Q: I am new to home care. What do I need to know about delegating tasks to home healthcare aides?
The Medicare Conditions of Participation (COPs) allow for the assignment of specific tasks to nonprofessional personnel, specifically home healthcare aides who are members of the home healthcare and hospice team. COP 484.36: Home Health Aide Service includes information about the training, assignment, duties, and supervision of home healthcare aides. In part, the COP states that the "Home Health Agency must ensure that the assignment of the home health aide to furnish care is based on the patient's need for personal care assistance identified, usually by the registered nurse, as part of the initial or subsequent patient assessment. The aide furnishes care following the written instructions of the registered nurse or, where appropriate, the therapist. It is assumed that the assigned tasks must be performed with some regularity if the desired outcome(s) are to be achieved." The assumption is that specific personal care tasks can be assigned to an aide who meets the criteria and training included in the COP.
The American Nurses Association (ANA) and the National Council of State Board of Nursing (NCSBN) jointly published the Position Statement on Delegation (2005) which states:
Delegation is a process that, used appropriately, can result in safe and effective nursing care. Delegation can free the nurse for attending more complex patient care needs, develop the skills of nursing assistive personnel and promote cost containment for the healthcare organization. The RN determines appropriate nursing practice by using nursing knowledge, professional judgment and the legal authority to practice nursing. RNs must know the context of their practice, including the state's Nurse Practice Act and professional standards as well as the facility/organization's policies and procedures related to delegation.
The NCSBN (2016, p. 5) states: "When certain aspects of nursing care need to be delegated beyond the traditional role and assignments of a care provider, it is imperative that the delegation process and the state nurse practice act be clearly understood so that it is safely and effectively carried out." The same article (p. 5) states: "Delegation has been a source of significant debate for many years and includes many philosophical discussions over the differences between assignment and delegation." The NCSBN defines both assignment and delegation. "Delegation is allowing a delegatee to perform a specific nursing activity, skill, or procedure that is beyond the delegatee's traditional role and not routinely performed. This applies to licensed nurses as well as unlicensed assistive personnel." Assignment is: "The routine care, activities, and procedures that are within the authorized scope of practice of the RN or LPN/VN or part of the routine functions of the UAP. The above are included in the coursework taught in the delegatee's basic educational program. A licensed nurse is still responsible for ensuring an assignment given to a delegate is carried out completely and correctly (p. 6, 7)."
ANA (2015a, p. 86) states: "Delegation is the transfer of responsibility for the performance of a task from one individual to another while retaining accountability for the outcome. Example: the RN in delegating a task to an assistive individual, the RN transfers the responsibility for the performance of the task but retains professional accountability for the overall care." Most importantly, delegation to a home healthcare aide or licensed practical nurse requires instruction about the task and ongoing supervision by the registered nurse. Provision 4.4 in the ANA's Code of Ethics for Nurses with Interpretative Statements (2015b, p. 17) states: "Nurses are accountable and responsible for assignment or delegation of nursing activities. Such assignment or delegation must be consistent with state practice acts, organizational policy, and nursing standards of practice." Another resource for readers is Delegation and You. When to Delegate and to Whom (Duggy & McCoy, 2016).
It is important to know the rules of your particular state. For example, the Pennsylvania Department of Health's website states: "Registered Nurses licensed in Pennsylvania may NOT delegate nursing functions to unlicensed persons." In 1994, the Board of Nursing attempted to pass regulations that include delegation. The Independent Regulatory Review Commission declined to approve these regulations, stating in part: "If the General Assembly had intended to grant registered nurses the authority to delegate functions to any other supportive personnel it would have been specifically provided within the Professional Nurse Law." Pennsylvania still lacks specific delegation language in its Nurse Practice Act. The Pennsylvania State Nurses Association supports legislation and registered nurse delegation that will place specific language into the Nurse Practice Act that will clarify the practice of delegation for the Commonwealth's RNs.
On February 23, 2017, the Pennsylvania Department of Health (PDOH) published Guidance to Home Care Agencies and Registries Licensed by PDOH. Governor Wolf's administration issued a policy clarification through the Departments of Health, Human Services, that:
clarifies the types of non-skilled services/activities that can be performed by direct care workers (DCWs) to assist individuals with disabilities with activities of daily living that could be performed independently but for their disability. DCWs include personal attendants, nursemaids, or other household aides. These non-skilled activities/services include assistance with bowel and bladder routines, assistance with medication, ostomy care, clean intermittent catheterization, assistance with skin care, and wound care. DCWs may perform these non-skilled services/activities, provided they do not represent or hold themselves out as being licensed nurses, licensed registered nurse, registered nurses, or practical nurses; or use in connection with their names, any designation tending to imply they are licensed to practice nursing.
This clarification in Pennsylvania is noted to encourage home healthcare nurses to be knowledgeable of policies in their state that have the potential to impact the special nursing care that registered nurses provide to patients. It is important that home healthcare nurses read their state's Nurse Practice Act to determine whether it includes, or lacks, specific delegation language. Now is the time for home healthcare nurses to be engaged with their state nurses' associations and elected officials to determine that language as provided for in the Medicare COPs and the ANA's Scope and Standards of Practice is included in your professional licensing law.
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