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

2. ©2014 LEAVITT PARTNERS 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. ©2014 LEAVITT PARTNERS 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. ©2014 LEAVITT PARTNERS 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. ©2014 LEAVITT PARTNERS 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. ©2014 LEAVITT PARTNERS 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. ©2014 LEAVITT PARTNERS 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. ©2014 LEAVITT PARTNERS 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

9. ©2014 LEAVITT PARTNERS Health Maintenance Task # States Allowing Delegation* Administer glucometer test41 Perform ostomy care including skin care and changing appliance40 Administer enema35 Gastrostomy tube feeding33 Administer eye/ear drops30 Perform intermittent catheterization30 Administer oral medications30 Administer oxygen therapy28 Insert suppository28 Administer medication on an as needed basis26 Administer medication through tubes25 Perform nebulizer treatment24 Administer medication via pre-filled insulin or insulin pen23 Draw up insulin for dosage measurement17 Administer intramuscular injection medications14 * 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

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