Nurse Delegation in LTCSS Overview

1. Nurse Delegation in LTCSSOverview Prepared for Pennsylvania Long Term Care Commission July 2014

2. 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

3. 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

4. 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

5. 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 • 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

6. 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

7. 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

8. 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

10. Delegation of Health Maintenance Tasks to LTSS Workers - 2014 16 Tasks 11-15 Tasks 6-10 Tasks 1-5 Tasks 0 Tasks Source: AARP, State Scorecard on Long-Term Services and Supports, 2014