Nurse Delegation Contract Monitoring Chart Audit
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1
2Nurse Delegation Contract Monitoring Chart Audit
Program Manager Use Only
NAME OF REGISTERED NURSE DELEGATE (RND)
PROVIDER ID NUMBER
CLIENT’S NAME
ND START DATE
D/C OF ND (DATE)
NUMBER OF NA’S
ADULT FAMILY HOME”S NAME
DELEGATED
SUPPORTED LIVING AGENCY’S NAME
TASK(S) DELEGATED
A. Referral Process
Yes
No
N/A
Term Care Manual / Contract
Documentation of how and when referral made?
SOP assessment within 48 hours of referral
B. RND Assessment of Client
WAC 246-840-930(12)(h)(i)(j)
Initial physical / systems assessment documented?
Assessment completed within three working days of
referral
SOP documentation returned in five (5) working days?
C. Delegation Process / Consent
WAC 246-840-930(10)(b)
Evidence of timely consent to delegation process?
Date – verbal:
Date – written:
Evidence of RND communication with collateral
contacts (C/RM/SW, MD, PA, etc.)
WAC 246-840-930(8) and
D. Long Term Care Workers Credentials / Training (Sample)
WAC 246-841-405(2)(a)(d)
Registered Nurse License current and without
restriction?
Certificates, transcripts or Credential and Training
verification form for training?
NA-R’s completed basic caregiver training (FOC,
DOH Web Check
Basic - Core Competency, DDA basic, DDA CORE
DOH Telephone Check
basic, Foster Parent PRIDE)
Completed 9-hour Core Delegation training
Completed 3-hour Special Focus on Diabetes
HomeCare Aide-Certified verified
Exempt Long Term Care Worker verification by letter
of employment, and training
E. Instructions for ND Task
WAC 246-840-930(12)(13)
Instruction for each nursing task?
Specific parameters for giving PRN medication?
Identify S/E unexpected outcomes or changes and
when to notify RND, physician or emergency
services?
WAC 246-840-930(18,19) and
F. Supervision and Client Changes
WAC 246-840-950(1)(a) / Contract
Nurse Visit Form used for 90 day visit documentation
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NURSE DELEGATION CONTRACT MONITORING CHART AUDIT
DSHS 10-448 (REV. 12/2015)
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