Z-0399.1

HOUSE BILL 2416

ByRepresentatives Graham and Riccelli; by request of Washington State Board of Nursing

AN ACT Relating to changing the legal title for advanced practice nurses; amending RCW 18.79.030, 18.79.040, 18.79.050, 18.79.060, 18.79.070, 18.79.110, 18.79.160, 18.79.170, 18.79.180, 18.79.200, 18.79.230, 18.79.240, 18.79.250, 18.79.256, 18.79.260, 18.79.270, 18.79.290, 18.79.400, 18.79.800, and 18.79.810; and providing an effective date.

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

Sec. 1. RCW 18.79.030 and 2023 c 123 s 19 are each amended to read as follows:

(1) It is unlawful for a person to practice or to offer to practice as a registered nurse in this state unless that person has been licensed under this chapter or holds a valid multistate license under chapter 18.80 RCW. A person who holds a license to practice as a registered nurse in this state may use the titles "registered nurse" and "nurse" and the abbreviation "R.N." No other person may assume those titles or use the abbreviation or any other words, letters, signs, or figures to indicate that the person using them is a registered nurse.

(2) It is unlawful for a person to practice or to offer to practice as an advanced practice registered nurse ((practitioner)) or as a nurse practitioner in this state unless that person has been licensed under this chapter. A person who holds a license to practice as an advanced practice registered nurse ((practitioner)) in this state may use the titles "advanced practice registered nurse ((practitioner))," "nurse practitioner," and "nurse" and the abbreviations "((A.R.N.P.))A.P.R.N." and "N.P." No other person may assume those titles or use those abbreviations or any other words, letters, signs, or figures to indicate that the person using them is an advanced practice registered nurse ((practitioner)) or nurse practitioner.

(3) It is unlawful for a person to practice or to offer to practice as a licensed practical nurse in this state unless that person has been licensed under this chapter or holds a valid multistate license under chapter 18.80 RCW. A person who holds a license to practice as a licensed practical nurse in this state may use the titles "licensed practical nurse" and "nurse" and the abbreviation "L.P.N." No other person may assume those titles or use that abbreviation or any other words, letters, signs, or figures to indicate that the person using them is a licensed practical nurse.

(4) Nothing in this section shall prohibit a person listed as a Christian Science nurse in the Christian Science Journal published by the Christian Science Publishing Society, Boston, Massachusetts, from using the title "Christian Science nurse," so long as such person does not hold himself or herself out as a registered nurse, advanced practice registered nurse ((practitioner)), nurse practitioner, or licensed practical nurse, unless otherwise authorized by law to do so.

Sec. 2. RCW 18.79.040 and 2020 c 80 s 15 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 individuals with illnesses, injuries, or disabilities, 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))board to be performed by registered nurses licensed under this chapter and that are authorized by the ((commission))board 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, in-home service agency, community-based care setting, 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, or advanced practice registered nurse ((practitioner)), or as directed by a licensed midwife within his or her scope of practice.

(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, (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. 3. RCW 18.79.050 and 2000 c 64 s 2 are each amended to read as follows:

"Advanced practice 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))board. Upon approval by the ((commission))board, an advanced practice 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 practice 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.

Sec. 4. RCW 18.79.060 and 2020 c 80 s 16 are each amended to read as follows:

"Licensed practical nursing practice" means the performance of services requiring the knowledge, skill, and judgment necessary for carrying out selected aspects of the designated nursing regimen under the direction and supervision of a licensed physician and surgeon, dentist, osteopathic physician and surgeon, physician assistant, podiatric physician and surgeon, advanced practice registered nurse ((practitioner)), registered nurse, or midwife.

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 the nursing care of the sick, without compensation, by an unlicensed person who does not hold himself or herself out to be a licensed practical nurse.

Sec. 5. RCW 18.79.070 and 2022 c 240 s 32 are each amended to read as follows:

(1) The state ((nursing care quality assurance commission))board is established, consisting of fifteen members to be appointed by the governor to four-year terms. The governor shall consider nursing members who are recommended for appointment by the appropriate professional associations in the state. No person may serve as a member of the ((commission))board for more than two consecutive full terms.

(2) There must be seven registered nurse members, two advanced practice registered nurse ((practitioner)) members, three licensed practical nurse members, and three public members on the ((commission))board. Each member of the ((commission))board must be a resident of this state.

(3)(a) Registered nurse members of the ((commission))board must:

(i) Be licensed as registered nurses under this chapter; and

(ii) Have had at least three years' experience in the active practice of nursing and have been engaged in that practice within two years of appointment.

(b) In addition:

(i) At least one member must be on the faculty at a four-year university nursing program;

(ii) At least one member must be on the faculty at a two-year community college nursing program;

(iii) At least two members must be staff nurses providing direct patient care; and

(iv) At least one member must be a nurse manager or a nurse executive.

(4) Advanced practice registered nurse ((practitioner)) members of the ((commission))board must:

(a) Be licensed as advanced practice registered nurses((practitioners)) under this chapter; and

(b) Have had at least three years' experience in the active practice of advanced practice registered nursing and have been engaged in that practice within two years of appointment.

(5) Licensed practical nurse members of the ((commission))board must:

(a) Be licensed as licensed practical nurses under this chapter; and

(b) Have had at least three years' actual experience as a licensed practical nurse and have been engaged in practice as a practical nurse within two years of appointment.

(6) Public members of the ((commission))board may not be a member of any other health care licensing board or commission, or have a fiduciary obligation to a facility rendering health services regulated by the ((commission))board, or have a material or financial interest in the rendering of health services regulated by the ((commission))board.

((In appointing the initial members of the commission, it is the intent of the legislature that, to the extent possible, the governor appoint the existing members of the board of nursing and the board of practical nursing repealed under chapter 9, Laws of 1994 sp. sess. The governor may appoint initial members of the commission to staggered terms of from one to four years. Thereafter, all members shall be appointed to full four-year terms.)) Members of the ((commission))board hold office until their successors are appointed.

When the secretary appoints pro tem members, reasonable efforts shall be made to ensure that at least one pro tem member is a registered nurse who is currently practicing and, in addition to meeting other minimum qualifications, has graduated from an associate or baccalaureate nursing program within three years of appointment.

Sec. 6. RCW 18.79.110 and 2023 c 126 s 8 are each amended to read as follows:

(1) The ((commission))board shall keep a record of all of its proceedings and make such reports to the governor as may be required. The ((commission))board shall define by rules what constitutes specialized and advanced levels of nursing practice as recognized by the medical and nursing profession. The ((commission))board may adopt rules or issue advisory opinions in response to questions put to it by professional health associations, nursing practitioners, and consumers in this state concerning the authority of various categories of nursing practitioners to perform particular acts.

(2) The ((commission))board shall approve curricula and shall establish criteria for minimum standards for schools preparing persons for licensing as registered nurses, advanced practice registered nurses((practitioners)), and licensed practical nurses under this chapter. The ((commission))board shall approve such schools of nursing as meet the requirements of this chapter and the ((commission))board, and the ((commission))board shall approve establishment of basic nursing education programs and shall establish criteria as to the need for and the size of a program and the type of program and the geographical location. The ((commission))board shall establish criteria for proof of reasonable currency of knowledge and skill as a basis for safe practice after three years' inactive or lapsed status. The ((commission))board shall establish criteria for licensing by endorsement. The ((commission))board shall determine examination requirements for applicants for licensing as registered nurses, advanced practice registered nurses((practitioners)), and licensed practical nurses under this chapter, and shall certify to the secretary for licensing duly qualified applicants. The ((commission))board shall adopt rules which allow for one hour of simulated learning to be counted as equivalent to two hours of clinical placement learning, with simulated learning accounting for up to a maximum of 50 percent of the required clinical hours.

(3) The ((commission))board shall adopt rules on continuing competency. The rules must include exemptions from the continuing competency requirements for registered nurses seeking advanced nursing degrees. Nothing in this subsection prohibits the ((commission))board from providing additional exemptions for any person credentialed under this chapter who is enrolled in an advanced education program.

(4) The ((commission))board shall adopt such rules under chapter 34.05 RCW as are necessary to fulfill the purposes of this chapter.

(5) The ((commission))board is the successor in interest of the board of nursing and the board of practical nursing. All contracts, undertakings, agreements, rules, regulations, decisions, orders, and policies of the former board of nursing or the board of practical nursing continue in full force and effect under the ((commission))board until the ((commission))board amends or rescinds those rules, regulations, decisions, orders, or policies.

(6) The members of the ((commission))board are immune from suit in an action, civil or criminal, based on its disciplinary proceedings or other official acts performed in good faith as members of the ((commission))board.

(7) Whenever the workload of the ((commission))board requires, the ((commission))board may request that the secretary appoint pro tempore members of the ((commission))board. When serving, pro tempore members of the ((commission))board have all of the powers, duties, and immunities, and are entitled to all of the emoluments, including travel expenses, of regularly appointed members of the ((commission))board.

Sec. 7. RCW 18.79.160 and 2004 c 262 s 6 are each amended to read as follows:

(1) An applicant for a license to practice as a registered nurse shall submit to the ((commission))board:

(a) An attested written application on a department form;

(b) An official transcript demonstrating graduation and successful completion of an approved program of nursing; and

(c) Any other official records specified by the ((commission))board.

(2) An applicant for a license to practice as an advanced practice registered nurse ((practitioner)) shall submit to the ((commission))board:

(a) An attested written application on a department form;

(b) An official transcript demonstrating graduation and successful completion of an advanced practice registered nurse ((practitioner)) program meeting criteria established by the ((commission))board; and

(c) Any other official records specified by the ((commission))board.

(3) An applicant for a license to practice as a licensed practical nurse shall submit to the ((commission))board:

(a) An attested written application on a department form;

(b) Written official evidence that the applicant is over the age of eighteen;

(c) An official transcript demonstrating graduation and successful completion of an approved practical nursing program, or its equivalent; and

(d) Any other official records specified by the ((commission))board.

(4) At the time of submission of the application, the applicant for a license to practice as a registered nurse, advanced practice registered nurse ((practitioner)), or licensed practical nurse must not be in violation of chapter 18.130 RCW or this chapter.

(5) The ((commission))board shall establish by rule the criteria for evaluating the education of all applicants.

Sec. 8. RCW 18.79.170 and 1994 sp.s. c 9 s 417 are each amended to read as follows:

An applicant for a license to practice as a registered nurse, advanced practice registered nurse ((practitioner)), or licensed practical nurse must pass an examination in subjects determined by the ((commission))board. The examination may be supplemented by an oral or practical examination. The ((commission))board shall establish by rule the requirements for applicants who have failed the examination to qualify for reexamination.

Sec. 9. RCW 18.79.180 and 1994 sp.s. c 9 s 418 are each amended to read as follows:

When authorized by the ((commission))board, the department shall issue an interim permit authorizing the applicant to practice registered nursing, advanced practice registered nursing, or licensed practical nursing, as appropriate, from the time of verification of the completion of the school or training program until notification of the results of the examination. Upon the applicant passing the examination, and if all other requirements established by the ((commission))board for licensing are met, the department shall issue the applicant a license to practice registered nursing, advanced practice registered nursing, or licensed practical nursing, as appropriate. If the applicant fails the examination, the interim permit expires upon notification to the applicant, and is not renewable. The holder of an interim permit is subject to chapter 18.130 RCW.

Sec. 10. RCW 18.79.200 and 1996 c 191 s 62 are each amended to read as follows:

An applicant for a license to practice as a registered nurse, advanced practice registered nurse ((practitioner)), or licensed practical nurse shall comply with administrative procedures, administrative requirements, and fees as determined under RCW 43.70.250 and 43.70.280.

Sec. 11. RCW 18.79.230 and 1994 sp.s. c 9 s 423 are each amended to read as follows:

A person licensed under this chapter who desires to retire temporarily from registered nursing practice, advanced practice registered nursing ((practice)), or licensed practical nursing practice in this state shall send a written notice to the secretary.

Upon receipt of the notice the department shall place the name of the person on inactive status. While remaining on this status the person shall not practice in this state any form of nursing provided for in this chapter. When the person desires to resume practice, the person shall apply to the ((commission))board for renewal of the license and pay a renewal fee to the state treasurer. Persons on inactive status for three years or more must provide evidence of knowledge and skill of current practice as required by the ((commission))board or as provided in this chapter.

Sec. 12. RCW 18.79.240 and 2020 c 80 s 17 are each amended to read as follows:

(1) In the context of the definition of registered nursing practice and advanced practice 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 technicians;

(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))board may have specifically authorized by rule adopted in accordance with chapter 34.05 RCW;

(p) Permitting the prescribing of controlled substances as defined in Schedule I of the Uniform Controlled Substances Act, chapter 69.50 RCW;

(q) Prohibiting the determination and pronouncement of death;

(r) Prohibiting advanced practice registered nurses((practitioners)), approved by the ((commission))board 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))board-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, 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 practice registered nurses((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 that doing so is permitted by their scope of practice;

(t) Prohibiting the practice of registered nursing or advanced practice registered nursing by a student enrolled in an approved school if:

(i) The student performs services without compensation or expectation of compensation as part of a volunteer activity;

(ii) The student is under the direct supervision of a registered nurse or advanced practice registered nurse ((practitioner)) licensed under this chapter, a pharmacist licensed under chapter 18.64 RCW, an osteopathic physician and surgeon licensed under chapter 18.57 RCW, or a physician licensed under chapter 18.71 RCW;

(iii) The services the student performs are within the scope of practice of: (A) The nursing profession for which the student is receiving training; and (B) the person supervising the student;

(iv) The school in which the student is enrolled verifies the student has demonstrated competency through his or her education and training to perform the services; and

(v) The student provides proof of current malpractice insurance to the volunteer activity organizer prior to performing any services.

(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. 13. RCW 18.79.250 and 2000 c 64 s 4 are each amended to read as follows:

An advanced practice 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))board;

(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))board;

(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 practice registered nurse ((practitioner)) or as a nurse practitioner.

Sec. 14. RCW 18.79.256 and 2015 c 104 s 1 are each amended to read as follows:

An advanced practice registered nurse ((practitioner)) may sign and attest to any certificates, cards, forms, or other required documentation that a physician may sign, so long as it is within the advanced practice registered nurse's((practitioner's)) scope of practice.

Sec. 15. RCW 18.79.260 and 2022 c 14 s 2 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, advanced practice registered nurse ((practitioner)), or midwife 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) or (f) 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))board 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 under chapter 18.88A RCW or home care aides certified under chapter 18.88B RCW. 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))board 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 assisted living facilities 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 as required by the ((commission))board by rule. If the registered nurse delegator determines that the individual is competent to perform the injection properly and safely, supervision and evaluation shall occur at an interval determined by the ((commission))board by rule.

(vi)(A) The registered nurse shall verify that the nursing assistant or home care aide, as the case may be, has completed the required core nurse delegation training required in chapter 18.88A or 18.88B RCW prior to authorizing delegation.

(B) Before commencing any specific nursing tasks authorized to be delegated in this section, a home care aide must be certified pursuant to chapter 18.88B RCW and must comply with RCW 18.88B.070.

(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 delegation of nursing care tasks only to registered or certified nursing assistants under chapter 18.88A RCW or to home care aides certified under chapter 18.88B RCW may include glucose monitoring and testing.

(g) The ((nursing care quality assurance commission))board 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.

Sec. 16. RCW 18.79.270 and 2020 c 80 s 19 are each amended to read as follows:

A licensed practical nurse under his or her license may perform nursing care, as that term is usually understood, of the ill, injured, or infirm, and in the course thereof may, under the direction of a licensed physician and surgeon, osteopathic physician and surgeon, dentist, naturopathic physician, podiatric physician and surgeon, physician assistant, advanced practice registered nurse ((practitioner)), or midwife acting under the scope of his or her license, or at the direction and under the supervision of a registered nurse, administer drugs, medications, treatments, tests, injections, and inoculations, whether or not the piercing of tissues is involved and whether or not a degree of independent judgment and skill is required, when selected to do so by one of the licensed practitioners designated in this section, or by a registered nurse who need not be physically present; if the order given is reduced to writing within a reasonable time and made a part of the patient's record. Such direction must be for acts within the scope of licensed practical nurse practice.

Sec. 17. RCW 18.79.290 and 1994 sp.s. c 9 s 429 are each amended to read as follows:

(1) In accordance with rules adopted by the ((commission))board, public school districts and private schools that offer classes for any of grades kindergarten through twelve may provide for clean, intermittent bladder catheterization of students or assisted self-catheterization of students who are in the custody of the school district or private school at the time. After consultation with staff of the superintendent of public instruction, the ((commission))board shall adopt rules in accordance with chapter 34.05 RCW, that provide for the following and such other matters as the ((commission))board deems necessary to the proper implementation of this section:

(a) A requirement for a written, current, and unexpired request from a parent, legal guardian, or other person having legal control over the student that the school district or private school provide for the catheterization of the student;

(b) A requirement for a written, current, and unexpired request from a physician licensed under chapter 18.71 or 18.57 RCW, that catheterization of the student be provided for during the hours when school is in session or the hours when the student is under the supervision of school officials;

(c) A requirement for written, current, and unexpired instructions from an advanced practice registered nurse ((practitioner)) or a registered nurse licensed under this chapter regarding catheterization that include (i) a designation of the school district or private school employee or employees who may provide for the catheterization, and (ii) a description of the nature and extent of any required supervision; and

(d) The nature and extent of acceptable training that shall (i) be provided by a physician, advanced practice registered nurse ((practitioner)), or registered nurse licensed under chapter 18.71 or 18.57 RCW, or this chapter, and (ii) be required of school district or private school employees who provide for the catheterization of a student under this section, except that a licensed practical nurse licensed under this chapter is exempt from training.

(2) This section does not require school districts to provide intermittent bladder catheterization of students.

Sec. 18. RCW 18.79.400 and 2010 c 209 s 7 are each amended to read as follows:

(1) By June 30, 2011, the ((commission))board shall adopt new rules on chronic, noncancer pain management that contain the following elements:

(a)(i) Dosing criteria, including:

(A) A dosage amount that must not be exceeded unless an advanced practice registered nurse ((practitioner)) or certified registered nurse anesthetist first consults with a practitioner specializing in pain management; and

(B) Exigent or special circumstances under which the dosage amount may be exceeded without consultation with a practitioner specializing in pain management.

(ii) The rules regarding consultation with a practitioner specializing in pain management must, to the extent practicable, take into account:

(A) Circumstances under which repeated consultations would not be necessary or appropriate for a patient undergoing a stable, ongoing course of treatment for pain management;

(B) Minimum training and experience that is sufficient to exempt an advanced practice registered nurse ((practitioner)) or certified registered nurse anesthetist from the specialty consultation requirement;

(C) Methods for enhancing the availability of consultations;

(D) Allowing the efficient use of resources; and

(E) Minimizing the burden on practitioners and patients;

(b) Guidance on when to seek specialty consultation and ways in which electronic specialty consultations may be sought;

(c) Guidance on tracking clinical progress by using assessment tools focusing on pain interference, physical function, and overall risk for poor outcome; and

(d) Guidance on tracking the use of opioids, particularly in the emergency department.

(2) The ((commission))board shall consult with the agency medical directors' group, the department of health, the University of Washington, and the largest professional associations for advanced practice registered nurses((practitioners)) and certified registered nurse anesthetists in the state.

(3) The rules adopted under this section do not apply:

(a) To the provision of palliative, hospice, or other end-of-life care; or

(b) To the management of acute pain caused by an injury or a surgical procedure.

Sec. 19. RCW 18.79.800 and 2017 c 297 s 8 are each amended to read as follows:

(1) By January 1, 2019, the ((commission))board must adopt rules establishing requirements for prescribing opioid drugs. The rules may contain exemptions based on education, training, amount of opioids prescribed, patient panel, and practice environment.

(2) In developing the rules, the ((commission))board must consider the agency medical directors' group and centers for disease control guidelines, and may consult with the department of health, the University of Washington, and the largest professional associations for advanced practice registered nurses((practitioners)) and certified registered nurse anesthetists in the state.

Sec. 20. RCW 18.79.810 and 2019 c 314 s 10 are each amended to read as follows:

By January 1, 2020, the ((commission))board must adopt or amend its rules to require advanced practice registered nurses((practitioners)) who prescribe opioids to inform patients of their right to refuse an opioid prescription or order for any reason. If a patient indicates a desire to not receive an opioid, the advanced practice registered nurse ((practitioner)) must document the patient's request and avoid prescribing or ordering opioids, unless the request is revoked by the patient.

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