Virginia Board of Nursing Sanctioning Reference Points Manual

Sanctioning Reference Points Instruction Manual Board of Nursing Adopted March 2006 Revised March 2011 Revised June 2013 Revised January 2017 Revised July 2022 Guidance Document 90-7 Prepared for Virginia Department of Health Professions Perimeter Center 9960 Mayland Drive, Suite 300 Henrico Virginia 23233-1463 804-367-4400 dhp.virginia.gov Prepared by VisualResearch, Inc. Post Office Box 1025 Midlothian, Virginia 23113 804-794-3144

Foreword Roughly two decades ago, the Virginia Department of Health Professions approved a workplan to study sanctioning in disciplinary cases for Virginia’s 13 health regulatory boards. The purpose of the study was to “…provide an empirical, systematic analysis of board sanctions for offenses and, based on this analysis, to derive reference points for board members…” The purposes and goals of the study were consistent with state statutes which specify that the Board of Health Professions (BHP) periodically review the investigatory and disciplinary processes to ensure the protection of the public and the fair and equitable treatment of health professionals. For the Board of Nursing, VisualResearch, Inc. (VRI) collected and analyzed over 100 factors on recently sanctioned cases. The factors measured case seriousness, respondent characteristics, and prior disciplinary history. Those factors identified as consistently associated with sanctioning provided the foundation for the creation of Sanctioning Reference Points (SRPs). Using both the data and collective input from the Board of Nursing and staff, VRI analysts developed a usable set of sanction worksheets to implement the reference system. Over the years, the SRP system has been modified to continually reflect current board practice. To make modifications, VRI relies on completed SRP worksheets, coversheets and hard copy files. The Department of Health Professions established an agency directive (76-3.2) to ensure that all respondents were scored on the worksheet in all eligible cases. These completed worksheets are the foundation for modifications made to the SRP manual. The boards receive periodic feedback on SRP agreement rates and reasons for departure from worksheet recommendations. This most recent BON SRP manual contains updated worksheets for all professions regulated by the Board of Nursing. In addition, Licensed Massage Therapists now have a worksheet separate from other BON professions. Consequently, this new SRP manual contains various changes to the Board of Nursing's Sanctioning Reference Points system.

1 Nurses-CNA-RMA-LMT Table of Contents General Information Sanctioning Reference Points for CNAs Overview Using the SRP System for CNAs Background Goals Case Types Covered on the CNA Worksheet Methodology Qualitative Analysis Sanctioning Threshold Outcomes Quantitative Analysis Characteristics of SRP System SRP Coversheet for CNAs Sanctioning Ranges SRP Worksheet for CNAs Discretionary Nature SRP Worksheet Instructions for CNAs General Instructions for Using the SRP System Sanctioning Reference Points for RMAs Completing the Coversheet and Worksheet Using the SRP System RMAs Worksheets Worksheets Not Used in Certain Cases Case Types Covered on the RMA Worksheet Sanctioning Threshold Outcomes Sanctioning Reference Points for Nurses SRP Coversheet for RMAs Using the SRP System for Nurses SRP Worksheet for RMAs SRP Worksheet Instructions for RMAs Case Types Covered on the Nursing Worksheets Sanctioning Terms Sanctioning Reference Points for LMTs Using the SRP System for LMTs SRP Coversheet for Nurses SRP Inability to Safely Practice Worksheet for Nurses Case Types Covered on the LMT Worksheet SRP Inability to Safely Practice Worksheet Instructions for Nurses Sanctioning Threshold Outcomes SRP Patient Care Worksheet for Nurses SRP Patient Care Worksheet Instructions for Nurses SRP Coversheet for LMTs SRP Fraud Worksheet for Nurses SRP Worksheet for LMTs SRP Fraud Worksheet Instructions for Nurses SRP Worksheet Instructions for LMTs

2 Nurses-CNA-RMA-LMT General Information Overview The Virginia Board of Health Professions has spent the last 18 years studying sanctioning in disciplinary cases. This ongoing effort examines all 13 health regulatory boards. Focusing on the Board of Nursing (BON), this manual contains background on the project, the goals and purposes of the Sanctioning Reference Points (SRP) system, and revised worksheets with offense and respondent factors that are scored in order to help Board members determine how similarly situated respondents have been treated in the past. This SRP system is based on a specific sample of cases, and thus only applies to those persons sanctioned by the Virginia Board of Nursing. Moreover, the worksheet and sanctioning thresholds have not been tested or validated on any other groups of persons. Therefore, they should not be used to sanction respondents coming before other health regulatory boards, other states, or other disciplinary bodies. The current SRP system is comprised of a series of worksheets which score several offense and respondent factors identified using statistical analysis and built upon the Department's effort to maintain standards of practice over time. The original BON SRP Manual was developed for the Board of Nursing by studying and evaluating respondents as two separate groups, Nurses (RN and LPN) and Certified Nurse Aides (CNA). This manual reflects the study and evaluation of four separate professions within the BON: Nurses, CNAs, Registered Medication Aides (RMA) and Licensed Massage Therapists (LMT). Several reasons for this delineation include: • The Board of Nursing has additional adverse “Findings” available to them for sanctioning a CNA, including Findings of Abuse, Neglect, or Misappropriation of Property. When such a “Finding” is made by the Board, federal laws and regulations state that a CNA can no longer work in a federally funded long-term care facility. The functional effect is similar to losing one’s certificate, since these facilities are the primary employers of CNAs. • It became clear, both through the interview process and through data gathering, that the profession of Massage Therapist should be on a separate worksheet from nursing professions due to differences in the functional skills required, types of cases heard, and criteria considered when making sanctioning decisions. • RMAs continue to have a separate worksheet due to the specific case types that result from the unique RMA scope of practice. Because of the differences in case types, variability in sanctioning, and case volume, the SRP worksheets contained in this manual are unique to each profession analyzed. Worksheets make use of different factors for scoring resulting in variability in points allocated for similar factors. Worksheet structure across professions is consistent. Nurse, CNA, RMA and LMT worksheets all score a single case type as well as offense and respondent factors with sanctioning thresholds found at the bottom of each worksheet. Nursing SRPs are comprised of a series of three broader, case-specific worksheets where the other professions make use of a single SRP worksheet. Greater detail on use of each profession’s worksheet is included herein. Additionally, each profession has a separate coversheet available to record the case type, recommended sanction, actual sanction, and reasons for departure (if applicable). The completed coversheets and worksheets will be evaluated as part of an on-going effort to monitor and refine the SRPs. These instructions and the use of the SRP system fall within current DHP and BON policies and procedures. Furthermore, all sanctioning recommendations are those currently available to and used by the Board of Nursing and are specified within

3 Nurses-CNA-RMA-LMT existing Virginia statute. If an SRP worksheet recommendation is more or less severe than a Virginia statute or DHP regulation, the existing laws or regulations supersede the worksheet recommendation. Background When the Board of Nursing adopted the first SRP manual in 2006, it was understood that a sanctioning system of this type was not intended to be a static document. The culture of the professions regulated by the BON changes over time as do the case types, factors related to sanctioning, and the sanctioning decisions themselves. The BON recognizes that ongoing monitoring and updating of the SRP worksheets and manual will be an inherent part of the process of consistency and fairness in sanctioning its licensees with the goal of protecting the public. This current evaluation of the practices of the BON relied heavily on the coversheets and worksheets from recent cases that ended in violation and a great deal of Board member and staff input. The analysis resulted in changes to the manual for the BON. Goals In 2001, the Board of Health Professions and the Board of Nursing cited the following purposes and goals for establishing SRPs: • Making sanctioning decisions more predictable • Providing an education tool for new Board members • Adding an empirical element to a process/system that is inherently subjective • Providing a resource for the BON and those involved in proceedings • Neutralizing sanctioning inconsistencies • Validating Board member or staff recall of past cases • Reducing the influence of undesirable factors e.g., overall Board makeup, race, ethnic origin, etc. • Predicting future caseloads and need for probation services and terms Methodology The fundamental question when developing a sanctioning reference system is deciding whether the supporting analysis should be grounded in historical data (a descriptive approach) or whether it should be developed normatively (a prescriptive approach). A normative approach reflects what policymakers feel sanction recommendations should be as opposed to what they have been. SRPs can also be developed using historical data analysis with normative adjustments. This approach combines information from past practice with policy adjustments in order to achieve a more balanced outcome. Each adopted SRP manual has been based on a descriptive approach with a limited number of normative adjustments. Qualitative Analysis Researchers conducted in-depth interviews with BON members, LMT committee members, and Board staff. Researchers also had informal conversations with representatives from the Attorney General’s office and the Executive Director of the Board of Health Professions. The interview results were used to build consensus regarding the purpose and utility of SRPs and to further guide the study’s analysis. Additionally, interviews helped ensure the factors that board members consider when sanctioning continued to be included during the quantitative phase of the study. Previous scoring factors, in addition to newly recognized factors, were examined for their continued relevance and sanctioning influence.

4 Nurses-CNA-RMA-LMT Quantitative Analysis Over 100 different factors were collected on each case to describe the case attributes Board members identified as potentially impacting sanctioning decisions. Researchers used data available through DHP’s case management system combined with primary data collected from hard copy files. The hard copy files contained investigative reports, Board notices, Board orders, and all other documentation made available to Board members when deciding a case sanction. Researchers used 202 Nurse, 78 CNA, 39 RMA and 42 LMT cases previously adjudicated by Board members to create a comprehensive database to analyze the offense and respondent factors which were identified by interviewees as potentially influencing sanctioning decisions. That database was then merged with DHP's data system L2K, making more variables eligible for analysis. The resulting database was analyzed to determine any changes in Board sanctioning that may have had an effect on the worksheet recommendations. Using statistical analysis to construct a “historical portrait” of past sanctioning decisions, the significant factors along with their relative weights were derived. Those factors and weights were formulated into sanctioning worksheets, which became the SRPs. Offense factors such as patient harm, patient vulnerability and case severity (priority level) were analyzed, as well as respondent factors such as existence of substance abuse, impairment at the time of offense, initiation of self-corrective action, and prior history of the respondent. Although, a myriad of factors can help explain sanction variation, only those “legal” factors the Board felt should consistently play a role in sanctioning decisions continued to be included on the worksheets. By using this method, the goal was to achieve more neutrality in sanctioning by ensuring the Board considers the same set of “legal” factors in disciplinary cases that warrant sanctioning decisions. Characteristics of the SRP System Sanctioning Ranges The SRPs consider and weigh the circumstances of an offense and the relevant characteristics of the respondent, providing the Board with a sanctioning model that encompasses roughly 80% of historical practice. Recognizing that aggravating and mitigating factors play a legitimate role in sanctioning decisions, approximately 20% of past cases receive sanctions either higher or lower than what the reference points indicate. The wide sanctioning ranges allow the Board to customize a particular sanction within the broader SRP recommended range. Discretionary Nature The SRP system should be viewed strictly as a decision-making tool giving the Board of Nursing complete discretion at any time to choose a sanction outside the SRP range. The importance of appropriate coversheet and worksheet completion on every case eligible for scoring cannot be overstated. This includes cases resolved at an informal conference by special conference committees and agency subordinates, and by prehearing consent order offers delegated to and authorized by Board staff. The coversheet and worksheets will be used only after it is determined that a violation has occurred. The Board indicated early in the SRP study that sanctioning is not only influenced by circumstances directly associated with the case, but also by the respondent’s past history. The empirical analysis supports the notion that both offense and respondent factors impact sanctioning decisions. Subsequently, the SRPs combine case type, offense and respondent factor scores to arrive at a “Total Worksheet Score” which is then used to determine the statistically driven sanctioning recommendation. For example, a respondent before the Board for a standard of care case may also receive points for having a history of disciplinary violations.

5 Nurses-CNA-RMA-LMT General Instructions for Using the SRP System Completing the Coversheet and Worksheet Ultimately, it is the responsibility of the BON to complete the SRP coversheet and worksheet in all applicable cases. The information relied upon to complete a coversheet and worksheet is derived from the case packet provided to the Board and the respondent. It is also possible that information discovered at the time of the informal conference may impact worksheet scoring. The SRP coversheet and worksheet, once completed, are confidential under the Code of Virginia. Additionally, the manual, including blank coversheets and worksheets, can be found on the Department of Health Professions web site: www.dhp.state.va.us (paper copy also available on request). Worksheets The worksheets along with scoring instructions are included in subsequent sections of this manual. Detailed instructions are provided for each factor on a worksheet and should be referenced to ensure accurate scoring. The scoring weights assigned to a factor on the worksheet cannot be adjusted and can only be applied as ‘yes or no’ with all or none of the points applied. In instances when a scoring factor is difficult to interpret, the Board has final authority in how a case is scored. Worksheets Not Used in Certain Cases The SRPs are not applied in any of the following circumstances: ▪ Action by Another Board – When a case which has already been adjudicated by a Board from another state appears before the Virginia Board of Nursing, the Board often attempts to mirror the sanction handed down by the other Board. The Virginia Board of Nursing usually requires that all conditions set by the other Board are completed or complied with in Virginia. The SRPs do not apply to cases previously heard and adjudicated by another Board. ▪ Compliance/Reinstatement – The SRPs should be applied to new cases only. This included vacated stays of suspension due to HPMP noncompliance. ▪ Confidential Consent Agreements (CCA) – SRPs will not be used in cases settled by CCA. ▪ Mandatory Suspensions – Virginia law requires that under certain circumstances (conviction of a felony, declaration of legal incompetence or incapacitation, license revocation in another jurisdiction) the license must be suspended. The sanction is defined by law and is therefore excluded from the Sanctioning Reference Point system. ▪ Licensed nurse practitioners (LNPs) – SRPs will not be used in LNP cases.

6 Nurses for Nurses (RN and LPN)

7 Nurses Using the SRP System for Nurses The SRP System for Nurses should be utilized for Licensed Practical Nurses and Registered Nurses. There are three SRP worksheet options for Nurses. The worksheets are grouped by offense type: Inability to Safely Practice, Patient Care, and Fraud. This organization is based on the most recent historical analysis of Board sanctioning. The SRP factors found on each worksheet are those which proved important in determining sanctioning outcomes. When multiple cases have been combined for disposition by the Board into one order, only one coversheet and worksheet is completed that encompasses the entire event. In these instances, the worksheet completed is selected according to the case type group which appears furthest to the left on the following table. For example, a Nurse found in violation of both practicing on an expired license and patient deprivation would have their case scored on an Inability to Safely Practice worksheet, since Inability to Safely Practice is to the left of Fraud on the table. If an offense type is not listed, find the most analogous offense type and use the appropriate scoring worksheet. Case Types Covered on the Nursing Worksheets Patient Care Fraud Impairment due to use of alcohol, illegal substances, or prescription drugs or incapacitation due to mental, physical, or medical conditions. Violation of the Drug Control Act (DCA) (to include dispensing for non-medicinal purposes, not in accordance with dosage, or dispensing without a relationship), prescription forgery, drug adulteration, patient deprivation, stealing drugs from patients, or personal use. Theft or diversion of drugs when a patient is not involved (e.g., pharmacies, hospitals, or facilities). Diagnosis/Treatment: Instances in which the diagnosis/treatment was improper, delayed, or unsatisfactory. Also includes failure to diagnose/treat & other diagnosis/treatment issues. Medication/Prescription: Dispensing, and administration errors. Also includes improper management of patient regimen and failure to provide counseling as well as other medication/prescription related issues. Exceeding Scope: practicing outside the permitted functions of license granted. Inappropriate Relationship: Dual, sexual or other boundary issue. Includes inappropriate touching and written or oral communications. Abuse/Abandonment/Neglect: Any sexual assault, mistreatment of a patient, inappropriate termination of provider/patient relationship, leaving a patient unattended in a health-care environment, failure to do what a reasonable person would do in a similar situation. Leaving patients, walking off an assigned shift without notifying a supervisor. Unlicensed Activity: Practicing a profession or occupation without holding a valid license as required by statute or regulation to include: practicing on a revoked, suspended, lapsed, non-existent or expired license, as well as aiding and abetting the practice of unlicensed activity. Misappropriation of Patient Property: stealing or use of patient property without authorization. Fraud – Patient Care: Performing unwarranted/unjust services or the falsification/alteration of patient records. Fraud – Non-Patient Care: Improper patient billing and falsification of initial/renewal licensure or employment documents. Business Practice Issues: Advertising, solicitation, records, inspections, self-referral of patients, required report not filed, prescription blanks, or disclosure. Using a VA protected title without the corresponding license. Drug Related – Security: Failure to maintain security of controlled substances

8 Nurses The sanctioning reference points worksheet for Nurses allows a respondent to be assessed in two ways: by the specific nature of the case and by the number of offense and respondent factors that are present. First, the Board chooses a worksheet based on the type of case (e.g., inability to safely practice vs. fraud). Then, a specific case type can be scored on the chosen worksheet. For example, if a respondent is before the Board for drug adulteration, an Inability to Safely Practice worksheet is chosen for completion. If this drug adulteration involved a patient, Case Type “B” (Drug Related with Patient Care) would be scored for a value of 20 points. The Board scores only one case type from the case type list (the most serious that occurred) and as many offense and respondent factors that are founded during case deliberations. The sanctioning table on each of the worksheets contains point thresholds for determining which sanction is recommended. After considering the sanction grid recommendation, the Board then fashions a more detailed sanction based on the individual case circumstances. The sanctioning grids on the worksheets contain four general outcomes: • No Sanction/Monetary Penalty • Reprimand • Probation/Stayed Suspension/Terms • Refer to Formal Hearing/Revocation/Suspension/Surrender Sanctioning Terms For reference, the table below identifies a list of possible “Terms” for Nurses that may be part of the sanctioning decision. Upon selection and completion of the appropriate worksheet, a coversheet is prepared to ensure a uniform record of each case and to facilitate recordation of other pertinent information critical for continued system monitoring, evaluation and improvement. If the Board feels the sanctioning grid does not recommend an appropriate sanction, the Board should depart either high or low things as: severity of the incident, age of prior record, dishonesty/obstruction, motivation, remorse, multiple offenses/isolated incident. ▪ Continuing education ▪ Quarterly self reports ▪ Quarterly job performance evaluations ▪ License shall be visible online with wording “Probation with Terms” ▪ Inform Board of beginning or changing employment (10 days) ▪ Practice restriction - oversight by a provider or, if LPN, by an RN ▪ Provide current/future treating providers with copy of order ▪ Written notification to employer/employees/associates ▪ Impairment/incapacitation - evaluation ▪ Impairment - supervised unannounced drug screens ▪ Drug administration restrictions ▪ Impairment/incapacitation - therapy with progress reports ▪ Practice restriction - setting ▪ Impairment - Shall be active in AA/NA

9 Nurses Case Name: License Number: Patient CareFraudNo Sanction/Monetary PenaltyReprimandProbation/Stayed Suspension/TermsFormal Hearing/Loss of LicenseTermsReprimandOffer COSurrenderCase Method:Worksheet Used:Sanctioning Result:Imposed SRP Coversheet for Nurses

10 Nurses a.b. Drug Related with Patient Care 20 c. Drug Related without Patient Care 10 Offense/Respondent Score (score all that apply) a. License ever taken away 50 b. Case involved a mental health admission 40 c. Act of commission 30 d. Any prior Virginia Board violations 20 e. Past difficulties (substances, mental/physical) 15 f. Evidence of drug diversion 10 g. Respondent failed to initiate corrective action 10 h. Any action against the respondent (employer, criminal, civil) 10 (Case Type + Offense/Respondent)ReprimandProbationTermsSurrender141 and up61-140Score0-2021-60SRP Inability to Safely Practice Worksheet for Nurses

11 Nurses serious case type that is highest on the list. (See page 7 for an expanded list) a. Inability to Safely Practice 40 b. Drug Related Patient Care 20 c. Drug Related Without Patient Care 10 a. Enter “50” if the respondent’s license was previously revoked, suspended, or summarily suspended in any state. b. Enter “40” if the case involved a mental health admission. The admission can be either voluntary or a temporary detention order (TDO). c. Enter “30” if this was an act of commission. An act of commission is interpreted as purposeful or with knowledge. d. Enter “20” if the respondent has any prior orders issued by the Virginia Board of Nursing finding them in violation. e. Enter “15” if the respondent has had any past difficulties in the following areas: drugs, alcohol, mental capabilities or physical capabilities. Scored here would be prior convictions for DUI/DWI, inpatient/outpatient treatment, and bona fide mental health care for a condition affecting his/her abilities to function safely or properly. f. Enter “10” if there was evidence of drug diversion. This evidence can include but is not limited to taking too long to waste g. Enter “10” if the respondent failed to take corrective action prior to the time at which the SRP worksheet is being h. Enter “10” if any action was taken against the respondent. This action may include action by the employer, civil action, or a SRP Inability to Safely Practice Worksheet Instructions for Nurses

12 Nurses a. Inappropriate Relationship 50 b.c. Abuse/Abandonment/Neglect 30 a. License ever taken away 40 b. Act of commission 35 c. Past difficulties (substances, mental/physical) 30 d. Patient injury 25 e. Evidence of drug diversion 20 f. Any action against the respondent (employer, criminal, civil) 20 g. Any prior Virginia Board violations 5 h. Respondent failed to initiate corrective action 5 ReprimandProbationTermsSurrender141 and up71-14041-700-40ScoreSRP Patient Care Worksheet for Nurses

13 Nurses serious case type that is highest on the list. (See page 7 for an expanded list) a. Inappropriate Relationship 50 b. Standard of Care 45 c. Abuse/Abandonment/Neglect 30 a. Enter “40” if the respondent’s license was previously revoked, suspended, or summarily suspended in any state. b. Enter “35” if this was an act of commission. An act of commission is interpreted as purposeful or with knowledge. c. Enter “30” if the respondent has had any past difficulties in the following areas: drugs, alcohol, mental capabilities or physical capabilities. Scored here would be prior convictions for DUI/DWI, inpatient/outpatient treatment, and bona fide mental health care for a condition affecting his/her abilities to function safely or properly. d. Enter “25” if a patient was intentionally or unintentionally injured. Injury includes any physical injury, physical abuse and death. e. Enter “20” if there was evidence of drug diversion. This evidence can include, but is not limited to taking too long to waste f. Enter “20” if any action was taken against the respondent. This action may include action by the employer, civil action or a g. Enter “5” if the respondent has any prior orders issued by the Virginia Board of Nursing finding them in violation. h. Enter “5” if the respondent failed to take corrective action prior to the time at which the SRP worksheet is being SRP Patient Care Worksheet Instructions for Nurses

14 Nurses SRP Fraud Worksheet for Nurses a.b. Other Fraud 20 a. Act of commission 40 b. License ever taken away 35 c. Any patient involvement 30 d. Respondent failed to initiate corrective action 30 e. Any action against the respondent (employer, criminal, civil) 25 f. Any prior Virginia Board violations 25 g. Patient especially vulnerable 10 h. Evidence of drug diversion 10 ReprimandProbationTermsSurrender136 and up51-85Score0-5086-135

15 Nurses serious case type that is highest on the list. (See page 7 for an expanded list.) a. Misappropriation of Patient Property 30 b. Other Fraud 20 a. Enter “40” if this was an act of commission. An act of commission is interpreted as purposeful or with knowledge. b. Enter “35” if the respondent’s license was previously revoked, suspended, or summarily suspended in any state. c. Enter “30” if the offense involves a patient. Patient involvement is direct contact with a patient. d. Enter “30” if the respondent failed to take corrective action prior to the time at which the SRP worksheet is being e. Enter “25” if any action was taken against the respondent. This action may include action by the employer, civil action or a f. Enter “25” if the respondent has any prior orders issued by the Virginia Board of Nursing finding them in violation. g. Enter “10” if the patient is especially vulnerable. Patients in this category must be at least one of the following: under age 18, over age 65, or mentally/physically handicapped. h. Enter “10” if there was evidence of drug diversion. This evidence can include, but is not limited to taking too long to waste Complete the coversheet, including the grid sanction, the imposed sanction and the reasons for departure if applicable.SRP Fraud Worksheet Instructions for Nurses

16 CNAs for CNAs

17 CNAs Using the SRP System for CNAs A single sanctioning reference points worksheet is used to score all CNA disciplinary cases (unlike Nursing cases, which are scored on one of three different worksheets). When multiple cases have been combined for disposition by the Board into one order, enter the point value for the case type group which appears highest on the following table. One coversheet and worksheet are completed that encompasses the entire event. For instance, if a respondent is before the Board for both a Standard of Care and an Inability to Safely Practice violation, the Case Type selected would be Inability to Safely Practice. This table is used for CNAs only. Case Types Covered on the CNA Worksheet Dual, sexual or other boundary issue. Includes inappropriate touching and written or oral communications Stealing or use of patient property without authorization incapacitation due to mental, physical or medical conditions. Prescription forgery, drug adulteration, patient deprivation, stealing drugs from patients Theft or diversion of drugs when a patient is not involved (e.g., pharmacies, hospitals, or facilities). Neglect Leaving a patient unattended in a health-care environment. Failure to provide assistance to a patient(s) in need. Verbal Violation Leaving patients, walking off an assigned shift without notifying a supervisor. Instances in which the diagnosis/treatment was improper, delayed, or unsatisfactory. Also includes failure to diagnose/treat & other diagnosis/treatment issues Practicing without holding a valid certificate as required by statute or regulation to include: practicing on a revoked, suspended, lapsed, non-existent or expired certificate, as well as aiding and abetting the practice of unlicensed activity Improper patient billing or falsification of initial/renewal licensure or employment documents Disclosing unauthorized client information without permission or necessity The sanctioning reference points worksheet for CNAs allows a respondent to be assessed in two ways: by the nature of the case (e.g., inability to safely practice vs. abuse) and by the number of offense and respondent factors that are present. The Board scores only one case type from the case type list (the most serious that occurred) and as many offense and respondent factors that are founded during case deliberations.

18 CNAs The CNA worksheet has three thresholds with increasing point values and respectively increasing sanction severities. The table below shows threshold scores leading to the available sanctions. After considering the sanction grid recommendation, the Board should fashion a more detailed sanction(s) based on the individual case circumstances. Sanctioning Thresholds for CNAs Score Sanctioning Recommendation 0-100 Probation Take no Action Terms: ▪ Certificate shall be visible online with wording “Probation with Terms” ▪ inform Board of beginning or changing employment (10 days) ▪ provide current/future treating practitioners with copy of order ▪ written notification to employer/employees/associates ▪ impairment/incapacitation - evaluation ▪ impairment - supervised unannounced drug screens ▪ drug administration restrictions ▪ impairment/incapacitation - therapy with progress reports ▪ practice restriction - setting ▪ impairment - Shall be active in AA/NA 101-149 Reprimand Refer to Formal Surrender Finding of Misappropriation of Patient Property If the Board feels the sanctioning grid does not recommend an appropriate sanction, the Board may depart either high or low • Severity of the incident • Remorse • Age of prior record • Cause for the action • Dishonesty/Obstruction • Multiple offenses/Isolated incident

19 CNAs Case Name: Certificate Number: Case Type: Abuse/Inappropriate RelationshipNeglectVerbal Violations0-100101-149TermsReprimandOffer COSurrenderFinding of MisappropriationCase Method:Sanction Threshold Level:Imposed SRP Coversheet for CNAs

20 CNAs a. Abuse/Inappropriate Relationship 70 b. Misappropriation of Patient Property 60 c. Inability to Safely Practice 50 d. Neglect 40 e. Verbal Violation 30 f. Abandonment/Standard of Care/Fraud 10 Offense/Respondent Score (score all that apply) a. Act of commission 60 b. Patient injury 50 c. Impaired while practicing 45 d. Respondent failed to initiate corrective action 40 e. Any patient involvement 30 ProbationTermsSurrenderFinding of MisappropriationReprimandScore0-100101-149SRP Worksheet for CNAs

21 CNAs serious case type that is highest on the list. (See page 17 for an expanded list.) a. b. c. d. Neglect e. Verbal Violation f. a. Enter “60” if this was an act of commission. An act of commission is interpreted as purposeful or with knowledge. b. Enter “50” if a patient was intentionally or unintentionally injured. Injury includes any physical injury, physical abuse and death. c. Enter "45" if the respondent was impaired while practicing. Score this factor only if the respondent was at work during the time of impairment. Impairment includes substance abuse (alcohol or drugs) or mental/physical incapacitation. d. Enter “40” if the respondent failed to take corrective action prior to the time at which the SRP worksheet is being e. Enter “30” if the offense involved a patient. Examples of patient involvement may include direct contact with a patient, misappropriation of patient property, falsifying patient records, etc. Worksheet Score of 120 is recommended for “Reprimand.” SRP Worksheet Instructions for CNAs

22 RMAs for Registered Medication Aides

23 RMAs Using the SRP System for RMAs A single sanctioning reference points worksheet is used to score all Registered Medication Aide (RMA) disciplinary cases (unlike Nursing cases, which are scored on one of three different worksheets). When one respondent’s multiple cases have been combined for disposition by the Board into one order, enter the point value for the case type group which appears highest on the following table. Only one coversheet and worksheet are completed that encompasses the entire event. For instance, if a respondent is before the Board for both a Standard of Care and an Inability to Safely Practice violation, the Case Type selected would be Inability to Safely Practice. This table is used for RMAs only. Case Types Covered on the RMA Worksheet incapacitation due to mental, physical, or medical conditions. Prescription forgery, drug adulteration, patient deprivation, stealing drugs from patients, or personal use Theft or diversion of drugs when a patient is not involved (e.g., pharmacies, hospitals, or facilities). Verbal Violation/Neglect Leaving a patient unattended in a health-care environment. Failure to provide assistance to patient(s) in need. Instances in which the medication administration or diagnosis/treatment was improper, delayed, or unsatisfactory. Also includes failure to diagnose/treat & other diagnosis/treatment issues Medication dispensing and/or administration errors. Also includes improper management of patient medication regimen as well as other medication/prescription-related issues. Performing unwarranted/unjust services or the falsification/alteration of patient records. Leaving patients, walking off an assigned shift without informing a supervisor. Misappropriation of Patient Property/Fraud Stealing or use of patient property without authorization Improper patient billing or falsification of initial/renewal licensure or employment documents Practicing a profession or occupation without holding a valid registration as required by statute or regulation to include: practicing on a revoked, suspended, lapsed, non-existent or expired registration, as well as aiding and abetting the practice of unlicensed activity. Disclosing unauthorized client information without permission or necessity.

24 RMAs The sanctioning reference points worksheet for RMAs allows a respondent to be assessed in two ways: by the nature of the case (e.g., inability to safely practice vs. standard of care) and by the number of offense/respondent factors that are present. The board scores only one case type from the case type list (the most serious that occurred) and as many offense and respondent factors that are founded during case deliberations. The RMA worksheet has four thresholds with increasing point values and correspondingly increasing sanction severities. The table below shows threshold scores leading to the available sanctions. After considering the sanction grid recommendation, the Board should fashion a more detailed sanction(s) based on the individual case circumstances. Sanctioning Thresholds for RMAs Score Sanctioning Recommendation 0-15 16-50 Reprimand 51-70 Probation Terms ▪ Registration shall be visible online with wording “Probation with Terms” ▪ inform Board of beginning or changing employment (10 days) ▪ provide current/future treating practitioners with copy of order ▪ written notification to employer/employees/associates ▪ impairment/incapacitation - evaluation ▪ impairment - supervised unannounced drug screens ▪ drug administration restrictions ▪ impairment/incapacitation - therapy with progress reports ▪ practice restriction - setting ▪ Shall be active in AA/NA 71 and up Surrender If the Board feels the sanctioning grid does not recommend an appropriate sanction, the Board may depart either high or low ▪ Severity of the incident ▪ Age of prior record ▪ Dishonesty/Obstruction ▪ Motivation ▪ Remorse ▪ Cause for the action ▪ Multiple offenses/Isolated incident

25 RMAs Case Name: Certificate or Registration Number: Case Type:Verbal Violations/NeglectMisappropriation of Property/Fraud0-1516-5051-7071 and upTermsReprimandOffer COSurrenderCase Method:Sanction Threshold Level:Imposed SRP Coversheet for RMAs

26 RMAs a. Inability to Safely Practice 50 b. Physical Abuse 40 c. Verbal Violation/Neglect 25 d. Standard of Care/Abandonment 15 e. Misappropriation of Patient Property/Fraud 10 f. Unlicensed Activity 5 a. Patient injury 40 b. Evidence of drug diversion 25 c. Any action against the respondent (employer, criminal, civil) 10 d. Act of commission 10 e. Any patient involvement 10 f. Past difficulties (substances, mental/physical) 5 g. Financial or material gain 5 h. Respondent failed to initiate corrective action 5 ReprimandProbationTermsSurrender71 and up51-70Score0-1516-50SRP Worksheet for RMAs

27 RMAs serious case type that is highest on the list. (See page 23 for an expanded list.) a. b. c. Verbal Violations/Neglect d. e. Misappropriation of Patient Property/Fraud f. a. Enter “40” if a patient was intentionally or unintentionally injured. Injury includes any physical injury, physical abuse and death. b. Enter “25” if there was evidence of drug diversion. This evidence can include, but is not limited to taking too long to waste controlled substances, suspicious amounts of controlled substances being pulled, pulling medication for patients other than your own, outside of the medical directive, without pain assessments, excessive wastage, suspicious c. Enter “10” if any action was taken against the respondent. This action may include action by the employer, civil action, or a criminal conviction related to this offense. This factor includes respondents pleading guilty with first offender status. d. Enter “10” if this was an act of commission. An act of commission is interpreted as purposeful or with knowledge. e. Enter “10” if the offense involves a patient. Examples of patient involvement may include direct contact with a patient, misappropriation of patient property, falsifying patient records, etc. f. Enter “5” if the respondent has had any past difficulties in the following areas: drugs, alcohol, mental capabilities or physical capabilities. Scored here would be prior convictions for DUI/DWI, inpatient/outpatient treatment, and bona fide mental health care for a condition affecting his/her abilities to function safely or properly. g. Enter “5” if the respondent's motivation for the violation was financial or material gain. h. Enter “5” if the respondent failed to take corrective action prior to the time at which the SRP worksheet is being Worksheet Score of 20 is recommended for “Reprimand.” Complete the coversheet, including the grid sanction, the imposed sanction, and the reasons for departure if applicable.SRP Worksheet Instructions for RMAs

28 LMTs for Licensed Massage Therapists

29 LMTs Using the SRP System for LMTs A single sanctioning reference points worksheet is used to score all Licensed Massage Therapists (LMT) disciplinary cases (unlike Nursing cases, which are scored on one of three different worksheets). When one respondent’s multiple cases have been combined for disposition by the Board into one order, enter the point value for the case type group which appears highest on the following table. One coversheet and worksheet comprise the entire event. For instance, if a respondent is before the Board for both a Standard of Care and an Inability to Safely Practice violation, the Case Type selected would be Inability to Safely Practice. This table is used for LMTs only. Case Types Covered on the LMT Worksheet Dual, sexual or other boundary issue. Includes inappropriate touching and/or communication, written or oral incapacitation due to mental, physical or medical conditions. Prescription forgery, stealing drugs from patients, or personal use Theft or diversion of drugs when a patient is not involved (e.g., pharmacies, hospitals, or facilities). Improper patient billing or falsification of initial/renewal licensure or employment documents. Failure to obtain or document CE requirements. Instances in which the diagnosis/treatment was improper, delayed, or unsatisfactory. Also includes failure to diagnose/treat & other diagnosis/treatment issues. This includes, but is not limited to: failure to consider medical history, inappropriate technique, lack of informed consent, and practicing beyond the scope Practicing a profession or occupation without holding a valid license as required by statute or regulation to include: practicing on a revoked, suspended, lapsed, non-existent or expired license, as well as aiding and abetting the practice of unlicensed activity. The sanctioning reference points worksheet for LMTs allows a respondent to be assessed in two ways: by the nature of the case (e.g., inability to safely practice vs. standard of care) and by the number of offense and respondent factors that are present. The Board scores only one case type from the case type list (the most serious that occurred) and as many offense and respondent factors that are founded during case deliberations. The LMT worksheet has three thresholds with increasing point values and correspondingly increasing sanction severities. The table below shows threshold scores leading to the available sanctions. After considering the sanction grid recommendation, the Board should fashion a more detailed sanction(s) based on the individual case circumstances.

30 LMTs Sanctioning Thresholds for LMTs 0-50 Reprimand 51-85 Probation Terms ▪ License shall be visible online with wording “Probation with Terms” ▪ inform Board of beginning or changing employment (10 days) ▪ provide current/future treating practitioners with copy of order ▪ written notification to employer/employees/associates ▪ impairment/incapacitation – evaluation ▪ impairment – supervised unannounced drug screens ▪ impairment/incapacitation – therapy with progress reports ▪ practice restriction – setting ▪ Shall be active in AA/NA 86 and up Surrender If the Board feels the sanction recommendation is not appropriate, the Board may depart either high or low when handing down a sanction. If the Board disagrees with the sanction recommendation and imposes a sanction greater or less than the recommended sanction, “Yes” should be checked and a short explanation should be recorded on the coversheet. The explanation could identify the factors and the reasons for departure. This process will ensure the worksheet is revised appropriately to reflect current Board practice. If a particular reason is continually cited, the Board can examine the issue more closely to determine if the worksheet should be modified to better reflect Board practice. • Severity of the incident • Age of prior record • Dishonesty/Obstruction • Motivation • Remorse • Cause for the action • Multiple offenses/Isolated incident A space is provided on the coversheet to record the reason(s) for departure. Due to the uniqueness of each case, the reason(s) for departure may be wide-ranging.

31 LMTs Case Name: Certificate or Registration Number: Case Type:0-5051-8586 and upTermsReprimandOffer COSurrenderCase Method:Sanction Threshold Level:Imposed SRP Coversheet for LMTs

32 LMTs a. Abuse/Inappropriate Relationship 50 b. Inability to Safely Practice 35 c. Fraud/Continuing Education 25 d. Standard of Care 15 e. Unlicensed Activity 10 a. Concurrent criminal conviction 40 b. Past difficulties (substances, mental/physical) 30 c. Case involved a mental health admission 25 d. Concurrent action by employer 20 e. Act of commission 15 f. Respondent failed to initiate corrective action 15 g. License ever taken away by any state 10 h. Financial or material gain 10 i. Any prior Virginia Board violations 10 j. Patient physical injury 10 ReprimandProbationTermsSurrender86 and upScore51-850-50SRP Worksheet for LMTs

33 LMTs serious case type that is highest on the list. (See page 29 for an expanded list.) a. b. c. d. e. a. Enter "40" if the respondent received a criminal conviction related to this offense. This factor includes respondents pleading guilty with first offender status. b. Enter “30” if the respondent has had any past difficulties in the following areas: drugs, alcohol, mental capabilities or physical capabilities. Scored here would be prior convictions for DUI/DWI, inpatient/outpatient treatment, and bona fide mental health care for a condition affecting his/her abilities to function safely or properly. c. Enter “25” if the case involved a mental health admission. The admission can be either voluntary or a temporary detention order (TDO). d. Enter “20” if the respondent received any action from his/her employer in response to the current incident. This may include, but is not limited to: suspension, termination, or disciplinary counseling notice. e. Enter “15” if this was an act of commission. An act of commission is interpreted as purposeful or with knowledge. f. Enter “15” if the respondent failed to take corrective action prior to the time at which the SRP worksheet is being g. Enter “10” if the respondent’s LMT license was previously revoked, suspended, or summarily suspended in any state or if any license type was previously revoked by the Virginia Department of Health Professions. h. Enter "10" if the respondent's motivation for the violation was financial or material gain. i. Enter “10” if the respondent has any prior orders issued by the Virginia Board of Nursing finding them in violation. j. Enter “10” if a patient was intentionally or unintentionally injured. Injury includes, but is not limited to, any physical injury that requires first aid, subsequent treatment, and emergency care. Worksheet Score of 70 is recommended for “Probation/Stayed Suspension/Terms.” Complete the coversheet, including the grid sanction, the imposed sanction, and the reasons for departure if applicable. SRP Worksheet Instructions for LMTs