1. LVN SCOPE OF PRACTICE
TALA August, 2018 Linda Abel, RN

2. OBJECTIVES Understand the role of the Board of Nursing
Review the LVN Scope of Practice
Differentiate between RN and LVN nursing practice
Review the concerns associated the LVN practice in AL
Consider some models for safe practice by LVNs in AL
Our purpose today is to help clarify the role of the LVN in the assisted living setting. We will review the role of the Board of Nursing and its rules regarding LVN practice. While it is true that assisted living communities are not required to have a nurse, it is also very important to understand that all nurses must comply with the rules of the BON, even when working in a setting that does not require a nurse under the rules governing that setting. In addition, nurses must remember that even if their position in the community is that of administrator or other position that does not require a nursing license, a nurse is always held accountable by the Board for their actions based upon their licensure.

3. History and Purpose of the Board of Nursing
The Nursing Practice Act (NPA) creates the Board of Nursing (BON)
2004—RN and LVN Boards were merged and in 2007 the Board of Nurse Examiners was renamed Board of Nursing
The purpose of the Board of Nursing:
To protect and promote the welfare of the people
of Texas by ensuring that each person holding a
license as a nurse in the State of Texas is competent
to practice safely.
(Texas Occupations Code Chapter 301)
Texas and California are the only states to use the title “LVN” or Licensed Vocational Nurse. The other states use “LPN” or Licensed Practical Nurse.
New York was the first state to issue an LPN license.
In 1952, HB47 created the Texas Board of Nurse Examiners.

4. Standards of Nursing Practice—ALL nurses (217.11)
Some standards apply to all nurses—LVN, RN, APRN: (1) (A) Know and conform to the Texas NPA and the board’s rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse’s current area of nursing practice; (D)Accurately and completely report and document (i) the client’s status including signs and symptoms (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments;
Item (1) (A) makes it clear that it is the responsibility of the RN and LVN to know the laws and the BON’s rules relating to their practice.
Item (1) (D) deals with the requirement to document, regardless of company policies.,

5. Standards, continued…
(v) Client response(s); and (vi) Contacts with other health care team members concerning significant events regarding client’s status; (H) Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations; (M) Institute appropriate nursing interventions that might be required to stabilize a client’s condition and/or prevent complications; (T) Accept only those nursing assignments that take into consideration client safety and that are commensurate with the nurse’s educational preparation, experience, knowledge, and physical and emotional ability.
Item 6 makes it clear that documentation regarding the reporting of changes of condition must be included in the resident record. The LVN must report such changes to the LVN’s clinical supervisor as well as to the resident’s health care provider and must document the changes and the report.
Item “H” indicates that it is the responsibility of the nurse to obtain orientation and training when entering a new care situation, such as assisted living. “A nurse is a nurse is a nurse” is NOT true. Nurses who are entering assisted living without previous experience in AL need orientation to ensure competence. Companies must ensure adequate orientation and training for nurses new to assisted living and this practice setting.
Item “T” makes it clear that it is the responsibility of the nurse to accept duties that are consistent with the NPA, that is, within their scope of practice and educational preparation.

6. RN and LVN Nursing RN Professional nursing Independent role
Develops and implements the nursing process
Supervises, coordinates, delegates
NPA (2)
LVN
Vocational nursing
Supervised role
Assists in the development and implementation of the nursing process
NPA (5) and

7. LVN Practice and Education
Directed scope of nursing practice in which supervision is required.
Performance of an act that requires a specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of vocational nursing NPA (5)
Basic education (nursing school): 558 hours of theory 840 hours of clinical
Continuing Education
Position statement Continuing Education: Limitations for Expanding Scope of Practice.
Clarifies that expansion of an individual nurse’s scope of practice has licensure-related limitations. Informal continuing education or on-the-job training cannot be substituted for formal education leading to the next level of practice/licensure.
In-Services—Board rule (1)
(G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices
The LVN’s practice is a directed or supervised practice. In other words, the LVN is not permitted to practice without a clinical supervisor. The LVN may report administratively to a non-clinical person, but clinical practice and decisions must be supervised by a qualified clinical person.
Note that the Position Statement (15.10 on Continuing Education) makes it clear that additional continuing education or on-the-job training DOES NOT allow the LVN to function beyond the rules of the BON for LVNs.
Also, regarding continuing education and as a reminder, nurses whose focus is geriatric care are required to have at least two contact hours of CE in every licensure cycle. (20 hours of nursing CE are required every 2 years for re-licensure.)
We encourage communities and companies to make it possible for nurses to attend this annual conference since the nursing sessions focus on nursing in the assisted living setting and meet the geriatric care CE requirement.
(h) Older Adult or Geriatric Care. A nurse, including an APRN, whose practice includes older adult or geriatric populations shall complete at least two contact hours of CE, as defined in this chapter, in every licensure cycle after January 1, 2014.
  (1) The minimum two contact hours of CE required shall include information relating to elder abuse, age related memory changes and disease processes, including chronic conditions, and end of life issues. The minimum two contact hours of CE may include information related to health maintenance and health promotion of the older adult or geriatric populations.

8. Standards Specific to Vocational Nurses- Rule 217.11 (2)
The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician’s assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding and influencing the outcome of an individual’s performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and:
Shall utilize a systematic approach to provide individualized, goal-directed nursing care by:
Collecting data and performing focused nursing assessments;
Participating in the planning of nursing care needs for clients;
participating in the development and modification of the comprehensive nursing care plan for assigned clients
This rule clearly indicates the persons who may serve as the LVN’s clinical supervisor. Please be aware that some have tried to tell the Board that the resident’s physician supervises the LVN’s practice. The Board’s response is that the physician would most likely answer “no” to the question “Do you supervise this LVN’s clinical practice in the assisted living community?”. Note the definition of supervision and you can understand why the Board does not feel that the each resident’s physician serves to supervise the LVN’s practice within the community.
The Board’s FAQs (2) state that the term predictable describes health conditions that behave or occur in an expected way. A predictable health condition does not mean that the patient is always stable; Instead, predictable health conditions follow an expected range or pattern that allows the LVN with his/her clinical supervisor to anticipate and appropriately plan for the needs of patients. For example (Board’s example); It is appropriate for a LVN to care for a patient with a diagnosis of asthma. The disease process for asthma, while sometimes acute in nature, is predictable or well-known, and the symptoms can be anticipated. The LVN assists his/her clinical supervisor in the development of a plan, in which the LVN provides care, prevents possible complications and stabilizes the symptoms of asthma. In addition, when complications arise or events occur that are outside the predicted range, the LVN must be able to recognize this change in condition and notify his/her clinical supervisor.

9. LVN Standards, continued
Implementing appropriate aspects of care within the LVN’s scope of practice; and
Assisting in the evaluation of the client’s responses to nursing interventions and the identification of client needs;
(B) Shall assign specific tasks, activities and functions to unlicensed personnel commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made and shall maintain appropriate supervision of unlicensed personnel.
(C) May perform other acts that require education and training as prescribed by board rules and policies, commensurate with the licensed vocational nurse’s experience, continuing education, and demonstrated licensed vocational nurse competencies.
Note item iv which again reminds the LVN that their practice must be within their scope of practice.
Item “B” indicates that the LVN may make assignments to unlicensed persons, but it is important to remember that LVN’s do not delegate certain nursing tasks, including medication administration. Only RNs may delegate, following the rules set forth by the Board.

10. Supervision
Supervision is Required The practice of vocational nursing must be performed under the supervision of a registered nurse, physician, physician assistant, podiatrist or dentist. Supervision Supervision is defined as the active process of directing guiding, and influencing the outcome of an individual’s performance of an activity. Rule (2)
It is the responsibility of each LVN to ensure he/she has the appropriate clinical supervision.
LVNs cannot supervise an RN’s clinical practice. An LVN ED can supervise an RN as an administrator, but not regarding clinical matters.
All nurses, RNs and LVNs must remember that they are required to report to the BON any nurse working outside his/her scope of practice, including an LVN working without supervision.

11. Supervison concerns
In recent years, the trend has seen LVNs moving toward more community settings, including assisted living, where there are more concerns about supervision and practice.
Lack of RN oversight
On-call duties
Medication policies and procedures
Inadequate documentation

12. Board Position Statement: Supervision
Supervision is required for the LVN scope of practice.
LVNs are not licensed for independent nursing practice.
A LVN must ensure that he/she has an appropriate clinical supervisor.
Proximity of the clinical supervisor depends on skills and competency of the LVN, patient conditions and practice setting.
Direct, on-site supervision may not always be necessary depending on the LVN’s skill and competence and should be determined on a case-by-case situation taking into consideration the practice setting laws.
However, clinical supervisors must provide timely and readily available supervision and may have to be physically present to assist LVNs should emergent situation occur.

13. Board Position Statement: Setting
Setting may include areas with well-defined policies, procedures and guidelines with assistance and support from appropriate clinical supervisors.
As competencies are demonstrated, if the LVN transitions to other settings, it is the LVN’s responsibility to ensure he/she has an appropriate clinical supervisor and that the policies, procedures and guidelines for that particular setting are available to guide the LVN practice.
It is important to note that there must be well-defined polies, procedures and guidelines to aid the LVN in their practice in the AL setting. And there must be adequate assistance and support from the LVN’s clinical supervisor. We will address some practical ways of ensuring safe LVN practice with supervision later in the presentation.

14. Board Position Statement: Assessment
Assists, contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information.
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RN's initial and comprehensive assessment.
The LVN reports and documents the assessment information and changes in patient conditions to an appropriate clinical supervisor.
The Comprehensive Assessment required under the AL regulations would easily fit within the guideline stated here of a focused assessment to collect data and gather information. Since it is not required that the comprehensive assessment be completed by a nurse, it certainly would not fall under the definition of a nursing assessment, UNLESS your company or community makes it such.
Also note that the second bullet point would apply if there is involvement of the RN for a specific resident and is not required under the AL regs as part of the comprehensive assessment.

15. Board Position Statement: Planning
Uses clinical reasoning based on established evidence-based policies, procedures and guidelines for decision-making.
May assign specific daily tasks and supervise nursing care to other LVNs or UAPs.
As mentioned earlier, the LVN may assign tasks to unlicensed persons but does not delegate tasks included under the delegation rule for RNs.

16. Board Position Statement: Implementation
Provides safe, compassionate and focused nursing care to patients with predictable health care needs.
Implements aspects of the nursing care plan, including emergency interventions under the direction of the RN or another appropriate clinical supervisor.
Contributes to the development and implementation of teaching plans for patients and their families with common health problems and well-defined health needs.
Again the Board stresses the implementation of care UNDER RN supervision or another appropriate clinical supervisor.

17. Board Position Statement: Evaluation
Participates in evaluating effectiveness of nursing interventions.
Participates in making referrals to resources to facilitate continuity of care.

18. Frequently Asked Questions
The following slides address some of the FAQs related to LVN practice. These questions and answers are taken from the Board website.

19. FAQ: Co-signing documentation
Must an RN sign behind or "co-sign" nursing actions performed by an LVN? In general, BON staff does not recommend a nurse co-sign anything unless he/she has directly witnessed an act ( such as narcotic wastage) or has gone behind another nurse and personally performed the same assessment with the same findings. As discussed above, each licensed nurse is responsible for accepting assignments that are within the educational preparation, experience, knowledge, and physical and emotional ability of the individual nurse [Rule (1)(T)]. Both LVNs and RNs are required to document the nursing care they render; each is held accountable for doing it accurately and completely. THE QUESTION OF AN RN CO-SIGNING AFTER AN LVN MOST OFTEN ARISES IN SITUATIONS WHEN AN ATTEMPT IS MADE TO EXPAND THE LVN’S SCOPE OF PRACTICE BY HOLDING THE RN RESPONSIBLE FOR EXPANDED TASKS PERFORMED BY THE LVN. THE RN CO-SIGNING FOR SOMETHING THAT IS BEYOND THE LVN’S SCOPE OF PRACTICE DOES NOT LEGITIMIZE THE LVN’S ACTIONS. A nurse never functions “under the license” of another nurse. Therefore, if a patient requires a comprehensive assessment performed by an RN, the assignment (or a portion thereof) may not be given to an LVN. If such an assignment is inadvertently given to an LVN, he/she is responsible for notifying the nurse who made the assignment that it is beyond his/her scope of practice to perform the assigned task. Each nurse has a duty to maintain client safety [217.11(1)(B)] that includes communication with appropriate personnel. Position Statement 15.14, Duty of a Nurse in Any Setting, further explains a nurse’s duty to a client.
Please note that the underling and all caps are mine for emphasis during this discussion.

20. FAQ: LVNs performing Initial Assessments
Can an LVN perform an “initial” assessment?
The answer depends on many factors, as with most practice questions. Board Rule , Standards of Nursing Practice, refers to focused assessments performed by LVNs [Board Rule (2)(A)] and comprehensive assessments performed by RNs...
[Board Rule (3)(A)]. Nothing in the Board’s rules refers to initial assessments; therefore, the Texas Board of Nursing does not define nor does it determine whether an LVN may complete an initial assessment. Board staff recommends contacting the agency that regulates the specific type of practice setting to determine if other laws and regulations apply. If other regulations require that an RN perform the initial patient/client assessment, then the LVN cannot perform the assessment for the RN.
In situations requiring comprehensive assessments by an RN, the LVN cannot begin by performing a focused assessment and have the RN follow up with an assessment of only those parameters not assessed by the LVN. A comprehensive assessment is a different level of assessment requiring that the RN use his/her own independent nursing judgment. Board Rule (1) (T) clarifies that a nurse is responsible for accepting assignments based on the nurse’s individual educational preparation, experience, knowledge, skills, and abilities. Likewise, when a nurse makes assignments to another person(s), the nurse must consider the educational preparation, experience, knowledge, and skills of the person(s) receiving the assignment [Board Rule (1)(S)].
For points 1 and 2, remember that the AL regs do not require a nursing assessment and that the comprehensive assessment must be performed ay “appropriate staff”. This would allow the LVN to complete that assessment.
The third point “comprehensive assessment” language refers to a nursing assessment which must be performed by a RN.

21. FAQ: Practice Recommendations for Newly Licensed Nurses
Does the Board of Nursing (BON) have any recommendations for newly licensed LVNs or RNs as they begin their nursing practice? The newly licensed nurse is in a transitional process and as a novice practitioner, the new LVN or RN is inexperienced and not fully integrated into his/her nursing role and setting. Based on this belief, the Board provides the following guidance to newly licensed LVNs or RNs: The newly licensed LVN must ensure that he or she has appropriate supervision. The LVN has a directed scope of practice, which means the LVN must have a registered nurse, advanced practice registered nurse, physician, physician assistant, dentist or podiatrist as a supervisor of his or her clinical nursing practice. 2. It is recommended that a newly licensed nurse not practice in independent settings, such as group homes, assisted living facilities and home or school health, where access to a clinical supervisor is limited for a period of months post-licensure. This allows the newly licensed nurse sufficient practice experience in more structured settings and the opportunity to assimilate knowledge learned in school consistently into practice.
The importance of this FAQ is the guidance it gives regarding hiring a new LVN to work in the AL setting. If the new LVN would be the only nurse, it certainly would not be a wise decision based on this recommendation of the Board. In addition, the amount and availability of the supervisor would be vastly more important for a new graduate.

22. Newly licensed nurses, continued…
3. It is recommended that a newly licensed nurse not hold a position as a charge nurse or nurse manager for a period of six (6) months, unless a lesser time period is mutually agreed upon by the newly licensed nurse and the supervising nurse based upon the evaluation of competency of the newly licensed LVN or RN. 4. The Board believes it is essential for newly licensed nurses to seek and receive direction, supervision, consultation and collaboration from experienced nurses during the transition into nursing practice. In any practice setting where newly licensed LVNs and RNs are employed, experienced nurses should be willing to supervise and mentor novice nurses. 5. Once licensed, direct supervision should be continued for a period of six months, or a lesser time period if agreed upon by the newly licensed nurse and the supervising nurse. Competence to perform without direct supervision should be mutually determined by the newly licensed nurse and the supervising nurse and should be demonstrated and supported by documentation. Newly licensed nurses are permitted to perform any function that falls within the scope of nursing practice for which they have received educational preparation and have demonstrated minimal competency.
Further, point 3 indicates that a charge nurse position should not be held by a new graduate; so certainly, a new graduate , RN or LVN, should not be THE nurse for a community. Note also that point 5 indicates the need for demonstration of minimal competency. This item also speaks to the need to evaluate the competencies of any newly-hired nurse, regardless of previous experience and length of licensure.

23. FAQ: LVNs Performing Triage/Telephonic Nursing/Being On-Call
Can LVNs in any practice setting be "on-call" to deal with after-hours issues called in by patients, families, or facility staff? Can an LVN perform "triage" duties (either telephone triage such as for home health or on-site such as an Emergency Room)? Finally, can an RN be on "back-up on-call" in case the LVN has questions? Can the RN be the one ultimately responsible [with the LVN relaying his/her assessment (telephonic or actual assessment)] to the RN?
Triage is commonly defined as the sorting of patients and prioritizing of care based on the degree of urgency and complexity of patient conditions. Telephone triage is the practice of performing a verbal interview and making a telephonic assessment with regard to the health status of the caller. As the caller may not accurately describe symptoms, and/or may not accurately perceive or communicate the urgency of the situation or condition prompting the call, nurses who perform these functions must have specific educational preparation, as the consequences of inadequate triage can be devastating.1
Intro to slide:
This is an area of great concern for us in assisted living. Many companies and communities have LVNs taking call when there is no nurse in the community.
Let’s consider the questions listed at the beginning:

24. LVN on call, continued…
Though the BON does not regulate employers, and the NPA and rules are not prescriptive to specific practice settings, THE BOARD BELIEVES ON-CALL DUTIES, TELEPHONIC NURSING, AND/OR BEING ON-CALL TO HANDLE URGENT/EMERGENT ISSUES TELEPHONICALLY ARE ALL BEYOND THE SCOPE OF PRACTICE FOR LVNS. Exceptions could be made to this general stance in settings where the LVN utilizes an established, standardized, and validated decision-tree process (most likely computerized) that guides the LVN through a specific pathway of questions leading to an end-point determination of recommended action for the caller. It is in settings where the LVN would be required to independently engage in assessment (either telephonically or face-to-face) for purposes of triaging a patient that are of concern to the Board.
The Board's concerns are based on the fact that LVNs are not educationally prepared to perform triage assessments, either telephonically or in the role of the health care professional initially assessing a client to determine treatment priorities in any setting. A board document titled "Differentiated Entry Level Competencies of Graduates of Texas Nursing Programs"* states in part that "LVN nursing programs in Texas prepare entry-level bedside nurses to care for acutely and chronically ill patients with predictable health outcomes in structured healthcare delivery settings." This document further describes that LVNs are educated in basic head-to-toe assessment using the senses of sight, smell, touch, and hearing. In either telephonic or face-to- face triage, the LVN is likely to be dealing with a situation where the client's condition is not predictable.
Again, the all caps are mine for emphasis.

25. LVN on call, continued…
In alignment with the educational preparation for vocational nursing, Rule , Standards of Nursing Practice, establishes that LVNs "...collect data and perform focused nursing assessments of the health status of individuals"[217.11(2)(A)(I)]. NPA section and Rule (2) further establishes that LVNs have a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist.
Placing an LVN in a position to perform duties requiring comprehensive (versus "focused") assessments of patients potentially experiencing unpredictable changes in health status, as well as making independent nursing judgments (such as would be required for either telephonic or on-site initial triage) may place the LVN in a position that violates the BON's Standards of Nursing Practice.

26. Both the Interpretive Guideline for LVN Scope of Practice Under Rule and Position Statement “Continuing Education: Limitations for Expanding Scope of Practice”, further clarify that while LVNs may expand their practice with post-licensure continuing nursing education, this does not permit the LVN to expand his/her practice to a level that requires RN education, training, and licensure (such as comprehensive assessment). This relates to Rule (1)(B) which holds each nurse accountable to maintain client safety. This standard supersedes any doctor's order or facility policy, thus the nurse cannot avoid his/her "duty" to maintain client safety by placing responsibility for nursing actions on another party. Position Statement 15.14, Duty of a Nurse in Any Practice Setting, further clarifies the nurse's duty, regardless of the type of nursing license held.

27. LVN on call continued…
It remains the opinion of the board (consistent with the opinion of the former Board of VN Examiners) that on-site triage and/or telephone triage (by an "on-call" LVN) that requires the LVN to perform a comprehensive assessment and make independent treatment decisions on the basis of information supplied by the client is beyond the scope of practice for an LVN. Triage is not taught in one-year vocational nurse education programs. The LVN has not received education in the complex and finite details of comprehensive assessment as provided in a professional registered nurse education program that would include the knowledge base necessary for on-site and telephone triage.
It is not acceptable to have either an RN or advanced practice registered nurse (APRN) on "back-up call" to an LVN who is also responding only telephonically to clients in need. As the LVN's formal education does not prepare the LVN to perform telephonic assessments, the LVN may not be able to determine what information is essential to obtain and then relay to an RN or APRN. In addition, if a client situation is emergent, even if the RN or APRN subsequently call the client back, the delay in securing emergent treatment may result in serious harm or patient death

28. FAQ: LVNs On-Call/Telephone Triage in Independent Living Environments
Specific to assisted living, the Board states:
LVNs and RNs have been disciplined in the past for not making prudent judgments with regard to taking appropriate and timely action to safeguard patients in an independent living environment. Regardless of job experience, an LVN does not have educational background equivalent to that of the RN, and is not educated or trained to analyze and synthesize symptoms or otherwise conduct a comprehensive assessment telephonically with a client. Additionally, if emergent action is needed and the LVN is unable to discern this need due to limited assessment abilities, assistance that may be necessary to save the client's life could be delayed.
Remember that the Board rules for delegation includes assisted living as an “independent living environment”.

29. DADS-BON LVN ON-Call Pilot
2011 Legislature, SB directed the Texas Department of Aging and Disability Services (DADS) and the Texas Board of Nursing (BON) to develop and conduct a pilot program to evaluate licensed vocational nurses (LVNs) providing on-call services by telephone to individuals receiving services in the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Medicaid waivers and in intermediate care facilities for individuals with an intellectual disability or related condition (ICFs/IID) with 13 or fewer beds. Since residents cared for in these settings have many of the same needs as residents in assisted living, the results of this study seem relevant to the discussion of the LVN being on call in the assisted living setting.
The next group of slides contain information on a pilot study jointly conducted by DADS and the BON to consider expanding the role of the LVN to include the ability to be on-call.

30. LVN On-Call Pilot Overview
The provision of on-call telephone services means: providing telephone services any time of the day or night, to handle non- urgent, urgent, and emergent conditions an individual may experience; making a telephone assessment; providing instructions to an unlicensed person over the phone regarding that condition; and reporting those instructions to a registered nurse (RN) clinical supervisor.
The LVN On-Call Pilot Program was developed to determine the impact of allowing LVNs to function with an expanded scope of practice on the quality of care provided to individuals served in the designated intellectual and developmental disability (IDD) programs. The pilot began September 1, 2011, and concluded August 31, 2015.

31. LVN On-Call Pilot Overview, continued…
There is a growing need for nursing services to individuals with IDD who are living in the community and an insufficient number of RNs who choose to work in this setting.
Because of the difficulty in employing RNs, some LVNs informally began performing certain functions outside their legal scope of practice, including telephone on-call services.
The purpose of this pilot was to formally test the concept of allowing LVNs to perform on-call services provided by telephone without negatively affecting quality of care.

32. LVN On-Call Pilot Communication Protocol
The communication protocol described how the LVN would provide on-call telephone services and when to communicate with the RN clinical supervisor. In the absence of any existing standardized and validated protocols for LVNs providing on-call services in these care settings, the communication protocol was developed using current standards of practice and evidence- based references with input from the advisory committee.
The communication protocol identified a new model to define the collaborative relationship between the LVN and the RN. This new model was intended to maximize communication between the LVN and the RN to develop a team approach for meeting the ongoing and emergent needs of individuals in these programs (See Appendix D).
These communication protocol will be posted on the TALA website. We will consider these protocols later as a possible START to the development of specific policies and procedures for RN-LVN communication, but NOT as a guide to LVN on-call procedures.

33. LVN On-Call Pilot continued…
Challenges, other than administrative within DADS and BON:
The lack of documentation by both nursing and direct care staff when an incident occurred made it difficult to evaluate if a nurse followed communication and operational protocols correctly.
Lack of documentation by both nursing and direct care staff: When an incident occurred, it was difficult to evaluate if a nurse acted correctly. Early in the record review process, it was identified by DADS nurses that, although all the records had been sent as requested, it was difficult to evaluate the incident with the client.
Direct staff did not always complete a note when they called a nurse.
The nurse did not always document the telephonic evaluation. The LVN infrequently charted when or if a call was placed to the RN to report an incident and whether the incident was resolved as required by the communication protocol.
As we review the challenges that were present in the pilot groups, consider how many of these same challenges would be present in many assisted living communities today,

34. LVN On-Call Pilot continued…
Turnover of personnel at provider organizations led to potential gaps in training in pilot protocols.
Understanding of the LVN’s scope of practice varied among providers.
Providers have difficulty recruiting, hiring and retaining RNs as reported by advisory committee provider members.
Training in management of a critical incident or death varied from provider to provider.

35. LVN On-Call Pilot continued…
Lessons learned:
Direct and frequent communication among direct care providers and the nurse on-call is essential for safe care of individuals.
Providers employing nurses must understand scope of practice for RNs and LVNs.
Based on a survey of providers, the most frequently cited reason for not participating in the pilot was the need to have an RN available to the LVN for consultation while taking calls.
Would these same lessons apply to your community?

36. LVN On-Call Pilot continued…
Recommendations:
BON does not recommend expansion of the LVN scope of practice in the community setting of HCS/TxHmL and ICF/IID, including the provision of on-call services by telephone. Results of chart reviews do not support the safety or efficiency of expanding the LVN scope of practice to provide on-call telephone services in this setting.
The state should develop training to improve the ability of direct care staff to recognize deterioration in status in individuals who have chronic medical diagnosis. Need for improved training in management of a critical incident or death: Record reviews revealed inconsistency among providers in documentation of a critical incident, including a death. In some cases, an incident form was filled out; in others, direct care or nursing staff, or both, filled out a progress note. In some instances, staff was empowered to call emergency services prior to supervisors, but in other documentation stated that the supervisor was called first and then instructed staff to call.
Direct care staff should contact nursing staff directly to communicate client health care needs and status changes as opposed to through a third party such as a house administrator.
Nursing orientation at a provider level should include training on documentation in the IDD care setting. Reviews demonstrated the need for continued training in documentation of nurses in community settings.
If the Board does not recommend the expansion of the LVN scope of practice in these settings, we believe it is safe to say that they would also not recommend its expansion in assisted living.
We also believe that if the Board recommends the development of training for direct care staff in the recognition of deterioration in the condition of residents and the management of critical incidents in the settings of the pilot that the same could be said of our setting.
The third recommendation is also pertinent. We believe that, in too many communities, staff report clinical issues to a non-clinical administrator/supervisor rather than directly to a clinical person.
The next recommendation for improved training on documentation by nurses in the pilot settings is also applicable to our setting. Our experience is that nursing documentation in the AL setting is often minimal, incomplete, or non-existent.

37. LVN On-Call Pilot continued…
The state should convene a workgroup consisting of DADS, BON, and IDD stakeholders to identify and resolve issues involving nursing scope of practice in community settings. BON should continue educational offerings aimed to teach LVN scope of practice.
Increase information sharing about existing educational materials: DADS and BON in partnership with provider associations should increase efforts to inform nurses and providers about continuing education and certification for nurses who care for individuals with IDD that is available through the Developmental Disabilities Nurses Association.
The next recommendation related to educational offerings regarding the LVN scope of practice is one reason for this workshop today. We believe that we must take the initiative to ensure safe practice for the sake of our residents and our nurses.
Lastly, the recommendation for targeted continuing education for nurses specifically related to the area of practice in the pilot is also applicable for us and we believe that this is a first step in doing just that. And this is another reason why we encourage nurses to attend the TALA manager’s classes and the TALA conference.

38. So now what?
Let’s consider some practical implications of the scope of LVN practice and the role of the LVN in the assisted living community setting. What are your concerns or challenges? What is working for you? In what ways have you been able to obtain supervision for your LVNs?