DEPARTMENT OF HEALTH

(Nursing Care Quality Assurance Commission)

[Filed January 31, 2022, 11:02 a.m.]

Preproposal statement of inquiry was filed as WSR 21-19-104.

Title of Rule and Other Identifying Information: WAC 246-840-365, 246-840-367, 246-840-533, and 246-840-930. The nursing care quality assurance commission (commission) is proposing amendments to specific credential and license requirements for nurse technicians (NT), licensed practical nurses (LPN), registered nurses (RN), and advanced registered nurse practitioners (ARNP) in response to the coronavirus disease 2019 (COVID-19) pandemic and the critical demand for health care professionals.

Hearing Location(s): On March 11, 2022, at 1:15 p.m. In response to the coronavirus disease 2019 (COVID-19) public health emergency, the commission will not provide a physical location for this hearing to promote social distancing and the safety of the citizens of Washington state. A virtual public hearing, without a physical meeting space, will be held instead. You can register in advance for this meeting at https://us02web.zoom.us/meeting/register/tZckceCvqTotGdNcx73dCsgb1liq0vopFKnE.

Date of Intended Adoption: March 11, 2022.

Submit Written Comments to: Shad Bell, P.O. Box 47864, Olympia, WA 98504, email https://fortress.wa.gov/doh/policyreview, fax 360-236-4738, by February 25, 2022.

Assistance for Persons with Disabilities: Contact Shad Bell, phone 360-236-4711, fax 360-236-4711, TTY 711, email Shad.Bell@doh.wa.gov, by February 25, 2022.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The commission is proposing amendments to WAC 246-840-365, 246-840-367, 246-840-533, and 246-840-930. The commission proposes amending these rule sections to adopt certain emergency rule language that the commission has approved for permanent rule making.

Proposed amendments to WAC 246-840-365 and 246-840-367 remove nonevidence-based licensure requirements for inactive, reactivating, and expired ARNP licensees. The purpose of these amendments is to clarify what requirements are applicable to ARNPs returning to active status.

Proposed amendments to WAC 246-840-533 include emergency rule language that incorporates the practice/academic partnership model for nursing preceptors, interdisciplinary preceptors, and proctors in clinical or practice settings for nursing students located in Washington state.

Proposed amendments to WAC 246-840-930 include nonsubstantive housekeeping changes.

Reasons Supporting Proposal: The proposed changes to WAC 246-840-365 and 246-840-367 are consistent with prior revisions made to WAC 246-840-360 and 246-840-342. These revisions removed licensure requirements for ARNP renewal and out-of-state endorsement that did not have any evidence of better practice outcomes.

Proposed amendments to WAC 246-840-533 incorporates the practice/academic partnership model for nursing preceptors, interdisciplinary preceptors, and proctors in clinical or practice settings for nursing students located in Washington state. In response to the coronavirus disease 2019 (COVID-19), the commission approved the practice/academic partnership model in order to assist with the strain on clinical placement of students during the pandemic. This model is a strategy that allows nursing students who are employed by a facility work in the role of a student nurse for compensation and, in conjunction with the student's nursing education program, receive academic credit toward meeting clinical requirements.

Proposed amendments to WAC 246-840-930 include changing numeric words to numbers and changing the word "occurs" to "occur."

Statutory Authority for Adoption: RCW 18.79.010, 18.79.110, and 18.79.260.

Rule is not necessitated by federal law, federal or state court decision.

Agency Comments or Recommendations, if any, as to Statutory Language, Implementation, Enforcement, and Fiscal Matters: Not applicable.

Name of Proponent: Washington state nursing care quality assurance commission, governmental.

Name of Agency Personnel Responsible for Drafting and Implementation: Shad Bell, 111 Israel Road S.E., Tumwater, WA 98504, 360-236-4711; Enforcement: Catherine Woodard, 111 Israel Road S.E., Tumwater, WA 98504, 360-236-4757.

A school district fiscal impact statement is not required under RCW 28A.305.135.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Shad Bell, P.O. Box 47864, Olympia, WA 98504-7864, phone 360-236-4711, fax 360-236-4738, TTY 711, email Shad.Bell@doh.wa.gov.

The proposed rule does not impose more-than-minor costs on businesses. Following is a summary of the agency's analysis showing how costs were calculated. The proposed rules do not impact businesses, the proposed rules only impact provider licensing requirements.

Paula R. Meyer, MSN, RN, FRE

Nursing Care Quality

Assurance Commission

AMENDATORY SECTION(Amending WSR 19-08-031, filed 3/27/19, effective 4/27/19)

WAC 246-840-365Inactive and reactivating an ARNP license.

To apply for an inactive ARNP license, an ARNP shall comply with WAC 246-12-090 or 246-12-540, if military related.

(1) An ARNP may apply for an inactive license if he or she holds an active Washington state ARNP license without sanctions or restrictions.

(2) To return to active status the ARNP:

(a) Shall meet the requirements identified in ((chapter 246-12 WAC, Part 4))WAC 246-12-090 through 246-12-110, Inactive credential for nonmilitary practitioners;

(b) Must hold an active RN license under chapter 18.79 RCW without sanctions or restrictions;

(d) Shall submit evidence of current certification by the commission approved certifying body identified in WAC 246-840-302(1)((;

(e) Shall submit evidence of thirty contact hours of continuing education for each designation within the past two years; and

(f) Shall submit evidence of two hundred fifty hours of advanced clinical practice for each designation within the last two years.

(3) An ARNP applicant who does not have the required practice requirements, shall complete two hundred fifty hours of supervised advanced clinical practice for every two years the applicant may have been out of practice, not to exceed one thousand hours.

(4) The ARNP applicant needing to complete supervised advanced clinical practice shall obtain an ARNP interim permit consistent with the requirements for supervised practice defined in WAC 246-840-340 (4) and (5))).

(((5)))(3) To regain prescriptive authority after inactive status, the applicant must meet the prescriptive authority requirements identified in WAC 246-840-410.

AMENDATORY SECTION(Amending WSR 19-08-031, filed 3/27/19, effective 4/27/19)

WAC 246-840-367Expired license.

When an ARNP license is not renewed, it is placed in expired status and the nurse must not practice as an ARNP.

(1) To return to active status when the license has been expired for less than two years, the nurse shall:

(a) Meet the requirements of ((chapter 246-12 WAC, Part 2))WAC 246-12-020 through 246-12-051, Initial and renewal credentialing of practitioners;

(b) Meet ARNP renewal requirements identified in WAC 246-840-360; and

(2) ((Applicants who do not meet the required advanced clinical practice requirements must complete two hundred fifty hours of supervised advanced clinical practice for every two years the applicant may have been out of practice, not to exceed one thousand hours.

(3) The ARNP applicant needing to complete supervised advanced clinical practice shall obtain an ARNP interim permit consistent with the requirements for supervised practice defined in WAC 246-840-340 (4) and (5).

(4))) If the ARNP license has expired for two years or more, the applicant shall:

(a) Meet the requirements of ((chapter 246-12 WAC, Part 2))WAC 246-12-020 through 246-12-051, Initial and renewal credentialing of practitioners;

(b) Submit evidence of current certification by the commission approved certifying body identified in WAC 246-840-302(3);

(d))) Submit evidence of ((two hundred fifty))250 hours of advanced clinical practice completed within the prior two years; and

(((e)))(d) Submit evidence of an additional ((thirty))30 contact hours in pharmacology if requesting prescriptive authority, which may be granted once the ARNP license is returned to active status.

(((5)))(3) If the applicant does not meet the required advanced clinical practice hours, the applicant shall obtain an ARNP interim permit consistent with the requirements for supervised advanced clinical practice as defined in WAC 246-840-340 (4) and (5).

AMENDATORY SECTION(Amending WSR 19-08-026, filed 3/27/19, effective 4/27/19)

WAC 246-840-533Nursing preceptors, interdisciplinary preceptors, and proctors in clinical or practice settings for nursing students located in Washington state.

(1) Nursing preceptors, interdisciplinary preceptors, and proctors may be used to enhance clinical or practice learning experiences after a student has received instruction and orientation from program faculty who confirm the student is adequately prepared for the clinical or practice experience. For the purpose of this section:

(a) A nursing preceptor means a practicing licensed nurse who provides personal instruction, training, and supervision to any nursing student, and meets all requirements of subsection (4) of this section.

(b) An interdisciplinary preceptor means a practicing health care provider who is not a licensed nurse, but provides personal instruction, training, and supervision to any nursing student, and meets all requirements of subsection (5) of this section.

(c) A proctor means an individual who holds an active credential in one of the professions identified in RCW 18.130.040 who monitors students during an examination, skill, or practice delivery, and meets all requirements of subsection (6) of this section.

(2) Nursing education faculty are responsible for the overall supervision and evaluation of the student and must confer with each primary nursing and interdisciplinary preceptor, and student at least once during each phase of the student learning experience:

(a) Beginning;

(b) Midpoint; and

(3) A nursing preceptor or an interdisciplinary preceptor shall not precept more than two students at any one time.

(4) A nursing preceptor may be used in nursing education programs when the nursing preceptor:

(a) Has an active, unencumbered nursing license at or above the level for which the student is preparing;

(b) Has at least one year of clinical or practice experience as a licensed nurse at or above the level for which the student is preparing;

(d) Is oriented to the written role expectations of faculty, preceptor, and student prior to beginning the preceptorship; and

(e) Is not a member of the student's immediate family, as defined in RCW 42.17A.005(27); or have a financial, business, or professional relationship that is in conflict with the proper discharge of the preceptor's duties to impartially supervise and evaluate the nurse.

(5) An interdisciplinary preceptor may be used in nursing education programs when the interdisciplinary preceptor:

(a) Has an active, unencumbered license in the area of practice appropriate to the nursing education faculty planned student learning objectives;

(b) Has the educational preparation and at least one year of clinical or practice experience appropriate to the nursing education faculty planned student learning objectives;

(d) Is oriented to the written role expectations of faculty, preceptor, and student prior to beginning the preceptorship; and

(6) A proctor who monitors, teaches, and supervises students during the performance of a task or skill must:

(a) Have the educational and experiential preparation for the task or skill being proctored;

(b) Have an active, unencumbered credential in one of the professions identified in RCW 18.130.040;

(c) Only be used on rare, short-term occasions to proctor students when a faculty member has determined that it is safe for a student to receive direct supervision from the proctor for the performance of a particular task or skill that is within the scope of practice for the nursing student; and

(d) Is not a member of the student's immediate family, as defined in RCW 42.17A.005(27); or have a financial, business, or professional relationship that is in conflict with the proper discharge of the preceptor's duties to impartially supervise and evaluate the nurse.

(7) A practice/academic partnership model may be used to permit practice hours as a nursing technician, as defined in WAC 246-840-010(30), to be credited toward direct care nursing program clinical hours, and academic credit. Use of this model must include:

(a) Endorsement by the nurse administrator placed in the student's file that:

(i) Traditional clinical experiences in a required area of study are limited or not available to the program; or

(ii) Circumstances are present in which the student will gain greater educational benefit from the nursing student-employee role;

(b) A nursing preceptor or nursing supervisor who has experience and educational preparation appropriate to the faculty-planned student learning experience. The nursing preceptor or nursing supervisor must be responsible for ensuring the requirements of WAC 246-840-880 are met;

(c) Nursing program faculty that work with health care facility representatives to align clinical skills and competencies with the nursing student-employee work role/responsibilities;

(d) Nursing student-employees with faculty-planned clinical practice experiences that enable the student to attain new knowledge, develop clinical reasoning/judgment abilities, and demonstrate achievement of clinical objectives and final learning outcomes of the nursing program if the nursing student-employee is in the final nursing course;

(e) The nursing student-employee use of reflection on the development or achievement of clinical objectives and final learning outcomes as designed by nursing education faculty;

(f) Nursing education faculty responsible for the overall supervision and evaluation of the nursing student-employee on a weekly basis;

(g) Evaluation by nursing education faculty to include documentation of the nursing student-employee achievement of clinical objectives and final learning outcomes and competencies of the nursing program; and

(h) Nursing technicians be enrolled in a commission-approved nursing program and be in good standing to receive academic credit.

AMENDATORY SECTION(Amending WSR 13-15-063, filed 7/15/13, effective 8/15/13)

WAC 246-840-930Criteria for delegation.

(1) Before delegating a nursing task, the registered nurse delegator decides the task is appropriate to delegate based on the elements of the nursing process: ASSESS, PLAN, IMPLEMENT, EVALUATE.

ASSESS

(2) The setting allows delegation because it is a community-based care setting as defined by RCW 18.79.260 (3)(e)(i) or an in-home care setting as defined by RCW 18.79.260 (3)(e)(ii).

(3) Assess the patient's nursing care needs and determine the patient's condition is stable and predictable. A patient may be stable and predictable with an order for sliding scale insulin or terminal condition.

(4) Determine the task to be delegated is within the delegating nurse's area of responsibility.

(5) Determine the task to be delegated can be properly and safely performed by the nursing assistant or home care aide. The registered nurse delegator assesses the potential risk of harm for the individual patient.

(6) Analyze the complexity of the nursing task and determine the required training or additional training needed by the nursing assistant or home care aide to competently accomplish the task. The registered nurse delegator identifies and facilitates any additional training of the nursing assistant or home care aide needed prior to delegation. The registered nurse delegator ensures the task to be delegated can be properly and safely performed by the nursing assistant or home care aide.

(7) Assess the level of interaction required. Consider language or cultural diversity affecting communication or the ability to accomplish the task and to facilitate the interaction.

(8) Verify that the nursing assistant or home care aide:

(a) Is currently registered or certified as a nursing assistant or home care aide in Washington state without restriction;

(b) Has completed both the basic caregiver training and core delegation training before performing any delegated task;

(c) Has a certificate of completion issued by the department of social and health services indicating completion of the required core nurse delegation training;

(d) Has a certificate of completion issued by the department of social and health services indicating completion of diabetes training when providing insulin injections to a diabetic client; and

(e) Is willing and able to perform the task in the absence of direct or immediate nurse supervision and accept responsibility for their actions.

(9) Assess the ability of the nursing assistant or home care aide to competently perform the delegated nursing task in the absence of direct or immediate nurse supervision.

(10) If the registered nurse delegator determines delegation is appropriate, the nurse:

(a) Discusses the delegation process with the patient or authorized representative, including the level of training of the nursing assistant or home care aide delivering care.

(b) Obtains written consent. The patient, or authorized representative, must give written, consent to the delegation process under chapter 7.70 RCW. Documented verbal consent of patient or authorized representative may be acceptable if written consent is obtained within ((thirty))30 days; electronic consent is an acceptable format. Written consent is only necessary at the initial use of the nurse delegation process for each patient and is not necessary for task additions or changes or if a different nurse, nursing assistant, or home care aide will be participating in the process.

PLAN

(11) Document in the patient's record the rationale for delegating or not delegating nursing tasks.

(12) Provide specific, written delegation instructions to the nursing assistant or home care aide with a copy maintained in the patient's record that includes:

(a) The rationale for delegating the nursing task;

(b) The delegated nursing task is specific to one patient and is not transferable to another patient;

(c) The delegated nursing task is specific to one nursing assistant or one home care aide and is not transferable to another nursing assistant or home care aide;

(d) The nature of the condition requiring treatment and purpose of the delegated nursing task;

(e) A clear description of the procedure or steps to follow to perform the task;

(f) The predictable outcomes of the nursing task and how to effectively deal with them;

(g) The risks of the treatment;

(h) The interactions of prescribed medications;

(i) How to observe and report side effects, complications, or unexpected outcomes and appropriate actions to deal with them, including specific parameters for notifying the registered nurse delegator, health care provider, or emergency services;

(j) The action to take in situations where medications and/or treatments and/or procedures are altered by health care provider orders, including:

(i) How to notify the registered nurse delegator of the change;

(ii) The process the registered nurse delegator uses to obtain verification from the health care provider of the change in the medical order; and

(iii) The process to notify the nursing assistant or home care aide of whether administration of the medication or performance of the procedure and/or treatment is delegated or not;

(k) How to document the task in the patient's record;

(l) Document teaching done and a return demonstration, or other method for verification of competency; and

(m) Supervision shall occur at least every ((ninety))90 days. With delegation of insulin injections, the supervision occurs at least weekly for the first four weeks, and may be more frequent.

(13) The administration of medications may be delegated at the discretion of the registered nurse delegator, including insulin injections. Any other injection (intramuscular, intradermal, subcutaneous, intraosseous, intravenous, or otherwise) is prohibited. The registered nurse delegator provides to the nursing assistant or home care aide written directions specific to an individual patient.

IMPLEMENT

(14) Delegation requires the registered nurse delegator teach the nursing assistant or home care aide how to perform the task, including return demonstration or other method of verification of competency as determined by the registered nurse delegator.

(15) The registered nurse delegator is accountable and responsible for the delegated nursing task. The registered nurse delegator monitors the performance of the task(s) to assure compliance with established standards of practice, policies and procedures and appropriate documentation of the task(s).

EVALUATE

(16) The registered nurse delegator evaluates the patient's responses to the delegated nursing care and to any modification of the nursing components of the patient's plan of care.

(17) The registered nurse delegator supervises and evaluates the performance of the nursing assistant or home care aide, including direct observation or other method of verification of competency of the nursing assistant or home care aide. The registered nurse delegator reevaluates the patient's condition, the care provided to the patient, the capability of the nursing assistant or home care aide, the outcome of the task, and any problems.

(18) The registered nurse delegator ensures safe and effective services are provided. Reevaluation and documentation occur((s)) at least every ((ninety))90 days. Frequency of supervision is at the discretion of the registered nurse delegator and may be more often based upon nursing assessment.

(19) The registered nurse must supervise and evaluate the performance of the nursing assistant or home care aide with delegated insulin injection authority at least weekly for the first four weeks. After the first four weeks the supervision shall occur at least every ((ninety))90 days.