1. health and fitness

DIRECT SERVICE WORKERS
MEDICATION ADMINISTRATION AND
NON-COMPLEX TASKS IN THE HCBS
SETTING
Bruce D. Greenstein
Secretary
DIRECT SERVICE WORKER
MEDICATION ADMINISTRATION TRAINING
CHRONOLOGICAL HISTORY OF RELATED LEGISLATION AND RULE MAKING
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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
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CHRONOLOGICAL HISTORY CONTINUED
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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
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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
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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
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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
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NURSING BOARD’S RULES FOR DELEGATION
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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
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LSBN WEB SITE FOR DELEGATING SELECT NURSING
TASKS TO UNLICENSED PERSONNEL
• http://www.lsbn.state.la.us/Portals/1/Docum
ents/DeclaratoryStatements/delegation.pdf
• http://www.lsbn.state.la.us/NursingPractice/S
copeofPractice.aspx
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS
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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
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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
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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
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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
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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
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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
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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
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AUTHORIZED MEDICATION ADMINISTRATION AND
NON-COMPLEX TASKS
 provision of routine hydration, nutrition or
medication by way of an established gastrotube;
 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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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 is done.
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS
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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
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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
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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
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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
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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
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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
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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
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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
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DSW WEB SITE
• http://new.dhh.louisiana.gov/index.cfm/direct
ory/detail/713
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS
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QUESTIONS
?
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS
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