All About Delegation PDF

Understanding Community Based
Nurse Delegation
2016
Presented by ALTSA Nurse Delegation Program Managers

Nurse Delegation Program
Nurses Contracted with Aging and Disability

Services Administration (ALTSA) are managed by:
Doris Barret, RN
(360) 725-2553
barreda@dshs.wa.gov
Erika Parada RN
(360) 725-2450
ParadE@dshs.wa.gov
This training is
Required for RN’s who wish to contract with DSHS

and be paid for Nurse Delegation services
Offered for other WA-licensed RN’s who wish to

delegate in other circumstances
Clarify rules for community based nurse delegation

not a certification course
Attendees may earn 7.0 contact hours
of Continuing Nursing Education by
Signing attendance sheet

Must attend entire training
Completing the evaluation form
•First law/rules in 1996 (included task

list)
•Expansion has included broadening to
other settings
•Eliminated task list in 2000
•Most recent change included adding
insulin injections, but no other
injections
CURRENTLY
 Nurse Delegation serves about 8000 Long

Term Care (LTC) and Developmentally
Disabled (DD) clients/year
 Costs for delegating nurses approximate
average =$700/client/year
Client Types:
Private
LTC
Pay
DD
Who are LTC Clients?
• These are “aging” clients who
live in a community setting
• LTC clients’ case managers
work at a home and community
service (HCS) office or an area
agency on aging (AAA) office
LTC clients may have
• Chronic conditions
• Diabetes
• Mental health diagnosis
• Congestive heart failure
• Dementia
• Chronic lung disease
Who are our DDA clients?
• Eligibility originates prior to age
eighteen
• Live in community settings
• May rent an apartment
• DD Case/Resource Managers are in
DDD offices, not HCS offices
• Current client may be adult or child
Qualifiers for DDA services:
1. DD = a variety of diagnoses identified

prior to age 18 including
2. Mental retardation
3. Cerebral palsy, epilepsy, autism or
4. Other conditions diagnosed and
described in WAC 388-825-030
DDA Regional Coordinators
Phone/Email by Region
FAX
REGION NAME PHONE NUMBER EMAIL
Region 1: Spokane Wilma Brown 509-329-2940 509-568-3037 brownWH@dshs.wa.gov
Region 1: Kennewick Gail Blegen-frost 509-374-2124 509-734-7103 blegGD@dshs.wa.gov
Region 2 N Meg Hindman 360-714-5005 360-714-5001 HindmMM@dshs.wa.gov
Region 2 S Kathleen Wood 206-568-5783 206-720-3334 woodkm@dshs.wa.gov
Region 3 Denise Pech 253-404-5540 253-593-2052 pechDL@dshs.wa.gov

How are DD clients different from LTC clients?
DD clients may have:
• Unique and complex medical needs
• Behaviors that are managed by creating
positive behavioral support
• Multiple and frequent medication changes
• Some settings may have high staff turnover
and require frequent training by RND
Confusion In The Nurse Practice Act
General Delegation:
 All nurses learn in nursing school
WAC 246-840-010(7) and 246-840-700-(2)(a)
Community Based Nurse Delegation Program –

A specific set of circumstances for delegating in
community-based settings, delineated in WA Nurse
Practice Act WAC 246-840-910 to 970
Purpose of ND Program
Consistent standards of practice
Support authority of RN to make
independent professional decisions
Enhance client choice
Protect the public in community-based and
in-home care settings
WAC 246-840-910
Is outlined in WA State law and rule
LAW = RCW 18.79A.260(3)(e)

Revised Code of Washington
RULE = WAC 246-840-910 to 970

Washington Administrative Code
Rules and laws apply to anyone
receiving nurse delegation services
• Medicaid clients
• Clients receiving services thru Supported Living
agencies
• Clients residing in a licensed adult family home
• Client receiving services in an assisted living facility
• Private pay clients
Only a Registered Nurse may delegate
 Not an LPN
 Current WA RN license required
 Licensed without restriction

Long Term Care Worker (LTCW)
For Community/Residential & In-home Delegation
NA-R NA-C HCA-C

The ND Program Described
RN assesses a client

 RN evaluates and teaches a long
term care worker (LTCW)
 LTCW performs a nursing task
 RN provides ongoing supervision
and evaluation of task and client
 Long Term Care worker could not perform task

without ND process (r/t scope of practice)
 Client must be stable (not an emergency service)
 RN must be notified of every change in client
condition or treatment
 All parties must be willing
• Based on the Nursing Process
– Assess
– Plan
– Implement
– Evaluate
Per WAC 246-840-910 to 970, Delegation of
Nursing Care Tasks in Community-Based and
In-Home Care Settings
Assess
1. Setting
2. Client
3. Long Term Care Worker
4. Task
Nurse Delegation Program—
Assess/Setting
1. Setting
• Adult Family Home (AFH)
• State certified program for individuals
with Developmental Disabilities (DD)
• In-home setting (LTC or DD)
• Assisted Living (AL)
*formerly known as Boarding Home (BH)
Assess/Setting
Adult Family Home
 No nurse required; 2-6 clients in
homelike setting
Assisted Living (>6 clients)

 Boarding Homes now called assisted
living and may have contract
Assess/Setting
State certified program/DD clients
Care by Supported Living Agency

 Client in a Companion Home
 Client in a Group Training Home
Assess/Client
2. Client consents—RND responsibility
to obtain
– Client consent OR
– Authorized representative may consent
– Documented verbal (dated) consent OK
– Written obtained (and dated) within 30 days
– Faxed or scanned document signature OK
WAC 246.840.930 (10)
Assess/Client
2. Client consents—RND responsibility
to obtain
 Initial delegation only, not for new tasks
 If using consent obtained by previous RN delegator,

must have copy in your file or obtain new one
WAC 246.840.930(10)
Assess/Client
 Full system nursing assessment
 Contracted ALTSA nurse must assess within 3
working days
 RND determines client’s clinical needs
 C/RM determines client’s behavioral and ADL needs
(CARE assessment)
 If different, discuss with C/RM to reach consensus
WAC 246-840-930(3)
Assess/Client
2. Client is stable and predictable
 As assessed by delegating nurse
 Client’s clinical and behavioral status known
 Not requiring frequent evaluation
 Not requiring frequent nursing presence
WAC 246-840-920(16)
Assess/Client
Client is stable and predictable
and includes:
Sliding Scale Insulin
WAC 246-840-930 (2)
 Hospice
WAC 246-840-930 (2)
Assess/Caregiver
3. Long Term Care Worker/ Caregiver (as of
2012)
◦ Long term care worker must be a registered
nursing assistant (NA-R) or certified nursing
assistant (NA-C/CNA) or Home Care Aide
Certified (HCA-C)
◦ No restrictions on license
◦ Current, not expired
◦ https://fortress.wa.gov/doh/providercredentialsearch/
SearchCriteria.aspx
Assess/Caregiver
3. Long term Care Workers/
Caregivers (HCA-C or NA-R & NA-C)
– 9 Hour Nurse Delegation for Nursing Assistants”

AND
– 3 Hour “Special Focus on Diabetes”
RCW 18.88B.070
RCW 18.88A.210
Nurse Delegation Program--
Assess/Caregiver
**LTC WORKERS EXEMPT FROM BASIC TRAINING
• RN’s, LPN’s, CNA’s, ARNP

• Certified counselor, speech language pathologist
assistant or audiologist, OT, PT or home health aide
employed by a Medicare-certified home health
agency.
Assess/Caregiver
**LTC WORKERS EXEMPT FROM BASIC TRAINING
• LTC worker (HCS) employed sometime between
1/1/2011 and 1/6/2012 who completed the basic
training requirements in effect as of the date of hire
• LTC worker (DDA) employed before 1/1/2016 who
completed the basic training requirements in effect
as of the date of hire
Assess/Caregiver
3. LTCWs not certified must have an NAR and one
of the additional caregiver trainings prior to being
delegated to:
1. HCA Basic Training (Core Competency) (40 hours)
2. Revised Fundamental of Caregiver (RFOC) or alternative DSHS
approved course
3. DDA Basic Training (Supported Living or Group Training Home)
(32 hours)
4. PRIDE Training (Foster Care Setting)
5. DDA CORE Basic Training (40 hours)
Exempted Long Term Care Worker-HCS
Hired after Jan 7th 2012 – Trng requirement changes
75 Hours Training
- 5 hours orientation and safety
- 70 hours
30-40 Basic Core Competencies
30-40 Population Specific
(mental health, dementia, etc) –
Must have completed required training
within 200 days of hire
If hired prior to January 7th 2012

- Must have letter of employment verification
(see requirements)
Exempted Long Term Care Worker-DDA
Hired after Jan 1st 2016– Trng requirement
changes
75 Hours Training
- 5 hours orientation and safety
70 Hours
40 DDA CORE Basic
30 Population Specific
Working prior to January 1st 2016
Must have DDA letter of exemption
Assess/Task
4. Task
– Any task that is not prohibited
WAC 246-840-910(1-4)
– Task is within delegating nurse’s scope of
practice WAC 246-840-930(4)
– Consult Decision Tree if questions
WAC 246-840-940
Assess/Task
Now
Previous
Assess/Task
Prohibited tasks =
• Injectable medication except insulin
• Sterile procedures
• Central line maintenance
• Anything requiring nursing judgment
WAC 246-840-910(1-4)
Nurse Delegation Program—Assess/Task
4. Examples of some delegated tasks
• Administration of oral, topical, inhaled
medications and drops
• Suctioning (not sterile)
• In and out catheters/ bladder irrigation
• Tube feedings, colostomy care
• Blood glucose monitoring
• Simple dressings
• Insulin injections
Based on the Nursing Process
– Assess
– Plan
– Implement
– Evaluate
Plan
Plan
 Written instructions
 Teach injection technique for insulin
 Determine competency
 Consult Decision Tree in WAC

Plan
Provide specific written instructions
(Task Sheet)
 Clear description of the steps to follow
 Task is specific to an individual client
Sample instructions on the ND website at:

https://www.dshs.wa.gov/altsa/residential-care-
services/nurse-delegation-program select Resources
find Job Aids”
Plan
Provide specific written instructions
(Task Sheet)
 If task delegated is medication administration, verify
medications
 Verify when meds added or dosages changed with
pharmacist, health care provider, etc, if no written
order, Rx
 Document how you verified the medication (MAR,
MD orders, and Pharmacy, etc.)
Plan
When delegating insulin injections,
RND must
• Teach proper use of insulin for a specific client
• Instruct and demonstrate safe injection technique
• Determine caregiver’s competency to inject insulin

safely
• 4 initial, weekly, RND supervisory visits required

(regardless of circumstance)
Plan
Determining Competency of Nursing Assistants
 Determine competency of each LTCW
individually
 Decide the method to be used at each visit
◦ Return demonstration
◦ Verbal description
◦ Record review
 Delegation is specific to one nursing assistant
(not transferable)
Plan
Consult Decision Tree
• Nurse Practice Act

• Critical thinking process
• Helps if delegation is appropriate
WAC 246.840.940
Implement
– Assess
– Plan
– Implement
– Evaluate
Implement
Implement
 Teach each LTCW to perform task and when
to communicate with RND
 ND is responsible for teaching the task
 LTCW is responsible for performing the task correctly

as taught
WAC 246-840-930
Implement
 Document entire ND process including
competency of each LTCW
 In private homes, RND must set up a client

chart including
 All ND forms, orders, medication record

 All LTCW(s) documentation of delegated
tasks
 RN notes and records ND activities
Evaluate
– Assess
– Plan
– Implement
– Evaluate
Evaluate
Supervisory Visits – 2 Components:
(minimum of every 90 days/more frequently
when delegating insulin)
Composed of:
A. Assessment of Client
B. Supervise Long Term Care Worker
(each/name)
Evaluate
Supervisory Visits – 1st Component:
A. Assessment of Client
– Condition—stable & predictable
– Response to the task
– Modify task?
Evaluate
Supervisory Visits – 2nd Component:
B. Supervise Long Term Care Worker (each/name)
– Care provided
– Capability of LTCW
– Documentation
– Re-training needed?
– Validation of current credential
Evaluate
Evaluate (every 90 days and more frequently when
delegating insulin)
Modification/re-training
– Rescinding--task, caregiver, delegation
– Rescinding—responsibility of RND
– Assumption from another RND
WAC 246-840-960
Evaluate every 90 days
– Visit date is no longer than 90 days since the last
supervisory visit
– Different from every 3 months
– Give yourself a cushion
– Plan supervisory visit at least 2 weeks before the
3 months date
– Call the clients/provider prior to arriving for
scheduled visit
• For insulin, evaluate more frequently
– Requirement is: 4 initial, weekly supervisory
visits
• Minimum = once a week during the first four weeks
(7 day intervals)
– No more than a week apart
– More frequently is allowed
• Depends on RND comfort level
Evaluation/supervision must include
– Physical assessment of client

– Document condition remains stable and
predictable
– Supervise each LTCW delegated (name them)
– Indicate how you supervised each one
– Assess
– Plan
– Implement
– Evaluate
Per WAC 246-840-910 to 970, Delegation of Nursing Care
Tasks in Community-Based and In-Home Settings
Summary
• RCW/WAC set basic expectations for
nurse delegation process in Washington State
• Apply to all registered nurses who participate in
the nurse delegation program whether state
contracted or not
• The RND uses the nursing process
to evaluate both the client condition and
caregiver competency
CREDENTIAL & TRAINING
REQUIRMENTS
 BINGO GAME
 X ON CORRECT TRAINING
 CHOOSE BLOCKS OF YOUR CHOICE

1. Licensed Practical Nurse working in an Adult Family
Home in 2012
2. He worked in April 2011 as a Nursing Assistant

Registered (NAR) working for a Supported Living
agency required to give insulin
3. Nursing Assistant Certified (NA-C/ CNA) working in an

Adult Family Home 2013 applying fentanyl patch.
4. It is February 2012 with Home Care Aide-Certified
working in an Assisted Living Facility giving insulin.
5. Nursing Assistant Registered working in an in-

home setting with hospice client who requires insulin
injections and wound care. They were hired prior to
January 7th 2012.
6. It is February 2012 with Nursing Assistant Registered

working for a Supported Living agency giving insulin.
NAR worked for Home Care Agency in 2011.
7. Just hired in AFH after January 7, 2012 & did not
work 2011 thru Jan 1-6 2012. NAR working in an
Adult Family Home giving insulin.
8. Home Care Aide Certified working in an AFH
with administration of oral medication February
2013.
9. NAR working in Supported Living to administer
insulin injection after 1/1/2016
WHEN DELEGATION MAY NOT BE NEEDED
1. Personal Care
2. Basic First Aid
3. Self Directed Care
4. Medication Assistance
WHEN DELEGATION MAY NOT BE NEEDED
1. Personal Care – shampoo, catheter care
2. Basic First Aid – Band-Aid

3. Self Directed Care (doesn’t need delegation)
 Only in private homes
 Only by an Individual Provider (IP), not
agency worker (AP)
 Client trains and supervises caregiver and
task
 May provide anything an able-bodied
person could do for themselves
RCW 74.39.050
WAC 388-71-05640
4. Insulin
Insulin Pen – Simple Care Task
 The Long term Care Worker may:
 Dial the dose
 Insert the needle
 Hand the pen to client for self injecting
Insulin Pump
 Insert cassette
 Attach tubing
 Client must insert needle
RCW 74.39.050
WAC 388-71-05640
4. Insulin (continued)
 If Insulin must be drawn into syringe from a

bottle it must be delegated.
 Synthetic Insulin cannot be delegated
 Byetta
 Victoza
Medication Assistance
5. Medication Assistance
(doesn’t need delegation)
 Describes ways we can help an individual take
their own medications
 May be done by a lay person (non-practitioner)
 Client in community setting or their own home

WAC 246-888-020
Both functional and cognitive piece must be met if
client is eligible for Medication Assistance.
Client must be
◦ Able to get the medication where it needs to go
“must be able to put the medication into his or
her mouth or apply or instill.” (functional)
◦ Aware that they are taking medication

“does not necessarily need to state the name of
the medication, intended effects, side effects, or
other details…” (cognitive)
WAC 246-888-020
BOTTOM LINE !
Both functional and cognitive pieces must be met
o If individual is not able to physically ingest or
apply
OR
o If individual cannot indicate an awareness that
he/she is taking a medication,
THEN the medication must be administered by a

person legally authorized to do so.
WAC 246-888-020
What is Prohibited?
Medication Assistance with
intravenous and injectable medications
is specifically excluded except:
“handing the prefilled insulin syringe”

to an individual who can self-inject.
WAC 246-888-020
Individual retains the right to refuse
 Occurs “immediately prior to the ingestion or

application of medication.”
(WAC 246-888-020)
EXCEPTION IN ASSISTED LIVING FACILITY
If client cannot put medication in own mouth, or
apply or instill
He/she may “accurately direct others” to do so,
under Medication Assistance WAC
THIS IS NOT CALLED SELF-

DIRECTED CARE
WAC 388-78A-2090(2)(a)
Lay person (non-practitioner) may

assist by
 Opening, pouring
 Reminding, coaching
WAC 246-888-020
 Crushing, dissolving
 Mix with food or liquids
WAC 246-888-050
However, if medication altered
(= cut, crushed, mixed or dissolved)
• Client must be aware medication is in food

• A practitioner determines it is safe to do so
AND
• Documented on container or client record
WAC 246.888.060
• OK to use an enabler
• Examples of enablers: glass, cup, spoon, bowl,

straw, cloth, adapted table surface
• “Hand over hand” administration NOT

allowed
WAC 246-888-050
May we assist with nebulizers or meds through a G-tube?
 Same rules apply
Is oxygen covered under Med Asst?

 No, because pharmacy board does not consider
oxygen to be a medication.
WAC 246.888.080,090, 100

• Blue Board Exercise
– Select which category the task belongs in

Process for Nurse Delegation
A. Step by Step Process for Initial
Delegation (including forms)
B. Client Scenarios
A. Step by Step Process for Delegation
(including forms)
1. Obtain (& document) referral

*from CM/CRM (if state client)
*from other source (not a state client)
In the state system, what is a referral?
o DSHS Referral form (details next slide)
o Copy of most recent assessment
(CARE/ISP/behavior plan)
o Copy of client’s release of information
from time of admission to state services
(including forms)
DSHS Electronic Forms at

http://www.dshs.wa.gov/msa/forms/eforms.html
(Use “control F”, type in Nurse Delegation)
2. Obtain consent to delegation process

Consent form is translated into eight (8)
languages besides English.
*Check the DSHS Forms website for availability.
• Once a referral form is received, the
state ND contract requires your assessment
to be done within 3 working days.
• If unable to meet this deadline, discuss with

C/RM.
Forms - Walkthrough
Forms - Walkthrough
Forms - Walkthrough
Forms - Walkthrough
(consent)
-- contact client or authorized representative
--obtain before starting delegation

--documented verbal OK; must be signed
within 30 days
--version of consent document used must not
prohibit injections, if delegating insulin
(Use DSHS 13-678 Revised 2009)
Consent for Delegation form

Forms - Walkthrough
Forms - Walkthrough
(including forms)
3. Check credentials for All delegated
caregivers
• Print DOH Credential check AND
• Attach to Credentials form OR
• document certificate number on form
• Verify classes and enter dates
Credentials and Training Form

Forms - Walkthrough
Forms - Walkthrough
(including forms) ‘
4. Assess client using a system by system nursing

assessment—(no state form)
This is different from the 20-page
comprehensive admission
assessment form
(including forms)
B. Use own assessment form (sample in packet)
(including forms)
5. Complete task sheet for each delegated

nursing task (Job aids are available)
Instructions for Nursing Task

Forms - Walkthrough
Multiple ways to
verify medications
Forms - Walkthrough
(including forms)
6. Complete Nursing Visit form for

– Initial client or caregiver
– Change in condition
– Supervisory
– Other
Nursing Visit form

Nursing Visit form

Charting by
Forms - Walkthrough exception.
Forms - Walkthrough
Rescinded 2/1/14
This date allows for a cushion.

Must visit within 90 days (not 91).
(including forms)
7. Complete Supplementary Forms if

needed
--PRN medication form
--Change in medical orders
--Assumption form
--Rescinding form
PRN Medication form

Forms - Walkthrough
Forms - Walkthrough
MD order: Ativan 2-4 mg every 4 hours PRN agitation. Must obtain new, more specific order.
Not acceptable order

for nurse delegation
Forms - Walkthrough
8. Complete Supplementary Forms if needed

Change in Medical Orders form
Change in Medical Orders form

Forms - Walkthrough
Multi-functional use
Forms - Walkthrough
Choice/decision up to the
delegating RND
Assumption form
needed
See Assumption form

Rescinding form
needed
See Rescinding form

Exercise: Select ND Forms
1. Mrs. K is 79 year old and lives by herself in her home. She has a DX of
arthritis, angina, and a recent blood clot in her right leg. The case
manager has sent you a referral but is not sure what task need to be
delegated. She has a daughter who is unable to assist with her care
due to her work schedule. They have found an agency caregiver. What
forms need to be completed?
2. The current RND is retiring and has asked you if you wanted an
additional client. You agree. This client lives in supported living.
There are multiple caregivers. This client is on insulin and has BGC
daily. What forms must you complete
Exercise: Select ND Forms
3. Your client just returned home from the hospital. He has been on oral
hypoglycemic and is not on insulin. He has a new caregiver from an
agency. He also has several other medication changes. What forms
must you complete?
4. You receive a TC from your caregiver stating your client went to the MD
and has new medication orders. He said the MD also changed his pain
medication to be used only as needed instead of four times a day.
What forms must you complete.
5. Your client has just been put on Hospice care. She was independent in
managing her medications but the case manager called you with a
referral to see her. She has new care givers. What forms must you
complete?
B. Client Scenarios/Group Exercise
Client Scenarios/Group Exercise
History:
Mrs. Mabel Smith is a state client who is receiving paid dare and services through
the Aging and Long Term Supports Administration (ALTSA). She is moving into
an Adult Family Home (AFH) related to changes in her mobility. She would like to
try living in a smaller environment. Mrs. Smith’s husband passed away nine years
ago, she has lived in an Assisted Living Facility (ALF) for four years now. Mrs.
Smith requires medication assistance with her oral medication; however her eye
drops need to be instilled (administered) by a Long Term Care Worker (LTCW).
The LTCW’s providing care for Mrs. Smith are: Rita Book NA-R, Will Powers
HCA-C and Iona Ford NA-C. The Case Manager (CM) with ALTSA, Home and
Community Services (HCS) is Chris Coe, CM. You refer to the CARE assessment
for Mrs. Smith’s care needs.
1
Mrs. Smith has been referred to you by her CM, Chris Coe to assess the need for
Nurse Delegation. Mrs. Smith is now living in Sunrise Beach Cove AFH and this
will be her initial Nurse Delegation visit. You have assessed Mrs. Smith and she is
able to take her oral medications with the help of the LTCW who reminds her when
medications are due and hands her the medication in a med-cup. However, Mrs.
Smith needs the LTCW to perform installation of her eye drops for glaucoma.
2
During the next month, Lena the AFH Provider calls you because Mrs. Smith has
been hospitalized for increased confusion, she was later diagnosed with Pneumonia.
Mrs. Smith will be returning to the Sunrise Beach Cove AFH with the following new
orders: oral antibiotics, glucose monitoring and Lantus insulin injections 8 units ever
A.M and AC, for diabetes. Per your conversation with Lena you determine the clients
cognition has returned to baseline; however she is unable to self inject her insulin and
needs delegation for this task. Lena states the discharge planner at the hospital told
her Mrs. Smith had redness on her “tail bone area”, that has not gone away. You call
Chris Coe, CM to relay the recent information. Chris Coe, CM asks you to continue
delegation for her eye drops, glucose monitoring and insulin injections once Mrs.
Smith returns home. Chris Coe, CM has also asked you to complete the Skin
Observation Protocol (SOP), provide training to the LTCW’s on prevention of
Pressure Ulcers (PU) and return the documentation to her within the required time
frame (5 days).
3
Lena has taken Mrs. Smith to see her Doctor as a follow up to her hospitalization.
She called you to let you know she has a new caregiver who needs to be delegated
and that Rita Book NA-R has quit. Lena tells you Mrs. Smith has some increased
strength and mobility and is now able to inject her own insulin using a new insulin
pen. Mrs. Smith still needs her eye drops instilled and will need glucose monitoring
done for her. Lena also tells you the red area over her “tail bone” is now clear. She
asks that you continue delegation for the eye drops and glucose monitoring to her
new LTCW, Anna Conda. You agree to continue delegation to the LTCW’s.
4
During the subsequent month, Mrs. Smith’s son calls Lena and states his mother has
been doing well with her ambulation and insulin pen injections and would like to
move in with him. You determine the client will have an agency LTCW from
Caregivers-R-Us who will come into the home. Mrs. Smith will continue needing
Nurse Deletion for her eye drops and glucose monitoring when she leaves Sunrise
Beach Cove AFH. You let Mrs. Smith and her son know you will no longer be able
to continue Nurse Delegation with her since she will be moving to another County in
which you do not provide Delegation. You have worked on a safe transition plan
with Chris Coe, CM and Mrs. Smith to include assumption of Nurse Delegation
services by Ferris Wheeler, RND.
Contracting With ALTSA
DO YOU NEED A CONTRACT WITH ALTSA?
Only if you wish to be paid for delegating for

Medicaid clients in :
• AFH
• DD certified programs
• Private homes on appropriate waiver

Contracting With ALTSA
WHAT SERVICES CAN I PROVIDE
UNDER AN ND CONTRACT?
 ALTSA Nurse Delegation, LTC or DD clients
 Skin Observation Protocol for an existing ND

client
 DD Skilled Nursing tasks (1-time)

Skin Observation Protocol
– CM or CRM refers
– Must be current delegation client *
(*except DD)
– Timelines must be met
– Forms/process on website
http://www.aasa.dshs.wa.gov/Professional/ND/SOPres
ources.htm
WHAT ARE THE REQUIREMENTS TO
GET AN ND CONTRACT WITH DSHS?
• RND orientation class
• Experienced RN (2 years) or equivalent
experience determined by ND Program
Manager
• Professional liability insurance
• Criminal background check
• National Provider Index (NPI)
• Core Provider Agreement
WHAT ARE THE REQUIREMENTS TO GET A
ND CONTRACT WITH THE DEPARTMENT?
• Business license
• Nursing license without restrictions
• Submit completed packet to ND Program

Manager for approval
WHAT IF I WANT TO DO TRAINING?
For a LTC community instructor contract
• Check the website at
http://www.adsa.dshs.wa.gov/professional/trai
ning/1029/commreq.htm
• Contact Hutchins Julia @ 360-725-2548
WHAT IF I WANT TO DO TRAINING?
For a DDA contract for ND core training
(9-hr or 3-hr)
• Contact specific Regional ND Coordinator
1. Identify your region – See Colored
Map
2. See Pink Sheet in Your Packet
Regional DDA ND Coordinators
FAX
REGION NAME PHONE NUMBER EMAIL
Region 1: Spokane Wilma Brown 509-329-2940 509-568-3037 brownWH@dshs.wa.gov
Region 1: Kennewick Gail Blegen-frost 509-374-2124 509-734-7103 blegGD@dshs.wa.gov
Region 2 N Meg Hindman 360-714-5005 360-714-5001 HindmMM@dshs.wa.gov
Region 2 S Kathleen Wood 206-568-5783 206-720-3334 woodkm@dshs.wa.gov
Region 3 Denise Pech 253-404-5540 253-593-2052 pechDL@dshs.wa.gov

OTHER STATE NURSING CONTRACTS
• Contact your local Area Agency on Aging for a

Waivered Skilled Nursing contract
• Contact Doris Barret, 360/725-2553 or

barreda@dshs.wa.gov for a Private Duty
Nursing contract
NURSE Delegation Program
Contract Details
• Contract with ALTSA/HCA

• Authorized by Case/Resource Manager
• Assessment, documentation, travel time,
collateral contacts and billing time are
billable
Contract Requirements
Complete Contract Packet
• Letter of interest/resume
• Copy of Driver License & RN license
• Business License
• Professional Liability insurance
• Background check
• NPI number
• Core Provider Agreement
• W-9 Request
Process Mapping
Completed packet to:
ALTSA Contract Unit
ND Program Manager
CPA to HCA
ALTSA Contract Unit
ND Program Manager
Contract Requirements
• Required to have NPI number
• Computer
• Use Microsoft Internet Explorer version 6.0

and above
NURSE Delegation Program Contract—
Rolodex Sheet
• Set up your Rolodex referral sheet
NURSE Delegation Program Contract
Billing Process
 PRIOR TO LOGGING IN TO
PROVIDER ONE
 Receive a welcome letter in the US mail
 Email with your Domain and User Name
 A second email with your temporary password
Nurse Delegation Program Contract
WHAT ND ACTIVITIES MAY I BILL?
• Initial delegation assessment
• Supervisory visits/re-evaluating client
• Collateral contacts (with family, physician,
pharmacist, case managers)
• Time spent in travel
• Billing
Sample Billing Scenarios
• Example one—Scooby Do
• Example two-- Mrs. Jones

NURSE DELEGATION
PROVIDER ONE
Nurse Delegation
Webinar or Direct Training
1. Must have completed RND Orientation Class
2. Must have completed nurse delegation contract
3. List of current clients—minimum 1 client required
4. Register for a lab—must bring your own computer
5. Must bring completed rolodex sheet
Billing Labs: 2/24/2016 : 3/15/2016 : 4/19/2016 : 5/17/2016
Where: Blake West—Olympia, Washington
How: Register for a class, go:
https://www.dshs.wa.gov/altsa/home-and-community-services/providerone-billing-lab
Before starting the claim process, you should have the following information at hand:
• Your NPI
• Taxonomy (pg. 25)
• Client ID (Authorization)
• Client Birthdate (pg. 26)
• Authorization # (Authorization)
• Diagnosis Code (pg. 29)
• Service (Procedure) Code (Authorization & pg. 45-55)
• Modifier (Authorization & pg. 45-55)
• Unit Rate (Authorization)
• Unit Type (Authorization)
http://www.hca.wa.gov/medicaid/provider/Pages/training.aspx
Contract
HOW AM I PAID UNDER AN ALTSACONTRACT?
• Payment in 15-minute increments (units)
• Current (2016) = $8.24/unit, $32.96/hour
• Rates set by legislative action

WHAT IS THE PAYMENT POLICY FOR
DDA CLIENTS?
50 units = 12.5 hours/month allowable
51-100 units must submit an additional units

form.
One unit = 15 minutes; 4 units = 1 hour
Complete “DDA” Request for Additional Units form if

more hours needed (prior approval required)
http://www.aasa.dshs.wa.gov/Professional/ND/
WHAT IS THE PAYMENT POLICY
FOR LTC CLIENTS?
36 units= 9 hours/month maximum may be
authorized
One unit = 15 minutes; 4 units = 1 hour
Complete “Aging” Request for Additional Units Form

if additional units are required
http://www.aasa.dshs.wa.gov/Professional/ND/
Put new one

SET UP BUSINESS PROCESSES
that support and document the units billed
• Client services
• Collateral contacts
• Travel time
• Billing Time
YOU MUST MARKET YOUR OWN SERVICES
• Contact Case/Resource Managers, Social Work
Supervisors in your region
• Develop marketing materials
o Flyers
o Business Cards
o Website
• Contact other delegating nurses
• Build your own caseload
REMEMBER, YOU ARE BILLING MEDICAID.
Your documentation must support
• Number of units billed
• Services provided in the month they are billed
 Visits must be completed; don’t bill before they’re done.
• If you don’t document it, you didn’t do it!
• Remember to be HIPPA Compliant
PROGRAM RESPONSIBILITIES
• Contracted RND Responsibilities
• Case/Resource Manager Responsibilities
• ND Program Manager Responsibilities

A. Contracted RND Responsibilities
1. Document when, how and from
whom referral was received
2. If necessary, arrange for an
interpreter to participate in your
initial visit. (Consult website for instructions)
3. Evaluate client within 3 working days
for an initial ND referral
RND Responsibilities (cont)
4. Return referral form to case/or resource

manager with results of the
assessment (also required for RND payment)
5. Notify CM/CRM when client condition

changes or delegation is rescinded
6. Maintain duplicate ND files (copy
with client, copy with you)
7. Keep your files for 6 years
8. Send client files if requested to case
manager or to ND PM for contract
monitoring
10. Set up client file in private home
(already in place in AFH/DDD)
11. Teach LTCW(s) where and how to
document a delegated task
12. In private homes, send nurse visit form
to home care agency/Home Health if
requested
13. Maintain WA State RN license

14. Maintain minimum amounts
professional liability insurance
15. Report instances of suspected or
actual abuse per RCW 74.34.020
Contracted RND Responsibilities (cont)
16. Provide data for the Skin Observation
Protocol* when requested by the
client’s Case/Resource Manager on an
existing ND client.
17. Communicate with ND Program

Managers if questions
*http://www.aasa.dshs.wa.gov/Professional/ND/SOP
resources.htm
Case/Resource Manager
Responsibilities
1. Send referral form to RND
2. Send most recent client assessment
(CARE/ISP/behavior plan)
3. Send the client’s release of
information form
Case/Resource Manager Responsibilities
4. Authorize payment for 12 months in Provider

One, using RND provider number
5. Communicate to RND if client eligibility or

authorized representative changes
Case/Resource Manager Responsibilities
6. In private home settings, C/RM must assure

that caregiver has appropriate credentials and
training for delegation (Nursing Assistant
registration and appropriate course
completed) before referring to nurse
delegator.
Summary of Nurse Delegation
Program Training
RCW, WAC are the same for DD and LTC
 Based on the nursing process
 Services billed in units (1 unit = 15 minutes)
 Communication is key to the process
 Documentation is essential to success
 ND Program Managers available for support
QUESTIONS
• Program Evaluation–
– Complete the program evaluation form at this time
– You must turn this in to the ND Program Manager
if you wish to receive your certificate validating
continuing education contact hours.
Nurse Delegation Program Managers
Doris Barret, RN
360/725-2553
barreda@dshs.wa.gov
Erika Parada ,RN

360-725-2450
parade@dshs.wa.gov
Thank you for being

a good audience!!

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Understanding Community Based

Presented by ALTSA Nurse Delegation Program Managers

Nurses Contracted with Aging and Disability

Required for RN’s who wish to contract with DSHS

Offered for other WA-licensed RN’s who wish to

Clarify rules for community based nurse delegation

Signing attendance sheet

•First law/rules in 1996 (included task

 Nurse Delegation serves about 8000 Long

1. DD = a variety of diagnoses identified

Region 1: Kennewick Gail Blegen-frost 509-374-2124 509-734-7103 blegGD@dshs.wa.gov

Region 2 N Meg Hindman 360-714-5005 360-714-5001 HindmMM@dshs.wa.gov

Region 2 S Kathleen Wood 206-568-5783 206-720-3334 woodkm@dshs.wa.gov

Region 3 Denise Pech 253-404-5540 253-593-2052 pechDL@dshs.wa.gov

Community Based Nurse Delegation Program –

LAW = RCW 18.79A.260(3)(e)

RULE = WAC 246-840-910 to 970

 Current WA RN license required

 Licensed without restriction

NA-R NA-C HCA-C

RN assesses a client

 Long Term Care worker could not perform task

3. Long Term Care Worker

Assisted Living (>6 clients)

Care by Supported Living Agency

 If using consent obtained by previous RN delegator,

– 9 Hour Nurse Delegation for Nursing Assistants”

• RN’s, LPN’s, CNA’s, ARNP

If hired prior to January 7th 2012

 Teach injection technique for insulin

 Consult Decision Tree in WAC

 Task is specific to an individual client

Sample instructions on the ND website at:

• Instruct and demonstrate safe injection technique

• Determine caregiver’s competency to inject insulin

• 4 initial, weekly, RND supervisory visits required

• Nurse Practice Act

 ND is responsible for teaching the task

 LTCW is responsible for performing the task correctly

 In private homes, RND must set up a client

 All ND forms, orders, medication record

– Physical assessment of client

 CHOOSE BLOCKS OF YOUR CHOICE

2. He worked in April 2011 as a Nursing Assistant

3. Nursing Assistant Certified (NA-C/ CNA) working in an

5. Nursing Assistant Registered working in an in-

6. It is February 2012 with Nursing Assistant Registered

WHEN DELEGATION MAY NOT BE NEEDED

1. Personal Care – shampoo, catheter care

2. Basic First Aid – Band-Aid

 If Insulin must be drawn into syringe from a

 May be done by a lay person (non-practitioner)

 Client in community setting or their own home

◦ Aware that they are taking medication

THEN the medication must be administered by a

“handing the prefilled insulin syringe”

 Occurs “immediately prior to the ingestion or

THIS IS NOT CALLED SELF-

Lay person (non-practitioner) may

• Client must be aware medication is in food

• Examples of enablers: glass, cup, spoon, bowl,

• “Hand over hand” administration NOT