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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:

  1. Change of Condition Notice to the Physician (’93 Memo);
  2. Fever Guideline as it relates to Physician Notification. (’93 Memo);
  3. Crushing Medications (’93 Memo);
  4. Adding Medications to Food (’93 Memo);
  5. Physical Restraints (’94 Memo); and
  6. 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 are still 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

  1. Change of Condition Notice to the Physician, and
  2. 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:

  1. Crushing Medications, and
  2. 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.

  1. 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: and

  1. Maintaining Skin Integrity and Nursing Management of Pressure Ulcers Update.

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 Licensed/Certified Discipline

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 nursing homes.

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 414-227-4705.

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