2363-S.E AMS HEA S5159.1

ESHB 2363 - S COMM AMD

By Committee on Health & Long-Term Care

    Strike everything after the enacting clause and insert the following:

    "Sec. 1.  RCW 18.88A.030 and 1995 1st sp.s. c 18 s 52 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 except as authorized in public and private schools under RCW 28A.210.260 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. 2.  RCW 18.88A.210 and 1995 1st sp.s. c 18 s 46 are each amended 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)) initial delegating nurse obtains written consent to the nurse delegation process from the patient or a person authorized under RCW 7.70.065.  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 or nursing assistant will be participating in the process.  The written consent must include at a minimum the following:

(i) A list of the tasks that could potentially be delegated per RCW 18.88A.210; and

(ii) A statement that a nursing assistant through the nurse delegation process will be performing a task that would previously have been performed by a registered or licensed practical nurse;

    (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)) utilizing one or more of the following:  (i) Verification of competency via return demonstration ((under observation while performing the task)); (ii) other methods for verification of competency to perform the nursing task; or (iii) assurance that the nursing assistant is competent to perform the nursing task as a result of systems in place in the community residential program for the developmentally disabled, adult family home, or boarding home providing assisted living services;

    (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 or by whatever means is deemed appropriate by the registered nurse 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;

    (c) Professional nursing organizations;

    (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.

    Sec. 1.  RCW 18.88A.230 and 1997 c 275 s 6 are each amended 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 based on patient safety issues.  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)) may impose a civil fine of not less than two hundred fifty dollars nor more than one thousand dollars on a community residential program, adult family home, or boarding home under chapter 18, Laws of 1995 1st sp. sess. that knowingly permits an employee to perform a nursing task except as delegated by a nurse pursuant to chapter 18, Laws of 1995 1st sp. sess.

    Sec. 2.  1995 1st sp.s. c 18 s 54 (uncodified) is amended to read as follows:

    A special legislative task force is established to monitor implementation of sections 45 through 53 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)) 1998, 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 sections 45 through 53 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)) 1999, unless extended by act of the legislature.

    Sec. 3.  RCW 28A.210.260 and 1994 sp.s. c 9 s 720 are each amended to read as follows:

    Public school districts and private schools which conduct any of grades kindergarten through the twelfth grade may provide for the administration of oral medication of any nature to students who are in the custody of the school district or school at the time of administration, but are not required to do so by this section, subject to the following conditions:

    (1) The board of directors of the public school district or the governing board of the private school or, if none, the chief administrator of the private school shall adopt policies which address the designation of employees who may administer oral medications to students, the acquisition of parent requests and instructions, and the acquisition of dentist and physician requests and instructions regarding students who require medication for more than fifteen consecutive school days, the identification of the medication to be administered, the means of safekeeping medications with special attention given to the safeguarding of legend drugs as defined in chapter 69.41 RCW, and the means of maintaining a record of the administration of such medication;

    (2) The board of directors shall seek advice from one or more licensed physicians or nurses in the course of developing the foregoing policies;

    (3) The public school district or private school is in receipt of a written, current, and unexpired request from a parent, or a legal guardian, or other person having legal control over the student to administer the medication to the student;

    (4) The public school district or the private school is in receipt of (a) a written, current and unexpired request from a licensed physician or dentist for administration of the medication, as there exists a valid health reason which makes administration of such medication advisable during the hours when school is in session or the hours in which the student is under the supervision of school officials, and (b) written, current, and unexpired instructions from such physician or dentist regarding the administration of prescribed medication to students who require medication for more than fifteen consecutive work days;

    (5) The medication is administered by ((an)) a consenting employee designated by or pursuant to the policies adopted pursuant to subsection (1) of this section and in substantial compliance with the prescription of a physician or dentist or the written instructions provided pursuant to subsection (4) of this section;

    (6) The medication is first examined by the employee administering the same to determine in his or her judgment that it appears to be in the original container and to be properly labeled; and

    (7) The board of directors shall designate a consenting professional person licensed pursuant to chapter 18.71 RCW or chapter 18.79 RCW as it applies to registered nurses and advanced registered nurse practitioners, to train and supervise the designated school district personnel in proper medication procedures.

NEW SECTION. Sec. 4.  This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect immediately."

ESHB 2363 - S COMM AMD

By Committee on Health & Long-Term Care

    On page 1, beginning on line 2 of the title, after "18.88A.210," strike "and 18.88A.230" and insert "18.88A.230, and 28A.210.260"

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