2071.e

AN ACT Relating to authorizing the delegation of nursing care tasks for the provision of health treatment to individuals in community residential programs for the developmentally disabled, residents in adult family homes, and residents of licensed boarding homes contracting to provide assisted living services; amending RCW 18.79.040, 18.79.260, 18.88A.030, and 70.128.130; adding new sections to chapter 18.88A RCW; creating new sections; and prescribing penalties.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

NEW SECTION. Sec. 1. A new section is added to chapter 18.88A RCW to read as follows:

The legislature recognizes that nurses have been successfully delegating nursing care tasks to family members and auxiliary staff for many years. The opportunity for a nurse to delegate to nursing assistants qualifying under section 2 of this act may enhance the viability and quality of care in community health settings for long-term care services and to allow citizens to live as independently as possible with maximum safeguards.

NEW SECTION. Sec. 2. A new section is added to chapter 18.88A RCW to read as follows:

(1) A nurse may delegate specific care tasks to nursing assistants meeting the requirements of this section and who provide care to individuals in community residential programs for the developmentally disabled certified by the department of social and health services under chapter 71A.12 RCW, to individuals residing in adult family homes licensed under chapter 70.128 RCW, and to individuals residing in boarding homes licensed under chapter 18.20 RCW contracting with the department of social and health services to provide assisted living services pursuant to RCW 74.39A.010.

(2) For the purposes of this section, "nursing assistant" means a nursing assistant-registered or a nursing assistant-certified. Nothing in this section may be construed to affect the authority of nurses to delegate nursing tasks to other persons, including licensed practical nurses, as authorized by law.

(3) Before commencing any specific nursing care tasks authorized under this chapter, the nursing assistant must (a) provide to the delegating nurse a certificate of completion issued by the department of social and health services indicating the completion of basic core training as provided in this section, (b) be regulated by the department of health pursuant to this chapter, subject to the uniform disciplinary act under chapter 18.130 RCW, and (c) meet any additional training requirements identified by the nursing care quality assurance commission and authorized by this section.

(4) A nurse may delegate the following care tasks:

(a) Oral and topical medications and ointments;

(b) Nose, ear, eye drops, and ointments;

(c) Dressing changes and catheterization using clean techniques as defined by the nursing care quality assurance commission;

(d) Suppositories, enemas, ostomy care;

(e) Blood glucose monitoring;

(f) Gastrostomy feedings in established and healed condition.

(5) On or before September 1, 1995, the nursing care quality assurance commission, in conjunction with the professional nursing organizations, shall develop rules for nurse delegation protocols and by December 5, 1995, identify training beyond the core training that is deemed necessary for the delegation of complex tasks and patient care.

(6) Nursing task delegation protocols are not intended to regulate the settings in which delegation may occur but are intended to ensure that nursing care services have a consistent standard of practice upon which the public and profession may rely and to safeguard the authority of the nurse to make independent professional decisions regarding the delegation of a task. Protocols shall include at least the following:

(a) Ensure that determination of the appropriateness of delegation of a nursing task is at the discretion of the nurse;

(b) Allow delegation of a nursing care task only for patients who have a stable and predictable condition. "Stable and predictable condition" means a situation, as defined by rule by the nursing care quality assurance commission, in which the patient's clinical and behavioral status is known and does not require frequent presence and evaluation of a registered nurse;

(c) Assure that the delegations of nursing tasks pursuant to this chapter have the written informed consent of the patient consistent with the provisions for informed consent under chapter 7.70 RCW, as well as with the consent of the delegating nurse and nursing assistant. The delegating nurse shall inform patients of the level of training of all care providers in the setting;

(d) Verify that the nursing assistant has completed the core training;

(e) Require assessment by the nurse of the ability and willingness of the nursing assistant to perform the delegated nursing task in the absence of direct nurse supervision and to refrain from delegation if the nursing assistant is not able or willing to perform the task;

(f) Require the nurse to analyze the complexity of the nursing task that is considered for delegation and determine the appropriate level of training and any need of additional training for the nursing assistant;

(g) Require the teaching of the nursing care task to the nursing assistant including return demonstration under observation while performing the task;

(h) Require a plan of nursing supervision and reevaluation of the delegated nursing task. "Nursing supervision" means that the registered nurse monitors by direct observation the skill and ability of the nursing assistant to perform delegated nursing tasks. Frequency of supervision is at the discretion of the registered nurse but shall occur at least every sixty days;

(i) Require instruction to the nursing assistant that the delegated nursing task is specific to a patient and is not transferable;

(j) Require documentation and written instruction related to the delegated nursing task be provided to the nursing assistant and a copy maintained in the patient record;

(k) Ensure that the nursing assistant is prepared to effectively deal with the predictable outcomes of performing the nursing task;

(l) Include in the delegation of tasks an awareness of the nature of the condition requiring treatment, risks of the treatment, side effects, and interaction of prescribed medications;

(m) Require documentation in the patient's record of the rationale for delegating or not delegating nursing tasks.

(7) A basic core training curriculum on providing care for individuals in community residential programs for the developmentally disabled certified by the department of social and health services under chapter 71A.12 RCW shall be in addition to the training requirements specified in subsection (5) of this section. Basic core training shall be developed and adopted by rule by the secretary of the department of social and health services. The department of social and health services shall appoint an advisory panel to assist in the development of core training comprised of representatives of the following:

(a) The division of developmental disabilities;

(b) The nursing care quality assurance commission;

(d) A state-wide organization of community residential service providers whose members are programs certified by the department under chapter 71A.12 RCW.

(8) A basic core training curriculum on providing care to residents in residential settings licensed under chapter 70.128 RCW, or in assisted living pursuant to RCW 74.39A.010 shall be mandatory for nursing assistants prior to assessment by a nurse regarding the ability and willingness to perform a delegated nursing task. Core training shall be developed and adopted by rule by the secretary of the department of social and health services, in conjunction with an advisory panel. The advisory panel shall be comprised of representatives from, at a minimum, the following:

(a) The nursing care quality assurance commission;

(b) Professional nurse organizations;

(c) A state-wide association of community residential service providers whose members are programs certified by the department under chapter 71A.12 RCW;

(d) Aging consumer groups;

(e) Associations representing homes licensed under chapters 70.128 and 18.20 RCW; and

(f) Associations representing home health, hospice, and home care agencies licensed under chapter 70.127 RCW.

NEW SECTION. Sec. 3. A new section is added to chapter 18.88A RCW to read as follows:

On or before December 1, 1995, the department of health and the department of social and health services, in consultation with the nursing care quality assurance commission, shall develop and clarify program and reimbursement policies, as well as clarify barriers to current delegation, relating to the ability and authority of a nurse to delegate care tasks in the programs and services operating under their authority.

The nursing care quality assurance commission shall develop model forms that will assist in standardizing the practice of delegation.

NEW SECTION. Sec. 4. A new section is added to chapter 18.88A RCW to read as follows:

(1) The nurse and nursing assistant shall be accountable for their own individual actions in the delegation process. Nurses acting within the protocols of their delegation authority shall be immune from liability for any action performed in the course of their delegation duties. Nursing assistants following written delegation instructions from registered nurses performed in the course of their accurately written, delegated duties shall be immune from liability.

(2) No person may coerce a nurse into compromising patient safety by requiring the nurse to delegate if the nurse determines it is inappropriate to do so. Nurses shall not be subject to any employer reprisal or disciplinary action by the Washington nursing care quality assurance commission for refusing to delegate tasks or refusing to provide the required training for delegation if the nurse determines delegation may compromise patient safety. Nursing assistants shall not be subject to any employer reprisal or disciplinary action by the nursing care quality assurance commission for refusing to accept delegation of a nursing task. No community residential program, adult family home, or boarding home contracting to provide assisted-living services may discriminate or retaliate in any manner against a person because the person made a complaint or cooperated in the investigation of a complaint.

(3) The department of social and health services shall impose a civil fine of not less than one hundred dollars nor more than one thousand dollars on a community residential program, adult family home, or boarding home under this act that knowingly permits an employee to perform a nursing task except as delegated by a nurse pursuant to this act.

NEW SECTION. Sec. 5. A new section is added to chapter 18.88A RCW to read as follows:

The aging and adult services administration of the department of social and health services shall establish a toll-free telephone number for receiving complaints regarding delegation of specific nursing tasks to nursing assistants, in conjunction with any other such system maintained for long-term care services. Complaints specifically related to nurse-delegation shall be referred to the nursing care quality assurance commission for appropriate disposition in accordance with established procedures.

Sec. 6. RCW 18.79.040 and 1994 sp.s. c 9 s 404 are each amended to read as follows:

(1) "Registered nursing practice" means the performance of acts requiring substantial specialized knowledge, judgment, and skill based on the principles of the biological, physiological, behavioral, and sociological sciences in either:

(a) The observation, assessment, diagnosis, care or counsel, and health teaching of the ill, injured, or infirm, or in the maintenance of health or prevention of illness of others;

(b) The performance of such additional acts requiring education and training and that are recognized by the medical and nursing professions as proper and recognized by the commission to be performed by registered nurses licensed under this chapter and that are authorized by the commission through its rules;

(c) The administration, supervision, delegation, and evaluation of nursing practice. However, nothing in this subsection affects the authority of a hospital, hospital district, medical clinic, or office, concerning its administration and supervision;

(d) The teaching of nursing;

(e) The executing of medical regimen as prescribed by a licensed physician and surgeon, dentist, osteopathic physician and surgeon, podiatric physician and surgeon, physician assistant, osteopathic physician assistant, or advanced registered nurse practitioner.

(2) Nothing in this section prohibits a person from practicing a profession for which a license has been issued under the laws of this state or specifically authorized by any other law of the state of Washington.

(3) This section does not prohibit (a) the nursing care of the sick, without compensation, by an unlicensed person who does not hold himself or herself out to be a registered nurse, ((or)) (b) the practice of licensed practical nursing by a licensed practical nurse, or (c) the practice of a nursing assistant, providing delegated nursing tasks under chapter 18.88A RCW.

Sec. 7. RCW 18.79.260 and 1994 sp.s. c 9 s 426 are each amended to read as follows:

A registered nurse under his or her license may perform for compensation nursing care, as that term is usually understood, of the ill, injured, or infirm, and in the course thereof, she or he may do the following things that shall not be done by a person not so licensed, except as provided in RCW 18.79.270 and section 2 of this act:

(1) At or under the general direction of a licensed physician and surgeon, dentist, osteopathic physician and surgeon, podiatric physician and surgeon, physician assistant, osteopathic physician assistant, or advanced registered nurse practitioner acting within the scope of his or her license, administer medications, treatments, tests, and inoculations, whether or not the severing or penetrating of tissues is involved and whether or not a degree of independent judgment and skill is required;

(2) Delegate to other persons ((~~engaged in nursing,~~)) the functions outlined in subsection (1) of this section in accordance with chapter 18.88A RCW;

(3) Instruct nurses in technical subjects pertaining to nursing;

(4) Hold herself or himself out to the public or designate herself or himself as a registered nurse.

Sec. 8. RCW 18.88A.030 and 1994 sp.s. c 9 s 709 are each amended to read as follows:

(1) A nursing assistant may assist in the care of individuals as delegated by and under the direction and supervision of a licensed (registered) nurse or licensed practical nurse.

(2) A health care facility shall not assign a nursing assistant-registered to provide care until the nursing assistant-registered has demonstrated skills necessary to perform competently all assigned duties and responsibilities.

(3) Nothing in this chapter shall be construed to confer on a nursing assistant the authority to administer medication unless delegated as a specific nursing task pursuant to this chapter or to practice as a licensed (registered) nurse or licensed practical nurse as defined in chapter 18.79 RCW.

(4) Certification is voluntary for nursing assistants working in health care facilities other than nursing homes unless otherwise required by state or federal law or regulation.

(5) The commission may adopt rules to implement the provisions of this chapter.

Sec. 9. RCW 70.128.130 and 1989 c 427 s 26 are each amended to read as follows:

(1) Adult family homes shall be maintained internally and externally in good repair and condition. Such homes shall have safe and functioning systems for heating, cooling, hot and cold water, electricity, plumbing, garbage disposal, sewage, cooking, laundry, artificial and natural light, ventilation, and any other feature of the home.

(2) Adult family homes shall be maintained in a clean and sanitary manner, including proper sewage disposal, food handling, and hygiene practices.

(3) Adult family homes shall develop a fire drill plan for emergency evacuation of residents, shall have smoke detectors in each bedroom where a resident is located, shall have fire extinguishers on each floor of the home, and shall not keep nonambulatory patients above the first floor of the home.

(4) Adult family homes shall have clean, functioning, and safe household items and furnishings.

(5) Adult family homes shall provide a nutritious and balanced diet and shall recognize residents' needs for special diets.

(6) Adult family homes shall establish health care procedures for the care of residents including medication administration and emergency medical care.

(a) Adult family home residents shall be permitted to self- administer medications.

(b) Adult family home providers may administer medications and deliver special care only to the extent ((~~that the provider is a licensed health care professional for whom the administration of medications is within the scope of practice under Washington~~)) authorized by law.

NEW SECTION. Sec. 10. The secretary of health in consultation with the Washington nursing care quality assurance commission, the school of public health and community medicine and the school of nursing of the University of Washington, and the department of social and health services shall monitor the implementation of this act and shall make an interim report by December 31, 1996, and a final report by December 31, 1997, to the legislature on the effectiveness of this act, including protecting the health and safety of persons with developmental disabilities and residents of adult family homes and boarding homes providing assisted living services, including the appropriateness of the tasks allowed for delegation, level and type of training and regulation of nursing assistants, and with any recommendations for improvements. The report shall be based on direct observation, documentation, and interviews, and shall specifically include outcome data on the following:

(1) Patient, nurse, and nursing assistant satisfaction;

(2) Medication errors, including those resulting in hospitalization;

(3) Noncompliance with required training;

(4) Noncompliance with nurse delegation protocols;

(5) Incidence of harm to patients, including abuse and neglect;

(6) Impact on access to care;

(7) Impact on patient independence;

(8) Impact on patient quality of life; and

(9) Incidence of coercion in the nurse-delegation process.

NEW SECTION. Sec. 11. A special legislative task force is established to monitor implementation of this act. The task force shall consist of four members from the house of representatives, no more than two of whom shall be members of the same caucus, who shall be appointed by the speaker of the house of representatives, and four members from the senate, no more than two of whom shall be members of the same caucus, who shall be appointed by the president of the senate. The task force shall:

(1) Review the proposed nurse delegation protocols developed by the nursing care quality assurance commission;

(2) Review the proposed core and specialized training curricula developed by the department of social and health services and by the nursing care quality assurance commission;

(3) Review the program and reimbursement policies, and the identified barriers to nurse delegation, developed by the department of health and department of social and health services;

(4) Submit an interim report of its findings and recommendations on the above actions to the legislature by January 1, 1996;

(5) During 1996, conduct hearings to assess the effectiveness with which the delegation protocols, the core training, and nurse oversight are being implemented, and their impact on patient care and quality of life;

(6) Review and approve the proposed study designs;

(7) By February 1, 1997, recommend to the legislature a mechanism and time frame for extending nurse delegation provisions similar to those described in this act to persons residing in their own homes;

(8) During 1997, receive interim reports on the findings of the studies conducted in accordance with this act, and conduct additional fact-finding hearings on the implementation and impact of the nurse delegation provisions of this act.

The office of program research and senate committee services shall provide staff support to the task force. The department of health, the department of social and health services, and the nursing care quality assurance commission shall provide technical support as needed. The task force shall cease to exist on January 1, 1998, unless extended by act of the legislature.