DIRECT SERVICE WORKERS

1. DIRECT SERVICE WORKERS MEDICATION ADMINISTRATION AND NON-COMPLEX TASKS IN THE HCBS SETTING Bruce D. Greenstein Secretary

2. DIRECT SERVICE WORKERMEDICATION ADMINISTRATION TRAININGCHRONOLOGICAL HISTORY OF RELATED LEGISLATION AND RULE MAKING • Statutory authority for Direct Service Workers and medication attendants is comprised of Part 1, Louisiana R.S. 37:1021 through 1025 and Part II R.S. 37:1031 through 1034. • Senate Bill 271 (Act 306) of the 2005 Regular Session established within the Department of Health and Hospitals the Direct Service Worker Registry, defined who a direct service worker is and their scope of practice. • House Bill 697 (Act 451) of the 2005 Regular Session gave DHH in conjunction with the Louisiana State Board of Nursing the authority to promulgate rules and regulations for direct service workers to be able administer certain medications and to perform non-complex tasks when delegated by a registered nurse. This was contingent upon the worker receiving at least 16 hours of training in the fundamentals of medication administration and at least 6 hours of person specific training from a registered nurse who has assessed the health status of the individual receiving services and that the worker can perform the tasks in a safe and appropriate manner. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

3. CHRONOLOGICAL HISTORY CONTINUED • First work group meeting to develop rules required by HB 697 held on July 19, 2005. Work group members included representatives from LSNA, LSBN, LSU Human Development Center, DHH, LSBPNE, Home Care Association, Advocacy Center and home and community based service providers. • Draft notices of intent sent to work group members for review on 1/3/06, 1/18/06, 1/23/06, 1/24/06 and 2/1/06 but was never published in the La Register. • Senate Bill 546 (Act 552) of the 2008 Regular Session amended the statute to specify that the direct service worker must complete required training no later than 36 months after promulgation of regulations. It established provision that DHH and the Louisiana State Board of Nursing to meet quarterly to review data collected by DHH relevant to the administration of health care tasks authorized by the statute. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

4. CHRONOLOGICAL HISTORY CONTINUED • House Bill 642 (Act 299) of the 2011 Regular Session further amended the statute relative to training of direct service workers by a registered nurse to perform non-complex tasks and provided for person specific training. It specified that the direct service worker receive the required training no later than 12 months after promulgation of regulations. It established provision for DHH and the Louisiana State Board of Nursing to meet at least annually to review data collected by DHH relevant to the health care tasks authorized by the statute. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

5. RN AUTHORITY TO DELEGATE In Louisiana, R.S. 37:913(14)(f)provides that registered nursing includes delegating nursing interventions to qualified nursing personnel in accordance with criteria established by the Board of Nursing. LAC 46:XLVII.3703 sets the standards for the implementation of the statutory mandate. The term “delegating nursing interventions” is defined and criteria are provided for all delegated activities, for delegation to licensed practical nurses, and for delegation to unlicensed nursing personnel. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

6. RN AUTHORITY TO DELEGATE CONTINUED The registered nurse who delegates nursing interventions retains the responsibility and accountability to assure that the delegated intervention is performed in accord with established standards of practice, policies and procedures. Appropriate assessment, planning, implementation and evaluation are integral activities in the fulfillment of the registered nurse’s responsibility and accountability. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

7. NURSING BOARD’S RULES FOR DELEGATION the person has been adequately trained for the task; the person has demonstrated that the task has been learned; the person can perform the task safely in the given nursing situation; the patient’s status is safe for the person to carry out the task; appropriate supervision is available during the task implementation; and the task is in a established policy of the nursing practice setting and the policy is written, recorded and available to all. Contingent upon the registered nurse's evaluation of each patient's condition and also upon the registered nurse's evaluation of the competency of each unlicensed nursing personnel, registered nurses may delegate non-complex tasks to unlicensed nursing personnel. A non-complex task is one that can safely be performed according to exact directions, with no need to alter the standard procedure, and the results are predictable. A complex task is one that requires judgment to safely alter the standard procedure in accordance with the needs of the patient; or requires the consideration of a number of factors in order to perform the procedure; or requires judgment to determine how to proceed from one step to the next. iii. The administration of medications is a complex task but the administration of certain medications is being allowed by LSBN under the provisions of the DSW rule. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

8. LSBN WEB SITE FOR DELEGATING SELECT NURSING TASKS TO UNLICENSED PERSONNEL http://www.lsbn.state.la.us/Portals/1/Documents/DeclaratoryStatements/delegation.pdf http://www.lsbn.state.la.us/NursingPractice/ScopeofPractice.aspx LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

9. PHYSICIAN DELEGATION It is the position of the Board that the practice of medicine as defined by the La Medical Practice Act, R.S. 37:1262 (1) may only be undertaken by a Louisiana licensed physician or an unlicensed individual who functions solely under a licensed physician’s direction and immediate personal supervision – i.e., where they physician is physically present in the office or suite where the procedure is being performed at all times that the unlicensed assistant is on duty (irrespective of the employee’s level of training or experience) and retains full responsibility to the patients for the training, delivery and results of all services rendered. – LBME Newsletter April 2010 LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

10. 9243. GENERAL REQUIREMENTS A registered nurse shall authorize and monitor medication administration and non-complex tasks performed by direct service workers. A registered nurse may delegate to a licensed practical nurse components of the training and supervision of the DSW. This decision is based upon assessment of the task to be performed. The RN shall retain responsibility and accountability. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

11. 9245. TRAINING REQUIREMENTS FOR THE PERFORMANCE OF MEDICATION ADMINISTRATION AND NON-COMPLEX TASKS • MEDICATION ADMINISTRATION • DSWs shall receive 16 hours of medication administration training which has been coordinated and approved by an RN. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

12. TRAINING REQUIREMENTS CONTINUED • NON-COMPLEX TASKS DSWs shall receive person –specific training from a RN who has assessed the health status of the person and who has determined that the DSW can competently perform the tasks in a safe, appropriate manner. • Competency shall be certified in writing • Training shall be repeated if necessary • Additional person-specific training shall be provided when there is a change in health status or physician orders.This training may be performed over the phone if based upon the RN’s assessment, it is safe to do so. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

13. TRAINING REQUIREMENTS CONTINUED Any direct service worker currently employed to perform the procedures authorized by the rule shall complete the training no later than 12 months after promulgation of the final rule. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

14. 9247. ANNUAL COMPETENCY EVALUATION The DSW shall undergo an annual competency evaluation performed by a RN to determine whether he/she is competent to perform the authorized person-specific medication administration and non-complex tasks that they are assigned safely and appropriately. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

15. 9249. AUTHORIZED MEDICATION ADMINISTRATION AND NON-COMPLEX TASKS • The following tasks may be performed for a person whose condition is stable, the tasks are performed according to exact directions of the RN, there is no need to alter the standard procedure and the results are predictable. • administration of oral and topical medication, ointments, suppositories or a pre-measured unit dose provided by the manufacturer of an oral inhalant aerosol; LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

16. AUTHORIZED MEDICATION ADMINISTRATION AND NON-COMPLEX TASKS • provision of routine hydration, nutrition or medication by way of an established gastro-tube; • other non-complex tasks (the determination of whether a task is non-complex is based upon the assessment of the RN) LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

17. 9251. DSW RESPONSIBILITIES Following the exact instructions of the RN in the performance of all authorized procedures; Notifying the employer or RN when the health status of the client changes so they can be reassessed; Notifying the employer or RN when prescribed procedures or medications or dosages change so additional person specific training can be done; Notifying the employer, RN or client if a finding is placed against them on the DSW registry. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

18. 9253. RN RESPONSIBILITIES Training; Assuring that the condition of the client is stable; Assuring that the DSW demonstrates competency; Assisting in the development of the plan of care; Annual competency evaluation of the worker; Completing required documentation for the; worker’s file for the licensing agency. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

19. 9255. EMPLOYER RESPONSIBILITIES Assuring that no DSW performs tasks for which they are not authorized under the provisions of the rule; Assuring that the required training is received and a competency evaluation is performed by the RN; Maintaining all required documentation of training LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

20. EMPLOYER RESPONSIBILITIES CONTINUED Assuring that the DSW does not have a finding placed against him/her on the DSW registry; Notifying the RN of any changes in the health status of the client that may affect the ability of the DSW to perform the authorized procedures safely; Cooperating with Health Standards during monitoring surveys. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

21. 9257. LIABILITY A RN who has properly trained and documented competency shall not be liable for any civil damages as a result of an act of omission by the DSW; A physician licensed in La. who is rendering care shall not be liable for civil damages resulting from negligence or omission; Licensed provider agencies shall be liable for acts of omissions of DSWs they employ. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

22. 9259. TERMINATION OF AUTHORIZATION TO PERFORM SERVICES The condition of the client has become unstable; RN certifies that DSW can no longer safely perform the task; A finding has been placed on the DSW registry; Additional person-specific training by the RN not completed if indicated; Annual competency evaluation not completed; Client or legal representative has requested that the DSW not longer be authorized to perform procedures. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

23. 9261. VIOLATIONS AND NON-COMPLIANCE Health Standards is responsible for investigation of complaints and non-compliance; If a DSW is found to be performing tasks that are not in accordance with regulations, HSS shall require that the worker immediately cease; If the professional performance of a licensed nurse is found to be questionable by HSS a referral shall be made to the appropriate licensing board. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

24. IDR AND APPEAL When a direct service worker feels that he/she has been wrongfully accused, they have the right to request an informal dispute resolution (IDR) through Health Standards and an administrative hearing through the department’s Division of Administrative Law (DAL). The worker must be afforded their right to all due process before a finding can be placed on the DSW Registry. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

25. SUMMARY OF PUBLIC HEARING COMMENTS DSW REGISTRY MEDICATION ADMINISTRATION AND NON-COMPLEX TASKS • Significant financial impact to providers • Lost revenue due to Medicaid rate cuts • Deep revenue cuts through resource allocation Response: This is not an issue that can be addressed in this Notice of Intent. • State Supports and Service Centers throughout the state could offer training on a weekly basis. This would ensure consistency in content and quality of training. Response: OCDD will take this under advisement and explore the possibility. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

26. SUMMARY OF PUBLIC HEARING COMMENTS CONTINUED • The rule would create a threat to health and safety by causing delays in the provider’s ability to get new employees trained and into the client’s home. Response: As long as the DSW has had the 16 hours of basic training in client care as specified in State licensing standards, Section 5055 (K) and passed a competency evaluation, they may begin work with a client. They may not administer medications or perform non-complex tasks until the additional training is successfully completed. Other arrangements for medications and/or non-complex tasks would need to be in place for the client until this isdone. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

27. SUMMARY OF PUBLIC HEARING COMMENTS CONTINUED • Many agencies use contract RNs who are not on call to train the worker each time a medication order is changed. Response: Agencies will be expected to have access to an RN that can provide the necessary training. • Regulations are already in place to allow for assessment of a client via the 90L which is completed on an annual basis. To require an annual assessment by an RN, is a duplication of services. Response: Other assessments would suffice if they are comprehensive and address all of the client’s needs but may not be used in lieu of the RN’s assessment. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

28. SUMMARY OF PUBLIC HEARING COMMENTS CONTINUED • If the RN is going to be responsible for training and assessment of competency, they should be held liable for all civil damages as a result of errors by the workers. Response: The RN’s liability is protected by state statute. • Children are in danger of being excluded from communities and possibly placed in a long term care facility if physician delegation is not allowed. Response: Concerns regarding physician delegation no longer being an option for medication administration, should be addressed with the Board of Medical Examiners. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

29. SUMMARY OF PUBLIC HEARING COMMENTS CONTINUED • Is training required for over the counter drugs? Response: The need for training in administration of over the counter drugs should be based upon assessment by the RN. • What is the time frame to train staff on new medications or changed medications? What if there are multiple clients involved when this occurs? How can one RN train all timely? Response: Training is required prior to administration of medications. • How does this affect clients that are in a self-direction program? Response: The requirements apply equally. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

30. SUMMARY OF PUBLIC HEARING COMMENTS CONTINUED • The rule seems to stop consumers from using pill organizers or containers. There are new technologies and packaging available that take away much of the decision making related to administration of medications. Response: The use of special packaging and new technologies does not substitute for training if the client can’t self-administer. There must be oversight by an RN. • Is the 16 hours of training per calendar year or on a quarterly basis? Response: The 16 hours of training is required prior to the worker administering medications. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

31. SUMMARY OF PUBLIC HEARING COMMENTS CONTINUED • What type of assessment is the RN supposed to perform? What questions need to be answered? Response: The assessment should address complexity of the client’s needs and competency of the worker. • Providers need a list of diseases or conditions that would require more frequent assessment. Response: The client’s diagnosis and level of functioning should be included in the plan of care. Could training be performed over the phone? Response: The RN may make a determination based upon his/her assessment of the worker’s competency that training can be safely performed over the phone. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

32. SUMMARY OF PUBLIC HEARING COMMENTS CONTINUED • Providers should have greater flexibility in the use of LPN vs RN. Response: The RN may use professional judgment regarding delegation to LPNs. • Most DSWs are not required to take vital signs. Is the intent of the legislation to require DSWs to receive training in skills proficiency such as taking vital signs? Response: The DSW would be required to receive training in taking vital signs if applicable to the medications being administered. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

33. SUMMARY OF PUBLIC HEARING COMMENTS CONTINUED • The rule does not address self- administration or self- direction by the client. Response: If the client is able to self- administer medications, training of the worker is not necessary. • The definition of “stable and predictable” in Section 9201 may not apply to all individuals who receive HCBS services. Some clients may not be considered stable and predictable and therefore the RN could not delegate medication administration. This would leave families or the client with the responsibility. Response: The RN will determine based upon assessment of the client whether their condition is stable and predictable. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

34. SUMMARY OF PUBLIC HEARING COMMENTS CONTINUED • The RN should be able to delegate to the LPN. An LPN should be able to perform an annual competency evaluation under the supervision of the RN. Response: Using professional judgment, the RN may make a determination that delegation to an LPN is appropriate. The decision is based upon assessment of the individual task to be performed. • Please define “change in health status” as referenced in Section 9253. Response: The RN will determine change in health status. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

35. DSW WEB SITE http://new.dhh.louisiana.gov/index.cfm/directory/detail/713 LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

36. QUESTIONS ? LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS