Updating Nurse Practice Guidelines
and Standards of Practice
PDF Version of
BQA 04-022 (PDF, 27 KB)
DATE: September 1, 2004 DSL-BQA-04-022
TO: Nursing Homes NH 11
Replaces BQC #93-003-3 and BQA #94-030-18 for Nursing Homes (Both memos still
applicable for Home Health Agencies)
FROM: Michael J. Steinhauer, Resident Care Review Section,
Bureau of Quality Assurance
Victoria Griffin, Nurse Consultant for Long Term Care
via: Criselda Ros-Dukler, Director, Bureau of Quality Assurance
In 1993 and 1994, the Bureau of Quality Compliance (BQC), later renamed
the Bureau of Quality Assurance (BQA), issued the above-referenced memos as
a joint effort of the Wisconsin Nurses Association (WNA), the Wisconsin
Association of Medical Directors (WAMD), and BQC. The intent was to provide
guidance to facilities on several aspects of clinical nursing care:
- Change of Condition Notice to the Physician (’93 Memo);
- Fever Guideline as it relates to Physician Notification. (’93 Memo);
- Crushing Medications (’93 Memo);
- Adding Medications to Food (’93 Memo);
- Physical Restraints (’94 Memo); and
- Maintaining Skin Integrity and Nursing Management of Pressure Ulcers (’94).
The guidelines were offered as a model for nursing homes (and home health
agencies) to use in setting up working arrangements with attending
physicians that maximized care, communication and efficiency. This current
memorandum does not affect home health agencies; both BQC 93-003 and 94-030
applicable to them.
After consultation with both WNA and WAMD, it was agreed that updates to
the 1993 and 1994 memos were appropriate. Furthermore, we believe it
necessary to expand the intent of those documents to the broader context of
compliance with standards of practice (SOPs).
Updating BQC 93-003-3
Currently, the WNA has agreed to establish a workgroup to revisit the
- Change of Condition Notice to the Physician, and
- Fever Guideline as it relates to Physician Notification Updates.
Once completed, the update would be made available under the auspices of
the WNA through newsletters, web-site updates, membership bulletins, etc.
The use of any published guidelines by the WNA is strictly voluntary. There
are no regulations that require their use. Guidelines do not take the place
of, or exempt, facilities from meeting state and federal regulatory
requirements. However, the 1993 and 1994 guidelines have not been found to
be in conflict with state and federal regulations, and in some cases
"guidelines" can rise to the level of a standard of practice and
have been most useful for facilities.
The BQA Pharmacy Consultant, Doug Engelbert, in concert with the WAMD,
will review the guidance specified in the 1993 memorandum regarding:
- Crushing Medications, and
- Adding Medications to Food Updates.
When this is completed, the nursing home community will be updated on
current practices and allowances based on the regulations relevant to these
issues. We will issue a BQA memo under separate cover that will be available
on the BQA web-site and other information outlets as soon as possible.
Updating BQA 94-030 for Nursing Homes
The Bureau of Quality Assurance has decided to archive the 1994 Nurse
Practice Guidelines for physical restraint usage, maintaining skin
integrity, and nursing management of pressure ulcers.
- Physical Restraints Update.
Nursing homes are advised to consult BQA 98-003 for specific
interpretations based on regulatory guidance in this area. BQA restraint
memos are available at:
- Maintaining Skin Integrity and Nursing Management of Pressure Ulcers
Over the last decade there has been considerable research related to the
prevention and treatment of pressure sores resulting in the publication of
numerous clinical practice guidelines and standards of practice.
Current Expectations for Selecting Standards of Practice for Each
Federal regulation 42 CFR 483.20(k)(3)(i) (Federal Tag 281) requires that
services provided or arranged by the facility must meet professional
standards of quality and be provided by qualified persons in accordance with
each resident’s written plan of care. Federal regulation 42 CFR 483.75(b)
(Federal Tag 492) requires that the facility operate and provide services in
compliance with all applicable federal, state, and local laws, regulations,
and codes, and with accepted professional standards and principles that
apply to professionals providing services in the facility. With respect to
these regulations, the BQA, the WNA, and the WAMD have agreed that it would
be appropriate to comment on the jointly shared expectations we have for
We urge facilities to revisit and familiarize themselves with current
professional and regulatory standards that govern each licensed/certified
discipline that provides services in the facility. Guidance to surveyors
under Federal Tag 492 describes "Accepted professional standards and
principles" as including "the various practice acts and scope of
practice regulations in each State, and current commonly accepted health
standards established by national organizations, boards and councils."
We also urge facilities to select SOP specific to clinical conditions and
diagnoses applicable to the resident population served by the nursing home.
Guidance to surveyors under Federal Tag 281 helps to define standards of
practice and possible resources the facility may use.
SOPs are specific to the management of clinical conditions by each
licensed/certified discipline. Standards may be published by licensing
boards, an accreditation body (JCAHO), regulatory agencies (CMS, OSHA, DHFS),
and professional organizations. Possible reference sources for a SOP include
current manuals or textbooks on nursing, social work, physical therapy,
etc.; standards published by professional organizations such as the American
Dietetic Association, American Medical Association, American Medical
Directors Association, American Nurses Association, National Association of
Social Work, Agency of Health Care Policy and Research, American Pain
Society, Center for Disease Control, etc.; current professional journals;
and other comparable sources.
In our collective experience, facilities are not universally identifying,
training staff on, and implementing a chosen SOP. Failure to identify and
implement the SOP may lead to a deficient practice and citation of Federal
Tag 281 or 492. The selection of a SOP is advisable for all disciplines
providing care to the resident.
The WNA, WAMD, and BQA also support standards that are evidence-based and
outcome-oriented. BQA does not endorse any single SOP for any specific
discipline, but expects facilities to have elected such standards, amended
for current clinical practice, to use and follow. Of course, each SOP is to
be applied to each resident based on specific needs and goals.
Please note the difference between a selected standard of practice and a
"best practice" clinical intervention. The BQA, WNA, and WAMD
suggest that a best practice is a clinical practice, treatment and
intervention that results in the best possible outcome for the resident and
the facility providing the services. However, a best practice does not
necessarily have its origin in a SOP or Clinical Practice Guideline, and
need not be endorsed by a national organization.
If you have any further questions about this matter, please do not
hesitate to contact Vicky Griffin, RN, LTC Nurse Consultant, at
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