Nurse Delegation in LTCSS
Overview
Prepared for Pennsylvania Long Term Care Commission
July 2014
Background
• State policy surrounding scope of practice and allowable
delegation of tasks involved in the provision of LTCSS is a
complex public policy issue that involves multiple
state agencies with jurisdiction over regulation of
professional practice, professional licensure/certification,
health care policy and LTCSS service delivery and
financing
• Establishment of nurse delegation models requires a
comprehensive approach encompassing statutory and
regulatory provisions as well as adequate systems and
resources for training, oversight and quality
assurance
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Nurse Delegation
• State Nurse Practice Acts establish which health
maintenance tasks can be delegated to paid direct care
workers providing services in a home setting.
• Key reasons for authorizing nurse delegation with
respect to LTCSS include:
– Supporting family caregivers – nurses can train family
caregivers to perform tasks but if the family member is
employed or away from the home for other reasons (i.e. respite),
a paid caregiver often steps in to provide care
– Service costs – costs to public funding sources such as Medicaid
is reduced if health maintenance task can be safely performed by
direct care worker rather than a nurse
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Nurse Delegation
• State law and regulations governing nurse delegation
typically specify:
– What tasks can be delegated, to whom, for whom
and under what conditions
– Accountability, responsibility and liability
provisions
– Process to modify or rescind a delegation
– Protections and complaint process
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What Tasks, To Whom, For Whom, Conditions
• Provisions
– Specific nursing tasks that can be delegated and those that are
prohibited from being delegated
– Nurse maintains independent professional decision making
authority over delegation of a nursing task delegation
– Assessment parameters and decision tree tool often provided
•
•
•
•
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Client Condition – “stable and predictable”
Care setting and circumstances
Task complexity and frequency, skills required, safety and risks
Skills, ability and willingness of direct care worker
Accountability, Responsibility, Liability
• Provisions
– Nurse delegator remains responsible for the delegated nursing
task and must monitor performance of the task(s)
– Training requirements for nurse delegators and for direct care
workers
– Level and frequency of direct and indirect supervision of direct
care worker required
– Regular, periodic review and reevaluation of delegations
– Documentation requirements
– Applicable liability/immunity provisions
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Modify/Rescind Delegation
• Provisions - Modifications
– Responsibility remains with original nurse delegator
– Nurse delegator responsible to verify modification with health
care provider and to review and reaffirm delegation decision
– Provisions regarding allowing transfer of delegation to another
nurse and if allowed, procedures to do so
• Provisions - Rescission
– Criteria/circumstances under which delegation can/should be
rescinded
– Documentation requirements
– Nurse delegator initiates and participates in alternative plan to
assure continuity of care
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Protections and Complaint Process
• Provisions - Protections
– Protections against coercion or employer reprisals related to
• Requiring a nurse delegator to delegate a task that they have
determined in their professional judgment is inappropriate for
delegation
• Direct care worker refusing to accept delegation of a task based on
patient safety concerns
• Provisions – Complaints
– Process to receive and investigate complaints regarding
registered nurse delegators
– Process to receive and investigate complaints regarding
performance of delegated tasks by direct care workers
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Health Maintenance Task
# States Allowing
Delegation*
Administer glucometer test
41
Perform ostomy care including skin care and changing appliance
40
Administer enema
35
Gastrostomy tube feeding
33
Administer eye/ear drops
30
Perform intermittent catheterization
30
Administer oral medications
30
Administer oxygen therapy
28
Insert suppository
28
Administer medication on an as needed basis
26
Administer medication through tubes
25
Perform nebulizer treatment
24
Administer medication via pre-filled insulin or insulin pen
23
Draw up insulin for dosage measurement
17
Administer intramuscular injection medications
14
* Based on information in AARP, State Scorecard on Long-Term Services and Supports for Older Adults, People with
Physical Disabilities and Family Caregivers, 2014; Exhibit A16
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Delegation of Health Maintenance Tasks to LTSS Workers - 2014
16 Tasks
11-15 Tasks
6-10 Tasks
1-5 Tasks
0 Tasks
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Source: AARP, State Scorecard on Long-Term Services and Supports, 2014