Part 11.
BOARD OF NURSE EXAMINERS
Chapter 218.
DELEGATION OF SELECTED NURSING TASKS
22 TAC §§218.1 - 218.11
(Editor's note: The text of the following sections proposed for
repeal will not be published. The sections may be examined in the offices
of the Board of Nurse Examiners or in the Texas Register office, Room 245,
James Earl Rudder Building, 1019 Brazos Street, Austin.)
The Board of Nurse Examiners proposes the repeal
of §§218.1 - 218.11 concerning Delegation of Selected Nursing Tasks
by Registered Professional Nurses to Unlicensed Personnel; Purpose; Definitions;
General Criteria for Delegation; Supervision; Unlicensed Personnel to Whom
Tasks are Delegated by Other Licensed Practitioners; Nursing Students Working
as Unlicensed Personnel; Nursing Tasks That May Not Be Delegated; Administration
of Medications; Specific Nursing Task Which May Be Delegated; Nursing Tasks
That May Not Be Routinely Delegated; Exclusion from Rules.
The repeal would allow for the adoption of new sections.
Katherine A. Thomas, MN, RN, Executive Director, has determined that there
will be no fiscal implications for state or local government as a result of
enforcing or administering the rule.
Katherine A. Thomas, MN, RN has determined that for each year of the first
five years the repeals as proposed are in effect the public benefits from
promotion of independent living for clients who might otherwise be institutionalized.
There will be no effect on local government nor businesses to comply with
the rule.
Written comments on the proposed repeals may be submitted to Katherine
Thomas, Board of Nurse Examiners, P.O. Box 430, Austin, Texas, 78767-0430.
The repeals are proposed under the Nursing Practice Act, (Texas
Occupational Code §301.151) which provides the Board of Nurse Examiners
with the authority and power to make and enforce all rules and regulations
necessary for the performance of its duties and conducting of proceedings
before it.
There are no other rules, codes, or statutes that will be effected by this
proposal.
§218.1.Purpose.
§218.2.Definitions.
§218.3.General Criteria for Delegation.
§218.4.Supervision.
§218.5.Unlicensed Personnel to Whom Tasks are Delegated by Other Licensed Practitioners.
§218.6.Nursing Students Working as Unlicensed Personnel.
§218.7.Nursing Tasks That May Not Be Delegated.
§218.8.Administration of Medications.
§218.9.Specific Nursing Task Which May Be Delegated.
§218.10.Nursing Tasks That May Not Be Routinely Delegated.
§218.11.Exclusion from Rules.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of
the Secretary of State, on February 7, 2000.
TRD-200000927
Katherine A. Thomas, MN, RN
Executive Director
Board of Nurse Examiners
Earliest possible date of adoption: March 19, 2000
For further information, please call: (512) 305-6811
22 TAC §§218.1 - 218.11
The Texas Board of Nurse Examiners (BNE) proposes new §§218.
- 218.11 concerning Delegation of Selected Nursing Tasks by Registered Professional
Nurses to Unlicensed Personnel; Purpose; Definitions; RN Accountability for
Delegated Tasks; General Criteria for Delegation; Supervision; Delegation
of Specific Tasks; Delegation of Tasks for the Client in Independent Living
Environments with Stable and Predictable Health Care Needs Who Participate
in the Management of Delegated Tasks; The Medication Aide Permit Holder; Supervising
Unlicensed Personnel Performing Tasks Delegated by Other Practitioners; Nursing
Students Working as Unlicensed Personnel.
The BNE, at the April 1999 Board meeting, voted to establish a Task Force
to review the delegation rule beginning in September 1999. After considerable
study and review, the Task Force recommended revised language to the Board
at the January 20, 2000 Board meeting. In summary, the Task Force found that
there has been a reluctance of nurses to delegate based on perceived "risk"
of negative licensure action. The Board agreed that the rules of delegation
should allow more, not less, discretionary power for the RN to delegate care
for those individuals in independent living environments who are stable and
predictable, capable of directing their own care and who would be managing
that care except for their disability. The intent of these proposed rules
is to improve the RN's understanding of their licensure obligation under the
delegation rules and to facilitate the ability of individuals to live in the
community rather than in an institutional setting. The proposed rules primarily
promote the concept of delegation for nursing tasks which frequently occur
in activities of daily living and which do not require the unlicensed person
to exercise nursing judgment.
The proposed rules lists specific tasks to encourage the RN to be discretionary
based upon the clients needs and are not designed to restrict the RN's practice.
The proposed rules are written in an effort to broaden the tasks delegated
to stable and predictable clients within the independent living environment.
The proposed rules seek to expand RN delegation of medication administration
when the independently living client is stable, predictable, and able to participate
in the management of the delegated task. The proposed rules expand delegated
medication administration when appropriate to include inhalation therapy for
prophylaxis/maintenance, unit dose medications and the administration of subcutaneous
injectable insulin.
At the January 20, 2000 Board meeting the BNE voted to repeal current Chapter
218 and authorized BNE staff to proposed new Chapter 218 for a comment period
of 30 days. Further, if no comments are received following the 30 day comment
period, the staff is authorized to submit the adoption of new Chapter 218
indicating that the Board has determined that the reasons for adopting the
chapter continue to exist.
Katherine A. Thomas, RN, MN, Executive Director, has determined that for
the first five-year period the sections are in effect there will be no fiscal
implications for state or local government as a result of enforcing or administering
the sections.
Katherine A. Thomas, RN, MN has determined that for each year of the first
five years the sections are in effect the public benefit will be an enhance
nursing practice in the areas identified by the sections without economic
costs or local employment impact. There is no effect on local government,
nor businesses to comply with the rule.
Questions about the content of this proposed rule may be directed to Kim
Flores at (512) 305-6841 at the BNE office. Written comments on the proposal
may be submitted to Ms. Flores, Nursing Consultant- Practice, Texas Board
of Nurse Examiners, P.O. Box 430, Austin, Texas, 78767-0430.
The new rules are proposed under the Nursing Practice Act, Texas
Occupations Code §301.151, which provides the Board of Nurse Examiners
with authority and power to make and enforce all rules and regulations necessary
for the performance of its duties.
There are no other rules, codes, or statutes that will be affected by this
proposal.
§218.1.Purpose.
The Texas Board of Nurse Examiners (BNE or Board) recognizes that changes
in health care delivery have and will continue to influence the way nursing
care is delivered. The Board believes that the registered nurse (RN) is in
a unique position to develop and implement a nursing plan of care that incorporates
a professional relationship between the RN and the client. The Board recognizes
that the RN's responsibility may vary from that of the nurse providing care
at the bedside of an acutely ill client to managing health care delivery in
institutional and community settings. Assessment of the nursing needs of the
client, the plan of nursing actions, implementation of the plan, and evaluation
are essential components of professional nursing practice and are the responsibilities
of the RN. The full utilization of the services of a RN may require delegation
of selected nursing tasks to unlicensed personnel. The scope of delegation
and the level of supervision by the RN may vary depending on the setting,
the complexity of the task, the skills and experience of the unlicensed person,
the client's physical and mental status, and the client's ability and willingness
to be involved in the management of his/her own care. The following sections
govern the RN in delegating nursing tasks to unlicensed personnel across a
variety of settings where nursing care services are delivered.
§218.2.Definitions.
The following words and terms, when used in this chapter, shall have
the following meanings, unless the context clearly indicates otherwise. Additional
definitions which are exclusively related to the delegation of tasks for clients
in independent living environments with stable and predictable health care
needs who participate in the management of the delegated task may be found
in §218.8 of this title (relating to Delegation of Tasks for the Client
in Independent Living Environments with Stable and Predictable Health Care
Needs Who Participate in the Management of Delegated Tasks).
(1)
Activities of daily living--Limited to the following activities:
bathing, dressing, grooming, routine hair and skin care, meal preparation,
feeding, exercising, toileting, transfer/ambulation and assistance with self
administered medications.
(2)
Client--Refers to the individual and/or his/her family
or significant others.
(3)
Delegation--Authorizing an unlicensed person to provide
nursing services while retaining accountability for the outcome. It does not
include situations in which an unlicensed person is directly assisting a RN
by carrying out nursing tasks in the presence of a RN.
(4)
Unlicensed person--An individual, not licensed as
a health care provider, who is monetarily compensated to provide certain health
related tasks and functions in a complementary or assistive role to the RN
in providing direct client care or carrying out common nursing functions.
The term includes, but is not limited to, nurse aides, orderlies, assistants,
attendants, technicians, home health aides, medication aides permitted by
a state agency, and other individuals providing personal care/assistance of
health related services.
§218.3.RN Accountability for Delegated Tasks.
(a)
The RN is accountable for tasks delegated to unlicensed
persons.
(b)
Licensure accountability is met when the delegating RN
has complied with and can verify compliance with §§218.5, 218.7(2)
and 218.8 of this title (relating to General Criteria for Delegation; Delegation
of Specific Task; and Delegation of Tasks for the Client in Independent Living
Environments with Stable and Predictable Health Care Needs Who Participate
in the Management of Delegated Tasks) as appropriate.
§218.4.Application of Chapter.
This chapter does not apply to RNs who:
(1)
supervise or instruct others in the gratuitous nursing
care of the sick;
(2)
are qualified nursing faculty or preceptors directly
supervising or instructing nursing students in the performance of nursing
tasks while enrolled in accredited nursing programs;
(3)
instruct and/or supervise an unlicensed person in
the proper performance of nursing tasks as a part of an education course designed
to prepare persons to obtain a state license, certificate or permit that authorizes
the person to perform such tasks;
(4)
practice in situations in which the unlicensed person
is directly assisting the RN by carrying out nursing tasks in the RN's presence;
and
(5)
assign tasks to or supervise LVNs or other licensed
practitioners practicing within the scope of their license.
§218.5.General Criteria for Delegation.
The following standards must be met before the RN delegates nursing
tasks to unlicensed persons. These criteria apply to all instances of RN delegation.
Additional criteria, if appropriate to the particular task being delegated,
may also be found in §218.7(2) and §218.8 of this title (relating
to Delegation of Specific Task and Delegation of Tasks for the Client in Independent
Living Environments with Stable and Predictable Health Care Needs Who Participate
in the Management of Delegated Tasks).
(1)
The RN must make an assessment of the client's nursing
care needs. The RN should, when the client's status allows, consult with the
client, and when appropriate the client's family and/or significant other(s),
to identify the client's nursing needs prior to delegating nursing tasks.
(2)
The nursing task must be one that a reasonable and
prudent RN would find is within the scope of sound nursing judgment to delegate.
The RN should consider the five rights of delegation: the right task, the
right person to whom the delegation is made, the right circumstances, the
right direction and communication by the RN, and the right supervision as
determined by the RN.
(3)
The nursing task must be one that, in the opinion
of the delegating RN, can be properly and safely performed by the unlicensed
person involved without jeopardizing the client's welfare.
(4)
The nursing task must not require the unlicensed person
to exercise nursing judgment or intervention except in emergency situations.
(5)
The unlicensed person to whom the nursing task is
delegated must be adequately identified. The identification may be by individual
or, if appropriate, by training, education, and/or certification/permit of
the unlicensed person.
(6)
The RN shall have either instructed the unlicensed
person in the delegated task or verified the unlicensed person's competency
to perform the nursing task. The verification of competence may be done by
the RN making the decision to delegate or, if appropriate, by training, education,
experience and/or certification/permit of the unlicensed person.
(7)
The RN shall adequately supervise the performance
of the delegated nursing task in accordance with the requirements of §218.6
of this title (relating to Supervision).
(8)
If the delegation continues over time, the RN shall
periodically evaluate the delegation of tasks and shall incorporate this evaluation
into the client's Plan of Care.
§218.6.Supervision.
The registered professional nurse shall provide supervision of all
nursing tasks delegated to unlicensed persons in accordance with the following
conditions. These supervision criteria apply to all instances of RN delegation.
Additional criteria, if appropriate to the particular task being delegated
may be found in §218.7(2) and §218.8 of this title (relating to
Delegation of Specific Task and Delegation of Tasks for the Client in Independent
Living Environments with Stable and Predictable Health Care Needs Who Participate
in the Management of Delegated Tasks).
(1)
The degree of supervision required shall be determined
by the RN after an evaluation of appropriate factors involved including, but
not limited to, the following:
(A)
the stability of the status of the client;
(B)
the training, experience and capability of the unlicensed
person to whom the nursing task is delegated;
(C)
the nature of the nursing task being delegated; and
(D)
the proximity and availability of the RN to the unlicensed
person when the nursing task will be performed.
(2)
The RN or another equally qualified RN shall
be available in person or by telecommunications, and shall make decisions
about appropriate levels of supervision using the following examples as guidelines:
(A)
In situations where the RN's regularly scheduled presence
is required to provide nursing services, including assessment, planning, intervention
and evaluation of the client whose health status is changing and/or to evaluate
the client's health status, the RN must be readily available to supervise
the unlicensed person in the performance of delegated tasks. Settings include,
but are not limited to acute care, long term care, rehabilitation centers
and/or clinics providing public health services.
(B)
In situations where nursing care is provided in the client's
residence but the client's status is unstable and unpredictable and the RN
is required to assess, plan, intervene and evaluate the client's unstable
and unpredictable status and need for skilled nursing services, the RN shall
make supervisory visits at least every fourteen calendar days. The RN shall
assess the relationship between the unlicensed person and the client to determine
whether health care goals are being met. Settings include, but are not limited
to group homes, foster homes and/or the client's residence.
§218.7.Delegation of Specific Tasks.
The tasks which follow apply to RN delegation in all settings. Additional
tasks which may be delegated for the client in independent living environments
with stable and predictable health care needs who participate in the management
of delegated tasks may be found in §218.8 of this title (relating to
Delegation of Tasks for the Client in Independent Living Environments with
Stable and Predictable Health Care Needs Who Participate in the Management
of Delegated Tasks).
(1)
Tasks Which are Most Commonly Delegated. By way of example,
and not in limitation, the following nursing tasks are ones that are most
commonly the type of tasks within the scope of sound professional nursing
practice to be considered for delegation, regardless of the setting, provided
the delegation is in compliance with §218.5 of this title (relating to
General Criteria for Delegation) and the level of supervision required is
determined by the RN in accordance with §218.6 of this title (relating
to Supervision):
(A)
non-invasive and non-sterile treatments;
(B)
the collecting, reporting, and documentation of data including,
but not limited to:
(i)
vital signs, height, weight, intake and output, capillary
blood and urine test for sugar and hematest results;
(ii)
environmental situations;
(iii)
client or family comments relating to the client's care;
and
(iv)
behaviors related to the plan of care;
(C)
ambulation, positioning, and turning;
(D)
transportation of the client within a facility;
(E)
personal hygiene and elimination, including vaginal irrigations
and cleansing enemas;
(F)
feeding, cutting up of food, or placing of meal trays;
(G)
socialization activities;
(H)
activities of daily living; and
(I)
reinforcement of health teaching planned and/or provided
by the registered nurse.
(2)
Discretionary Delegation Tasks.
(A)
In addition to General Criteria for Delegation outlined
in §218.5 of this title, the nursing tasks in subparagraph (B) of this
paragraph may be delegated to an unlicensed person only:
(i)
if the RN delegating the task is directly responsible for
the nursing care given to the client;
(ii)
if the agency, facility, or institution employing unlicensed
personnel follows a current protocol for the instruction and training of unlicensed
personnel performing nursing tasks under this subsection and that said protocol
is developed with input by registered nurses currently employed in the facility
and includes:
(I)
the manner in which the instruction addresses the complexity
of the delegated task;
(II)
the manner in which the unlicensed person demonstrates
competency of the delegated task;
(III)
the mechanism for reevaluation of the competency; and
(IV)
an established mechanism for identifying those individuals
to whom nursing tasks under this subsection may be delegated; and
(iii)
if the protocol recognizes that the final decision as
to what nursing tasks can be safely delegated in any specific situation is
within the specific scope of the RN's professional judgment.
(B)
the following are nursing tasks that are not usually within
the scope of sound professional nursing judgment to delegate and may be delegated
only in accordance with, §218.5 of this title and subparagraph (A) of
this paragraph. Treatments which include:
(i)
sterile procedures--those procedures involving a wound
or an anatomical site which could potentially become infected;
(ii)
non-sterile procedures--such as dressing or cleansing
penetrating wounds and deep burns;
(iii)
invasive procedures--inserting tubes in a body cavity
or instilling or inserting substances into an indwelling tube, unless allowed
in this paragraph, paragraph (1) of this section, §218.8(f) of this title.
(iv)
care of broken skin other than minor abrasions or cuts
generally classified as requiring only first aid treatment;
(3)
Nursing Tasks That May Not Be Delegated.
By way of example, and not in limitation, the following are nursing tasks
that are not within the scope of sound professional nursing judgment to delegate:
(A)
physical, psychological, and social assessment which requires
professional nursing judgment, intervention, referral, or follow-up;
(B)
formulation of the nursing care plan and evaluation of
the client's response to the care rendered;
(C)
specific tasks involved in the implementation of the care
plan which require professional nursing judgment or intervention;
(D)
the responsibility and accountability for client health
teaching and health counseling which promotes client education and involves
the client's significant others in accomplishing health goals; and
(E)
administration of medications, except as permitted by §218.8(f)
of this title and §218.9 of this title (relating to Administration of
Medications).
§218.8.Delegation of Tasks for the Client in Independent Living Environments with Stable and Predictable Health Care Needs Who Participate in the Management of Delegated Tasks.
(a)
Purpose.
(1)
The Texas Board of Nurse Examiners recognizes that public
preference in the provision of health care services includes a greater opportunity
for clients to share with the RN in choice and control for delivery of services
in the community based setting. The Board believes that it is essential that
the registered nurse who works with the client in an independent living environment
with stable and predictable health care needs, and the ability to participate
in the management of the delegated task understand the delegation rules. The
RN shall work with the client in his/her pursuit of independent living and
shall include the client in the management of the client's needs and support
the client and family throughout their experience in the health care system.
(2)
In addition to the General Criteria for Delegation
in §218.5, in situations involving clients with stable and predictable
health care needs, the RN, with the client shall: verify the training, experience
and competency of the unlicensed person to whom the delegation is made; verify
the client's ability and willingness to participate in his/her own health
care; provide communication and direction for the safe completion of any delegated
task; and supervise the unlicensed person's performance of the task.
(b)
Definitions Related to the Client with Stable and Predictable
Health Care Needs:
(1)
"Administration of Medications"--Removal of an individual/unit
dose from a previously dispensed, properly labeled container; verifying it
with the medication order; giving the correct medication and the correct dose
to the proper client at the proper time by the proper route; and promptly
recording the time and dose given.
(2)
"Client"--Refers to the individual and/or his/her
family or significant others.
(3)
"Ability to participate in the delegation decision"--the
ability and willingness to participate in one's own health care.
(4)
"Independent living environment"--A client's individual
residence which may include a home or homelike setting such as the client's
home, a group home, foster home, or assisted living facility and includes
where the client works, attends school, or engages in other community activities.
(5)
"Stable and predictable"--A situation where the client's
clinical and behavioral status is determined to be non-fluctuating and consistent.
A stable/predictable condition involves long term health care needs which
are not recuperative in nature and do not require the regularly scheduled
presence of a registered nurse or licensed vocational nurse. Excluded by this
definition are situations where the client's clinical and behavioral status
is expected to change rapidly or in need of the continuous/continual assessment
and evaluation of a registered nurse or licensed vocational nurse.
(c)
Application of this Section.
(1)
Applies to situations meeting the following criteria:
(A)
The client resides in a home or homelike setting such as
the client's home, a group home, foster home, or assisted living facility
and includes where the client works, attends school, or engages in other community
activities;
(B)
The client has the ability to participate in the delegation
decision, is able and willing to participate in the management and direction
of the delegated task with minimal nursing supervision. This shall be ascertained
in light of the overall situation of the client based on assessment of factors
set out in subsection (d)(2) of this section.
(C)
The health condition relative to which the task is being
performed is a stable, predictable condition requiring minimal nursing supervision.
(2)
Applies to in-home hospice care;
(3)
Does not apply to settings where:
(A)
laws or administrative rules governing licensing of the
setting require the regularly scheduled presence of a registered nurse or
licensed vocational nurse; or
(B)
nursing services are continuously provided such as in an
acute care facility, long term care facility, rehabilitation center or clinic.
(d)
Criteria for Delegation Under this Section. A RN delegating
tasks under this section must meet the following criteria:
(1)
Comply with §218.5 and §218.7(2) of this title
(relating to General Criteria for Delegation and Delegation of Specific Tasks)
and in addition:
(2)
Assess the situation with the client to determine:
(A)
the client's ability to participate in the delegation decision
and ability and willingness to participate in the management and direction
of the delegated task with minimal nursing supervision.
(B)
the adequacy and reliability of support systems available
to the client;
(C)
the stability and predictability of the client's health
status relative to which delegation occurs;
(D)
the client's knowledge base about his/her health status
and the delegated task;
(E)
the client's ability to communicate with the unlicensed
person in traditional or non-traditional ways;
(F)
how frequently the client's status shall be reassessed
to determine that delegation continues to be appropriate;
(G)
the unlicensed person's ability to recognize and inform
the RN of data on client changes related to the delegated task; and
(H)
the experience and competency of the unlicensed person
to perform the delegated task.
(3)
The RN determines the need for supervisory visits
in consultation with the client and, when appropriate, family and/or significant
other(s) as necessary to assure that safe and effective services are being
provided.
(e)
Additional Delegable Tasks Under this Section: In accordance
with this section, in addition to those identified in §218.7 of this
title, include:
(1)
medication administration in compliance with subsection
(f) of this section;
(2)
assistance with feeding is broadened to include tube
feeding through permanently placed feeding tubes;
(3)
assistance with elimination is broadened to include
intermittent catheterization, digital stimulation associated with a bowel
program, tasks related to external stoma care including but not limited to
pouch changes, measuring I & O, and skin care surrounding the stoma area;
and
(4)
assistance with other activities necessary to maintain
the independence of the client such as maintenance of skin integrity and mobility.
(f)
Administration of Medications for the Client in Independent
Living Environments with Stable and Predictable Health Care Needs Who Participate
in the Management of Delegated Tasks.
(1)
In independent living environments where the client's clinical
and behavioral status is stable and predictable, does not require the regular
presence and assessment, intervention and evaluation by a RN, and the client
has expressed his/her ability and willingness to participate in the management
of his/her care, including in-home hospice settings where the client's deteriorating
condition is predictable, the RN may delegate the administration of medications.
The delegation may only occur after the RN has trained or verified the training
and/or experience of the unlicensed person to administer the medication. The
administration of medications may be delegated only in accordance with this
section.
(A)
The RN may delegate medications which are administered
orally or via permanently placed feeding tubes, sublingually, or topically.
These include eye, ear and nose drops and vaginal or rectal suppositories,
and unit dose medication administration by way of inhalation for prophylaxis
and/or maintenance.
(B)
The RN may delegate the administration of oral unit dose
medications from the client's daily reminder pill container under the following
conditions:
(i)
The client meets all requirements for delegation of medication
administration as specified in this paragraph;
(ii)
The RN has placed the unit dose medication(s) from the
properly dispensed prescription bottle into the client's daily reminder pill
container;
(iii)
The client and the unlicensed person involved in such
delegation activity have been instructed by the RN about each medication placed
in such a container with regard to distinguishing characteristics of each
medication, proper time, dose, route and adverse effects which may be associated
with the medication;
(iv)
The RN shall provide to the client and to the unlicensed
person(s) instructions to contact the RN involved with the delegation before
the medication is administered in instances in which there are questions concerning
the medications or changes in the client's status related to the medication
being given. Examples of situations which would be brought to the attention
of the RN include but are not limited to instances in which the medications
appear to be rearranged or missing;
(v)
The RN shall make supervisory visits in the event there
are changes in the client's status related to the medication being given and
at least every fourteen calendar days to the client's location to evaluate
the proper and safe medication administration from the client's daily reminder
pill container; and
(vi)
The registered nurse shall obtain in writing the client's
agreement to have a properly trained unlicensed person which the RN has determined
is competent to perform the administration of medications from the client's
daily reminder pill container.
(C)
The RN may delegate the administration of subcutaneous
injectable insulin under the following conditions:
(i)
The client meets all requirements for delegation of medication
administration as specified in subparagraph (A) of this paragraph;
(ii)
A registered nurse is available on call for consultation/intervention
24 hours each day;
(iii)
The registered nurse must provide teaching of all aspects
of subcutaneous injectable insulin to the client and the unlicensed person
to include, but not limited to proper technique for determination of the client's
blood sugar prior to each subcutaneous injection of insulin, proper injection
technique, risks, side effects and the correct response(s). The RN must leave
written instructions for the performance of the administration of subcutaneous
injectable insulin, including a copy of the protocol as ordered by the physician,
for the unlicensed person to use as a reference;
(iv)
The registered nurse must delegate the administration
of subcutaneous injectable insulin to an unlicensed person, specific to one
client. The RN must teach that the administration of subcutaneous injectable
insulin is to be performed only for the patient for whom the instructions
are provided;
(v)
The registered nurse may delegate the administration of
subcutaneous injectable insulin to additional unlicensed persons providing
care to the specific client provided the registered nurse limits the number
of unlicensed persons to the number who will remain proficient in performing
the task and can be safely supervised by the registered nurse;
(vi)
The registered nurse shall instruct the unlicensed person
that the task is client specific and not transferable to other clients or
providers;
(vii)
The registered nurse shall make supervisory visits in
the event there are changes in the client's status and at least every fourteen
calendar days to the client's location to evaluate the proper and safe medication
administration of subcutaneous injectable insulin by the unlicensed person(s);
and
(viii)
The registered nurse shall obtain in writing the client's
agreement to have a properly trained unlicensed person which the RN has determined
is competent to perform the administration of subcutaneous injectable insulin.
(2)
A RN shall not delegate the following tasks
to any medication provider:
(A)
calculation of any medication doses except for measuring
a prescribed amount of liquid medication and breaking a tablet for administration,
provided the RN has calculated the dose;
(B)
administration of the initial dose of a medication that
has not been previously administered to the client;
(C)
administration of medications by an injectable route except
as described for SQ insulin in paragraph (1)(C) of this subsection;
(D)
administration of medications by way of a tube inserted
in a cavity of the body except as stated in this subsection;
(E)
responsibility for receiving verbal or telephone orders
from a physician, dentist, or podiatrist; and
(F)
responsibility for ordering a client's medication from
the pharmacy.
§218.9.The Medication Aide Permit Holder.
(a)
A RN may delegate the administration of medication to clients
in long term care facilities and home health agencies to medication aides
if:
(1)
the medication aide holds a valid permit issued by the
appropriate state agency to administer medications in that facility or agency;
(2)
the RN assures that the medication aide functions
in compliance with the laws and regulations of the agency issuing the permit;
(3)
the route of administration is oral, via a permanently
placed feeding tube, sublingual or topical including eye, ear or nose drops
and vaginal or rectal suppositories.
(b)
The following tasks may not be delegated to the Medication
Aide Permit Holder:
(1)
calculation of any medication doses except for measuring
a prescribed amount of liquid medication and breaking a tablet for administration,
provided the RN has calculated the dose;
(2)
administration of the initial dose of a medication
that has not been previously administered to the client;
(3)
administration of medications by an injectable route
(other than allowed by § 218.8(f) of this title (relating to Delegation
of Tasks for the Client in Independent Living Environments with Stable and
Predictable Health Care Needs Who Participate in the Management of Delegated
Tasks);
(4)
administration of medications used for intermittent
positive pressure breathing or other methods involving medication inhalation
treatments (other than allowed by §218.8(f)(1)(A) of this title);
(5)
administration of medications by way of a tube inserted
in a cavity of the body except as stated in §218.8(f) of this title;
(6)
responsibility for receiving verbal or telephone orders
from a physician, dentist, or podiatrist; and
(7)
responsibility for ordering a client's medication
from the pharmacy;
§218.10.Supervising Unlicensed Personnel Performing Tasks Delegated by Other Practitioners.
(a)
If a registered professional nurse practices in a collegial
relationship with another licensed practitioner who has delegated tasks to
an unlicensed person over whom the RN has supervisory responsibilities, the
RN's licensure accountability is met if the RN:
(1)
verifies the training of the unlicensed person; and
(2)
verifies that the unlicensed person can properly and
adequately perform the delegated task without jeopardizing the client's welfare.
(b)
If the RN cannot verify the unlicensed person's capability
to perform the delegated task, the RN must communicate this fact to the licensee
who delegated the task as the delegating licensee retains accountability for
the task being performed by the unlicensed person.
§218.11.Nursing Students Working as Unlicensed Personnel.
Certain nursing tasks may be delegated to professional nursing students
working as unlicensed personnel in agencies, facilities, or institutions provided
the students are currently enrolled in accredited professional nursing programs
or are on semester breaks from such programs, and that the student has demonstrated
a satisfactory level of performance of the task(s) which will be delegated.
This delegation must be consistent with §218.7(1) and (2) of this title
(relating to Delegation of Specific Tasks). Section 218.7(3) of this title
which prohibits delegation of certain tasks also applies to nursing students
working as unlicensed personnel.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State, on February 7, 2000.
TRD-200000928
Katherine A. Thomas, MN, RN
Executive Director
Board of Nurse Examiners
Earliest possible date of adoption: March 19, 2000
For further information, please call: (512) 305-6811
22 TAC §§221.1 - 221.14
(Editor's note: The text of the following sections proposed for
repeal will not be published. The sections may be examined in the offices
of the Board of Nurse Examiners or in the Texas Register office, Room 245,
James Earl Rudder Building, 1019 Brazos Street, Austin.)
The Board of Nurse Examiners proposes the repeal §§221.1-221.14,
concerning Definitions; Titles; Education; Requirements for Initial Authorization
to Practice; Petitions for Waiver; Interim Approval; New Graduates; Maintaining
Authorization as an Advanced Practice Nurse; Inactive Status; Reinstatement
or Reactivation of Advanced Practice Nurse Status; Identification; Functions;
Scope of Practice; and Enforcement. At the October 1999 meeting of the Board
of Nurse Examiners, board members were briefed on the requirements of TX76RSB1340
which amended the Nursing Practice Act by adding Article 4527(e) regarding
the adoption of rules that regulate the provision of anesthesia services in
outpatient settings by persons licensed by the board. At that time, the Board
adopted a new version of Chapter 221 on an emergency basis. This allowed the
Board to be in compliance with the legislative mandate to have rules in effect
by January 7, 2000 and allowed for resolution of conflicts between the Board
of Medical Examiners and the Board of Nurse Examiners rules before rules are
permanently adopted. Most of Chapter 221 remains unchanged from the emergency
rules which were published in the November 19, 1999 issue of the
Texas Register
(24 TexReg 10255) and which took effect November 28,
1999. Amendments were made to §221.14(b)(2), (c)(6)(C) and (D) to further
refine the rules and provide greater clarity in instances where the rules
may appear vague. The new rules were published as proposed in the February
4, 2000 issue of the
Texas Register
(25 TexReg
663).
The repeal will coincide with the adoption of new sections published as
proposed in the February 4, 2000 issue of the
Texas
Register
, the notice of repeal was inadvertently omitted in the February
4, 2000 notice.
Katherine A. Thomas, MN, RN, Executive Director, has determined that there
will be no fiscal implications for the state or local government as a result
of enforcing or administering the rule.
Written comments on the proposed repeal may be submitted to Katherine A.
Thomas, Board of Nurse Examiners, Post Office Box 430; Austin, Texas 78767-0430.
The repeal is proposed under the Nursing Practice Act, Texas
Occupations Code, Section 301.151, which provides the Board of Nurse Examiners
with the authority and power to make and enforce all rules and regulations
necessary for the performance of its duties and conducting of proceedings
before it.
There are no other rules, codes, or statutes that will be effected by this
proposal.
§221.1.Definitions.
§221.2.Titles.
§221.3.Education.
§221.4.Requirements for Initial Authorization to Practice.
§221.5.Petitions for Waiver.
§221.6.Interim Approval.
§221.7.New Graduates.
§221.8.Maintaining Authorization as an Advanced Practice Nurse.
§221.9.Inactive Status.
§221.10.Reinstatement or Reactivation of Advanced Practice Nurse Status.
§221.11.Identification.
§221.12.Functions.
§221.13.Scope of Practice.
§221.14.Enforcement.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of
the Secretary of State, on February 9, 2000.
TRD-200001001
Katherine A. Thomas, MN, RN
Executive Director
Board of Nurse Examiners
Earliest possible date of adoption: March 19, 2000
For further information, please call: (512) 305-6816
Chapter 501.
PROFESSIONAL CONDUCT
Subchapter A. GENERAL PROVISIONS
22 TAC §501.52
The Texas State Board of Public Accountancy (Board) proposes
new §501.52 concerning Definitions. This new rule is the result of the
Rule Review required by Rider 167 of the General Appropriations Act of 1997.
The new §501.52 will allow unnecessary definitions from old §501.2
to be eliminated, grammatical changes to be made to existing definitions,
a technically correct definition of "financial statement" consistent with
those set by accounting standard setting bodies, and the rest of the definitions
to be transferred from old §501.2.
William Treacy, Executive Director of the Board, has determined that for
the first five-year period the proposed new rule will be in effect:
A. the additional estimated cost to the state expected as a result of enforcing
or administering the rule will be none in that the Rule is only being relocated,
unnecessary definitions are being deleted, and grammatical changes are being
made;
B. the estimated reductions in costs to the state and to local governments
as a result of enforcing or administering the rule will be none in that the
Rule is only being relocated, unnecessary definitions are being deleted, and
grammatical changes are being made;
C. the estimated loss or increase in revenue to the state as a result of
enforcing or administering the rule will be none in that the Rule is only
being relocated, unnecessary definitions are being deleted, and grammatical
changes are being made.
Mr. Treacy has determined that for the first five-year period the rule
is in effect the public benefits expected as a result of adoption of the proposed
new rule will be that an accurate list of definitions will be used in the
Rules of Professional Conduct.
The probable economic cost to persons required to comply with the rule
will be none in that the Rule is only being relocated, unnecessary definitions
are being deleted, and grammatical changes are being made.
Mr. Treacy has determined that a Local Employment Impact Statement is not
required because the proposed new rule will not affect a local economy.
The Board requests comments on the substance and effect of the proposed
amendment from any interested person. Comments must be received at the Board
no later than noon on March 19, 2000. Comments should be addressed to Amanda
G. Birrell, General Counsel, Texas State Board of Public Accountancy, 333
Guadalupe, Tower III, Suite 900, Austin, Texas 78701 or faxed to her attention
at (512) 305-7854.
Mr. Treacy has determined that the proposed rule will not have an adverse
economic effect on small businesses because the Rule is only being relocated,
unnecessary definitions are being deleted, and grammatical changes are being
made.
The Board specifically invites comments from the public on the issues of
whether or not the proposed rule will have an adverse economic effect on small
business; if the rule is believed to have such an effect, then how may the
Board legally and feasibly reduce that effect considering the purpose of the
statute under which the rule is to be adopted; and if the rule is believed
to have such an effect, how the cost of compliance for a small business compares
with the cost of compliance for the largest business affected by the rule
under any of the following standards: (a) cost per employee; (b) cost for
each hour of labor; or (c) cost for each $100 of sales. See Texas Government
Code, §2006.002(c).
The new rule is proposed under the Public Accountancy Act, Tex.
Occupations Code, §901.151 (Vernon 1999) which authorizes the Board to
adopt rules deemed necessary or advisable to effectuate the Act.
No other article, statute or code is affected by this proposed new rule.
§501.52.Definitions.
The following words and terms, when used in this chapter, shall have
the following meanings, unless the context clearly indicates otherwise. The
masculine shall be construed to include the feminine or neuter and vice versa,
and the singular shall be construed to include the plural and vice versa.
(1)
Act--The Public Accountancy Act, Chapter 901, Occupations
Code (Vernon's 1999).
(2)
Advertisement--A message which is transmitted to persons
by, or at the direction of, a certificate or registration holder and which
has reference to the availability of the certificate or license holder to
perform professional services.
(3)
Board--The Texas State Board of Public Accountancy.
(4)
Certificate or registration holder--The holders of
all currently valid:
(A)
certificates issued to individuals who have been awarded
the designation certified public accountant by the board pursuant to the Act,
or pursuant to corresponding provisions of a prior Act; and
(B)
registrations with the board for the practice of public
accounting in this state.
(5)
Charitable organization--An organization which
has been granted tax-exempt status under the Internal Revenue Code of 1986, §501(c),
as amended.
(6)
Client-
(A)
The person or entity which retains a certificate or registration
holder for the performance of professional services regardless of the fee
arrangement;
(B)
any person or entity upon whose financial statements the
certificate or registration holder is retained to report or opine, whether
or not this is the same person or entity which retains the certificate or
registration holder.
(7)
Commission--Compensation for recommending or
referring any product or service to be supplied by another person.
(8)
Contingent fee--A fee for any service where no fee
will be charged unless a specified finding or result is attained, or in which
the amount of the fee is otherwise dependent upon the finding or result of
such service. However, a certificate or registration holder's non-contingent
fees may vary depending, for example, on the complexity of the services rendered.
Fees are not contingent if they are fixed by courts or governmental entities
acting in a judicial or regulatory capacity, or in tax matters if determined
based on the results of judicial proceedings or the findings of governmental
agencies acting in a judicial or regulatory capacity, or if there is a reasonable
expectation of substantive review by a taxing authority.
(9)
Financial statements-A presentation of financial data,
including accompanying notes, derived from accounting records and intended
to communicate an entity's economic resources or obligations at a point in
time, or the changes therein for a period of time, in accordance with generally
accepted accounting principles or a comprehensive basis of accounting other
than generally accepted accounting principles. Incidental financial data to
support recommendations to a client or in documents for which the reporting
is governed by Statements on Standards for Attestation Engagements and tax
returns and supporting schedules do not constitute financial statements for
the purposes of this definition.
(10)
Firm--A proprietorship, partnership, or professional
or other corporation, or other business engaged in the practice of public
accountancy.
(11)
Good standing--Compliance by a certificate or registration
holder with the board's licensing rules, including the mandatory continuing
education requirements and payment of the annual license fee, and any penalties
and other costs attached thereto. In the case of board-imposed disciplinary
or administrative sanctions, the certificate or registration holder must be
in compliance with all the provisions of the board order to be considered
in good standing.
(12)
Licensee--The holder of a license issued by the board
to a certificate or registration holder pursuant to the Act, or pursuant to
provisions of a prior act.
(13)
Person--An individual, partnership, corporation,
registered limited liability partnership, or limited liability company.
(14)
Practice of public accountancy--The practice of public
accountancy includes the client practice of public accountancy and the industry
or government practice of public accountancy.
(A)
Client Practice. Client practice of public accountancy
is the offer to perform or the performance by a certificate or registration
holder for a client or a potential client of a service involving the use of
accounting, attesting, or auditing skills. The phrase "service involving the
use of accounting, attesting, or auditing skills" includes:
(i)
the issuance of reports on, or the preparation of, financial
statements, including historical or prospective financial statements or any
element thereof;
(ii)
the furnishing of management or financial advisory or
consulting services;
(iii)
the preparation of tax returns or the furnishing of advice
or consultation on tax matters;
(iv)
the advice or recommendations in connection with the sale
or offer for sale of products (including the design and implementation of
computer software), when the advice or recommendations routinely require or
imply the possession of accounting or auditing skills or expert knowledge
in auditing or accounting; and/or
(v)
litigation support services.
(B)
Industry or government practice. Industry or government
practice of public accountancy is:
(i)
the preparation of, or reporting on, financial statements
(including historical or prospective financial statements or any element thereof)
by an individual licensed under the Act, of the individual's employer or an
entity affiliated with the employer, when the financial statement or report
is to be used by an investor, a third party, or a financial institution;
(ii)
the preparation of a tax return of the individual's employer
or an entity affiliated with the employer, if the tax return is filed with
a taxing authority; or
(iii)
the supervision of those activities described in clauses
(i) and (ii) of this subparagraph.
(C)
A certificate or registration holder not engaged or employed
to any extent in either the client practice of public accountancy or the industry
or government practice of public accountancy is not engaged in the practice
of public accountancy. Furthermore, the preparation of reports exclusively
for internal use by the management and/or board of directors of the individual's
employer or an entity affiliated with the employer are not the practice of
public accountancy.
(D)
For purposes of this section, an entity shall be deemed
"affiliated with" a licensee's employer only if, and so long as, the employer
(directly or indirectly through another entity affiliated with the employer)
possesses the power to direct the management of the entity through ownership
of a majority of the voting securities or other applicable voting equity interests
of the entity.
(15)
Practice unit--An office of a firm required
to be registered with the board for the purpose of practicing public accountancy.
(16)
Professional services--Any services performed or
offered to be performed in the course of the practice of public accountancy.
(17)
Report--When used with reference to financial statements,
means either an engagement performed through the application of procedures
under the Statement on Standards for Accounting and Review Services or any
opinion, report, or other form of language that states or implies assurance
as to the reliability of any financial statements and/or includes or is accompanied
by any statement or implication that the person or firm issuing it has special
knowledge or competence in accounting or auditing. Such a statement or implication
of special knowledge or competence may arise from use by the issuer of the
report of names or titles indicating that he or it is an accountant or auditor
or from the language of the report itself. The term "report" includes any
form of language which disclaims an opinion when such form of language is
conventionally understood to imply any assurance as to the reliability of
the financial statements to which reference is made and/or special competence
on the part of the person or firm issuing such language; and it includes any
form of language conventionally used with respect to a compilation or review
of financial statements, and any other form of language that implies such
special knowledge or competence.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of
the Secretary of State on February 4, 2000.
TRD-200000780
William Treacy
Executive Director
Texas State Board of Public Accountancy
Earliest possible date of adoption: March 19, 2000
For further information, please call: (512) 305-7848
22 TAC §507.6
The Texas State Board of Public Accountancy (Board) proposes
new §507.6 concerning Employee Training and Education Assistance Program.
Proposed new §507.6 will allow the Board to have a policy on providing
assistance for education and training for an employee under certain conditions.
William Treacy, Executive Director of the Board, has determined that for
the first five-year period the proposed new rule will be in effect:
A. The additional estimated cost to the state and to local governments
expected as a result of enforcing or administering the new rule will be zero
for local governments because the rule only affects the Board. The Board has
no historical data on costs to the state but the rule has a maximum of $1,200.00
per year.
B. The estimated reduction in costs to the state and to local governments
as a result of enforcing or administering the new rule will be zero for local
governments because the rule only affects the Board. There will be no reduction
in costs to the state.
C. the estimated loss or increase in revenue to the state or to local governments
as a result of enforcing or administering the new rule will be zero for local
governments because the rule only affects the Board. There will be no affect
on state revenue.
Mr. Treacy has determined that for the first five-year period the new rule
is in effect the public benefits expected as a result of adoption of the proposed
new rule will be that the Board will have rules governing the circumstances
under which the Board will assist its employees' job-related education and
training, which should improve the quality of services offered and performance.
The probable economic cost to persons required to comply with the new rule
will be zero because this rule affects only the Board.
Mr. Treacy has determined that a Local Employment Impact Statement is not
required because the proposed new rule will not affect a local economy.
The Board requests comments on the proposed new rule from any interested
person. Comments must be received at the Board no later than noon on March
17, 2000. Comments should be addressed to Amanda Birrell, General Counsel,
Texas State Board of Public Accountancy, 333 Guadalupe, Tower III, Suite 900,
Austin, Texas 78701 or faxed to her attention at (512) 305-7854.
Mr. Treacy has determined that the proposed new rule will not have an adverse
economic effect on small businesses because the proposed rule is an internal
rule that affects only the Board. The Board specifically invites comments
from the public on the issues of whether or not the proposed new rule will
have an adverse economic effect on small business; if the rule is believed
to have such an effect, then how may the Board legally and feasibly reduce
that effect considering the purpose of the statute under which the rule is
adopted; and if the rule is believed to have such an effect, how the cost
of compliance for a small business compares with the cost of compliance for
the largest business affected by the rule under any of the following standards:
(a) cost per employee; (b) cost for each hour of labor; or (c) cost for each
$100 of sales. See Texas Government Code, §2006.002(c).
The new rule is proposed under the Public Accountancy Act, Tex.
Occupations Code, §901.151 (Vernon 1999) which provides the agency with
the authority to adopt rules deemed necessary or advisable to effectuate the
Act and the State Employees Training Act, §656 of the Government Code.
No other article, statute or code is affected by this proposed new rule.
§507.6.Employee Training and Education Assistance Program.
(a)
Pursuant to the State Employees Training Act, Section 656
of the Government Code, it is the policy and practice of the board to encourage
an employee's professional development through training and education programs.
(b)
The board may provide assistance for education and training
for an employee if the executive director determines that the education or
training will enhance the employee's ability to perform current or prospective
job duties and will benefit both the board and the employee.
(c)
Financial assistance may be awarded for some or all of
the following expenses:
(1)
tuition, including correspondence courses that fulfill
degree, professional or General Equivalence Diploma (GED) program plan requirements;
(2)
degree plan pertinent College Level Equivalency Program
examinations if the employee receives college credit or waiver of course requirements;
(3)
degree plan pertinent Life Experience Assessments
if the employee receives college credit; and
(4)
required fees, including lab fees, and books.
(d)
Financial assistance granted under this program shall not
exceed $1,200 per year per employee.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State on February 4, 2000.
TRD-200000783
William Treacy
Executive Director
Texas State Board of Public Accountancy
Earliest possible date of adoption: March 19, 2000
For further information, please call: (512) 305-7848
Chapter 218.
DELEGATION OF SELECTED NURSING TASKS BY REGISTERED PROFESSIONAL NURSES TO UNLICENSED PERSONNEL
Chapter 221.
ADVANCE PRACTICE NURSES
Part 22.
TEXAS STATE BOARD OF PUBLIC ACCOUNTANCY
Chapter 507.
EMPLOYEES OF THE BOARD