Nurse Delegation Contract Monitoring Chart Audit Page 2
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1
2Client assessment documented at least every 90
days?
If insulin delegated must have four (4) visits
documented seven (7) day intervals
Documentation of how medication(s) verified and
documented (if delegating meds)?
Listing of documented medication on an approved ND
form:
G. Assume / Rescind RN Delegation Duties
WAC 246-840-960(3)
Assumption / rescinding on this client?
Assumption / rescinding date documented?
Case / Resource Manager notified of
assumption/rescinding
H. Billing / Administrative
Provider One Requirements
Records justify time billed on RND tracking form?
Additional units form submitted for units needed >36
or 100 units in the month?
I.
Caregiver Interview: Provide contact information where LTCW or AFH Provider or House Manager can be
reached (for example, Client home)
Has your Registered Nurse Delegator been to the
client’s home within the last 90 days?
Can the Registered Nurse Delegator be reached
easily when there are questions and/or concerns with
the delegated tasks?
REVIEWED BY: PRINTED NAME
TITLE
DATE
Changes are required for all “NO” answers.
RND Response
(RND to sign, date and return with this section completed).
1) Indicate the changes you will incorporate into your future ND practice for all NO answers. Attach additional sheets to
this form when returned. If you already have documents that support changing a NO answer to a YES, please
submit.
RND SIGNATURE
DATE
PRINTED NAME
2) Please mail your response to
Mary
Pasion, (360) 725-3230, at PO Box 45600, Olympia WA 98504-5600.
3) You will receive a final notice within 30 working days that the ND Program Managers have accepted your changes.
ND PM Response to RND
We have reviewed and accepted your changes.
Additional action is necessary, which may include further training, technical assistance or corrective action. The
specific action required is outlined in the attached letter.
NDPM SIGNATURE
DATE
PRINTED NAME
Thank you for your response!
Erika Parada
RN, NDPM, (360) 725-2450
Doris Barret
RN, NDPM, (360) 725-2553
Page 2 of 2
NURSE DELEGATION CONTRACT MONITORING CHART AUDIT
DSHS 10-448 (REV. 12/2015)
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