STATE OF TENNESSEE

STATE OF TENNESSEE

COMPTROLLER OF THE TREASURY

BOARD OF NURSING AND INTERSTATE NURSE LICENSURE COMPACT

Performance Audit Report September 2017

Justin P. Wilson, Comptroller

Division of State Audit Sunset Performance Section

DEBORAH V. LOVELESS, CPA, CGFM, CGMA Director

JOSEPH SCHUSSLER, CPA, CGFM Assistant Director

SANDRA TULLOSS Audit Manager

Janora Bryson In-Charge Auditor

Lisa Williams, CGFM, CFE Staff Auditor

Amy Brack Editor

Amanda Adams Assistant Editor

Comptroller of the Treasury, Division of State Audit Suite 1500, James K. Polk State Office Building 505 Deaderick St. Nashville, TN 37243-1402 (615) 401-7897

Reports are available at ptroller.sa/AuditReportCategories.asp

Mission Statement The mission of the Comptroller's Office is

to make government work better.

Comptroller Website ptroller.

STATE OF TENNESSEE

COMPTROLLER OF THE TREASURY

DEPARTMENT OF AUDIT DIVISION OF STATE AUDIT

S U I T E 1 5 0 0 , JAMES K. POLK STATE OFFICE BUILDING 505 DEADERICK STREET

NASHVILLE, TENNESSEE 37243-1402

PHONE (615) 401-7897 FAX (615) 532-2765

September 14, 2017

The Honorable Randy McNally Speaker of the Senate The Honorable Beth Harwell Speaker of the House of Representatives The Honorable Mike Bell, Chair Senate Committee on Government

Operations The Honorable Jeremy Faison, Chair House Committee on Government

Operations and

Members of the General Assembly State Capitol Nashville, Tennessee 37243

and

Elizabeth Lund, RN Executive Director Board of Nursing 665 Mainstream Dr. Nashville, TN 37243

and Brent Earwood, RN, APRN Board Chair Board of Nursing 119 Bascom Road Jackson, TN 38305

and Juanita Turnipseed, RN, APRN Vice Chair Board of Nursing 8817 Ivy Mount Lane Nolensville, TN 37135

Ladies and Gentlemen:

Transmitted herewith is the performance audit of the Board of Nursing and the Interstate Nurse Licensure Compact. This audit was conducted pursuant to the requirements of the Tennessee Governmental Entity Review Law, Section 4-29-111, Tennessee Code Annotated.

This report is intended to aid the Joint Government Operations Committee in its review to determine whether the Board of Nursing and the Interstate Nurse Licensure Compact should be continued, restructured, or terminated.

Sincerely,

17262

Deborah V. Loveless, CPA Director

State of Tennessee

Audit Highlights

Comptroller of the Treasury

Division of State Audit

Performance Audit Board of Nursing

and Interstate Nurse Licensure Compact

September 2017

_________

FINDINGS

Board of Nursing

Department of Health management cannot effectively monitor licensees and board operations because of inherent limitations of the Licensure and Regulatory System In 2015, the Department of Health implemented a computer system called the Licensure and Regulatory System (LARS) to store the licensure information for all of the state's health professions. We evaluated LARS and found that it had two flaws. First, information was unintentionally removed from users' screens when changes were made to parts of the system, causing staff confusion about data fields within the system. Second, the system had limited reporting capabilities, which lessened management's ability to monitor the department's performance (page 4).

The Department of Health's Office of Investigations should ensure all investigations are completed in a timely manner and improve its monitoring of disciplined practitioners The Department of Health's Office of Investigations (the office) reviews and investigates complaints that are brought against licensed and unlicensed practitioners. We reviewed how the department processes and conducts nurse investigations and how it monitors disciplined practitioners. We found that some investigations were not completed on time. In addition, the Licensure and Regulatory System had not been updated to assign new priority levels to investigations. Finally, we found that while the department hired additional office staff to monitor licensees subject to disciplinary actions, this monitoring remained manual (page 6).

Board of Nursing management does not know true application processing time because the Licensure and Regulatory System does not record the date paper applications were received The Division of Health Related Boards' administrative staff is responsible for processing licensure and certification applications. This includes entering key information about the applicant and application into the Licensure and Regulatory System. We determined that LARS does not capture the date that paper based applications are received by the board. Rather, LARS only captures the date the staff began processing the application. In our sample, we determined that there can be a significant time difference between when paper applications are received by the board and when they are entered into LARS by technicians. As a result, the department needs to be able to systematically monitor actual processing times. Without the information about receipt date for paper based applications in LARS or some other mechanism, department management does not have a full view of the process (page 11).

The Board of Nursing should consider using the National Practitioner Data Bank when conducting background checks on potential licensees The December 2009 performance audit of the Health Related Boards recommended that the state's health boards consider using the National Practitioner Data Bank to obtain information on applicants' licensing and disciplinary history in other states. In lieu of querying the National Practitioner Data Bank when reviewing applicants' backgrounds, the Board of Nursing queries the National Council of State Boards of Nursing's database, called Nursys. While Nursys provides potentially helpful information, it does not contain information about all nursing professions. As a result, Nursys may give an incomplete history of an applicant in other states (page 12).

Interstate Nurse Licensure Compact

The enhanced nursing compact is expected to become effective in January 2018, necessitating its addition to the Tennessee Governmental Entity Review Law The National Council of State Boards of Nursing created the Interstate Nurse License Compact (the compact currently in place) in 2000 to allow registered nurses and licensed practical nurses to practice in all signatory states using one multistate license. In May 2015, the National Council of State Boards developed a new, enhanced compact, the Nurse Licensure Compact, which is intended to replace the original compact. The enhanced compact's commission is expected to convene in August 2017 to set an effective date of approximately January 28, 2018. Upon its implementation, Tennessee Code Annotated provides that the enhanced compact automatically goes into effect and the current compact terminates. However, the new, enhanced compact does not have a scheduled termination date in the Tennessee Governmental Entity Review Law (page 15).

Performance Audit Board of Nursing

and Interstate Nurse Licensure Compact

TABLE OF CONTENTS

Page

INTRODUCTION

1

Purpose and Authority for the Audit

1

Organization and Statutory Responsibilities

1

AUDIT SCOPE

3

PRIOR AUDIT FINDINGS

3

OBJECTIVES, METHODOLOGIES, AND CONCLUSIONS

4

Board of Nursing

4

Licensure and Regulatory System

4

Finding 1 ? Department of Health management cannot effectively

monitor licensees and board operations because of inherent

limitations of the Licensure and Regulatory System

4

Investigations and Disciplinary Monitoring

6

Finding 2 ? The Department of Health's Office of Investigations should

ensure all investigations are completed in a timely manner

and improve its monitoring of disciplined practitioners

6

Licensure Application Process

10

Finding 3 ? Board of Nursing management does not know true

application processing time because the Licensure and

Regulatory System does not record the date paper

applications were received

11

TABLE OF CONTENTS (Continued)

Page

Finding 4 ? The Board of Nursing should consider using the National

Practitioner Data Bank when conducting background checks

on potential licensees

12

Regulation of Public School Nurses

13

Interstate Nurse Licensure Compact

14

Finding 5 ? The enhanced nursing compact is expected to become

effective in January 2018, necessitating its addition to the

Tennessee Governmental Entity Review Law

15

APPENDICES

16

Appendix 1 ? Board of Nursing Members

16

Appendix 2 ? Active Nursing Licensees

17

Appendix 3 ? Board of Nursing Licensure and Certification Fees

17

Appendix 4 ? Board of Nursing Financial Information

18

Performance Audit Board of Nursing

and Interstate Nurse Licensure Compact

INTRODUCTION

PURPOSE AND AUTHORITY FOR THE AUDIT

This performance audit of the Board of Nursing and the Interstate Nurse Licensure Compact was conducted pursuant to the Tennessee Governmental Entity Review Law, Title 4, Chapter 29, Tennessee Code Annotated. Under Section 4-29-239 (a)(2), the Board of Nursing is scheduled to terminate June 30, 2018. Under Section 4-29-239(a)(27), the Interstate Nurse Licensure Compact is scheduled to terminate on June 30, 2018. However, in January 2018, the Interstate Nurse Licensure Compact is expected to be repealed and replaced by the Enhanced Nurse Licensure Compact, pursuant to Title 63, Chapter 7, Parts 3 and 4, Tennessee Code Annotated. The new compact does not yet have a scheduled termination date.

The Comptroller of the Treasury is authorized under Section 4-29-111 to conduct a limited program review audit of the Board of Nursing and the Interstate Nurse Licensure Compact and to report to the Joint Government Operations Committee of the General Assembly. This audit is intended to aid the committee in determining whether the Board of Nursing and the Interstate Nurse Licensure Compact should be continued, restructured, or terminated.

ORGANIZATION AND STATUTORY RESPONSIBILITIES

The Board of Nursing was created in 1911 and is authorized by Section 63-7-201, Tennessee Code Annotated. Its mission is to "safeguard the health, safety and welfare of Tennesseans by requiring that all who practice nursing within this state are qualified and licensed to practice." The board is composed of 10 board members who have at least 5 years of experience as a registered nurse, advanced practice nurse, or licensed practical nurse, and 1 consumer member. See Appendix 1 (page 16) for the current board composition, and Appendix 2 (page 17) for the statitistics and descriptions of the various licenses. The Department of Health's Division of Health Related Boards oversees the administrative staff that assists the board with the licensure, education, and practice of the more than 140,000 nurses who are licensed in the state.

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