HOUSE BILL REPORT

ESHB 2473

As Passed Legislature

Title: An act relating to creating a medication assistant endorsement for certified nursing assistants who work in nursing homes.

Brief Description: Creating a medication assistant endorsement for certified nursing assistants who work in nursing homes.

Sponsors: House Committee on Health Care & Wellness (originally sponsored by Representatives Green, Hinkle, Johnson, Van De Wege, Ryu and Roberts).

Brief History:

Committee Activity:

Health Care & Wellness: 1/23/12, 1/26/12 [DPS];

Health & Human Services Appropriations & Oversight: 2/2/12, 2/3/12 [DPS(HCW)].

Floor Activity:

Passed House: 2/10/12, 96-0.

Senate Amended.

Passed Senate: 2/29/12, 44-4.

Passed House: 3/3/12, 96-0.

Passed Legislature.

Majority Report: The substitute bill be substituted therefor and the substitute bill do pass. Signed by 10 members: Representatives Cody, Chair; Jinkins, Vice Chair; Schmick, Ranking Minority Member; Hinkle, Assistant Ranking Minority Member; Clibborn, Green, Harris, Kelley, Moeller and Van De Wege.

Staff: Chris Cordes (786-7103).

Majority Report: The substitute bill by Committee on Health Care & Wellness be substituted therefor and the substitute bill do pass. Signed by 11 members: Representatives Dickerson, Chair; Appleton, Vice Chair; Johnson, Ranking Minority Member; Schmick, Assistant Ranking Minority Member; Cody, Green, Harris, Kagi, Overstreet, Pettigrew and Walsh.

Staff: Amy Skei (786-7109).

Background:

The Department of Health registers nursing assistants and certifies those who complete required education and training as determined by the state Nursing Care Quality Assurance Commission (Nursing Commission). Nursing assistants may assist in providing care to individuals under the direction and supervision of a licensed or registered nurse. Nursing assistants work in various health care facilities, such as hospitals, nursing homes, hospices, and other entities delivering health care services.

A registered nurse may delegate nursing care tasks that are within the nurse's scope of practice to other individuals where the nurse finds it to be in the patient's best interest. Before delegating a nursing care task, the registered nurse must determine the competency level of the person to perform the delegated task, evaluate the appropriateness of the delegation, and supervise the person performing the delegated task. With some exceptions, registered nurses may not delegate tasks requiring nursing judgment, substantial skill, the administration of medications, or the piercing or severing of tissues.

In home and community-based care settings, registered nurses may delegate medication assistance and certain other nursing tasks to nursing assistants working with patients who are in a stable and predictable condition. The nursing assistant must first complete Department of Social and Health Services' basic core nurse delegation training. The assistance may not include assistance with intravenous or injectable medications except for prefilled insulin syringes.

Registered nurses working for a home health or hospice agency are allowed to delegate the application, instillation, or insertion of medications to a registered or certified nursing assistant under a plan of care.

Summary of Engrossed Substitute Bill:

A program is established to allow certified nursing assistants (CNA) to receive a medication assistant endorsement to administer, under registered nurse supervision, certain medications and treatments in a nursing home.

Medication Assistant Endorsement. Beginning July 1, 2013, a CNA may seek a medication assistant endorsement from the Department of Health. To be issued the endorsement, a CNA must:

• maintain his or her nursing assistant certification in good standing;

• complete the hours of documented work as a CNA that is required by the Nursing Commission;

• successfully complete an education and training program approved by the Nursing Commission;

• pass an examination approved by the Nursing Commission; and

• complete continuing competency requirements as defined by the Nursing Commission.

Permitted Additional Tasks. A CNA with a medical assistant endorsement may perform and document the following additional tasks:

• administer medications orally, topically, and through inhalation; and

• perform simple prescriber-ordered treatments, as defined by the Nursing Commission, which may include monitoring blood glucose and blood oxygen saturation, changing noncomplex clean dressings, and administering oxygen.

These additional tasks may be performed only (1) in a nursing home, (2) if supervised by a designated registered nurse who is on site and immediately accessible, and (3) if these additional tasks are the primary responsibility of the medication assistant during the time the tasks are performed. The registered nurse must assess the patient and determine whether it is safe for the CNA to administer the medications or treatment.

The Nursing Commission may adopt rules regarding the medication assistant's primary responsibilities and limiting the duties that a CNA may perform while functioning as a medication assistant.

Prohibited Tasks. A medication assistant may not:

• accept telephone or verbal orders from a prescriber;

• calculate medication dosages;

• inject any medications;

• perform any sterile task;

• administer medications through a tube;

• administer Schedule I, II, or III controlled substances; or

• perform any task that requires nursing judgment.

A medication assistant's employer may restrict, but not expand, the range of functions permitted for a medication assistant.

Appropriation: None.

Fiscal Note: Available.

Effective Date: The bill takes effect on July 1, 2013, except for section 1, relating to legislative findings, and section 11, relating to rule-making, which take effect 90 days after adjournment of the session in which the bill is passed.

Staff Summary of Public Testimony (Health Care & Wellness):

(In support) It is hard for nurses to provide medications when urgent tasks need to be done. Other states with laws allowing medication assistants have good outcome data. They show few errors when on-site supervision is required. A national curriculum has been developed based on the data in these other states. It shows that with good supervision, a medication assistant is as safe as the licensed nurse, and when the assistant takes over the repetitive duties, it can free up the registered nurse for those duties requiring clinical judgment. The assistant cannot replace the licensed nurse's role in assessing the patient, calculating the medications, or educating the patient. There must be a clear scope of practice, required supervision, and clear standards. The safeguards in the bill are more stringent than the current requirements for medication assistance in in-home and community-based settings.

The state needs to prepare for the tsunami of need for health care services that is coming as the population ages. This bill helps build a needed career ladder for nursing assistants and the possibility of higher wages. It enhances job satisfaction for both registered nurses and nursing assistants. Nurses with some experience in health care prior to nursing school are more likely to stay in the field.

This is not a change in the scope of practice that will add costs to the system; instead it makes the system more efficient and improves patient safety. It adds another set of eyes on the patient, supplements the nursing staff, and helps build a team approach. The medication assistant will be responsible for his or her own actions within the scope of practice.

The Nursing Commission approved this concept unanimously. It reviewed the data thoroughly and held five public hearings. There were initial concerns because patients in nursing homes have increasingly complex health issues and frequently require multiple medications. However, the Nursing Commission supports the safeguards in the bill: approved training and an examination, limited routes of medicine administration, experience requirement, limited duties, supervision, patient assessment by the registered nurse, and continuing education.

(Neutral) If a nursing assistant has a medication assistant endorsement, is the assistant only performing medication assistant tasks? By removing the reference to "additional tasks," it could be made clear that they are not allowed to perform other tasks. This is important as the acuity of nursing home patients has increased over time. There are still many issues to work out with the Nursing Commission.

(Opposed) None.

Staff Summary of Public Testimony (Health & Human Services Appropriations & Oversight):

(In support) This bill allows certified nursing assistants to take more training to learn the mechanical processes involved in giving a patient a medication. Medication management will stay under the purview of a registered nurse who assesses how a patient responds to medication. This will improve outcomes in long-term care facilities because nurses will spend less time administering medications and more time assessing and evaluating patients. There is a looming nursing and caregiver shortage. This change will help develop the nurse workforce from within the caregiver community, leading to better retention. Twenty states already use nursing assistants in skilled nursing facilities to administer medication. Throughout the two-year development of this program, it has enjoyed near unanimous support of all interested parties. The Nursing Commission voted unanimously to endorse this proposal. This bill clearly defines the scope of practice parameters for medication endorsements that are sound in light of the available evidence.

(Opposed) None.

Persons Testifying (Health Care & Wellness): (In support) Representative Green, prime sponsor; Representative Hinkle; Dr. Suzanne Sikma, University of Washington Bothell Nursing Program; Dr. Mindy Schaffner, Nursing Care Quality Assurance Commission; Dr. Vicki McNealley and Gloria Dunn, Washington Health Care Association; Sarah Renfrow, Avamere Living; and Scott Sigmon, Aging Services of Washington.

(Neutral) Sofia Aragon, Washington State Nurses Association.

Persons Testifying (Health & Human Services Appropriations & Oversight): Representative Green, prime sponsor; Rich Miller, Washington Health Care Association; Dr. Suzanne Sikma, University of Washington, Bothell; and Scott Sigmon, Aging Services of Washington.

Persons Signed In To Testify But Not Testifying (Health Care & Wellness): None.

Persons Signed In To Testify But Not Testifying (Health & Human Services Appropriations & Oversight): None.