CHAPTER 13

NURSE DELEGATION

Nurse Delegation

A.Purpose

B.Policy

Nursing Care Tasks

A.Where Can Nursing Care Tasks Be Delegated?

B.What Nursing Care Tasks May Be Delegated?

C.What Nursing Care Tasks May Never Be Delegated?

D.Who Is Paid for Nurse Delegation Services?

TRAINING Requirements AND RESPONSIBILITIES

A.Caregiver Requirements and Responsibilities

B.Your Responsibilities

C.Registered Nurse Delegator Responsibilities

Authorizing Nurse Delegation Services

A.How to Authorize Nurse Delegation For In-Home Clients

B.How to Authorize Nurse Delegation for Residential Clients

C.How To Authorize Nurse Delegation For DDD Clients

TransferRING AN In-Home nurse Delegation Case

A.Assisting with Training/Registration Requirements

B.Documenting the Transfer Process in CARE

APPENDIX A: SSPS CODES FOR NURSE DELEGATION

Nurse Delegation

  1. Purpose

Nurse Delegation (ND) services can enhance the viability and quality of care in private homes and community/residential care settings and allow citizens to live as independently as possible with maximum safeguards.

Nurse Delegation is a service option that provides training and nursing oversight for caregivers who perform delegated nursing tasks. Clients who receive nurse delegation services must be considered “stable and predictable” by the delegating nurse, lack informal support to provide the delegated task, and be unwilling or unable to self-direct their care.

  1. Policy

CHAPTER 18.88A AND 18.79 RCW / THE LAW RELATING TO NURSING CARE
CHAPTER 388-76 WAC / ADULT FAMILY HOME MINIMUM LICENSING REQUIREMENTS
CHAPTER 388-110 WAC / CONTRACTED RESIDENTIAL CARE SERVICES
CHAPTER 246-840 WAC / REGISTERED NURSE DELEGATION IN COMMUNITY AND IN-HOME CARE SETTINGS
CHAPTER 388-71-0415 / SERVICES PROVIDED UNDER COPES

Nursing Care Tasks

  1. Where Can Nursing Care Tasks Be Delegated?

Registered Nurses (RN) can delegate specific nursing care tasks to nursing assistants, registered or certified, who provide care in Licensed Adult Family Homes, Licensed Boarding Homes, state-certified programs for the Developmentally Disabled, or COPES in-home care settings.

  1. What Nursing Care Tasks May Be Delegated?

The Registered Nurse Delegator (RND) may delegate specific nursing care tasks to nursing assistants whom they deem competent, for clients residing in settings specified by law. The most commonly delegated tasks are administration of medications and blood glucose testing. Others types of tasks may include tube feeding, simple wound care or colostomy care. Before delegating, the RND must determine that specific criteria described in the Nurse Delegation protocol (WAC 246-840-910 to 960) are met and ensure that the patient is in a stable and predictable condition.

  1. What Nursing Care Tasks May Never Be Delegated?

According to RCW 18.79.260(3)(e), the RND may not delegate:

  • Sterile procedures;
  • Administration of medications by injection;
  • Maintenance of central intravenous lines;
  • Acts that require nursing judgment.
  1. Who Is Paid for Nurse Delegation Services?
  • Only RNs or agencies under contract for nurse delegation with ADSA can be paid to provide nurse delegation services.
  • Home and Community Services will not pay RNs to delegate in a licensed BH.
  • If a licensed boarding home also has a contract as a Division of Developmental Disabilities (DDD) Group Home, DDD may pay for nurse delegation services. Contact the DDD case/resource manager or the DDD field services office.

TRAINING Requirements AND RESPONSIBILITIES

  1. Caregiver Requirements and Responsibilities

Before performing a delegated task, the caregiver must complete the:

  1. Registration or certification as a Nursing Assistant and renew annually;
  2. “Nurse Delegation for Nursing Assistants” 9-hour class.
  3. “Fundamentals of Caregiving” course or its equivalent.
  4. An NA-R may not perform a delegated before the course is completed.
  5. An NA-C may perform a delegated task before the course is completed.
  1. Your Responsibilities

When your client needs nurse delegation, you are responsible for ensuring that:

  • The client resides in an AFH or BH with staff prepared to delegate. AFHs and BHs are responsible for having staff already trained to provide delegated tasks if they admit clients who need nurse delegation.
  • In-home caregivers have the necessary training and registration to perform a delegated task. You will provide the caregiver with:
  1. A list of approved trainers for Fundamentals of Caregiving;
  2. an application forregistration as a Nursing Assistant;
  3. A signed and dated payment voucher for the application fee. Payment is provided for the initial registration fee only, not renewals. Follow instructions for completing the voucher and send the voucher and application to:

DOH- Health Professions

Department of Health

PO Box 47864

Olympia, WA 98504-7901

  1. A list of approved trainers for “Nurse Delegation for Nursing Assistants” class. The trainer must have a contract with the Area Agency on Aging to receive payment
  2. An hourly wage for the time spent in nurse delegation class.

In-home caregivers may need some but not all of the requirements described above. For instance, if they have:

  • Already completed the Fundamentals of Caregiving, then you must determine that they willing to accept delegation, provide them with information about additional training and registration requirements, and identify a contact person who can assist with the delegation training. If they are not an NA-R or NA-C, provide the application for registration (and payment voucher) as an NA-R.
  • Not completed Fundamentals of Caregiving and do not have HIV training, you must determine that they are willing to accept delegation and give them information about all of the training and registration requirements.
  • Already completed HIV training but not Fundamentals of Caregiving, then they may register as an NA-R. Nurse Delegation law still requires that they complete Fundamentals of Caregiving and Nurse Delegation for Nursing Assistants training before performing a delegated task. Again, determine that they are willing to accept delegation and give them information about completing the training requirements.
  1. Registered Nurse Delegator Responsibilities

The Registered Nurse Delegator must:

  1. Verify that the caregiver has met training and registration requirements, that the registration is current and without restriction, that the caregiver is competent to perform the delegated task.
  2. Assess the nursing needs of the client, determine the appropriateness of delegation in the specific situation, and if appropriate, teach the caregiver to perform the nursing task.
  3. Monitor the caregiver’s performance and continued appropriateness of the delegated task.
  4. Communicate the results of the supervision/assessment to you.
  5. Establish a communication plan with you.
  • Specify in the plan how often and when the RND will communicate with you.
  • Document the plan and all ongoing related communication in the client’s nurse delegation file.
  1. Document and perform all delegation activities as required by law, rule, and policy.
  2. Work with you, providers, and interested parties when rescinding RND to develop an alternative plan of care that ensures continuity for the provision of the task.

Authorizing Nurse Delegation Services

  1. How to Authorize Nurse Delegation For In-Home Clients

To start nurse delegation services for an in-home client, you must:

  1. Confirm that the client is eligible which means he/she:
  • Is on COPES,
  • Is unable or unwilling to self-direct, and
  • Needs professional assistance with a nursing care task.
  1. Document the client’s need for Nurse Delegation in CARE.
  2. Determine whether the client’s caregiver has met the training and registration requirements in Section B above, help them meet the requirements, or assist the client in finding a caregiver who is qualified to provide the delegated task.
  3. Document and refer to a contracted Registered Nurse Delegator (RND)[BB1]; documentation should include the date the client’s current assessment was sent to the RND.
  4. Document and establish a communication plan with the RND; specify in the plan how often and when you will communicate case related issues with the RND.
  5. Document all the above and any ongoing communication in the SER.
  6. Authorize the RND for payment not to exceed 20 units per month through SSPS, using the appropriate program code. (See Appendix A);
  7. Notify RND if client condition or financial eligibility changes.
  1. How to Authorize Nurse Delegation for Residential Clients

To start nurse delegation services for residential clients, you must:

  1. Confirm that the client is eligible which means he/she must need professional assistance with a nursing care task.
  2. Document the client’s need for Nurse Delegation in CARE.
  3. Ensure that the provider has staff qualified to provide delegation.
  4. Complete steps 4-8 above, for AFH clients.

Note: Beginning December 1, 2004, registered nurses (RN) who own an AFH may be paid for delegation for clients living in their AFH. The RN must be a contracted Registered Nurse Delegator (RND). Existing SSPS codes may be used.

  1. How To Authorize Nurse Delegation For DDD Clients

Nurse Delegation services may be providedto individuals served by certified community residential programs for the developmentally disabled. To initiate ND services for these individuals, contact the client’s Division of Developmental Disabilities (DDD) Case Manager or the DDD field services office.

TransferRING AN In-Home nurse Delegation Case

  1. Assisting with Training/Registration Requirements

If, before you transfer the case, the caregiver has not already completed the training and registration requirements in the Caregiver Requirements and Responsibilities section, you will need to:

  1. Assure that an interim plan of care is in place to meet the client’s nursing need until the IP/agency worker is qualified to do delegation. The interim plan should meet the client’s need until the caregiver is qualified (which at a maximum could be up to 4 months). However, you are encouraged to assist the caregiver to meet the training qualifications within the time frame required;
  2. Communicate to the receiving agency that the caregiver will be performing the delegated task once the training and registration requirements are completed.
  3. Begin the process of registration and training the caregiver, as described on page 4.

The receiving agency must monitor the training and registration process for the caregiver and make a referral and authorize payment for a contracted nurse delegator when the caregiver’s training and registration requirements are met.

  1. Documenting the Transfer Process in CARE
  1. On the treatment screen in CARE, select the provider type who will be performing the delegated task on the interim plan (do not select Nurse Delegation until delegation has begun).
  2. In the comment box, document that the caregiver is currently completing the nurse delegation training and registration requirements. Assign the nursing task to be delegated to a provider/informal support person who can perform the task until training and registration is completed.
  3. Document when the training requirements and registration process were explained to the caregiver.
  4. Once the caregiver is trained and delegation has started, indicate this in the SER notes.
  1. On the support screen, reassign the treatment to the RN delegator and reassign duties to the delegated caregiver.
  2. There is no need for the receiving agency to do a reassessment once delegation is started, as long as the client’s condition has not changed. When the next assessment is done, update the treatment screen to include nurse delegation, if appropriate.

APPENDIX A: SSPS CODES FOR NURSE DELEGATION

There are five SSPS codes for registered nurses providing Nurse Delegation:

  • 4760 State Paid AFH RN Delegation
  • 4560 MPC AFH RN Delegation
  • 5260 COPES AFH RN Delegation
  • 5288 COPES In-Home Delegation
  • 5460 MNRW AFH RN Delegation

All codes pay an individual registered nurse or an agency employing/contracting with registered nurses for nurse delegation activities. Billable services may include the initial nursing assessment, reassessments, teaching or supervising a nursing assistant, collateral contacts and related travel time.

Reason Codes should be selected to indicate the primary nursing task needed. Only one code may be selected.

CODE / TITLE
A / Oral/Topical Medication Admin.
B / Eye/Ear/Nose Drops Admin.
C / Blood Sugar Checks (Glucom.)
D / Oxygen Administration
E / Non-sterile Dressings
F / Other

The current rate for nurse delegation is $8.08 per unit. One unit equals 15 minutes. A maximum of 20 units (5 hours) may be authorized each month. The service may be authorized to continue for a maximum of 12 months

Nurse delegation is an intermittent service. The nurse is required to visit at least once every ninety days, and may not need to see a client more frequently. However, the delegating nurse may determine that some clients need to be seen more often. The statewide Program Managers are responsible to monitor the nurse’s performance including frequency of visits and SSPS payments. See Service Code Data Sheets in SSPS for additional information.

REvised 11/04PAGE 1

[BB1]This link only has AFH contractors.