BILL REQ. #:  Z-0013.4 

Read first time 01/18/11.   Referred to Committee on Health & Long-Term Care.

     AN ACT Relating to delegation to home care aides; amending RCW 18.79.260 and 74.39A.073; and adding new sections to chapter 18.88B RCW.

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

NEW SECTION.  Sec. 1   A new section is added to chapter 18.88B RCW to read as follows:
     The legislature recognizes that nurses have been successfully delegating nursing care tasks to family members and others for many years. The opportunity for a nurse to delegate to home care aides qualifying under this chapter may enhance the viability and quality of health care services in community-based care settings and in-home care settings to allow individuals to live as independently as possible with maximum safeguards.

Sec. 2   RCW 18.79.260 and 2009 c 203 s 1 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, to individuals with illnesses, injuries, or disabilities.
     (2) A registered nurse may, at or under the general direction of a licensed physician and surgeon, dentist, osteopathic physician and surgeon, naturopathic physician, optometrist, 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.
     (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, working for a home health or hospice agency regulated under chapter 70.127 RCW, may delegate the application, instillation, or insertion of medications to a registered or certified nursing assistant under a plan of care.
     (c) Except as authorized in (b) or (e) of this subsection, a registered nurse may not delegate the administration of medications. Except as authorized in (e) of this subsection, a registered nurse may not delegate acts requiring substantial skill, and may not delegate piercing or severing of tissues. Acts that require nursing judgment shall not be delegated.
     (d) 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.
     (e) For delegation in community-based care settings or in-home care settings, a registered nurse may delegate nursing care tasks only to registered or certified nursing assistants, home care aides, as defined by RCW 74.39A.009. Simple care tasks such as blood pressure monitoring, personal care service, diabetic insulin device set up, verbal verification of insulin dosage for sight-impaired individuals, or other tasks as defined by the nursing care quality assurance commission are exempted from this requirement.
     (i) "Community-based care settings" includes: Community residential programs for people with developmental disabilities, 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.
     (ii) "In-home care settings" include an individual's place of temporary or permanent residence, but does not include acute care or skilled nursing facilities, and does not include community-based care settings as defined in (e)(i) of this subsection.
     (iii) Delegation of nursing care tasks in community-based care settings and in-home 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.
     (iv) The determination of the appropriateness of delegation of a nursing task is at the discretion of the registered nurse. Other than delegation of the administration of insulin by injection for the purpose of caring for individuals with diabetes, the administration of medications by injection, sterile procedures, and central line maintenance may never be delegated.
     (v) When delegating insulin injections under this section, the registered nurse delegator must instruct the individual regarding proper injection procedures and the use of insulin, demonstrate proper injection procedures, and must supervise and evaluate the individual performing the delegated task weekly during the first four weeks of delegation of insulin injections. If the registered nurse delegator determines that the individual is competent to perform the injection properly and safely, supervision and evaluation shall occur at least every ninety days thereafter.
     (vi) The registered nurse shall verify that the ((nursing assistant)) delegated individual has completed the required core nurse delegation training required in chapter 18.88A RCW prior to authorizing delegation.
     (vii) 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.
     (viii) 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.
     (f) 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.
     (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. 3   A new section is added to chapter 18.88B RCW to read as follows:
     (1)(a) Before commencing any specific nursing care tasks authorized under RCW 18.79.260(3), a home care aide must:
     (i) Provide to the delegating nurse a transcript or certificate of successful completion of training issued by an approved instructor or approved training entity indicating the completion of basic core nurse delegation training; and
     (ii) Meet any additional training requirements mandated by the nursing care quality assurance commission. Any exception to these training requirements is subject to RCW 18.79.260(3)(e)(vi).
     (b) In addition to meeting the requirements of (a) of this subsection, before providing delegated nursing tasks that involve administration of insulin by injection to individuals with diabetes, the home care aide must provide to the delegating nurse a transcript or certificate of successful completion of training issued by an approved instructor or approved training entity indicating completion of specialized diabetes nurse delegation training. The training must include, but is not limited to, instruction regarding diabetes, insulin, sliding scale insulin orders, and proper injection procedures.
     (2) The home care aide is accountable for his or her own individual actions in the delegation process. Home care aides accurately following delegation instructions from a registered nurse are immune from liability regarding the performance of the delegated duties.
     (3) Home care aides are not subject to any employer reprisal or disciplinary action by the secretary for refusing to accept delegation of a nursing task based on his or her concerns about patient safety issues. No provider of a community-based care setting as defined in RCW 18.79.260, or in-home services agency as defined in RCW 70.127.010, may discriminate or retaliate in any manner against a person because the person made a complaint about the nurse delegation process or cooperated in the investigation of the complaint.

Sec. 4   RCW 74.39A.073 and 2009 c 580 s 10 are each amended to read as follows:
     (1) Effective January 1, 2011, except as provided in RCW 18.88B.040, all persons employed as long-term care workers for the elderly or persons with disabilities must meet the minimum training requirements in this section within one hundred twenty calendar days of employment.
     (2) All persons employed as long-term care workers must obtain seventy-five hours of entry-level training approved by the department. A long-term care worker must accomplish five of these seventy-five hours before becoming eligible to provide care.
     (3) Training required by subsection (4)(c) of this section will be applied towards training required under RCW 18.20.270 or 70.128.230 as well as any statutory or regulatory training requirements for long-term care workers employed by supportive living providers.
     (4) Only training curriculum approved by the department may be used to fulfill the training requirements specified in this section. The seventy-five hours of entry-level training required shall be as follows:
     (a) Before a long-term care worker is eligible to provide care, he or she must complete two hours of orientation training regarding his or her role as caregiver and the applicable terms of employment;
     (b) Before a long-term care worker is eligible to provide care, he or she must complete three hours of safety training, including basic safety precautions, emergency procedures, and infection control; and
     (c) All long-term care workers must complete seventy hours of long-term care basic training, including training related to core competencies and population specific competencies.
     (5) The department shall only approve training curriculum that:
     (a) Has been developed with input from consumer and worker representatives; and
     (b) Requires comprehensive instruction by qualified instructors on the competencies and training topics in this section.
     (6) A long-term care worker who wishes to perform a nurse delegated task pursuant to RCW 18.79.260 must be certified as a home care aide before being delegated by a registered nurse delegator. In addition, nurse delegation core training must be completed before a home care aide may be delegated a nursing task. Before administering insulin, a home care aide must also complete the specialized diabetes nurse delegation three hour training.
     (7) Individual providers under RCW 74.39A.270 shall be compensated for training time required by this section.
     (((7) The department of health shall adopt rules by August 1, 2010, to implement subsections (1), (2), and (3) of this section.
     (8) The department shall adopt rules by August 1, 2010, to implement subsections (4) and (5) of this section.))