Audit blasts monitoring of troubled licensees, identifies 10 solutions

An independent audit of an Oregon Board of Nursing program that monitors addicted nurses while allowing them to stay on the job paints a picture of a loosely run program that allows the nurses to continue working with 'limited oversight.'

The audit of the board's nurse monitoring program cited overworked case managers unable to consistently keep track of the nurses they are supposed to monitor.

The audit said that lacking adequate program guidelines, case managers are left to make critical decisions on whether nurses can stay on the job without endangering patients based on their individual judgment rather than established criteria.

The audit found that the monitoring program even lacks standards to determine which addiction and mental health professionals should be eligible to treat participating nurses, and what to do about addicted nurses who relapse while in the program.

Despite the report's critical findings, the Board of Nursing members had little reaction when auditor Brad Rafish presented the results at Thursday's board meeting. Most said they had not read the report, which had been delivered to them Wednesday evening.

Joan Bouchard, executive director of the board, said she believed the audit results did not demand an immediate response. 'I think the audit shows there are no emergencies or huge fires here,' Bouchard told the board.

In a Friday interview, Bouchard said she thought the report was fair. 'I think it's going to be helpful to us,' she said. 'It pointed out that we need more resources, and we know that.' Bouchard said that in June the board submitted its budget for the next two years, but that she would pursue avenues to increase the legislative request.

Problems with the Board of Nursing's nurse monitoring program were first brought to light by a series published last spring in the Portland Tribune.

The Tribune investigation revealed that some participants in the monitoring program remained on the job despite repeated drug and alcohol relapses and, in some cases, mistreatment of patients. At the time, Board of Nursing officials denied allegations of lax oversight.

But the board did allocate $68,000 to hire Rafish's firm, Talbot, Korvola and Warwick. The board also has formed its own nurse monitoring task force to look at the program.

150 nurses make up caseload

The nurse monitoring program is designed to allow nurses who come forward with alcohol and drug addictions to remain working while they receive treatment.

The program also is available to nurses suffering from mental illness.

The audit cited 'high caseloads and minimal monitoring' among the program's deficiencies.

The audit said a 'lack of timely reporting' made it difficult for case managers to keep track of whether nurses comply with their treatment plans and monitoring contracts.

Even regular urine screenings for drugs, a requirement for nurses in the program, are not always tracked, according to the audit. Each program coordinator, according to the audit, is responsible for monitoring about 150 nurses.

'The lack of timely reporting can hinder the ability of program coordinators to identify potential safety issues and heighten the risk of a participant practicing while impaired,' the audit noted.

Hirings, firings not reported

The Tribune series reported that nurses in the monitoring program can move from job to job without board knowledge, and that sometimes employers were not even aware that nurses they had hired were in the monitoring program and suffering addictions.

The audit confirmed the charges and suggested that employers be required to report whenever they hire or fire a nurse.

The audit made 10 recommendations in all, and made clear that for the program to work, additional money will be necessary. The audit recommended the board ask the Legislature for additional funding for a program coordinator and increased office staff.

Among the audit's findings:

• Nurses in the monitoring program are required to be undergoing treatment for their addictions and mental illnesses, but according to the audit the nurses themselves are allowed to select their treatment providers.

'The (Board of Nursing) has established no specific criteria for provider qualifications or competency,' the audit read. The audit's recommendation: that the board establish standards for treatment plans and providers, and a list of providers the board considers qualified to treat nurses.

• The audit noted that other state programs require participants to attend support groups as part of their treatment plan, but the nurse monitoring program does not. The audit recommended that support groups for addicted nurses be established and participation be required for nurses in the monitoring program.

Two issues raised by the Tribune series were not addressed in the audit.

Rather than run their own programs to monitor addicted licensees, many boards that oversee health professionals choose to contract with separate entities, often private businesses, that specialize in running addiction programs. For example, the Oregon Board of Medical Examiners, which oversees the state's physicians, contracts with the Oregon Health Professionals Program to do its monitoring.

Some experts believe that since public protection is supposed to be the board's first concern, separating the board from management of the monitoring program avoids any possible conflicts of interest.

Also, the Tribune series discovered that many nurses in the monitoring program find work in long-term care facilities such as nursing homes, where they often are the only nurse on duty and thus have little supervision. On-the-job supervision is supposed to be a requirement of the program.

Rafish said the scope of his investigation was established by the Board of Nursing, and that he was not directed to look specifically at those two issues. His audit did note, however, that nearly one in five nurses enrolled in the monitoring program works in a long-term care facility.

Executive Director Bouchard said the board's nurse monitoring task force would study the issue of where nurses are allowed to work while in the monitoring program.

Investigations said to be slow

In addition to the audit of the nurse monitoring program, Rafish presented the board with an audit of how it investigates and disciplines all nurses who have been the subject of complaints.

In that report, Rafish found that the board's overall approach to investigating and disciplining nurses about whom complaints have been made appeared to be 'fair,' but the board's lack of staff and antiquated record-keeping made it too slow.

'The current design and resources do not allow complaints to be processed in an efficient and effective manner,' the audit said.

Some disciplinary cases took almost three years to close, and the average was nearly a year, according to the audit. The Board of Nursing is required by rule to process complaints within 120 days, though extensions are permitted.

The audit also recommended the board put in place protocols that will make clear to nurses who have been the subjects of complaints that they must cooperate with the board. One out of every four nurses who were sent a letter about a complaint lodged against them did not respond.

The audit also recommended the board hire a new lead investigator with a law-enforcement or legal background to oversee the current investigators, all of whom are nurses.

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