1218-S AAS 4/8/99

 

 

 

SHB 1218 - S COMM AMD - S2485.4

By Committee on Health & Long-Term Care

 

                               ADOPTED AS AMENDED (Flr 312) 4/8/99

 

    Strike everything after the enacting clause and insert the following:

 

    "NEW SECTION.  Sec. 1.  In consideration of existing recommendations by the department of health with regard to nurse delegation and the parameters of nursing practice, the legislature finds that the provisions of chapter . . ., Laws of 1999 (this act) are necessary to expand the capacity of the nursing profession to adequately serve the public.

 

    Sec. 2.  RCW 18.88A.210 and 1998 c 272 s 10 are each amended to read as follows:

    (1) A ((nurse may delegate specific care tasks to)) nursing assistant((s)) meeting the requirements of this section ((and)) who provides 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)) community-based care settings, as defined in RCW 18.79.260(3), may accept delegation of nursing care tasks by a registered nurse as provided in RCW 18.79.260(3).

    (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 nurse delegation 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)).  Exceptions to these training requirements must adhere to RCW 18.79.260(3)(d)(iii).

    (((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 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 utilizing one or more of the following:  (i) Verification of competency via return demonstration; (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. 3.  RCW 18.88A.230 and 1998 c 272 s 11 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)) secretary 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)) community-based care setting as defined in RCW 18.79.260(3)(d) 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 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. 4.  RCW 18.79.260 and 1995 1st sp.s. c 18 s 51 are each amended to read as follows:

    (1) 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 18.88A.210:)).

    (((1))) (2) A registered nurse may, at or under the general direction of a licensed physician and surgeon, dentist, osteopathic physician and surgeon, naturopathic physician, 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.  Such direction must be for acts which are within the scope of registered nursing practice((;

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

    (3) A registered nurse may delegate tasks of nursing care to other individuals where the registered nurse determines that it is in the best interest of the patient.

    (a) The delegating nurse shall:

    (i) Determine the competency of the individual to perform the tasks;

    (ii) Evaluate the appropriateness of the delegation;

    (iii) Supervise the actions of the person performing the delegated task; and

    (iv) Delegate only those tasks that are within the registered nurse's scope of practice.

    (b) A registered nurse may not delegate acts requiring substantial skill, the administration of medications, or piercing or severing of tissues except to registered or certified nursing assistants who provide care to individuals in community-based care settings as authorized under (d) of this subsection.  Acts that require nursing judgment shall not be delegated, nor shall advanced registered nurse practitioners delegate prescriptive authority.

    (c) No person may coerce a nurse into compromising patient safety by requiring the nurse to delegate if the nurse determines that it is inappropriate to do so.  Nurses shall not be subject to any employer reprisal or disciplinary action by the 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.

    (d) For delegation in community-based care settings, a registered nurse may delegate nursing care tasks only to registered or certified nursing assistants.  Simple care tasks such as blood pressure monitoring, personal care service, or other tasks as defined by the nursing care quality assurance commission are exempted from this requirement.  "Community-based care settings" includes:  Community residential programs for the developmentally disabled, certified by the department of social and health services under chapter 71A.12 RCW; adult family homes licensed under chapter 70.128 RCW; and boarding homes licensed under chapter 18.20 RCW.  Community-based care settings do not include acute care or skilled nursing facilities.

    (i) Delegation of nursing care tasks in community-based care settings is only allowed for individuals who have a stable and predictable condition.  "Stable and predictable condition" means a situation in which the individual's clinical and behavioral status is known and does not require the frequent presence and evaluation of a registered nurse.

    (ii) The determination of the appropriateness of delegation of a nursing task is at the discretion of the registered nurse.  However, the administration of medications by injection, sterile procedures, and central line maintenance may never be delegated.

    (iii) The registered nurse shall verify that the nursing assistant has completed the required core nurse delegation training required in chapter 18.88A RCW prior to authorizing delegation.

    (iv) The nurse is accountable for his or her own individual actions in the delegation process.  Nurses acting within the protocols of their delegation authority are immune from liability for any action performed in the course of their delegation duties.

    (v) On or before June 30, 2000, the nursing care quality assurance commission, in conjunction with the professional nursing organizations and the department of social and health services, shall make any needed revisions or additions to nurse delegation protocols by rule, including standards for nurses to obtain informed consent prior to the delegation of nursing care tasks.  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 the profession may rely, and to safeguard the authority of the nurse to make independent professional decisions regarding the delegation of a task.

    (e) The nursing care quality assurance commission may adopt rules to implement this section.

    (4) Only a person licensed as a registered nurse may instruct nurses in technical subjects pertaining to nursing((;)).

    (((4))) (5) Only a person licensed as a registered nurse may hold herself or himself out to the public or designate herself or himself as a registered nurse.

 

    NEW SECTION.  Sec. 5.  A new section is added to chapter 18.79 RCW to read as follows:

    The dispensing of Schedules II through IV controlled substances subject to RCW 18.79.240(1)(s) is limited to a maximum of a seventy-two-hour supply of the prescribed controlled substance.

 

    Sec. 6.  RCW 18.79.050 and 1994 sp.s. c 9 s 405 are each amended to read as follows:

    "Advanced registered nursing practice" means the performance of the acts of a registered nurse and the performance of an expanded role in providing health care services as recognized by the medical and nursing professions, the scope of which is defined by rule by the commission.  Upon approval by the commission, an advanced registered nurse practitioner may prescribe legend drugs and controlled substances contained in Schedule V of the Uniform Controlled Substances Act, chapter 69.50 RCW, and Schedules II through IV subject to RCW 18.79.240(1) (r) or (s).

    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.

    This section does not prohibit:  (1) The nursing care of the sick, without compensation, by an unlicensed person who does not hold himself or herself out to be an advanced registered nurse practitioner((, or)); (2) the practice of registered nursing by a licensed registered nurse or the practice of licensed practical nursing by a licensed practical nurse; or (3) the delegation of nursing tasks to nursing assistants pursuant to RCW 18.79.260(3).

 

    Sec. 7.  RCW 18.79.240 and 1994 sp.s. c 9 s 424 are each amended to read as follows:

    (1) In the context of the definition of registered nursing practice and advanced registered nursing practice, this chapter shall not be construed as:

    (a) Prohibiting the incidental care of the sick by domestic servants or persons primarily employed as housekeepers, so long as they do not practice registered nursing within the meaning of this chapter;

    (b) Preventing a person from the domestic administration of family remedies or the furnishing of nursing assistance in case of emergency;

    (c) Prohibiting the practice of nursing by students enrolled in approved schools as may be incidental to their course of study or prohibiting the students from working as nursing aides;

    (d) Prohibiting auxiliary services provided by persons carrying out duties necessary for the support of nursing services, including those duties that involve minor nursing services for persons performed in hospitals, nursing homes, or elsewhere under the direction of licensed physicians or the supervision of licensed registered nurses;

    (e) Prohibiting the practice of nursing in this state by a legally qualified nurse of another state or territory whose engagement requires him or her to accompany and care for a patient temporarily residing in this state during the period of one such engagement, not to exceed six months in length, if the person does not represent or hold himself or herself out as a registered nurse licensed to practice in this state;

    (f) Prohibiting nursing or care of the sick, with or without compensation, when done in connection with the practice of the religious tenets of a church by adherents of the church so long as they do not engage in the practice of nursing as defined in this chapter;

    (g) Prohibiting the practice of a legally qualified nurse of another state who is employed by the United States government or a bureau, division, or agency thereof, while in the discharge of his or her official duties;

    (h) Permitting the measurement of the powers or range of human vision, or the determination of the accommodation and refractive state of the human eye or the scope of its functions in general, or the fitting or adaptation of lenses for the aid thereof;

    (i) Permitting the prescribing or directing the use of, or using, an optical device in connection with ocular exercises, visual training, vision training, or orthoptics;

    (j) Permitting the prescribing of contact lenses for, or the fitting and adaptation of contact lenses to, the human eye;

    (k) Prohibiting the performance of routine visual screening;

    (l) Permitting the practice of dentistry or dental hygiene as defined in chapters 18.32 and 18.29 RCW, respectively;

    (m) Permitting the practice of chiropractic as defined in chapter 18.25 RCW including the adjustment or manipulation of the articulation of the spine;

    (n) Permitting the practice of podiatric medicine and surgery as defined in chapter 18.22 RCW;

    (o) Permitting the performance of major surgery, except such minor surgery as the commission may have specifically authorized by rule adopted in accordance with chapter 34.05 RCW;

    (p) Permitting the prescribing of controlled substances as defined in Schedules I through IV of the Uniform Controlled Substances Act, chapter 69.50 RCW, except as provided in (r) or (s) of this subsection;

    (q) Prohibiting the determination and pronouncement of death;

    (r) Prohibiting advanced registered nurse practitioners, approved by the commission as certified registered nurse anesthetists from selecting, ordering, or administering controlled substances as defined in Schedules II through IV of the Uniform Controlled Substances Act, chapter 69.50 RCW, consistent with their commission-recognized scope of practice; subject to facility-specific protocols, and subject to a request for certified registered nurse anesthetist anesthesia services issued by a physician licensed under chapter 18.71 RCW, an osteopathic physician and surgeon licensed under chapter 18.57 RCW, a dentist licensed under chapter 18.32 RCW, or a podiatric physician and surgeon licensed under chapter 18.22 RCW; the authority to select, order, or administer Schedule II through IV controlled substances being limited to those drugs that are to be directly administered to patients who require anesthesia for diagnostic, operative, obstetrical, or therapeutic procedures in a hospital, clinic, ambulatory surgical facility, or the office of a practitioner licensed under chapter 18.71, 18.22, 18.36, 18.36A, 18.57, 18.57A, or 18.32 RCW; "select" meaning the decision-making process of choosing a drug, dosage, route, and time of administration; and "order" meaning the process of directing licensed individuals pursuant to their statutory authority to directly administer a drug or to dispense, deliver, or distribute a drug for the purpose of direct administration to a patient, under instructions of the certified registered nurse anesthetist.  "Protocol" means a statement regarding practice and documentation concerning such items as categories of patients, categories of medications, or categories of procedures rather than detailed case-specific formulas for the practice of nurse anesthesia;

    (s) Prohibiting advanced registered nurse practitioners from ordering or prescribing controlled substances as defined in Schedules II through IV of the Uniform Controlled Substances Act, chapter 69.50 RCW, if and to the extent:  (i) Doing so is permitted by their scope of practice; (ii) it is in response to a combined request from one or more physicians licensed under chapter 18.71 or 18.57 RCW and an advanced registered nurse practitioner licensed under this chapter, proposing a joint practice arrangement under which such prescriptive authority will be exercised with appropriate collaboration between the practitioners; and (iii) it is consistent with rules adopted under this subsection.  The medical quality assurance commission, the board of osteopathic medicine and surgery, and the commission are directed to jointly adopt by consensus by rule a process and criteria that implements the joint practice arrangements authorized under this subsection.  This subsection (1)(s) does not apply to certified registered nurse anesthetists.

    (2) In the context of the definition of licensed practical nursing practice, this chapter shall not be construed as:

    (a) Prohibiting the incidental care of the sick by domestic servants or persons primarily employed as housekeepers, so long as they do not practice practical nursing within the meaning of this chapter;

    (b) Preventing a person from the domestic administration of family remedies or the furnishing of nursing assistance in case of emergency;

    (c) Prohibiting the practice of practical nursing by students enrolled in approved schools as may be incidental to their course of study or prohibiting the students from working as nursing assistants;

    (d) Prohibiting auxiliary services provided by persons carrying out duties necessary for the support of nursing services, including those duties that involve minor nursing services for persons performed in hospitals, nursing homes, or elsewhere under the direction of licensed physicians or the supervision of licensed registered nurses;

    (e) Prohibiting or preventing the practice of nursing in this state by a legally qualified nurse of another state or territory whose engagement requires him or her to accompany and care for a patient temporarily residing in this state during the period of one such engagement, not to exceed six months in length, if the person does not represent or hold himself or herself out as a licensed practical nurse licensed to practice in this state;

    (f) Prohibiting nursing or care of the sick, with or without compensation, when done in connection with the practice of the religious tenets of a church by adherents of the church so long as they do not engage in licensed practical nurse practice as defined in this chapter;

    (g) Prohibiting the practice of a legally qualified nurse of another state who is employed by the United States government or any bureau, division, or agency thereof, while in the discharge of his or her official duties.

 

    Sec. 8.  RCW 18.79.250 and 1994 sp.s. c 9 s 425 are each amended to read as follows:

    An advanced registered nurse practitioner 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 18.79.260 and 18.79.270:

    (1) Perform specialized and advanced levels of nursing as recognized jointly by the medical and nursing professions, as defined by the commission;

    (2) Prescribe legend drugs and Schedule V controlled substances, as defined in the Uniform Controlled Substances Act, chapter 69.50 RCW, and Schedules II through IV subject to RCW 18.79.240(1) (r) or (s) within the scope of practice defined by the commission.  Continuing education requirements for advanced registered nurse practitioners shall include instruction on controlled substances;

    (3) Perform all acts provided in RCW 18.79.260;

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

 

    NEW SECTION.  Sec. 9.  A new section is added to chapter 18.71 RCW to read as follows:

    The commission is directed to jointly adopt by consensus, with the board of osteopathic medicine and surgery and the Washington state nursing care quality assurance commission, a process and criteria that implements the joint practice arrangements authorized under RCW 18.79.240(1)(s).

 

    NEW SECTION.  Sec. 10.  A new section is added to chapter 18.57 RCW to read as follows:

    The board is directed to jointly adopt by consensus, with the medical quality assurance commission and the Washington state nursing care quality assurance commission, a process and criteria that implements the joint practice arrangements authorized under RCW 18.79.240(1)(s).

 

    NEW SECTION.  Sec. 11.  A new section is added to chapter 18.79 RCW to read as follows:

    The commission is directed to jointly adopt by consensus, with the medical quality assurance commission and the board of osteopathic medicine and surgery, a process and criteria that implements the joint practice arrangements authorized under RCW 18.79.240(1)(s).

 

    NEW SECTION.  Sec. 12.  Sections 5 through 7 of this act take effect July 1, 2000.

 

    NEW SECTION.  Sec. 13.  The following acts or parts of acts are each repealed:

    (1) RCW 18.88A.220 (Delegation‑-Program and reimbursement policies) and 1995 1st sp.s. c 18 s 47; and

    (2) RCW 18.88A.240 (Delegation‑-Complaints) and 1995 1st sp.s. c 18 s 49.

 

    NEW SECTION.  Sec. 14.  If any provision of this act or its application to any person or circumstance is held invalid, the remainder of the act or the application of the provision to other persons or circumstances is not affected."

 

 

 

SHB 1218 - S COMM AMD S2485.4

By Committee on Health & Long-Term Care

 

                                                    ADOPTED 4/8/99

 

    On page 1, line 2 of the title, after "settings;" strike the remainder of the title and insert "amending RCW 18.88A.210, 18.88A.230, 18.79.260, 18.79.050, 18.79.240, and 18.79.250; adding new sections to chapter 18.79 RCW; adding a new section to chapter 18.71 RCW; adding a new section to chapter 18.57 RCW; creating a new section; repealing RCW 18.88A.220 and 18.88A.240; and providing an effective date."

 


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