Commonwealth of massachusetts board of registration in nursing



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Approved 12/9/15



COMMONWEALTH OF MASSACHUSETTS

BOARD OF REGISTRATION IN NURSING

239 Causeway Street, Room 417A

Boston, MA 02114

Minutes of the Regularly Scheduled Board Meeting

Wednesday, November 18, 2015

Board Members Present Board Members Not Present


K. Gehly, CNP, Chair A. Peckham, RN

P. Gales, RN, Vice Chair C. Tebaldi, CNP

S. Abbott, Public Member

A. Alley, RN

M. Beal, CNM

J. Killion, LPN

C. LaBelle, RN

E. Richard Rothmund, Public Member

C. Simonian, PharmD, RPh

S. Taylor, RN

C. Urena, LPN

Staff Present Staff Not Present

K. Ashe, RN, Nursing Education Coordinator L. Talarico, CNP, Nursing Practice Coordinator

O. Atueyi, JD, Board Counsel

V. Berg, Chief Board Counsel

H. Cambra, RN, JD, Complaint Resolution Coordinator

D. M. DeVaux, RN, SARP Coordinator

A. Fein, RN, JD, Complaint Resolution Coordinator

K. Fishman, Probation Monitor

K. Keenan, Licensing Coordinator

V. Iyawe, RN, SARP Coordinator

C. Silveira, RN, Assistant Director

T. Westgate, Program Coordinator
Guests

See attached list.



TOPIC:

Call to Order & Determination of Quorum



DISCUSSION:

None.
ACTION:

At 12:03 p.m., K. Gehly, Chairperson, called the November 18, 2015, Regularly Scheduled Board Meeting to order. Following Board member and staff introductions, Ms. Gehly called roll. A quorum of the Board members was determined to be present. Ms. Gehly also announced the meeting was being recorded.

TOPIC:

Approval of Agenda



DISCUSSION:

None.
ACTION:

Motion by M. Beal, seconded by A. Alley, and unanimously passed to approve the agenda as presented.
TOPIC:

Approval of Board Minutes for the September 9, 2015, Meeting of the Regularly Scheduled Board Meeting.


DISCUSSION:

None.



ACTION:

Motion by P. Gales, seconded by C. Urena, and unanimously passed to accept the Minutes of the September 9, 2015, Regularly Scheduled Board Meeting.


TOPIC:

Approval of Board Minutes for the October 1, 2015 Meeting of the Board of Registration in Nursing, Emergency Session


DISCUSSION:

None.
ACTION:



Motion by J. Killion, seconded by P. Gales, and unanimously passed to accept the Minutes of the October 1, 2015, Meeting of the Board of Registration in Nursing, Emergency Session.

TOPIC:

Reports, Announcements and Administrative Matters


  1. Executive Director’s Report

  2. Staff Report

  1. Deputy Executive Director

  2. Assistant Director

  3. Practice

  4. Education

  5. Complaint Resolution

  6. SARP

  7. Probation Monitor

  1. Announcements

  2. Request for Approval of SAREC Appointment

  3. Update on Fraudulent Application Related Matters


DISCUSSION:

  1. Executive Director’s Report: None

  2. Staff Reports:

  1. None

  2. Ms. Silveira reported that tentative offers have been made to candidates for the Board’s Executive Director and Deputy Executive Director positions and are pending completion of all background checks. She also noted that the National Patient Safety Foundation has issued a new report, RCA 2: Improving Root Cause Analyses and Actions to Prevent Harm. The report, available online at http://npsf.org/?page=RCA2, examines best practices related to root cause analyses and provides guidelines to improve the investigation of medical errors, adverse events and near misses.

  3. Board members reviewed Ms. Talarico’s previously distributed memos.

  4. Members reviewed Ms. Ashe’s previously distributed memo. Members were notified of the new NCSBN video: New Nurses: your License to Practice. Additionally All Board approved nursing programs were notified of the release of the video. The 2016 NCLEX –RN Basic test plan is available of the NCSBN web site, with the detailed test plan available December 2016. Ms. Ashe provided information regarding the Board’s Program Administrator Orientation held October 28, 2015, with 18 program administrators and faculty in attendance. All Board approved nursing programs received notification of the Domestic and Sexual Violence Education on behalf of L. Talarico Nursing Practice Coordinator.

  5. CRCs reviewed their previously distributed activity report. In addition, Ms. Fein presented an overview of a new Investigation Report which will be piloted beginning with the December 2015 Board meeting. Designed to timely address the volume of complaints and staff assignments in pending Board status, the pilot initiative was developed by the Complaint Resolution Coordinators in conjunction with the Office of Public Protection nursing investigation manager and staff following discussions with the Board’s Chairperson and Vice-Chairperson. A companion tool titled, Worksheet for Pilot Board Review and Action on Complaint, has also been developed to assist Board members in articulating and memorializing the quorum’s determination related to each pilot case. In response to Ms. Taylor’s inquiry regarding the reason for the pilot, Ms. Fein explained the pilot is intended to better utilize Board member expertise and to eliminate duplication, creating an expeditious process to protect the public.

  6. Members reviewed the SARP Coordinator’s previously distributed Monthly Activity Report.

  7. Members reviewed the Probation Monitor’s previously distributed 3rd quarterly activity report.

  1. Ms. Fein reminded Board members who have not yet completed the Conflict of Interest educational requirements that these must be completed by 11/30/15.

D. V. Iyawe recommended that the Board approve Stephen Swindells’ application for the SAREC Membership.

E. Ms. Cambra presented an oral report regarding the status of the review and evaluation process that is being conducted by Board and Division staff as a result of the fraudulent reciprocal license application. She identified, among other information, that no additional fraudulent applications have been identified since those addressed by the Board to date; the license verification audit being conducted has been expanded to cover an additional 15 year period; and that arrangements are underway between the Board and subject matter experts of NCSBN member boards to perform an external review of the Massachusetts nurse licensure application processes. Ms. Cambra identified that further information and status updates regarding these matters would be provided to the Board as it becomes available. In response, Ms. Gehly recognized Board and Division’s staff for their continued and extensive work in identifying and addressing the fraudulently obtained licenses, and related licensure application processes.


ACTION:

    1. None.

    2. Noted.

    3. Noted.

    4. Motion by C. Simonian, seconded by J. Killion, and unanimously passed to appoint Stephen Swindells as a SAREC Member.

    5. Noted.


TOPIC: Probation (PART 1)

Request for Termination of Probation in the Matter of C. Graziano, RN227428, NUR-2009-0211. The Probation Monitor presented her previously distributed Compliance Summary for Board Review and Action together with the Consent Agreement. This matter came before the Board as a request to terminate the probationary status on this nurse’s RN license. Specifically, the Licensee who obtained his nursing license on November 27, 1998, and has no previous complaints against his license, has completed the active practice and other terms and conditions of the Consent Agreement for One Year Probation he entered into with the Board. The Licensee did not work for the first two years of his probation, because he was attending a non-nursing school and subsequently had difficulty finding nursing employment commensurate with the Agreement.


The licensee has completed five (5) quarters of successful nursing practice, evidenced by the submission of Supervisor Evaluation Forms from his employers. The Licensee practiced successfully and without incident at 2 facilities during the Probationary period; Geriatric Authority of Holyoke (“GAH”) and Renaissance Manor of Westfield (“RMW”). GAH closed on or about April 15, 2014 and shortly thereafter the Licensee gained employment with RMW. K. Fishman recommended termination of the Licensee’s probation.
DISCUSSION: None.
ACTION:

Motion by M. Beal, seconded by S. Taylor, and unanimously passed to accept the Probation Monitor’s recommendation and terminate the probationary status.


TOPIC: Probation (PART 1)

Request for Termination of Stayed Probation in the Matter of W. Kirraga, RN257426, LN 62384 (expired), NUR-2011-0166. The Probation Monitor presented her previously distributed Compliance Summary for Board Review and Action together with related documentation. This case came before the Board as a request to terminate the six month stayed probation status on the Licensee’s nursing license(s), pursuant to the Consent Agreement he entered into with the Board on November 9, 2011. Specifically, this Licensee, who was issued his RN license in August 2003 and has no previous complaints against his license(s), has completed the terms and conditions of the Stayed Probation Agreement. He submitted documentation evidencing his successful nursing practice at Golden Living Centers for a period of more than one year. The Licensee has been subject to the Agreement for a period of almost five (5) years due to the fact that he had substantial difficulty obtaining a nursing job commensurate with the Agreement. K. Fishman recommended termination of the Licensee’s stayed probation.


DISCUSSION: None.
ACTION:

Motion by J. Killion, seconded by C. Simonian, and unanimously passed to accept the recommendation and terminate the Stayed Probation.


TOPIC: Probation (PART 1)

Request for Termination of Stayed Probation in the Matter of K. Goyau, LN88835, NUR-2012-0123. The Probation Monitor presented her previously distributed Compliance Summary for Board Review and Action together with related documentation. This case came before the Board as a request to terminate the Licensee’s stayed probationary status on her nursing license(s) pursuant to the Consent Agreement for Stayed Probation (Agreement) she entered into with the Board on April 17, 2013. Specifically, this Licensee, who was issued her nursing license in December 2011 and has no previous complaints against her license(s), had initial difficulties complying with the terms of the Agreement, but has now completed the terms and conditions of her Stayed Probation. Ms. Goyau has been employed as an RN at Hellenic since 07/09/2013 through the current date. Ms. Fishman stated that it appears that Licensee has demonstrated an ability to conduct the practice of nursing safely and competently based on her 4 latest quarterly reports covering the periods from August 2014 - October 2015. These reports indicate that there have been no incidents, and the Licensee was rated “meets” or “exceeds” in all categories. The supervisor has also indicated in his cover letters that Licensee has improved as a nurse and become more conscientious. Licensee demonstrated great improvement in her nursing practice from her quarterly reports covering the period August 2013-August 2014.


The Licensee failed to present her Agreement to her supervisor at Hellenic until 08/07/2013. Therefore, she worked several months without the required supervision. Licensee also received “needs improvement” in several categories on her 1st, 2nd, and 4th Quarterly reports. However, the cover letter with the 4th quarterly report indicated that the supervisor believed that she was improving. The Licensee received two (2) written warnings in August 2014. Licensee subsequently submitted letters of explanation for these violations, maintained her compliance with the Agreement and, improved her nursing performance. K. Fishman recommended termination of the Licensee’s probation.
DISCUSSION: A. Fein refreshed the Board’s recollection that this Licensee was a new nurse when she engaged in the conduct that gave rise to the probation, and the Licensee was working as a home health aide, not a nurse. P. Gales commented that she was concerned with Licensee’s violations while on probation. C. Pascarella provided additional information regarding Licensee to further K. Fishman’s summary to the Board. V. Berg inquired regarding whether the non-disciplinary status of this case was still in effect, and whether this was the first time this case was coming before the Board. K. Fishman responded that this was the first time this matter has come before the Board. K. Gehly, commented on the complexity of the issues in this case. C. LaBelle, asked a question regarding one of the Licensee’s probation violations, which K. Fishman then answered. A. Fein commented that the Licensee was working in a non-nursing position and as such she did not have the authority to engage in the activities that gave rise to the probation. V. Berg inquired as to whether the Board should learn more about Licensee’s current nursing practice. A. Fein reminded the Board that it had the option to extend the probationary period. H. Cambra, inquired to V. Berg regarding how Licensee’s non-disciplinary status might be affected. V. Berg responded that any affect was at the discretion of the Board.
ACTION:

(1) Motion by S. Taylor, seconded by M. Beal, and unanimously passed to EXTEND Licensee’s probation for one (1) additional Quarter (until March 2016). The Board also delegated authority to Board Staff to terminate the Licensee’s probation, if she complies with the terms of her probation during the extended probationary period.

(2) Motion by C. Urena, seconded by J. Killion, and unanimously passed to REPRIMAND Licensee for violating the terms of her Agreement by failing to notify her employer of her probation. Per V. Berg, the notice of reprimand will be sent to Licensee in the same notice as the extension of her probation.
TOPIC: Probation (PART 2)

Request for Termination of Stayed Probation in the Matter of F. Kimani, LN64172, NUR-2012-0038. A. Alley recused himself from this matter and left the room. The Probation Monitor presented her previously distributed Compliance Summary for Board Review and Action together with related documentation. This case came before the Board to request termination of stayed probation, as Licensee has now sufficiently complied with the terms and conditions of the Non-Disciplinary Consent Agreement for Stayed Probation, effective 08/09/2012. This Licensee was issued a nursing license on 08/11/2003 and has had no other complaints issued against her license. She has been employed at two facilities during the Probation period: Kindred Transnational Care and Rehab Westborough (“Kindred”) and Odd Fellows Home of Massachusetts (“Odd Fellows”).


The Licensee was terminated from Kindred in March 2013 due to an incident in which a resident’s chair alarm was not put in place and the resident fell and was injured. The Licensee received three (3) violation notices for her failure to answer the Probation Monitor’s request for a letter of explanation regarding her termination from the facility and for failing to notify the Probation Monitor of her new employment at Odd Fellows Home. A violation notice was also issued to Licensee for her failure to timely submit an affidavit per paragraph four (4)(h) of the Agreement and failing to notify her supervisor at Odd Fellows of her probation status within the required 30 day period.
In March 2014, the Licensee did finally submit a letter of explanation regarding her termination at Kindred in which she indicated that she was terminated for failure to properly monitor a nurse’s aide’s practice which resulted in the above-mentioned incident. The Licensee stated that the aide never communicated to her or anyone else in the facility that she felt overwhelmed, and the only time the aide admitted to feeling overwhelmed was during the DPH investigation. The Licensee also stated that the aide had over 20 years of experience and showed no signs of distress. DPH investigated this matter in April 2013 and the DPH investigator was unable to determine validity of the allegation.
Despite her earlier practice issues and violations noted in the summary, the Licensee has not had any incidents since she began working as a nurse at Odd Fellows Home. The Licensee has submitted six (6) quarterly supervision reports from Odd Fellows, with only one “needs improvement” rating in the category “manages stressful situations appropriately” with the comment “can become impatient with co-workers.” These reports cover the time period from April 2013 to May 2015: a period of more than two years. She has not been issued any violation notices during this period. K. Fishman recommended termination of the Licensee’s probation.
DISCUSSION: A. Fein highlighted for the Board the time periods of Licensee’s two jobs, and unemployment. H. Cambra commented regarding the similarity of the facts of this case and the previous case reviewed by the Board. K. Gehly inquired as to any Notices of Violation that were sent to the Licensee. K. Fishman replied in the affirmative and indicated when notices were sent to Licensee. K. Fishman highlighted the explanations for Licensee’s non-compliance, particularly Licensee’s unintentional failure to notify the Board due to a miscommunication between the Licensee and new supervisor, which is distinguishable from the facts of the previous case of intentional non-compliance. The Board members and staff identified the factual distinctions in this matter as compared to those in the previous case.
ACTION:

A. Alley had recused himself from any consideration of this matter and was not in the room. Motion by C. Simonian, seconded by M. Beal, and voted by all other members present to accept the recommendation and terminate the stayed probation.


TOPIC: Probation (PART 2)

Request for Termination of Probation in the Matter of G. Davey, RN211518, RN-05-105. The Probation Monitor presented her previously distributed Compliance Summary for Board Review and Action together with related documentation. This case came before the Board as a request to terminate the Probation status of this nurse’s license, as she has sufficiently complied with the terms and conditions of the Post Suspension Consent Agreement for Probation, effective July 02, 2012. This Licensee has no other complaints against her license.


The Licensee was briefly employed at two (2) different assisted living facilities where her employment did not work out. However, the Licensee has received consistent positive reports since September 2013, when her employment began at Wolfeboro Bay Center. Since then the Licensee has received seven (7) reports covering a period of over a year and a half of supervised nursing practice with no incidents, no individual counseling, no warnings, no needs improvement comments, and no other issues with her nursing practice. Wolfboro Bay has given Licensee a part-time weekend supervisor role, and she also maintains a part-time staff nurse position at the facility. Based on this information it would appear that Licensee has complied with the terms of her probation and is now capable of conducting the practice of nursing both competently and safely. K. Fishman recommended termination of the Licensee’s probation.

DISCUSSION: None.
ACTION:

Motion by J. Killion, seconded by P. Gales, and unanimously passed to accept the recommendation and terminate the probation.


TOPIC: Probation (PART 2)

Request for Termination of Stayed Probation in the Matter of N. Kasongo, LN66167, NUR-2012-0039. The Probation Monitor presented her previously distributed Compliance Summary for Board Review and Action together with related documentation. This case came before the Board to determine whether to terminate the stayed probation status on Licensee’s nursing license, pursuant to the Consent Agreement (“CA”) she entered into with the Board on October 15, 2012. Licensee was issued her LN license in August 2005 and has had no previous complaints issued against her license. Due to some instances of Licensee’s non-compliance with the Agreement, the Probation Monitor brought this case before the Board as it does not meet the requirements for staff action pursuant to the Board’s Discipline Policy 07-01.


While on Stayed probation, Licensee’s nursing practice has been excellent according all of the Form 2’s submitted by Licensee’s supervisor. Notably, Licensee’s supervisor indicated in a recent call that “he wishes he has fifteen more employees just like her.” However, Licensee violated the Agreement by failing to notify the Probation Monitor of her change of address, and submitted her Form 2’s late for each one due. K. Fishman recommended termination of the Licensee’s probation.
DISCUSSION: None.
ACTION:

Motion by P. Gales, seconded by C. Simonian, and unanimously passed to accept recommendation and terminate the stayed probation.


TOPIC: Complaint Resolution - None
DISCUSSION:
ACTION:
TOPIC: Practice - None
DISCUSSION:
ACTION:
TOPIC: EDUCATION

PART I

  1. 244 CMR 6.04(1)©&(1)(f) Administrative Changes

  1. Bay State College, Associate Degree RN

  2. Berkshire Community College, Practical Nursing Program

  3. Berkshire Community College, Associate Degree Program

  4. Holyoke Community College, Practical Nursing Program

  5. Quincy College, Practical Nurse and Associate Degree Programs

  6. Salem State University, Baccalaureate and Direct Entry

  1. 244 CMR 6.08(1)(h) 2014 NCLEX Evaluation Report

    1. Curry College, Baccalaureate Degree, Registered Nurse Program

    2. Medical Professional Institute, Practical Nursing Program

  1. 244 CMR 6.05(3)Full Approval Status, Westfield State University, Baccalaureate Degree, Registered Nurse Program

PART 2

  1. 2015 Quarter 3 NCLEX Performance Reports

  1. MA Licensure Candidates Regardless of State of Education

  2. MA Graduates Regardless of State of Licensure

  1. 244 CMR 6.04(1)(c)&(1)(f) Administrative Changes Shawsheen Technical Institute CEO


DISCUSSION:

PART 1

A. Members reviewed Ms. Ashe’s previously distributed memo.



  1. S. Taylor and A. Alley had recused themselves from this matter and previously left the room during discussion of this matter, Bay State College, Associate Degree RN

  2. Berkshire Community College, Practical Nursing Program. Board members were updated on the ongoing Program Administrator appointments to the Practical Nursing Program beginning October 2012 that has resulted in 5 Program Administrator changes. K Gehly reminded Board members that the changes began with the sudden loss of the Program Administrator for both the PN and ADN programs at Berkshire Community College in November 2014. Ms. Ashe added that the current Program Coordinators (Program Administrators) have teaching responsibilities in addition to being appointed Program Administrators. S. Taylor suggested that a letter to the Dean of the Health Program is warranted, requesting documentation of a plan for recruitment and appointment of a permanent program administrator for sustained leadership.

  3. Berkshire Community College, Associate Degree Program

  4. Holyoke Community College, Practical Nursing Program

  5. Quincy College, Practical Nurse and Associate Degree Programs

  6. Salem State University, Baccalaureate and Direct Entry

B. 1. Members reviewed Ms. Ashe’s previously distributed 244 CMR 6.08(1(h) 2014 NCLEX compliance report and attachments for Curry College Baccalaureate Degree Registered Nurse Program. S. Taylor had recused herself from this matter.

2. Members reviewed Ms. Ashe’s previously distributed 244 CMR 6.08(1(h) 2014 NCLEX compliance report and attachments for Medical Professional Institute, Practical Nursing Program. The Program Administrator, Mr. Paul Jones was in attendance to answer Board member questions. P. Gales asked for clarification on the writing of the NCLEX report. Mr. Jones stated the report was written in part by the Director of Education, which may have led to some confusion within the report. . S. Abbot asked for clarification on the Program Administrator schedule of 3 days/per week as a fulltime position, and who administers the program in his absence. Mr. Jones stated he is on call, and a clinical coordinator oversees the clinical sites. S Taylor asked for clarification and a rationale for the “ green light to test” policy for NCLEX and the withholding of the graduate’s Certificate of Graduation as stated in the student handbook, citing reports on the use of high stakes testing. Mr. Jones stated the policy will be revised, and the program is looking to other methods to improve NCLEX passing rates.

C. Members viewed Ms, Ashe’s previously distributed 244 CMR 6.05 Procedure for the Establishment and Continued Operation of a Nursing Education Program (3) Full Approval Status, and attachments for Westfield State University Baccalaureate Degree, Registered Nurse Program. Board members noted the Program had a completion rate of 85.5 % and an NCLEX first time pass rate of 81%.


PART 2

  1. Members reviewed Ms. Ashe’s previously distributed report. The Massachusetts Licensure Candidates Regardless of State of Education and the Massachusetts Graduates Regardless of State of Licensure report descriptions and details were reviewed. Ms. Ashe noted that the NCLEX RN and PN reports reflect Quarter 3 numbers which is generally the larges numbers reported per quarter, noting according to the Q 3 NCLEX 2015 MA Graduates Regardless of State of Licensure Q3 report pass rate percentages for ADN and BSN passing percentage increased slightly both groups.

  2. Member reviewed Ms. Ashe’s previously distributed memo244 CMR 6.04(1)(c)&(1)(f) Administrative Shawsheen Technical Institute.


ACTION:

Part I

A. 1. Motion by P. Gales, seconded by C. Simonian and unanimously passed to find compliance with 244 CMR 6.04(1)© and

6.04(1)(f) in the appointment of: Kay Higdon, MS, RN. Interim Program Administrator,(Program Administrator), Associate Degree-RN Program, Bay State College, Boston, MA.

2. Motion by M. Beal, seconded by C. Urena and unanimously passed to find compliance with regulation 244 CMR 6.04(1)(c) & (1)(f) in the notification of the appointments of:



  1. Susan St. John, MSN, RN, Chairperson Practical Nursing,(Program Administrator), Practical Nursing Program, Berkshire Community College, Pittsfield, MA . The Board requested an update on the College’s plan for the recruitment and appointment of a long term Program Administrator with oversight of Practical Nursing Program and the Associate Degree RN Program, further demonstrating sustained compliance with all regulations[ref: 244 CMR 6.011 and 6.08(1)(e)].

  2. Constance Flynn, MS, CAS, APRN, ANP-BC , Chairperson Associate Degree Program (Program Administrator), Associate Degree-RN Program, Berkshire Community College, Pittsfield, MA 

  3. Marjorie Bessette, MSN, RN, Chairperson Practical Nursing, (Program Administrator),Practical Nursing Program, Holyoke Community College), Holyoke, MA

  4. Linda C. Pendergast, Ph.D., RN, CNE, Dean of the Academic Division of Nursing, (Program Administrator), Practical Nurse and Associate Degree Programs, Quincy College, Quincy MA.

  5. Charlene Campbell MSN, Med, EN , Chairperson, (Program Administrator), Salem State University, Salem, MA,

B. 1. Motion by J. Killion, seconded by P.Gales, and unanimously passed to accept the 2014 NCLEX RN Performance Report submitted by the Curry College Baccalaureate Degree-RN program (Program), finding the Program has provided satisfactory evidence of compliance with regulations 244 CMR 6.04: Standards for Nursing Education Program Approval with the following recommendations adding; provide evidence of compliance with the immunization regulation [ref 244 CMR 6.04(3) (a)] specified by the MA DPH Adult Occupational Immunizations Massachusetts Recommendations and Requirements for 2015 due1/13/2016.
2. Motion by S Taylor seconded by P.Gales and unanimously passed to accept the 2014 NCLEX-RN Performance Report finding Medical Professional Institute, Practical Nursing Program has not provided satisfactory evidence of its compliance with the following regulations: 244 CMR 6.04(1)(b), (1)(c), (1)(e), (1)(g), (2)(b)(5), (3)(a)2, (4)(a), (4)(b)3, (4)(b)4, (4)(b)5, (5)(a), (5)(c) and (5)(f). As a result the Board has determined that the Program warrants Approval with Warning status and must as specified at 244 CMR 6.08(2):

  1. immediately notify all enrolled students and program applicants in writing, in accordance with established current Board guidelines, of the program’s Approval with Warning Status, the basis therefo, and the necessary corrective action(s) and;

  2. inform all program graduates, who have not yet written the NCLEX-PN, that they remain eligible to do so.

1. Direct the Program to submit a report, prepared by the Program Administrator and faculty addressing its correction of the cited deficiencies. The report will be reviewed at the Board’s April 13, 2016 meeting, and include;

  1. Documentation (e.g. faculty and student organization by-laws, standing committee membership and charges, instructor and administrator job descriptions, minutes of meetings, systematic evaluation plan) demonstrating the participation by faculty, administrators and students in program and parent institution governance;

  2. Job description and qualifications for the current Clinical Coordinator and clarify the Clinical Coordinator role acting as a co-Program Administrator;

  3. Job descriptions to identify both the Program Administrator and faculty role in developing and implementing the SEP.

  4. SEP revised to including specific timelines for review, methodologies on how data is obtained and specific measureable outcomes that demonstrate ongoing data collection, aggregation and synthesis that guide faculty in making informed program decisions.

  5. The Program SEP will consistently and specifically measure outcomes as defined in 244 CMR 6.01, as measurable performance indicator that shall include but not be limited to NCLEX performance, admission, retention and graduation rates, graduate satisfaction, employment rates and patterns with a goal to achieve in-depth evaluation, further analysis to reach optimal level of effective operation.

  6. Provide a records policy with details outlining what and how records are specifically maintained, along with a retirement dates including but not limited to school, student, faculty and graduate records

  7. Provide specific evidence of faculty maintenance of expertise appropriate to teaching responsibilities, including previous and ongoing faculty attendance and participation in professional development in item writing, item analysis and test blue prints that correlate with the NCLEX Detailed Test plan and course student learning outcomes.

  8. Provide evidence of strict adherence to establish policies including Admission policy, TEAS V admission scores, the Progression Policy with core nursing courses passing grade changed from a minimum C (73%) to a minimum B (80%) while providing a rational for the exclusion of two nursing courses, PN 104 and PN 105 as not included in this passing grade change.

  9. Provide a comparative summary table correlating graduate science course grades, frequency of repeating science courses, and NCLEX success.

  10. Provide evidence of detailed gap analysis according to all nursing courses and the 2014 NCLEX-PN Detailed Test Plan

  11. Incorporate professional nursing standards like the MA Department of Higher Education Practical Nurse Core Competences, Joint Commission National Patient Safety Goals, and the NCLEX-PN Detailed Test plan as frameworks for the development, implementation and evaluation of course, clinical and program outcomes demonstrating congruency.

  12. provide evidence from collected and aggregated confidential individualized student data that supports the implementation of 225 hours of Outside Work as contributing to NCLEX-PN success.

  13. Provide evidence of test blue prints, and nursing course exam construction to correlate with course student learning outcomes and NCLEX-Detailed Test Plan,

  14. Provide evidence of comprehensive learning resources including adequate number of full-time and part-time faculty and support personnel, with clarification of faculty to student ratio’s in clinical settings like public schools, day cares and preschools.

  15. Provide a detailed comparative analysis using confidential individual student data for passed and failed first time licensure candidates to determine student preparation by full-time, part-time (adjunct) faculty.

  16. Identify within the SEP the person, persons, responsible for ensuring that contracts are reviewed on specific times with specific parameters, such as students to faculty in a facility. Clarify contract language referring to “enhancing resources available to the facility for the providing of care to its patients.

2. Recommend the Program seek expert consultation to assist in the corrected the cited deficiencies.
C. Motion by P. Gales seconded by M. Beal, and unanimously passed to passed to grant Westfield State University (Parent Institution) Full Approval status for the operation of the Baccalaureate Degree Registered Nurse program(Program), finding the Parent Institution has provided satisfactory evidence of its compliance with 244 CMR 6.04.
Part II

A. 2015 Quarter 3 NCLEX Reports accepted by consensus.

B. Motion by P. Gales, seconded by J. Killion and unanimously passed to find compliance with 244 CMR 6.04(1)(c) and 6.04(1)(f) in the appointments of: Timothy Broderick Superintendent-Director Chief Executive Officer, Shawsheen Technical Institute.
TOPIC:

Requests for License Reinstatement



G. Grammont, LN54939; NUR-2011-0102
DISCUSSION:

T. Westgate presented her previously distributed memorandum outlining the Respondent’s conduct that gave rise to the Complaint and resulted in the suspension of his nursing license. Specifically, the Respondent admitted that on or about May 4, 2011, while employed as a LPN at Masconomet Healthcare ("Masconomet") in Topsfield, Massachusetts, and at Penacook Place ("Penacook") in Haverhill, MA, it was discovered that Respondent had diverted discontinued non-narcotic controlled substances from these facilities for a family member's use. Respondent acted beyond the scope of her authority, violated patient confidentiality, and failed to maintain the security and integrity of these controlled substances.

The Respondent’s license was Suspended effective September 27, 2013, and she has since complied with all of the requirements set forth in the Agreement and is eligible for reinstatement. T. Westgate recommended that the Board grant the Respondent’s request for license reinstatement on the condition that she enter into a standard consent agreement for Probation for 1 year and properly renew her nursing license.
ACTION:

Motion by E. R. Rothmund, seconded by M. Beal, and unanimously passed to reinstate the Respondents nursing license as outlined above.


TOPIC:

Strategic Development, Planning and Evaluation


  1. Systematic Policy Evaluation: None

  2. Topics for Next Agenda: None

  3. Establishment of New Board of Registration in Nursing Licensure Committee


DISCUSSION:

  1. There were no Board policies scheduled for review at this time.

  2. There were no additional agenda topics identified for inclusion in the December 2015 Board meeting agenda.

  3. Ms. Silveira presented Ms. Gales’ proposal that the Board establish a Licensure Committee to evaluate the current MA nurse licensure application-related processes. The primary objectives of the Committee would be to: identify processes potentially at risk for fraud and to recommend actions to reduce or eliminate those risks including quality measures and reasonable timeframes.


ACTION:

  1. None.

  2. None.

  3. Motion by S. Taylor, seconded by A. Alley, and unanimously passed to accept the recommendation that the Board: 1) in the absence of its Executive Director and Deputy Executive Director – key leadership roles in any new initiative to assure the integrity of the Board’s licensing process – act as a “committee-of-the-whole”, and as such, add a standing agenda item to the Board’s monthly regularly scheduled meeting agenda under Section X: Strategic Development, Planning and Evaluation and include a status update on the activities currently underway related to the receipt of falsified/fraudulent applications; and 2) designated Ms. Gales as its liaison to staff involved in those activities.


TOPIC:

G.L. c.30A, §21 Executive Session


DISCUSSION:

None.
ACTION:


Motion by J. Killion, seconded by A. Alley, and unanimously passed by roll call vote to go into Executive Session at 2:25 p.m. as per Purpose One of G.L. c.30A, §21 (a)(1).




Recess 2:25 p.m. to 2:45 p.m.


G.L. c. 30A, § 21 Executive Session 2:45 p.m. to 4:24 a.m.




Recess 4:24 p.m. to 4:32 p.m.
TOPIC:

Adjudicatory Session



DISCUSSION:

None
ACTION:

Motion by C. Simonian, seconded by C. Urena, and unanimously passed to go into Adjudicatory Session at 4:32 p.m. to discuss decisions in pending adjudicatory matters.

Adjudicatory Session 4:32 p.m. to 4:52 p.m.
TOPIC:

G.L. c. 112, s. 65C Session



DISCUSSION:

None
ACTION:


Motion by P. Gales, seconded by A. Alley, and unanimously passed by roll call vote to go into G.L. c. 112, s. 65C Session at 4:43 p.m. to discuss negotiated settlements of complaints.




G.L. c. 112, s. 65C Session 4:53 p.m. to 5:50 p.m.
TOPIC:

Adjournment


DISCUSSION:

There was no discussion.


ACTION:

Motion by M. Beal, seconded by E.R. Rothmund, and unanimously passed to adjourn the meeting at 5:51 p.m.

Minutes of the Board’s November 18, 2015, Regularly Scheduled Meeting were approved by the Board on December 9, 2015.


___________________________________________

Katherine Gehly, MSN, CNP


Chairperson

Board of Registration in Nursing


Agenda with exhibits list attached.

COMMONWEALTH OF MASSACHUSETTS
NOTICE OF THE REGULARLY SCHEDULED MEETING OF THE

BOARD OF REGISTRATION IN NURSING


November 18, 2015
239 Causeway Street ~ Room 417 A&B

Boston, Massachusetts 02114


PRELIMINARY AGENDA as of 11/12/15 10am


Estimated Time

#
      1. Item


Exhibits

Presented by

12:00 p.m.

I.
      1. CALL TO ORDER & DETERMINATION OF QUORUM











II.

APPROVAL OF AGENDA

Agenda







III.

APPROVAL OF BOARD MINUTES

  1. Draft Minutes for the September 9, 2015 Meeting of the Board of Registration in Nursing, Regular Session

  2. Draft Minutes for the October 1, 2015 Meeting of the Board of Registration in Nursing, Emergency Session




Minutes

Minutes








IV.

REPORTS, ANNOUNCEMENTS AND ADMINISTRATIVE MATTERS

  1. Executive Director’s Report

  2. Staff Report

      1. Deputy Executive Director

      2. Assistant Director (Oct and Nov)

      3. Practice (Oct and Nov)

      4. Education (Oct and Nov)

      5. Complaint Resolution

      6. SARP (Oct and Nov)

      7. Probation Monitor (Oct)

  3. Announcements

  4. Request for Approval of SAREC Appointment

  5. Update on Fraudulent Applications




--
--

Oral

Report


Report

Report


Report

Quarterly Report

Correspondence

Memo


Oral

--
--

CS

LT

KA



AF/HC

VI/DM


KF

ASF


VI

HC





V.

PROBATION

PART 1 (from 10/14/15 cancelled meeting agenda)

  1. Termination of Probation/Stayed Probation

  1. C. Graziano, RN227428, NUR-2009-0211

  2. W. Kirraga, RN257426, LN 62384, NUR-2011-0166

  3. K. Goyau, LN88835, NUR-2012-0123

PART 2

  1. Termination of Probation/Stayed Probation

  1. F. Kimani, LN64172, NUR-2012-0038

  2. G. Davey, RN211518, RN-05-105

  3. N. Kasongo, LN66167, NUR-2012-0039



Memo


Memo

Memo

Memo

Memo


Memo

KF

KF



KF

KF

KF



KF




VI.

COMPLAINT RESOLUTION

  1. Resolution of Pending Board Complaints: NONE

  2. Resolution of Pending Board Staff Assignments: NONE













VII.

PRACTICE: None









VIII.

EDUCATION

PART I (from 10/14/15 cancelled meeting agenda)

  1. 244 CMR 6.04(1)©&(1)(f) Administrative Changes

  1. Bay State College, Associate Degree RN

  2. Berkshire Community College, Practical Nursing Program

  3. Berkshire Community College, Associate Degree Program

  4. Holyoke Community College, Practical Nursing Program

  5. Quincy College, Practical Nurse and Associate Degree Programs

  6. Salem State University, Baccalaureate and Direct Entry

  1. 244 CMR 6.08(1)(h) 2014 NCLEX Evaluation Report

    1. Curry College, Baccalaureate Degree, Registered Nurse Program

    2. Medical Professional Institute, Practical Nursing Program

  1. 244 CMR 6.05(3)Full Approval Status, Westfield State University, Baccalaureate Degree, Registered Nurse Program

PART 2

  1. 2015 Quarter 3 NCLEX Performance Reports

  1. MA Licensure Candidates Regardless of State of Education

  2. MA Graduates Regardless of State of Licensure

  1. 244 CMR 6.04(1)(c)&(1)(f) Administrative Changes


Memo


Compliance Reports

Compliance Report

Report

Memo



KA

KA


KA

KA


KA





IX.

REQUESTS FOR LICENSE REINSTATEMENT:

  1. G. Grammont, LN54939, NUR-2011-0102




Memo

TW




X.

STRATEGIC DEVELOPMENT, PLANNING AND EVALUATION

  1. Systematic Policy Evaluation: NONE

  2. Topics for Next Agenda

  3. Establishment of New Board of Registration in Nursing Licensure Committee


Oral


Oral


CS

CS





2:00p.m.

XI.

EXECUTIVE SESSION

The Board will meet in Executive Session as authorized pursuant to M.G.L. c.30A, § 21(a)(1) for the purpose of discussing the reputation, character, physical condition or mental health, rather than professional competence, of an individual, or to discuss the discipline or dismissal of, or complaints or charges brought against, a public officer, employee, staff member or individual. Specifically, the Board will discuss and evaluate:



  • The Good Moral Character as required for registration for pending applicants.




  • The reputation, character, physical condition or mental health, rather than professional competence, of licensees relevant to their petitions for license status change, or compliance with licensing conditions, or petitions to modify consent agreements.




  • Pending disciplinary complaints that involve patient records and treatment of patients.




  • Approval of prior executive session minutes in accordance with M.G.L. ch.30A, § 22(f) for sessions held during the September 9, 2015 meeting.




CLOSED SESSION




XII.

ADJUDICATORY SESSION (M.G.L. c. 30A, § 18)

CLOSED SESSION




XIII.

M.G.L. c. 112, § 65C SESSION

CLOSED SESSION

6:00p.m.

XIV.

ADJOURNMENT











1 244 CMR 6.00:

APPROVAL OF NURSING EDUCATION PROGRAMS AND THE GENERAL CONDUCT THEREOF

Section 6.01: Definitions Administrator means the Registered Nurse designated the administrative authority and responsibility for the nursing education program.

(Approved 12/9/2015)




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