South Hills Health System Home Health Agency

SOUTH HILLS HEALTH SYSTEM AGENCY 653 Jefferson Health System, d/b/a South Hills Health System Home Health Agency, and Family Hos- pice, a wholly-owned subsidiary of South Hills Health System and South Hills Home Care Nurses Association/PSEA Health Care, Peti- tioner. Case 6–RC–11756 February 16, 2000 ORDER DENYING REVIEW BY CHAIRMAN TRUESDALE AND MEMBERS FOX AND BRAME The National Labor Relations Board has delegated its authority in this proceeding to a three-member panel, which has considered the Employer’s request for review of the Regional Director’s Decision and Direction of Election (pertinent parts of which are attached as an ap- pendix). The request for review is denied as it raises no substantial issues warranting review.1 See generally Charter Hospital of Orlando South, 313 NLRB 951 (1994). APPENDIX DECISION AND DIRECTION OF ELECTION As amended at the hearing, and in its posthearing brief, the Petitioner seeks to represent in a single unit all registered nurses including medical surgical nurses, mental health nurses, IV nurses, rehabilitation nurses, and intake nurses employed by the Employer at its Pittsburgh, Pennsylvania facilities and other branch facilities located in Western Pennsylvania, excluding guards, other professional employees, and supervisors within the meaning of the Act. The Employer contends that the peti- tioned-for unit is inappropriate in terms of composition, and that the only appropriate unit is a unit composed of all profes- sional employees, including registered nurses, and nonprofes- sional employees employed by the Employer. In the alterna- tive, the Employer argues that the only appropriate unit is a unit composed of all professional employees of the Employer. The Petitioner does not seek to represent the nonprofessional employees of the Employer on any basis, and it would not pro- ceed to an election in a combined professional-nonprofessional employee unit.1 In the alternative, the Petitioner would seek to represent all professional employees of the Employer, if that unit was found to be the sole appropriate unit for collective- bargaining purposes. There are approximately 200 employees in the petitioned-for unit, and approximately 240 employees in an Employer-wide all professional employee unit.2 There is no history of collective bargaining for any of the employees in- volved herein. 1 The only issue raised in the request for review is whether the Re- gional Director erred in finding appropriate the petitioned-for unit of registered nurses in a nonacute healthcare setting. 1 Sec. 9(b)(1) of the Act provides that professional employees may not be included in a bargaining unit with nonprofessionals unless they vote in favor of such inclusion. In Leedom v. Kyne, 249 F.2d 490 (D.C. Cir. 1957), the District of Columbia Court of Appeals construed the limitation in Sec. 9(b)(1) as intended to protect professional employees and held that the professionals’ right to this benefit does not depend on Board discretion or expertise and that the denial of this right must be deemed to result in injury. The United States Supreme Court, at 358 U.S. 184 (1958), affirmed this ruling. The operative effect of Sec. 9(b)(1) is that a mixed professional-nonprofessional employee unit cannot be found, as a matter of law, to be the sole appropriate unit for collective-bargaining purposes. Otherwise, the statutory limitations set forth in Sec. 9(b)(1) would be without meaning since professional employees would either have to be represented as part of an overall unit or not at all. In this case, no labor organization is seeking to represent the Employer’s nonprofessional employees on any basis. Thus, the question of whether a mixed unit of the Employer’s professional em- ployees and nonprofessional employees is appropriate is not an issue to be decided, and I therefore find it unnecessary to consider in any fur- ther detail the Employer’s contentions in this regard. The Employer’s reliance on the Board’s decision in Upstate Home For Children, 309 NLRB 986 (1992), in support of its mixed professional-nonprofessional unit contention is misplaced. In that case, the Board found that separate petitioned-for units limited to registered nurses and licensed practical nurses were inappropriate since other professional and nonprofessional employees shared a community of interest with the RNs and LPNs respectively. The Board did not hold that if the petitioner desired to represent the RNs, it had to do so only if the RNs were included in an overall unit with nonprofessional employees. SHHS is a Pennsylvania not for profit corporation and is a large, complex health organization with a number of subordi- nate entities, engaged in the provision of health care services in the Western Pennsylvania area. Subsidiary nonprofit corpora- tions of SHHS include Family Hospice, Long-Term Care Ser- vices Corporation, Health System Service Corporation, Jeffer- son Diversified Health Service Corporation, and JHS. SHHS is under the overall supervision of Executive Vice President and Chief Operating Officer Gary Perecko. Reporting to Perecko are, inter alia, Judith Talbert, executive director of Family Hos- pice and Gary Retone, executive director of Home Health. SHHS is basically a management and service corporation which provides a variety of services to its subsidiary corpora- tions, including administrative services, management services, and other support services. The operations of SHHS and its subsidiary corporations are primarily located on two campuses, commonly referred to as the Jefferson Campus and the Homestead Campus. The Jeffer- son Campus is located in Jefferson Borough, in the South Hills section of Allegheny County, Pennsylvania. The main building on the Jefferson Campus is Jefferson Hospital, which is a five- story acute care facility. It appears that SHHS maintains its offices on the Jefferson Campus. The Homestead Campus is located in Homestead, Pennsyl- vania, in the eastern section of Pittsburgh, Pennsylvania, ap- proximately 12 to 15 miles to the northeast of the Jefferson Campus. A number of buildings are located on the Homestead Campus, including a five-story structure formerly known as Homestead Hospital and now designated as Building 24. Home Health’s administrative offices are located on the fifth floor of this structure.3 In addition to its administrative office, Home Health main- tains five branch offices located in the Western Pennsylvania area, the Homestead branch office, which is also located on the 2 Although the record is not entirely clear, it appears that the Em- ployer is one of a number of business units. 3 These administrative offices include offices for management and administrative personnel, the central intake department, the utilization review department, and the allied health department. Other operations located at the Homestead Campus include, inter alia, a primary care facility, an emergency health care facility, a skilled nursing facility, and a personal care residence. 330 NLRB No. 107 DECISIONS OF THE NATIONAL LABOR RELATIONS BOARD 654 5th floor of building 24; Robinson Township; Monroeville; McMurray; and Pleasant Hills, which is located on the Jeffer- son campus. Family Hospice is not located at either the Jefferson or Homestead campuses, but is rather located in Castle Shannon, a suburban area adjacent to the southern part of Pittsburgh.4 Home Health is licensed by the Commonwealth of Pennsyl- vania to provide health care, including nursing and allied health services,5 to patients in their homes or residences. Home Health is certified by Health Care Finance Administration (HCFA) as a Medicare certified home health agency.6 Family Hospice is a licensed Medicare hospice and home care provider that provides health care services to terminally ill patients, and a variety of “end of life” services to these patients and their families. These services take place in patients’ homes, nursing homes, hospitals, and hospices.7 Home Health As noted, with respect to Home Health, although patient care services are provided in patients’ homes, its administrative operations are located in building 24 of the Homestead Cam- pus. Reporting to Home Health Executive Director Gary Re- tone are: Lynn Setar, Director of Client Relations; Susan Nav- ish, Director of Administration & Managed Care Services; Jill Johnson, Director of Clinical Operations; Christine Heasley, Director of Quality Management; JoAnn Parzick, Consultant for Special Projects; and Janet Rice, Financial Analyst. Report- ing to Jill Johnson are the directors for each of Home Health’s five branch offices. In addition, reporting directly to Johnson are Donna Westerbeck, Manager of Rehabilitation; Jan Muschar, Manager for Social Work/Mental Health Nursing; Susan Keitzer, Manager of IV Therapy; and Patricia Ginsberg, enterostimal therapy.8 Each branch office also has a clinical supervisor and a manager of operations, or patient care man- ager.9 The clinical supervisors are responsible for supervising patient care and managing care delivery teams. The patient care manager is responsible for managing authorization and reauthorization of care from the payee’s standpoint. Each 4 Family Hospice was “formed” in the early 1970s by a consortium of institutions including SHHS, Mercy Hospital, St. Clair Hospital, and South Hills Health Ministries. It formally became a subsidiary of SHHS in 1991. Family Hospice has its own Board of Directors which includes the chief financial officer of SHHS, a representative from Mercy Hospital, St. Clair Hospital and South Hills Health Ministries, respectively, and 10 other “at-large” positions. 5 Allied health services include physical therapy, occupational ther- apy, speech therapy, mental health nurses and social work services. 6 Approximately 3000 patients located in the Employer’s geographi- cal service area receive approximately 270,000 visits from Home Health personnel annually. 7 Approximately 10 percent of Family Hospice’s patients receive pa- tient care services pursuant to Family Hospice’s home care license. These patients are all terminally ill but receive home care health ser- vices, rather than hospice services, because of the nature of some of the services received, e.g., chemotherapy, which serves are not covered by Medicare if an individual is in a hospice program. 8 The parties stipulated, and I find, that the aforementioned individu- als, with the exception of Ginsberg, are supervisors within the meaning of the Act, inasmuch as they possess one or more of the authorities enumerated in Sec. 2(11) of the Act. 9 The parties stipulated, and I find, that the branch directors, clinical supervisors and managers of operations are supervisors within the meaning of the Act, inasmuch as they possess one or more of the au- thorities enumerated in Sec. 2(11) of the Act. branch office also has group facilitator, who is a registered nurse and who is primarily responsible for providing care to patients and coordinating care among care delivery teams, and for performing certain other tasks, such as telephoning physi- cians and laboratories. Each branch office has assigned to it approximately 25 RNs, approximately 8 nurses aides, and approximately 2 to 3 clinical employees. There are a total of approximately 130 RNs em- ployed at the various branch offices. These RNs are designated as staff medical surgical RNs. In addition to these staff regis- tered nurses, Home Health employs 5 or 6 IV RNs who report to Suzanne Keitzer, manager of IV therapy; approximately 18 to 20 mental health RNs who report to Jan Muschar, manager social work/mental health nursing; approximately 25 rehabilita- tion nurses who report to Denna Westerbeck, manager of reha- bilitation, and an enterostimal therapy RN, Patricia Ginsberg, who reports directly to Johnson. Ginsberg, the IV therapy RNs, the rehabilitation RNs and the mental health RN all perform direct patient care functions and work in the geographical areas serviced by one or more of the branch offices.10 In addition to the aforementioned nurses, Home Health employs at its admin- istrative offices five intake RNs who are responsible for proc- essing new patient referrals, e.g., ensuring the referral is appro- priate, obtaining information pertaining to each patient’s physi- cian(s) and medications, processing insurance and assigning patients to a specific branch office for care. These intake RNs report to JoAnn Parzick, consultant on special projects.11 All of Home Health’s RNs are paid at an hourly rate, between $16 and $22 per hour.12 In addition to the RNs, it appears that Home Health’s profes- sional staff consists of 2 salaried account representatives, who report to Lynn Setar, Director of Client Relations,13 4 occupa- tional therapists, 18 physical therapists and 4 speech therapists who ultimately report to Denna Westerbeck;14 and 4 social 10 The parties are in agreement that the medical surgical staff RNs, the IV therapy RNs, the mental health RNs, the rehabilitation RNs, and the enterostimal RN should all be included in the unit. 11 The parties are in agreement that the intake nurses should be in- cluded in the unit. 12 Two other RNs work at Home Health’s administrative offices at the Homestead Campus. Suzanne Resetar is a specialist of clinical systems who is responsible for developing education and training pro- grams for Home Health’s staff, and Margaret Santoro is the utilization review nurse. Both Resetar and Santoro report to Christine Heasley, director of outcome facility management. The record is not clear, whether the Petitioner seeks to include Resetar and/or Santoro in the unit. Accordingly, I shall permit Resetar and Santoro to vote subject to challenge in the election directed here. 13 The two account representatives perform marketing functions, e.g., they are responsible for going to physician offices and other facili- ties to speak about the services offered by Home Health. The account representatives do not engage in direct patient care work. 14 The occupational therapists and physical therapists report to team leader Lisa Simon, while the speech therapists report to team leader Gerry Petro. Both Simon and Petro report to Westerbeck. The occupa- tional therapists, speech therapists, and physical therapists, together with the rehabilitation nurses, work out of Home Health’s Allied Health Services department located at the Homestead Campus. Employees occupying these positions receive patient care assignments in geo- graphical areas covered by one or more of the branch offices. Home Health also uses the services of a number of independent physical therapists, occupational therapists, and speech therapists. The parties are in agreement that these independent contractors should not be in- SOUTH HILLS HEALTH SYSTEM AGENCY 655 workers who report to Jan Muschar, manager social work/mental health nursing. As noted, the Petitioner, contrary to the Employer, would exclude these positions from the peti- tioned-for unit.15 Once a patient referral is initially processed at the Home- stead Campus, it is assigned to a branch office nearest the pa- tient. Each branch office has a number of delivery teams com- prised of staff RNs, aides and, to the extent necessary, person- nel from each discipline, e.g., the various therapist occupations and/or social workers, and the specialized nurse occupations (IV nurses, mental health nurses, rehabilitation nurses, and the enterostimal nurse).16 The record reveals that each patient has a designated primary service provider (PSP) who is responsible for assessing the patient, developing and changing the plan of care, making necessary references, completing the bulk of the paperwork, and for facilitating interdisciplinary communica- tions between the staff RNs and the other occupational groups.17 Usually, the PSP is a staff RN, but in some cases the PSP may be from another nursing occupational group or from one of the therapist or social worker occupational groups. Each discipline, however, is responsible for providing an assessment of each patient receiving any specialized care, and for meeting goals and communicating with the patient’s physician regarding a plan of treatment.18 It appears that approximately 50 percent of the patients receive care from multiple disciplines, with a small number receiving care from all of the various disci- plines.19 cluded in the unit. The independent therapists conduct between 30 to 40 percent of the therapy visits. 15 The parties stipulated that the account representatives, occupa- tional therapists, speech therapists, physical therapists, and social workers are professional employees within the meaning of the Act. 16 According to Home Health, the multidisciplinary team approach to patient care is mandated by the Joint Commission on the Accreditation of Health Care Organizations (JACHO) which requires that all of Home Health’s services be coordinated, and that the services meet its stan- dards. 17 In addition, each branch office also employs a group facilitator to help coordinate care aspects of home care. For example, a group facili- tator would call a patient’s physician to procure a walker or cane for the patient as requested by physical therapy. By way of further example, a group facilitator would call to request the use of an aide on behalf of either a physical therapist or another RN for the purpose of bathing and providing personal care. 18 The social workers, all of whom have master’s degrees in social work, address the psycosocial needs of the patient and the patient’s family. Mental health RNs deal with the psychiatric and psychosocial aspects of patient care, e.g., depression which results after a major change in a patient’s health condition. When the PSP makes the initial assessment of a patient, it may be determined by the PSP that employees from other disciplines are also required to provide care. For example, if a patient has skin problems, the enterostimal nurse would be included on the delivery team, or, if the patient lives alone or appears to have been abused or neglected, a social worker may become involved. A physician’s order is necessary before such additional care can be added. 19 The patients who do not receive specialized care, approximately 50 percent of the patients, only receive direct care from the staff RNs and the aides. In many other cases, only a social worker may be as- signed to a patient in addition to a staff RN and aides. In this regard, Margaret Reynolds, a staff RN, testified that of her 33 current patients, only 4 are being seen by a physical therapist, and none are working with an occupational therapist or a speech therapist. Similarly, another staff nurse, LaVerne English, testified that of her current 20 patients, 3 The professional employees of the various disciplines do not appear to interact with any degree of frequency on a day-to-day basis. Usually, staff RNs visit the branch office each day, as do the other professional nurses, therapists, and social workers, who have patients in the branch offices’ geographical area. It does not appear, however, that employees spend any significant degree of time with one another at the branch offices. In addi- tion, it appears that employees from the various disciplines are discouraged from visiting the same patients on the same day.20 Further, the different care givers make their own scheduling arrangements for patient visits. The record reflects that the primary form of communication among employees providing care to the same patient is the Patient Interdisciplinary Communication Log (PIC Log) which remains in the patient’s homes. This log provides a place for caregivers to leave messages regarding the patient or plan of care.21 In some instances, another form of communication among the disciplines is the “case conference,” a meeting of all employees giving care to a patient where particular problems arise with respect to the patient, e.g., a patient is not reaching the goals set by the individual team members.22 These confer- ences are held for less than 25 percent of all patients.23 If a team member cannot attend due to scheduling conflicts, the team member must submit a verbal/written assessment of iden- tified patient problems to their clinical supervisor prior to the conference. Family Hospice Family Hospice employs approximately 14 RNs whom the parties agree should be included in the unit. In addition, Family Hospice’s professional staff24 appears to include 4 social work- ers and 5 employees holding various administrative positions.25 or 4 require the services of a social worker and 4 require physical ther- apy, while none require occupational or speech therapy. 20 There is a monthly schedule contained in the patient’s care folder which is kept at the patient’s home. Each RN or other health profes- sional is required to mark the calendar with anticipated dates of visits. The calendar is also used to denote those times when physician ap- pointments are scheduled and when any medical procedures (e.g., blood work, chemotherapy) will be done. 21 Several staff RNs testified, however, that they do not use the PIC Log on a regular basis. 22 For example, at one team conference held in December, 1999, at- tended by a staff RN, an aide, a mental health RN, and an occupational therapist, discussions ensued concerning the use of a glucometer and about the patient’s medications because issues had arisen about the patient’s blood sugar. As a result of the conference, the patient was reassigned to a different PSP and a different staff RN. 23 For example, Lisa Simon, team leader for physical and occupa- tional therapy, testified that she has not participated in any care confer- ences in the last 12 months. Each team conference is documented by a team conference record, and is documented on the most recent progress note/flow sheet which is contained in the patient’s care folder. 24 Family Hospice also employs two LPNs, six home health aides and a number of clerical employees. 25 These positions include the development coordinator, a position which is filled by Shirley Gautette, who is responsible for organizing all special events such as golf benefits and for writing all of Family Hospice’s publications. The person holding this position must possess a bachelor’s degree. The parties stipulated that the development coor- dinator is a professional employee within the meaning of the Act. The parties also stipulated that two part-time employees, Tom Foreman and Kirk Loadman-Copeland are professional employees within the mean- ing of the Act. These employees provide spiritual care to patients and DECISIONS OF THE NATIONAL LABOR RELATIONS BOARD 656 As previously indicated, Family Hospice is a licensed Medi- care hospice provider whose mission is to care for terminally ill patients. Reporting directly to Executive Director Judie Talbert are Michael Adametz, Manager of Business Services; Virginia Valentine, Manager of Clinical Operations; Marty Tiani, Man- ager of Development; Judie Speigel, Manager of Supportive Service; and Kay Falkenham, Manager of Planning and Pro- gram Development.26 Reporting to Manager of Clinical Opera- tions Virginia Valentine is clinical supervisor Jo Ellen Deasy to whom the RNs, aides, LPNs, and social workers report. Also reporting to Deasy is Patty Hartman, a registered nurse who acts as the intake coordinator for Family Hospice.27 At Family Hospice, services are also provided under a team- based approach, with staff divided into two teams, with each team having responsibility for patients within a specific geo- graphical area. Unlike Home Health, an RN is always the pri- mary care giver or care manager, and the team itself is com- prised only of RNs, aides and at times a social worker.28 Be- cause of the type of services rendered, volunteers and clergy also assist staff members in providing palliative care in accor- dance with Hospice Medicare benefits.29 More specifically, the record reflects that when a patient is referred to Family Hos- pice, an intake RN compiles as much information about the patient as possible, including the patient’s condition, history and family structure. The clinical supervisor, Deasy, then schedules an RN case manager to make the initial patient visit. The RN case manager will coordinate the care for the patient, including spiritual care30 or volunteers, as needed. In this re- gard, the case manager completes a series of paperwork includ- ing paperwork to assist other RNs in dispensing medications, a home health assignment form, and an initial spiritual assess- ment form. Nursing flow sheets and pain assessment flow sheets are also completed to document the patient’s condition and are used by team members to coordinate and provide care. their families and are required to possess a masters degree in divinity. Finally, the parties stipulated that two employees holding community liaison positions, Teresa Mervosh and Marjorie Wilder, and Marketing Service Coordinator Michelle Dreyfus, are professional employees within the meaning of the Act. Wilder is a registered nurse who also functions as an intake nurse at Mercy Hospital. Dreyfus is responsible for public relations for Family Hospice. The record is not clear whether the Petitioner would exclude Wilder from the petitioned-for unit. I shall, therefore, permit Wilder to vote subject to challenge in the election directed herein. 26 The parties stipulated, and I find, that the aforementioned indi- viduals are supervisors within the meaning of the act inasmuch as they possess one or more of the authorities set forth in Sec. 2(11) of the Act. 27 It appears that the parties are in agreement that Hartman should be included in the unit. Hartman works at Family Hospice’s administra- tive office and performs all referrals and intake processing. There is also a full-time RN, in addition to Wilder, who works at various hospi- tals, primarily on the oncology floors, performing intake functions. 28 An interdisciplinary Group Care Plan is prepared for each patient which has contributions from the Hospice medical director, RN case manager, social workers, and attending physicians. 29 Much of the care Family Hospice provides occurs in acute care fa- cilities, and Family Hospice is required to ensure that the plan of care is being followed in the hospital. The care manager must coordinate the services of Family Hospice with the hospital nursing staff, and other staff, for those patients admitted to acute care facilities. 30 Social workers, in conjunction with clergy, provide bereavement counseling to patients and their families. Other Factors Relevant to the Unit Determination SHHS’s Human Resources Department, which is located at the Homestead Campus, serves all of SHHS’s operations, in- cluding Home Health and Family Hospice. All personnel files of Home Health and Family Hospice employees are kept there. All employees of SHHS are subject to the same personnel poli- cies which are set forth in SHHS’s employee handbook and include such matters as timeclock/recordkeeping requirements, orientation program, wearing of ID badges, and dress code and attendance policies, codes of conduct, discipline program, work reduction policy, uniform payroll periods, benefit programs, job bidding, and transfer policies. The record does not reveal any instances of Home Health and Family Hospice RNs transferring between the two entities. Further, the record does not reveal any instances of interchange between RNs and other professional staff. Analysis and Conclusions The Petitioner, contrary to the Employer, contends that a unit limited to RNs employed at Home Health and Family Hospice is appropriate for the purpose of collective bargaining. Neither Home Health nor Family Hospice are acute care health care facilities. When determining the appropriate bar- gaining unit for nonacute health care facilities, such as Home Health and Family Hospice, the Board applies the “pragmatic or empirical community of interest” test set forth in Park Manor Care Center, Inc., 305 NLRB 872, 874–875 (1991). In this regard, the Board will consider community of interest fac- tors, and factors deemed relevant by the Board in its rulemak- ing proceedings in collective-bargaining units in the health care industry, the evidence presented during rulemaking with re- spect to units in acute care hospitals,31 and prior precedent. Specifically, the Board found during the rulemaking process that RNs in acute care hospitals constitute a discrete group because their distinctive interests warranted separate represen- tation. The factors relied upon by the Board in making this determination included: (1) unique work schedules, (2) unique responsibilities, (3) common supervision by other nurses, (4) separate labor market and distinct wages from those of other professionals, (5) separate education, training and licensing requirements, (6) interaction with other RNs, (7) lack of regular and recurring contact with other professionals, (8) lack of inter- change, and (9) history of representation and bargaining in separate units. 53 CFR at 33911–33917, 284 NLRB at 1543– 1552. Since Park Manor, the Board has not had occasion to con- sider whether a unit limited to registered nurses at a nonacute care home health facility, rather than a unit of all professional employees, is appropriate for collective bargaining purposes.32 The Employer argues that a unit limited to RNs, apart from other professionals of Home Health and Family Hospice, is not appropriate because the RNs constitute only a segment of the panoply of professionals interacting with one another to pro- vide multidisciplinary team-based care to patients. Thus, the Employer argues that this multidisciplinary team approach 31 See 53 CFR 33900 (1988) and 54 CFR 16336 (1989), set forth in 284 NLRB 1516, et. seq. 32 In Visiting Nurses Association of Central Illinois, 324 NLRB 55 (1997), the issue presented was whether a single facility, rather than a multi-site unit of home health care registered nurses was appropriate. The Board was not presented with the issue of whether other profes- sional employees must be included in the unit. SOUTH HILLS HEALTH SYSTEM AGENCY 657 demonstrates “an overwhelming degree of community of inter- est” among the professionals at issue herein. More specifically, the Employer argues that the utilization of PSPs, group facilita- tors, and care managers to coordinate patient care, the PIC Log process, and other forms of written communication and docu- ments prepared for each patient clearly establishes the high degree of functional integration of the work force. For the reasons set forth below, I find that the petitioned-for unit is appropriate for the purposes of collective bargaining. In this regard, I first note that there are a number of professional employees at Home Health and Family Hospice who the Em- ployer seeks to include in the unit who do not provide direct patient care services and are not part of any multidisciplinary health care team.33 Further, unlike, the therapists and social workers, RNs are paid by the hour and, generally, are the pri- mary caregivers who are responsible for assessing the patients, making necessary referrals, and developing and changing the plans of care. Significantly, the record clearly establishes, as set forth previously, that RNs are part of every delivery team, while therapists and/or social workers are part of delivery teams for approximately 50 percent of the patients. In addition, there is little face-to-face contact between RNs and other profes- sional groupings. There is little, if any, overlapping of time spent with a patient. Although social workers and therapists are part of the “team approach” utilized by the Home Health and Family Hospice, the argument made by hospitals during the rulemaking process that a “team approach” compels a conclusion that RNs must be 33 E.g., the administrative assistants at Home Health, the mandatory service coordinator, the development coordinator, and at least one community liaison person employed at Family Hospice. combined with other professionals was rejected by the Board. Specifically, the background data reviewed by the Board in the rulemaking process revealed that there are sometimes cross- over duties between RNs and other professionals, the evidence also established that licensing and other regulations clearly prevent RNs from doing much of the work of other profession- als—and other professionals from doing RN work. 53 CFR at 33912, 284 NLRB at 1544–1545. Thus, the Board concluded the fact that some hospitals utilize a multidisciplinary team concept did not “detract from the separate appropriateness of RN units.” 53 CFR at 33913, 284 NLRB at 1546–1547. In this regard, the Board emphasized that the utilization of a multidis- ciplinary team approach is a process to ensure that the elements of patient care are organized but that such a consideration did not “alter each licensed professional’s responsibility for his or her individual scope of practice.” Id. Additionally, the Board noted that the participation of some RNs in team care did not affect wages, hours, benefits, training, skills, or functions of RNs on or off the teams. Id. Based on the above, and the record as a whole, it does not appear that to the extent Home Health and Family Hospice provide multidisciplinary care, such a consideration compels a conclusion that a combined unit of RNs and other professional employees is the only unit appropriate for collective-bargaining purposes. Accordingly, in accordance with the “pragmatic or empirical community of interest test” set forth in Park Manor, I find a unit of RNs employed by Home Health and Family Hos- pice to be a unit appropriate for the purposes of collective bar- gaining. . . . .