing nursing home
l i c e n s u r e ( A. R. S. $ 36- 447 e t seq) and 2) provide q u a l i t y care t o the
r e s i d e n t s . The Board i s empowered t o examine prospective l i c e n s e e s ,
receive and i n v e s t i g a t e complaints, censure l i c e n s e e s and deny, revoke or
suspend l i c e n s e s on grounds l i s t e d i n $ 36- 446.07.
We found t h a t S t a t e r e g u l a t i o n of nursing care i n s t i t u t i o n administrators
is necessary t o s a t i s f y Federal requirements. C u r r e n t l y , F e d e r a l Medicare
provisions require t h a t a s t a t e agency c e r t i f y a d m i n i s t r a t o r s ' education
and t r a i n i n g . Further, the S t a t e w i l l need t o l i c e n s e nursing home
a d m i n i s t r a t o r s i f t h e L e g i s l a t u r e decides t o reimburse f o r long- term care
through i t s alternative- to- Medicaid program ( t h e Arizona Health Care Cost
Q
Containment System, or AliCCCS) ( see page 11).
The Board has not effectively monitored the performance of its licensees.
The Board has not utilized information maintained by the Department of
Health Services ( DIIS) which would help the Board monitor the performance of
nursing home administrators. Instead, the Board has been preoccupied with
establishing and maintainin& licensure and continuing education standards.
Without utilizing the DHS information, the Board's ability to identify
incompetent administrators is severely limited. Statutes should be amended
to authorize the Board to obtain and act on pertinent DHS information about
nursing home conditions, including complaint investigation reports and
annual inspection reports. The Board should also use this information when
considering licensees' renewal applications ( see page 17).
In addition, when compared to statutory requirements, the Board's membership
appears to be overrepresented by the nursing profession. This condition may
invalidate Board actions ( see page 27).
INTRODUCTION AND BACKGROUND
The Office of the Auditor General has conducted a performance a u d i t of the
Arizona Board of Examiners of Nursing Care I n s t i t u t i o n Administrators
( KIA) i n response t o a January 18, 1982, r e s o l u t i o n of the J o i n t
L e g i s l a t i v e Oversight Committee. This performance a u d i t was conducted a s
a part of the Sunset review s e t f o r t h i n Arizona Revised S t a t u t e s ( A. R. S.)
$$ 41- 2351 through 41- 2379.
The Arizona Board of Examiners of Nursing Care I n s t i t u t i o n Administrators
( NCIA Board or " Board") was created i n 1975 by A. R. S. $ 36- 446 e t seq a s
part of Federal requirements t o receive Medicaid funding i n Arizona
( pursuant t o T i t l e XIX of the S o c i a l S e c u r i t y Act). The Board is composed
of seven members, each appointed by the Governor f o r a three- year term.
No member may serve f o r more than two consecutive three- year terms. Three
members a r e required t o be a d m i n i s t r a t o r s , one representing a nonprofit
s k i l l e d nursing f a c i l i t y , one representing a p r o p r i e t a r y s k i l l e d nursing
f a c i l i t y and one representing a personal care f a c i l i t y . The other four
members must be ". . . r e p r e s e n t a t i v e of the professions concerned with
the care and treatment of the c h r o n i c a l l y ill o r the infirm e l d e r l y
p a t i e n t s . . . " ( A. R. S. $ 36- 446.02. B.). However, no more than two of
these four members may be from a s i n g l e profession. The n o n i n s t i t u t i o n a l
members of the Board a r e t o have no d i r e c t f i n a n c i a l i n t e r e s t i n nursing
care i n s t i t u t i o n s .
The goal of the Board is t o l i c e n s e competent and q u a l i f i e d people who
w i l l 1) a d m i n i s t e r n u r s i n g care f a c i l i t i e s i n accordance with the s t a t u t e s
governing nursing home l i c e n s u r e ( A. R. S. $ 36- 447 e t seq) and 2) provide
q u a l i t y c a r e t o the r e s i d e n t s . The Board is empowered t o examine
prospective l i c e n s e e s ; r e c e i v e and i n v e s t i g a t e complaints; censure
l i c e n s e e s and deny, revoke or suspend l i c e n s e s on grounds l i s t e d i n
§ 36- 446.07.
The Department of Health Services ( CHS) is a l s o involved i n t h e r e g u l a t i o n
of nursing homes. The DHS Bureau of Health Care I n s t i t u t i o n Licensure has
the r e s p o n s i b i l i t y t o l i c e n s e nursing home f a c i l i t i e s . DHS l i c e n s e s three
l e v e l s of care i n nursing care i n s t i t u t i o n s : p e r s o n a l , i n t e r m e d i a t e and
s k i l l e d ( highest l e v e l ) care. I n s t i t u t i o n s providing any of these l e v e l s
of care must employ a l i c e n s e d a d m i n i s t r a t o r . ( DHS a l s o l i c e n s e s
supervisory care homes, which do not provide nursing care and thus a r e not
required t o employ a l i c e n s e d a d m i n i s t r a t o r . ) DHS makes an annual
inspection of each f a c i l i t y and performs the annual Medicare c e r t i f i c a t i o n
f o r the Federal government when requested. DHS receives and i n v e s t i g a t e s
most of the complaints r e l a t e d t o nursing homes.
Q u a l i f i c a t i o n s f o r Licensure
The Board may approve an applicant f o r the n a t i o n a l and S t a t e l i c e n s u r e
examinations upon v e r i f i c a t i o n t h a t the applicant i s of good character and
has s a t i s f a c t o r i l y completed e i t h e r 1 ) a Board- approved education program
c o n s i s t i n g of an a s s o c i a t e degree or its hourly equivalent i n h e a l t h
i n s t r u c t i o n , 2) a n a s s o c i a t e degree or its hourly equivalent i n any f i e l d
p l u s 1 5 semester hours of h e a l t h i n s t r u c t i o n , or 3) s u f f i c i e n t education
and t r a i n i n g i n the f i e l d of h e a l t h c a r e f a c i l i t i e s a d m i n i s t r a t i o n . I f
a p p l i c a b l e , the Board must a l s o c e r t i f y an a p p l i c a n t ' s claim of l i c e n s u r e
i n other s t a t e s .
Written examinations a r e conducted i n Phoenix twice a year under the
Board's supervision. The Board may waive the n a t i o n a l exam f o r an
applicant who has been licensed i n another s t a t e with s u b s t a n t i a l l y
equivalent requirements. The Board a l s o has the power t o grant a
p r o v i s i o n a l l i c e n s e f o r a six- month period t o a q u a l i f i e d applicant when
an unexpected vacancy occurs a t a nursing home.
Currently there a r e approximately 240 l i c e n s e e s . The Board is s h i f t i n g
from an annual t o a biennial renewal cycle whereby l i c e n s e s s h a l l expire
June 30 of each even- numbered year. The Board r e q u i r e s 25 hours of
Board- approved continuing education c o u r s e s annually. ( With biennial
renewal, the requirement w i l l be 50 hours f o r the 2- year period.)
S t a f f inz and Fundinz
The Board has no full- time support s t a f f . A l l support s e r v i c e s
( s e c r e t a r i a l and c l e r i c a l ) a r e provided by the Arizona S t a t e Boards'
Administrative Office ( ASBAO), which was created i n 1976. ASBAO a l s o
serves a s the support s t a f f f o r nine other S t a t e boards or commissions.
The Board is a " 90- 10" Board i n t h a t 10 percent of a l l r e c e i p t s a r e
deposited i n t h e S t a t e General Fund and the balance i n the NCIA Fund,
which is used t o defray expenses of the Board ( s u b j e c t t o l e g i s l a t i v e
appropriation). The source and d i s p o s i t i o n of funds f o r f i s c a l years
1981- 82 through 1983- 84 a r e shown below.
TABLE 1
BOARD REVENUES AND EXPENDITURES
FOR FISCAL YEARS 1981- 82 THROUGH 1983- 84
Actual Estimated Requested
1981- 82 1982- 83 1983- 84
Balance forward from
previous years $ 16,400 $ 14,500 $ 14,300
Revenues :
Exams, l i c e n s e s , f e e s 18,300 22,800 38,800"
( 10% General Fund) ( 1,800) ( 2,300) ( 3,900)
90% NCIA Fund 16,500 20,500 34,900
Expenditures:
Personal s e r v i c e s 200 300 500
P r o f e s s i o n a l and outside
s e r v i c e s 14,700 16,300 19,300
Travel -
In- State 9 00 1,700 1,900
Out- of - State 400 - 0- 900
Other operating 2,200 2,400 2,700
Equipment - 0- - 0- - 0-
Total program 18,400 20,700 25,300
Balance forward $ 14,500 $ 14,300 $ 23,900
Source: Budget request f o r f i s c a l year 1983- 84
* Large increase due t o s h i f t t o b i e n n i a l c y c l e , wherein l i c e n s e s w i l l
be renewed June 30 of every even- numbered year.
Audit Scope and Purpose
The purpose of our audit was to determine whether
1. State licensure of nursing home administrators is necessary,
2. The Board is able to monitor effectively the activities of its
licensees, and
3. The Board has maintained its minimum entry requirements and
educational standards.
The Auditor General and staff express appreciation to the members of the
Arizona Board of Examiners of Nursing Care Institution Administrators for
their cooperation and assistance during the course of our audit.
SUNSET FACTORS
I n accordance with A. R. S. 5541- 2351 through 41- 2379, 11 f a c t o r s were
considered t o determine, i n p a r t , whether the Board of Examiners of
Nursing Care I n s t i t u t i o n Administrators should be continued or terminated.
1. Objective and purpose i n e s t a b l i s h i n g the Board
The s t a t u t e s do n o t s p e c i f y the purpose i n e s t a b l i s h i n g the NCIA
Board. However, according t o the Board p r e s i d e n t , the NCIA Board was
e s t a b l i s h e d
". . . i n response t o f e d e r a l l e g i s l a t i o n requiring
t h a t [ T i t l e XIX, o r Medicaid] payments on behalf of
p a t i e n t s a r e limited t o f a c i l i t i e s with S t a t e licensed
administrators."
The Board's primary objective appears t o be p r o t e c t i n g the public
h e a l t h and welfare by ensuring the competence of its l i c e n s e e s , both
i n i t i a l l y and during t h e i r p r a c t i c e s a s a d m i n i s t r a t o r s . The Board
president described the Board's s t a t u t o r y a u t h o r i t y and d u t i e s a s
follows :
"( 1) Examining and l i c e n s i n g a p p l i c a n t s ( A. R. S.
$ 36- 446.01) meeting q u a l i f i c a t i o n s ( A. R. S. s36- 446.04).
"( 2) Promulgating r u l e s , r e g u l a t i o n s and standards f o r
administering the s t a t u t e i n compliance with T i t l e XIX
of the S o c i a l S e c u r i t y Act and s e t f e e s not exceeding
maximums s e t f o r t h i n the s t a t u t e [ A. R. S. $ 36- 446.031.
" ( 3 ) Conduct examinations and i n v e s t i g a t i o n s [ A. R. S.
$ 36- 446.031 t o determine compliance of Nursing Care
I n s t i t u t i o n Administrators.
"( 4) Take d i s c i p l i n a r y a c t i o n f o r v i o l a t i o n s of
s t a t u t e [ A. R. S. 536- 446.071.
"( 5) Imposition of a requirement of continuing
education f o r renewal of l i c e n s e [ A. R. S. $ 36- 446.071.''
The e f f e c t i v e n e s s with which the Board has met its objective and
purpose and t h e e f f i c i e n c y with which tlie Board has operated
The Board appears t o have e f f e c t i v e l y maintained l i c e n s u r e and renewal
standards by monitoring education and other minimum q u a l i f i c a t i o n s .
In a d d i t i o n , the Board's approval of continuing education f o r renewal
a p p l i c a n t s should soon become more e f f i c i e n t , as the National
Association of Boards of Examiners of Nursing Care I n s t i t u t i o n
Administrators ( NAB) has recently assumed r e s p o n s i b i l i t y f o r approving
many t r a i n i n g courses n a t i o n a l l y . Currently, the Board reviews a l l
courses submitted f o r approval on a case- by- case b a s i s .
However, the Board needs t o become more a c t i v e i n monitoring i t s
l i c e n s e e s t o ensure t h e i r continued competence while p r a c t i c i n g as
a d m i n i s t r a t o r s . We recommend the Board and the Department of Health
Services Bureau of Health Care I n s t i t u t i o n Licensure ( DHS) e s t a b l i s h
procedures f o r sharing p e r t i n e n t nursing home information ( complaints
and inspection r e s u l t s ) which may r e f l e c t on t h e a d m i n i s t r a t o r ' s
performance ( see Finding 11, page 17).
The extent t o which the Board has operated within the public i n t e r e s t
According t o the Board president:
" The Board has operated within the public i n t e r e s t by
i t s c a r e f u l adherence t o the s t a t u t e s , by its
recommendation of changes i n the s t a t u t e s t h a t protect
the i n t e r e s t s of nursing home p a t i e n t s and by
aggressively pursuing the withholding of l i c e n s e from
those who do not f u l l y comply with the expectations of
the s t a t u t e s .
" The Board held two hearings l a s t year on complaints by
f a m i l i e s of nursing home r e s i d e n t s r e s u l t i n g i n the
delicensirig of one administrator. More recently
requests f o r renewal of l i c e n s e was denied t o f i v e
a p p l i c a n t s because of d e f i c i e n c i e s i n t h e i r continuing
education requirements.
" The Board formulated a p o s i t i o n it f e l t was i n the
public i n t e r e s t . The Board then s o l i c i t e d and received
comments from the public and f i n a l l y was successful
through r u l e promulgation i n overcoming a major
deficiency which was seen a s the absence of s i g n i f i c a n t
educational background f o r licensure."
However, a s mentioned i n Sunset Factor 2 and i n Finding 11, the Board
needs t o take a more a c t i v e r o l e i n monitoring its l i c e n s e e s by
obtaining information from DHS regarding nursing home d e f i c i e n c i e s f o r
which the administrator may be h e l d r e s p o n s i b l e .
4. The extent t o which r u l e s and r e ~ u l a t i o n s uromulgated by the Board a r e
c o n s i s t e n t with the l e g i s l a t i v e mandate
The Board revised its r u l e s and r e g u l a t i o n s i n 1982. These revised
r u l e s and r e g u l a t i o n s were approved by the Attorney General t o ensure
consistency with the s t a t u t e s . In a d d i t i o n , it appears the Board's
r u l e s and r e g u l a t i o n s a r e c o n s i s t e n t with T i t l e XIX of the Social
Security Act, a s required i n A. R. S. § 36- 446.03, subsection A, i n t h a t
the Board has s e t and maintained minimum standards f o r entry and
continuation of l i c e n s u r e .
The Board has yet t o r e v i s e its r u l e s and r e g u l a t i o n s based on 1982
s t a t u t o r y changes which added 1 ) d e f i n i t i v e grounds f o r d i s c i p l i n a r y
a c t i o n , including unprofessional conduct and 2) the a b i l i t y t o
censure, place on probation or deny a l i c e n s e t o any l i c e n s e e found t o
be i n v i o l a t i o n of the s t a t u t e s ( A. R. S. $ 36- 446.07). ( P r i o r t o t h i s ,
the Board had a u t h o r i t y only t o suspend or revoke a l i c e n s e . )
5 . The e x t e n t t o which the Board has encouraged input from t h e p u b l i c
before promulgating its r u l e s and r e g u l a t i o n s and t h e e x t e n t t o which
it has informed the Dublic a s t o i t s a c t i o n s and t h e i r e x ~ e c t e d i m ~ a c t
on the public
Accordink t o the p r e s i d e n t , the Board sends n o t i c e s of r u l e s hearings
t o r e p r e s e n t a t i v e s of two S t a t e and n a t i o n a l organizations of nursing
home a d m i n i s t r a t o r s , along with copies of proposed r u l e s . In
a d d i t i o n , l i c e n s e e s receive n o t i c e s of hearings and summaries of
proposed r u l e s . The Board publishes hearing n o t i c e s i n - The Arizona
Republic and posts n o t i c e s i n the S t a t e Senate press and media rooms.
6. The extent t o which the Board has been able t o i n v e s t i g a t e and resolve
complaints t h a t a r e within i t s j u r i s d i c t i o n
The Board appears t o have responded a p p r o p r i a t e l y t o the s i x
complaints received i n its s i x years of a c t i v i t y . Board a c t i o n on one
complaint r e s u l t e d i n the a d m i n i s t r a t o r giving up h i s l i c e n s e f o r f i v e
years. In a d d i t i o n , the president s t a t e d t h e Board has sought and
obtained s t a t u t o r y changes t o help it resolve complaints ( see Sunset
Factor 8). However, a s recommended i n Finding 11, the Board could
f u r t h e r improve i t s a b i l i t y t o monitor l i c e n s e e s by e s t a b l i s h i n g a
system of communication with DHS ( s e e page 17).
7. The e x t e n t t o which the Attorney General or any o t h e r a p p l i c a b l e
agency of S t a t e government has t h e a u t h o r i t y t o prosecute a c t i o n s
under enabling l e g i s l a t i o n
The Board is authorized by A. K. S. $ 36- 446.09, subsection B, t o seek
i n j u n c t i v e r e l i e f f o r v i o l a t i o n s of its s t a t u t e s . The Attorney
General is the Board's l e g a l advisor and, according t o the president,
" renders such l e g a l s e r v i c e s a s the Board r e q u i r e s pursuant to A. R. S.
s41- 192."
8. The extent t o which the Agency has addressed d e f i c i e n c i e s i n the
enabling s t a t u t e s which prevent it from f u l f i l l i n g its s t a t u t o r y
mandate
In 1982, the Board was successful i n obtaining passage of l e g i s l a t i o n
strengthening its a b i l i t y t o regulate l i c e n s e e s . A. R. S. s36- 446.07
was amended t o provide more d e f i n i t i v e grounds f o r d i s c i p l i n a r y a c t i o n
and t o allow the Board t o censure or place on probation any licensee
found t o be i n v i o l a t i o n of the s t a t u t e s . Also, a d e f i n i t i o n of
" unprofessional conduct" was added t o A. R. S. S36- 446.
In 1983, the Board sought l e g i s l a t i v e amendments which would
1) provide f o r compensation of Board members, 2) eliminate the
r e s t r i c t i o n on e s t a b l i s h i n g or handling a county p a t i e n t ' s t r u s t fund,
and 3) allow the Board t o reduce the f e e amount f o r an a d m i n i s t r a t o r
on i n a c t i v e l i c e n s e s t a t u s . House B i l l 2365, which incorporated these
changes, became law i n April 1983.
9. The e x t e n t t o which changes a r e necessary i n the laws of the Board t o
adequately comply with the f a c t o r s l i s t e d i n the subsection
As discussed i n Finding I1 ( page 1 7 ) , s t a t u t e s should be amended t o
provide f o r information- sharing between the Board and DHS.
10. The extent t o which the termination of the Board would s i g n i f i c a n t l y
harm the public h e a l t h , s a f e t y or welfare
Should the L e g i s l a t u r e decide t o include reimbursement f o r long- term
care i n the Arizona Health Care Cost Containment System ( AHCCCS),
S t a t e l i c e n s u r e of nursing care i n s t i t u t i o n a d m i n i s t r a t o r s w i l l be
required i n order f o r Arizona t o r e c e i v e F e d e r a l T i t l e XIX ( Medicaid)
funds. Even i f AHCCCS does not include long- term c a r e , Federal T i t l e
X V I I I ( Medicare) r e g u l a t i o n s r e q u i r e t h a t some S t a t e agency c e r t i f y
the education and t r a i n i n g of nursing home administrators. Meeting
t h i s requirement by continuing the present l i c e n s i n g system appears
d e s i r a b l e because 1) according t o a Federal o f f i c i a l , any changes i n
current l i c e n s u r e requirements may r a i s e questions a t the Federal
l e v e l regardinb Medicare funding; and 2) it is questionable t h a t
another agency could perform t h i s function more economically than the
Board. F i n a l l y , a s i d e from Federal requirements regarding the need
f o r l i c e n s u r e and the appropriate l e v e l of r e g u l a t i o n , s e v e r a l aging
s e r v i c e s o f f i c i a l s believe t h a t a d m i n i s t r a t o r l i c e n s u r e has
contributed t o the recent improvement i n the nursing home industry
( see Finding I, page 11).
11. The e x t e n t t o which the l e v e l of r e g u l a t i o n exercised by the Board is
appropriate and whether l e s s or more s t r i n g e n t l e v e l s of r e g u l a t i o n
would be a ~ ~ r o ~ r i a t e
Based on the response t o Sunset Factor 10, the current l e v e l of
r e g u l a t i o n appears appropriate.
FINDING I
STATE REGULATION OF NURSlNG CARE INSTITUTION ADMINISTFATORS SHOULD
CONTINUE.
State regulation of nursing care institution administrators is necessary
to satisfy Federal requirements. Administrators must be licensed if, in
the future, the Legislature determines Arizona's alternative to Medicaid
will provide reimbursement for long- term care. However, even if long- term
care is not included in Arizona's Medicaid program, the Federal Medicare
provisions require that a State agency certify the education and training
of nursing home administrators. Aside from Federal requirements for
regulation, several officials in the field of aging services have stated
that administrator licensure has been important in improving nursing home
conditions.
Background
The Federal government provides funding for nursing home care through
Titles XVIII and XIX of the Social Security Act. Title XVIII ( Medicare)
funding is based on nedical eligibility requirements, while Title XIX
( Medicaid) funding is based on income eligibility. Medicare funding is
available through several Arizona nursing homes; however, currently
Arizona receives no Medicaid funding for long- term care.
In 1974, the Legislature established the Medical Assistance Program
( A. R. S. $ 36- 2171, et seq), an indigent health care program designed to
receive and disburse Title XIX funds. The Board of Examiners of Nursing
Care Institution Administrators was established in 1975 as part of Federal
requirements for receiving Title XIX funding. The Legislature, however,
never provided for the State- matching funds needed to qualify for Federal
Medicaid monies; and in a 1981 Special Legislative Session, the Arizona
Medical Assistance Program was stricken from the statutes.
In the same 1981 Special Session, the Legislature established the Arizona
Eiealth Care Cost Containment System ( AHCCCS), a federally approved
alternative- to- Pledicaid program designed t o receive and disburse T i t l e
XIXfunds. Currently, AHCCCS i s i n the p i l o t stage, and its continuation is
subject t o l e g i s l a t i v e approval. A t p r e s e n t , AHCCCS does not provide f o r
reimbursement t o i n d i v i d u a l s receiving long- term ( nursing home) care. I f
AIICCCS is continued, t h e L e g i s l a t u r e w i l l determine whether Arizona's
a l t e r n a t i v e t o Medicaid w i l l reimburse f o r long- term care.
Medicare ( T i t l e XVIII) has reimbursed f o r l i m i t e d forms of nursing care i n
Arizona s k i l l e d nursing f a c i l i t i e s since 1966. According t o a Department of
Health Services ( DHS) o f f i c i a l , about 2 t o 3 percent of Arizona's nursing
hone r e s i d e n t s receive Medicare b e n e f i t s .
S t a t e Licensure of Nursing Home
Administrators i s a P r e r e q u i s i t e
f o r Receiving T i t l e XIX ( Medicaid)
Funds f o r Long- Term Care
I f AHCCCS reimburses f o r long- term care i n t h e f u t u r e , Arizona must require
its a d m i n i s t r a t o r s t o be licensed. Medicaid r e g u l a t i o n 42CFR 431.703 s t a t e s :
" The S t a t e l i c e n s i n g program must provide t h a t only
nursing homes supervised by an a d m i n i s t r a t o r licensed
i n accordance with the requirements of t h i s subpart may
operate i n the State."
Federal T i t l e X V I I I ( Medicare)
Requires S t a t e s t o Approve Education
of Nursing Home Administrators
Even i f AHCCCS does not reimburse f o r long- term c a r e , Federal r e g u l a t i o n s
governing Medicare c e r t i f i c a t i o n require the s t a t e s t o regulate nursing home
a d m i n i s t r a t o r s . While s t a t e l i c e n s u r e is not d i r e c t l y required, the nursing
home's governing body must appoint a q u a l i f i e d nursing home a d m i n i s t r a t o r ,
defined a s one who i s licensed as required by S t a t e law - or, i n the absence
of a Medicaid program, has obtained appropriate education and t r a i n i n g a s
approved by the responsible S t a t e agency. Medicare r e g u l a t i o n 42CFR
405.1101( a) d e f i n e s a q u a l i f i e d a d m i n i s t r a t o r a s a person who
"( 1) Is licensed a s required by S t a t e law: or
( 2 ) If the S t a t e does not have a Medicaid program, and
has no l i c e n s u r e requirement, is a high school graduate
( or e q u i v a l e n t ) , has completed courses i n admini-s
t r a t i o n or management approved by the appropriate
S t a t e agency, and has 3 years of supervisory management
experience i n a s k i l l e d nursing f a c i l i t y or r e l a t e d
h e a l t h program. . . ." ( emphasis added)
Thus, f o r Arizona nursing homes t o continue t o be able t o q u a l i f y f o r
Medicare reimbursement, some S t a t e agency must approve the course( s) of
t r a i n i n g for nursing home administrators. Meeting t h i s requirement by
continuing the present l i c e n s i n g system appears d e s i r a b l e f o r the
following reasons:
According t o a Federal o f f i c i a l , any changes i n current l i c e n s u r e
requirements could serve t o r a i s e questions a t the Federal l e v e l
regarding Medicare funding. A t the very l e a s t , the U. S.
Department of Health and Human Services ( DHHS) would have t o
approve the new agency a s appropriate t o perform t h i s
education- approval function.
It i s questionable t h a t another agency could perform the
education- approval function more economically than the Board.
The Board now operates with a budget of approximately $ 20,000,
a l l of which is recovered through l i c e n s u r e fees.
Nursing Home Conditions
Several o f f i c i a l s i n the f i e l d of aging s e r v i c e s believe t h a t
a d m i n i s t r a t o r l i c e n s u r e has been a t l e a s t somewhat instrumental i n
improving nursing home conditions.
A Federal DEiHS o f f i c i a l s a i d t h a t S t a t e l i c e n s u r e of nursing home
a d m i n i s t r a t o r s w a s a " catch- up" move t o adopt p r o f e s s i o n a l standards
s i m i l a r t o those of other healing a r t s professions. Before the 1970s, he
s a i d , t h e a d m i n i s t r a t o r was the " weakest l i n k i n the [ nursing home c a r e ]
chain." Other components of the nursing home industry have been regulated
f o r a long period of time. In Arizona, f o r example, nurses have been
l i c e n s e d s i n c e 1921, and nursing home f a c i l i t i e s have been licensed since
1953. But t h e a d m i n i s t r a t o r , i n charge of the f a c i l i t y ' s o v e r a l l operations
including s t a f f , was n o t l i c e n s e d u n t i l 1975. Typically, the DHHS o f f i c i a l
s a i d , the a d m i n i s t r a t o r had no more than a high school education and had
received no s p e c i f i c t r a i n i n g .
Two S t a t e DHS o f f i c i a l s noted they had seen much improvement i n the nursing
home industry i n recent years and a t t r i b u t e d t h i s improvement, a t l e a s t i n
p a r t , t o a d m i n i s t r a t o r l i c e n s u r e . One s a i d l i c e n s u r e has meant t h a t the
a d m i n i s t r a t o r has met higher q u a l i f i c a t i o n s , is f a m i l i a r with relevant laws
and r e g u l a t i o n s and receives updated t r a i n i n g through continuing education
requirements.
An o f f i c i a l from the Department of Economic Security Adult P r o t e c t i v e
Services ( APS) s t a t e d t h a t a d m i n i s t r a t o r l i c e n s u r e was necessary s o t h a t
someone could be held accountable f o r s e t t i n g standards i n the nursing
home. The APS o f f i c i a l believes l i c e n s u r e helps ensure t h a t a d m i n i s t r a t o r s
have t h e a p p r o p r i a t e t r a i n i n g and background.
F i n a l l y , the Board's president noted t h a t Federal requirements f o r
a d m i n i s t r a t o r l i c e n s u r e came as a r e s u l t of Congressional hearings regarding
poor care received by the e l d e r l y i n nursing homes nationwide. In these
hearings, Congress agreed t h a t poor nursing home a d m i n i s t r a t i o n was a
widespread problem. The Board president believes l i c e n s u r e has improved the
q u a l i t y of care received i n nursing homes. IIe c i t e d t h r e e f a c t o r s which
have s e t i t a p a r t from other types of a d m i n i s t r a t i o n , including t h a t of
h o s p i t a l s :
Nursing homes have had a long h i s t o r y of poor q u a l i t y care.
Their c l i e n t e l e is a vulnerable group and most w i l l l i v e out t h e i r
l i v e s a t the nursing home.
e U n t i l r e c e n t l y t h e r e has been no h i s t o r y of educational or t r a i n i n g
requirements t o assure b a s i c a d m i n i s t r a t o r competence.
The president s t a t e d t h a t while education requirements w i l l not guarantee a
good a d m i n i s t r a t o r , i t is a t o o l the Board uses t o attempt t o c r e a t e a n
environment of caring and concern f o r nursing home r e s i d e n t s .
CONCLUSION
State licensure of nursing care institution administrators should be
continued because
0 Administrators must be licensed if, in the future, the
Legislature determines the AHCCCS (~ edicaid)' program will provide
reimbursement for long- term care and
Even if AHCCCS does not reimburse for long- term care,
administrators' education and training must be certified by a
State agency according to Medicare regulations.
In addition, several officials in aging services believe that
administrator licensure has been instrumental in improving nursing home
conditions.
RECOMBENDATION
The Legislature should renew the enabling statutes of the Board of
Examiners of Nursing Care Institution Administrators.
FINDING I1
THE BOARD SHOULD OBTAIN AND UTILIZE DEPARTMENT OF HEALTH SERVICES'
IhFOUIATION TO STRENGTHEN THE BOARD'S REGULATORY ABILITY.
The Board has not u t i l i z e d information maintained by the Ijepartment of
Health Services Bureau of Health Care I n s t i t u t i o n Licensure ( DHS) which
would aid i n monitoring nursing home a d m i n i s t r a t o r s ' performance on the
job. Although the two agencies' functions a r e strongly r e l a t e d , the Board
has not s o l i c i t e d p e r t i n e n t information from DHS regarding matters t h a t
a f f e c t the h e a l t h and s a f e t y of nursing home p a t i e n t s . As a r e s u l t , DHS
has not r e f e r r e d any complaints t o the Board i n the past year, though it
appears t h a t several complaints should have been brought t o the Board's
a t t e n t i o n . This lack of communication from DHS to the Board impairs the
Board's a b i l i t y t o p r o t e c t t h e public from incompetent or negligent
administrators. The Board could strengthen its regulatory r o l e by
adopting some of the p r a c t i c e s used i n other s t a t e s t o obtain s i m i l a r
information.
Board and DHS Duties
Are Closely Related
The Board and the Bureau of Health Care I n s t i t u t i o n Licensure ( DHS) have
c l o s e l y r e l a t e d r e s p o n s i b i l i t i e s over nursing homes. DHS r e g u l a t e s the
nursing home f a c i l i t y whereas the Board r e g u l a t e s the i n d i v i d u a l i n charge
of the f a c i l i t y ' s day- to- day operations.
DI- IS l i c e n s e s and r e g u l a t e s the nursing care f a c i l i t i e s i n the S t a t e . In
t h i s capacity DHS l i c e n s e s and annually i n s p e c t s each f a c i l i t y . If the
i n s t i t u t i o n is c e r t i f i e d f o r Medicare, DIIS performs the annual inspection
f o r c e r t i f i c a t i o n . It receives and i n v e s t i g a t e s complaints from the
public as well a s complaints r e f e r r e d from other agencies, such a s county
h e a l t h departments, the Department of Economic S e c u r i t y , Adult P r o t e c t i v e
Services and s t a t e and county nursing home ombudsmen. Therefore, DHS a c t s
as the central agency responsible for investigating complaints against
nursing care institutions, including complaints against nursing home
personnel.
The Board, on the other hand, licenses and regulates the person
responsible for the day- to- day administration of the nursing home.
According to A. R. S. $ 36- 446,
" 1. ' Administrator1 or ' nursing care institution
administrator' means any individual who is charged with
the general administration of a nursing care
-
institution, whether or not such individual has an
ownership interest in such institution and whether or
not his or her functions and duties are shared with one
or more other individuals." ( emphasis added)
The Board is at least partially responsible for ensuring that DHS's
nursing home licensure requirements are being met by the administrator.
The Board examines applicants on DHS's facility licensure rules and
regulations regarding delivery of nursing services. In addition, the
Board has statutory authority to discipline a licensee for " unprofessional
conduct, " which could include an administrator's negligence or
incompetence in carrying out the DIlS requirements. The Board has the
power to suspend, revoke, censure or place on probation an administrator
who is found guilty of unprofessional conduct or any of several other
violations.
In~ ortant Information Ke~ arding
Problems Is Not Being Solicited
Although DHS receives most information regarding nursing home conditions,
the Board has not established either formal or informal means to obtain
pertinent information. As a result, DHS has not forwarded any complaints
or inspection reports to the Board in the past year, though it appears
that several complaints and reports warranted the Board's attention. This
lack of communication impairs the Board's ability to protect the public
from incompetent or negligent administrators.
DIIS i s the r e p o s i t o r y f o r information regarding nursing home conditions.
DHS receives numerous complaints from the public and i n s p e c t s each nursing
home annually. The Board, on the other hand, r e c e i v e s very few complaints
and conducts no routine f i e l d s u r v e i l l a n c e a c t i v i t i e s . In f a c t , the Board
has received only s i x complaints i n its s i x years of a c t i v i t y ( only one
complaint i n f i s c a l year 1981- 82).
Our review of DHS records revealed several examples of the types of
complaint i n v e s t i g a t i o n s the Board should have received f o r its review.
During f i s c a l year 1981- 82 DHS received 34 s u b s t a n t i a t e d corn plaint^:^
a g a i n s t 19 licensed nursing care i n s t i t u t i o n s . According t o the DHS
records we reviewed, none of t h e s e c o n p l a i n t s were r e f e r r e d t o the NCIA
Board. In a d d i t i o n , some annual inspection r e p o r t s indicated s u b s t a n t i a l
d e f i c i e n c i e s i n one or more areas of nursing home a d m i n i s t r a t i o n f o r which
the a d m i n i s t r a t o r might be held responsible; however, none of these
r e p o r t s were forwarded t o the Board. Since the a d m i n i s t r a t o r is charged
with the general a d m i n i s t r a t i o n of a nursing care i n s t i t u t i o n , any
s u b s t a n t i a t e d complaint, as well as annual inspection r e p o r t s noting
s e r i o u s d e f i c i e n c i e s , should be of i n t e r e s t t o the Board.
Following a r e two examples of DHS complaint i n v e s t i g a t i o n s about which the
Board should have been informed.
Case 1
DMS was requested t o i n v e s t i g a t e the death of a p a t i e n t who had " entered
the laundry, ingested and a s p i r a t e d sodium h y p o c h l o r i t e ( d r y b l e a c h ) , and
died of bronchopneumonia." The primary purpose of t h i s v i s i t , as s t a t e d
i n the DHS r e p o r t , was
"... to discuss procedures adopted by the f a c i l i t y t o
prevent a recurrence of such an accident and t o observe
and check i f these procedures have indeed been
implemented."
* DHS considers a complaint t o be s u b s t a n t i a t e d when it i n v e s t i g a t e s and
f i n d s one or more code v i o l a t i o n s of DHS r e g u l a t i o n s .
The a d m i n i s t r a t o r t o l d a DHS i n v e s t i g a t o r t h a t the following procedures
had been implemented and t h a t such an accident could never happen again:
1. Laundry doors would be shut a t a l l times,
2. Someone would be s t a f f i n g the laundry 24 hours a day, and
3. Detergents and other chemicals would be kept under lock.
However, upon i n v e s t i g a t i o n DHS found:
1. Laundry doors were open,
2. The laundry room was not s t a f f e d , and
3. Chemical s o l u t i o n s such a s t o i l e t bowl cleaners and detergents
were i n the unattended laundry.
DHS concluded t h a t " no e f f e c t i v e mechanism" had been developed t o ensure
the new procedures were implenented. We found no record t h a t t h i s case
had been r e f e r r e d t o the Board.
Case I1
DIiS responded to a n e x t e n s i v e l i s t of complaints a g a i n s t one nursing care
f a c i l i t y . DHS sent i n three teams of surveyors over a two- day period t o
review the f a c i l i t y ' s operation. Each team c i t e d numerous v i o l a t i o n s i n
the i n s p e c t i o n r e p o r t s . Following a r e some of the s u b s t a n t i a t e d
complaints r e s u l t i n g from the DHS i n v e s t i g a t i o n :
Unlocked room with e x t e r n a l medications and germicides;
P o t e n t i a l cross- contamination from using stock supplies f o r many
r e s i d e n t s ;
Thermometers n o t l a b e l e d clean o r s o i l e d ;
S a n i t a t i o n problems i n k i t c h e n e t t e s where water p i t c h e r s a r e
prepared f o r r e s i d e n t s ;
Cleaning agents found i n unlocked a r e a s ;
a One u n i t having no acceptable method of cleaning bed pans;
a Lack of r e s t o r a t i v e nursing;*
a Problems regarding communications with r e s i d e n t s ' f a m i l i e s ;
Lack of supervision of r e s i d e n t n u t r i t i o n ; and
a Problems with food purchasing, r e s u l t i n g i n i n s u f f i c i e n t amounts
given to r e s i d e n t s .
General comments i n DHS i n v e s t i g a t i v e r e p o r t s on th- is case revealed
extensive evidence of poor housekeeping, poor maintenance and a general
lack of concern f o r s a n i t a r y procedures on the p a r t of the employees. In
a d d i t i o n , t h e i n v e s t i g a t o r s had noted t h e i r general impression of the
majority of p a t i e n t s was t h a t they had l i t t l e or no a c t i v i t y or
i n t e r a c t i o n . F u r t h e r , a surveyor termed a s b l a t a n t the problems with
i n f e c t i o n c o n t r o l , r e s t o r a t i v e nursing, care of t o t a l care p a t i e n t s and
communication with f a m i l i e s .
Subsequently, the ENS bureau chief and a c t i n g a s s i s t a n t d i r e c t o r met f o r
two hours with t h e a d m i n i s t r a t o r and a s s i s t a n t a d m i n i s t r a t o r of the
nursing home t o d i s c u s s plans f o r c o r r e c t i o n . We found no evidence t h a t
the NCIA Board had been informed of t h i s meeting.
Problems i n the above two cases appear t o r e f l e c t on the competence of the
administrator. Since the Board does not receive t h i s type of information,
p o t e n t i a l harm to the public nay r e s u l t from allowing an incompetent or
negligent a d m i n i s t r a t o r t o continue p r a c t i c i n g .
* Restorative nursing is r e l a t e d t o physical therapy and/ or other
r e h a b i l i t a t i o n of t h e p a t i e n t .
According t o a DHS o f f i c i a l , DHS would r e f e r complaints and i n s p e c t i o n
r e p o r t s t o the Board only i f 1) the problem s p e c i f i c a l l y involved the
a d m i n i s t r a t o r , or 2) DHS determined t h a t repeated d e f i c i e n c i e s i n d i c a t e d
a problem with the a d m i n i s t r a t o r . Apparently DHS concluded t h a t the two
cases above did not meet e i t h e r of these c r i t e r i a , s i n c e the Board did not
receive these complaints or any i n s p e c t i o n r e p o r t s from DHS.* However, i n
our opinion, cases such a s t h o s e d e s c r i b e d e a r l i e r do r e f l e c t on the
a d m i n i s t r a t o r ' s competence and t h e r e f o r e should be of i n t e r e s t t o the
Board. In f a c t , according t o an o f f i c i a l of the U. S. Department of Health
and Human S e r v i c e s , Division of Health Standards and Q u a l i f i c a t i o n ( DHHS),
the Board should be taking a c t i o n a g a i n s t a l i c e n s e e i f t h e n u r s i n g home
i n which he i s employed has s e r i o u s l i f e - t h r e a t e n i n g d e f i c i e n c i e s .
We should note t h a t the Board has n o t requested DHS t o forward complaint
or i n s p e c t i o n information t o the Board. Since i t s c r e a t i o n i n 1976, the
Board has been preoccupied with e s t a b l i s h i n g and r a i s i n g standards f o r
l i c e n s u r e and renewal and has done r e l a t i v e l y l i t t l e t o monitor
performance of l i c e n s e e s .
Linkages Between the Board
and DHS Should Be Established
The Board could improve i t s a b i l i t y t o monitor l i c e n s e e performance by
e s t a b l i s h i n g communication linkages with DHS. As shown by the p r a c t i c e s
of other s t a t e s , s e v e r a l options have been used t o accomplish
this-- including i n f o m a l comn~ unications a s well a s formal, s t r ~ c ~ t u r a l
linkages. Arizona Board r e p r e s e n t a t i v e s i n d i c a t e d t h a t S t a t e law should
be amended t o f a c i l i t a t e t h i s sharing of information.
* It should be noted t h a t the only complaint the Board received i n
f i s c a l year 1981- 82 concerned an a d m i n i s t r a t o r ' s mishandling of
funds. The Board d i s c i p l i n e d t h e a d m i n i s t r a t o r by having him agree t o
give up h i s l i c e n s e f o r a period of f i v e years.
Ohio and C a l i f o r n i a have e s t a b l i s h e d informal linkages among agencies
involved with nursing homes. For example, i n Ohio the a d m i n i s t r a t o r s
board keeps copies of the h e a l t h department's complaint i n v e s t i g a t i o n
r e p o r t s and annual survey r e p o r t s showing d e f i c i e n c i e s i n each
a d m i n i s t r a t o r ' s renewal f i l e f o r the board's review. In both C a l i f o r n i a
and Ohio, the a d n l i n i s t r a t o r s board is n o t i f i e d of any a c t i o n the h e a l t h
department is pursuing against a nursing home. In C a l i f o r n i a , t h e board
is i n v i t e d t o p a r t i c i p a t e with the h e a l t h department when a d m i n i s t r a t i v e
proceedings a r e i n i t i a t e d a g a i n s t a l i c e n s e e . In t h i s c a s e t h e
proceedings can r e s u l t i n d i s c i p l i n a r y a c t i o n a g a i n s t the a d m i n i s t r a t o r ' s
l i c e n s e a s well a s the f a c i l i t y ' s l i c e n s e .
Florida s t a t u t e s were recently amended t o require t h a t a l l annual nursing
home inspection r e p o r t s be forwarded from t h e h e a l t h department t o the
a d m i n i s t r a t o r s board.
A number of s t a t e s have e s t a b l i s h e d formal, s t r u c t u r a l linkages t o improve
communication and coordination between t h e a d m i n i s t r a t o r s boards and the
h e a l t h departments ( or f a c i l i t y - l i c e n s i n g agency). I n a t l e a s t 10 s t a t e s
t h e h e a l t h departments a r e represented on the a d m i n i s t r a t o r s boards, and
i n a t l e a s t 8 s t a t e s the boards a r e located within the h e a l t h
departments. Table 2 lists these s t a t e s and the s t a t u s of each board
regarding composition and location.
According t o the Board and its Attorney General r e p r e s e n t a t i v e , the most
a c c e p t a b l e o p t i o n f o r Arizona would be t o amend S t a t e law t o 1) authorize
the Board t o a c t on information from DHS and other S t a t e agencies
regarding nursing home a d m i n i s t r a t i o n problems and 2 ) r e q u i r e t h a t DHS
forward t h i s information t o the Board. The Board r e p r e s e n t a t i v e s were
concerned t h a t the c u r r e n t s t a t u t e s ( A. R. S. $ 36- 446.07, subsection F) may
not authorize the Board to a c t on information received from other S t a t e
agencies.
Arkansas
Connecticut
Georgia
Iowa
Kansas
Kentucky
Massachusetts
14ontana
Nevada
New Jersey
New York
North Dakota
Ohio
Oklahoma
Tennessee
Texas
TABLE 2
BOARD COMPOSITIONS AND LOCATIONS I N 16 STATES
Health Department Board Located in
Represented on Board Health Department
* Health department representative is an ex officio ( nonvoting) member
of board.
The Board has not utilized information maintained by DIlS which would aid
the Board in monitoring and regulating the nursing home administrator's
performance on the job. Without this information, the Board's ability to
protect the public from incompetent or negligent administrators is
impaired.
1. The L e g i s l a t u r e should amend S t a t e law a s follows t o strengthen the
Board's r e g u l a t o r y a b i l i t y :
Require t h a t DHS forward t o the Board s u b s t a n t i a t e d complaints and
annual i n v e s t i g a t i o n r e p o r t s which r e v e a l a d m i n i s t r a t o r - r e l a t e d
problems. The Board, and not DHS, should d e f i n e which problems a r e
a d m i n i s t r a t o r related."
Authorize the Board t o a c t on p e r t i n e n t information from DHS and
other S t a t e agencies regarding nursing home a d m i n i s t r a t i o n problems.
2. The Board should maintain a renewal f i l e f o r each a d m i n i s t r a t o r which
c o n t a i n s a h i s t o r y of any s u b s t a n t i a t e d complaints and s e r i o u s
deficiency r e p o r t s from DHS.
* In response t o our recommendation, the Board p r e s i d e n t has already
contacted DHS t o d i s c u s s procedures f o r sharing information.
OTIIER PERTINENT INFOWIATION
The Board's current composition may t h r e a t e n the l e g a l i t y of i t s
decisions. The Board appears t o be overrepresented by the nursing
profession.
The Board c o n s i s t s of seven members appointed by the Governor. The
Board's composition i s s t r i c t l y l i m i t e d by A. R. S. s36- 446.02, which s t a t e s :
" B. The Board s h a l l include one a d m i n i s t r a t o r of a
nonprofit s k i l l e d nursing f a c i l i t y , one a d m i n i s t r a t o r
of a p r o p r i e t a r y s k i l l e d nursing f a c i l i t y , one
administrator of a personal care f a c i l i t y and four
members r e p r e s e n t a t i v e of the professions concerned
with the care and treatment of t h e c h r o n i c a l l y ill or
t h e i n f i r m e l d e r l y p a t i e n t s . No more than two members
of the Board s h a l l be from a s i n g l e profession."
( emphasis added)
Thus, the s t a t u t e s l i m i t r e p r e s e n t a t i o n from any one profession t o two
members. However, c u r r e n t l y there a r e three r e g i s t e r e d nurses on the
Board. We were unable t o obtain a d e f i n i t e explanation from the
Governor's o f f i c e f o r t h i s overrepresentation because of turnover i n the
p o s i t i o n responsible f o r appointments.
As evidenced by a similar s i t u a t i o n i n 1981, t h i s o v e r r e p r e s e n t a t i o n could
c r e a t e a problem f o r the Board. In April 1981, the Board's composition
was challenged because t h e t h r e e a d m i n i s t r a t o r s on the Board represented
nonprofit f a c i l i t i e s and the p r o p r i e t a r y segment of the industry was not
represented. On i t s Attorney General r e p r e s e n t a t i v e ' s advice, the Board
could not continue t o operate u n t i l the Governor appointed a p r o p r i e t a r y
administrator i n July 1981.
Board of Examiners f o r
Nursing Care I n s t i t u t i o n Administrators
1645 W. J e f f e r s o n , Room 312
Phoenix, Arizona 85007
May 31, 1983
Mr. Douglas R. Norton, Auditor General
S t a t e of Arizona
111 West Monroe, S u i t e 600
Phoenix, Arizona 85003
Dear M r . Norton:
IJe have reviewed t h e revised preliminary r e p o r t d r a f t
of the performance audit of the Arizona Board of Examiners
of Nursing Care I n s t i t u t i o n Administrators.
It is t h e f e e l i n g of t h e Roard t h a t b a s i c a l l y we have no
problem with e i t h e r of t h e two findings i n t h e r e p o r t .
Currently, t h e Boaad only has s t a t u t o r y a u t h o r i t y t o
suspend or revoke a l i c e n s e when someone e l e c t s t o f i l e
a complaint and where t h e Roard was able t o obtain information
t h a t would show cause t o suspend o r revoke t h e l i c e n s e .
Unless l e g i s l a t i o n i s passed t o give us the a u t h o r i t y t o
act on our own i n t h i s capacity, we do not f e e l we have
a u t h o r i t y t o monitor and/ or r e g u l a t e through independent
action and i n v e s t i g a t i o n n u r s i n g home a d m i n i s t r a t o r s performance
on the job.
Thank you f o r allowing us o u r i n p u t t o t h i s d r a f t .
Very t r u l y yours,
BOARD OF EYAXINERS FOR NURSING CARE
INSTITUTION ADMINSTRATORS
~ f i Lc. (~ ohnskon
Vice President
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