Enforcement Issues with Interstate Licensing 

Nurse Licensure Compacts (NLC) compliance risks

CJ Wolf, MD provides enforcement action summaries for the YouCompli blog. These summaries provide real-world examples of regulators’ response to practices that don’t fully comply with regulations. This month’s article looks at interstate licensing actions. 

The United States has a nursing shortage. Before the COVID pandemic, many openings were due to retiring nurses coming to the end of a long career. Now, many more nurses are leaving the profession due to burnout. Positions for traveling nurses are on the rise to fill gaps throughout the country.  

The Nurse Licensure Compact (NLC) allows nurses to have one multistate license with the ability to practice in their home state and other compact states. As of this writing, 39 jurisdictions (mostly states) are part of the NLC. Many other states have pending legislation. In an oversimplified sense, this means a nurse with a multi-state license can practice nursing in the other states in the NLC.  

However, this does not come without some risks. For the individual nurse, the risks include fines, loss of license and even jail where criminal activity is involved. For healthcare organizations, the risks include apprehension on the part of nurses and subsequent loss of nurses, nurses being fined or disciplined by state nursing boards, and potential reputational harm for healthcare organizations. As well, fines or criminal charges apply in some more severe cases.

Nurses banned in one state, practicing in another  

One of the major risks includes disciplinary action in one state not being communicated or acted upon in a timely fashion in another state. A nurse might jump to another participating jurisdiction to practice. The watch dog journalist group ProPublica and USA Today co-published some examples of nurses facing disciplinary action for this behavior.  

In one case, a nurse was banned in Arizona after multiple incidents at five different hospitals in the state. Doctors and other staff reportedly requested this nurse not be assigned to certain patients. Reports included failing orientation, not reporting for work, and scaring a patient whose catheter the nurse removed. Even after being banned in Arizona, the nurse, under a different last name, held a multistate license in Maryland. 

In another case, a nurse in a Dallas hospital administered a medication (undiluted vitamin K) too quickly. The patient died a short time later. The nurse had her Texas license suspended as a result. The following year the nurse was placed on probation in California because of the discipline that took place in Texas. However, she had a clear multistate license in Iowa. According to the reports, the nurse said she notified the Iowa nursing board about the incident in Texas. According to her, the Iowa board chose not to do anything. It was also reported that the Iowa board would not comment for the story due to privacy restrictions. 

Compliance officers should watch for: Nurses who have either lost licensure in one state, appear to be hopping around from state to state, or have citations and discipline from nursing boards in other states.  

Incomplete paperwork leads to nursing licensure restrictions 

A nurse licensed in Virginia was charged in Texas with practicing without a valid license. The nurse had begun the paperwork to change her primary residence to Texas. The Texas Board of Nursing issued an Agreed Eligibility Order, but the nurse failed to complete all the other required actions to endorse her license in Texas. The failure to complete the paperwork led to disciplinary action by the Texas Board of Nursing. 

In a different case about paperwork, the timing of the paperwork was at issue. In this case, an RN from Virginia was seeking endorsement for a privilege to practice in Texas. The allegation in the case was the nurse failed to apply for licensure in Texas within 30 days of establishing residence as required by Texas at the time. The nurse was charged by the Board of Nursing resulting in disciplinary action. The deadlines in these regulations can change (most are now 90 days) but it is vital for those seeking licensure to examine the regulations in the particular state in question.

Compliance officers should watch for: Dotting the i’s and crossing the t’s. Make sure there are policies and procedures for onboarding nurses. Make sure there are controls in place that prevent nurses from beginning work before all necessary paperwork and authorizations for work are completed.

Providing telehealth across state lines 

The boom in telehealth brings challenges as well. In this case, an RN who was also an advanced practice registered nurse (APRN) faced sanctions in multiple states due to an event in a telemedicine practice. The nurse possessed an RN license in Tennessee. She also had APRN licensure in Texas and West Virginia (as well as other states). The Texas APRN licensure included privileges to write prescriptions, but her West Virginia license did not allow this privilege. 

When she was living in Tennessee, she contacted West Virginia residents by phone and wrote prescriptions for patients. She did not have a patient/provider relationship with those patients and never had a face-to-face evaluation with the patients. The State of West Virginia suspended her license and scheduled a hearing. She surrendered her West Virginia license instead of proceeding to the hearing. Because of this occurrence in West Virginia, the State of Texas filed charges and she voluntarily surrendered her license there. Other states, including North Dakota, Vermont, Oregon, and Washington, also took disciplinary action against her license; and she voluntarily surrendered her license in those states. 

But each state took different disciplinary actions. In West Virginia she was barred from practice for five years. Oregon barred her for three years and Minnesota and Texas each barred her for one year. 

Telehealth services that cross state lines. This is especially important for locations that are near state lines or metropolitan communities that span multiple states such as the Northeast of the U.S.  

Though there may be many benefits resulting from the Nurse Licensure Compact (NLC), it is important to recognize some of the regulatory complexities. Organizations and practitioners need to perform the appropriate due diligence in order to meet the requirements of constantly changing regulations in this area. Nurses need to be clear on the limitations of their license in each state they want to practice in. Organizations need to double-check that out-of-state nurses have proper roles according to their license and that their backgrounds are clean.

CJ Wolf, MD, M.Ed is a healthcare compliance professional with over 22 years of experience in healthcare economics, revenue cycle, coding, billing, and healthcare compliance. He has worked for Intermountain Healthcare, the University of Texas MD Anderson Cancer Center, the University of Texas System, an international medical device company and a healthcare compliance software start up. Currently, Dr. Wolf teaches and provides private healthcare compliance and coding consulting services as well as training. He is a graduate of the University of Illinois at Chicago College of Medicine, earned a master’s in education from the University of Texas at Brownsville and was magna cum laude as an undergraduate at Brigham Young University in Provo, UT. In addition to his educational background, Dr. Wolf holds current certifications in medical coding and billing (CPC, COC) and healthcare compliance, ethics, privacy and research (CHC, CCEP, CHPC, CHRC).

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