DSHS Form 10-217 "Nurse Delegation: Credentials and Training Verification" - Washington

What Is DSHS Form 10-217?

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2018;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of DSHS Form 10-217 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

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Download DSHS Form 10-217 "Nurse Delegation: Credentials and Training Verification" - Washington

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Nurse Delegation:
1.
LONG TERM CARE WORKER’S (LTCW) NAME (PRINT)
Credentials and Training Verification
2. Credential Verification
Attach a copy of internet Provider Credential Search
http://www.doh.wa.gov/LicensesPermitsandCertificates/ProviderCredentialSearch.
OR COMPLETE THE FOLLOWING
Washington State Certificate / Registration Number for
NAR
NAC
HCA – C
Expiration Date:
3. Training Verification
NAR
NAC and HCA-C
Non-exempt LTCW
9 hour ND for nursing assistants
(employed after January 7, 2012 (HCS) and January 1, 2016 (DDA)):
Date:
9 hour ND for nursing assistants
Date:
3 hour special focus on diabetes
3 hour special focus on diabetes
Date:
Date:
Basic training:
HCS – 40 hours basic training
Date:
DDA – 40 hour CORE basic
Date:
Exempt LTCW
(employed one day from January 1, 2011 – January 6, 2012 (HCS) or
employed prior to January 1, 2016 (DDA)):
9 hour ND for nursing assistants
Date:
3 hour special focus on diabetes
Date:
Basic training:
HCS – Fundamentals of Care (FOC)
Date:
HCS – Revised Fundamentals of Care (RFOC)
Date:
DDA – 32 hour letter
Date:
4. Exempt Long Term Care Workers
The HCS LTCW employed one day between January 1, 2011 and January 6, 2012 and the DDA LTCW employed any
time prior to January 1, 2016 should have a letter from the employer who employed them stating they have completed the
basic training requirements in effect on the date of his or her hire. The Registered Nurse Delegator must obtain proof of
employment prior to delegation of an exempt LTCW.
Letter of employment verification type:
Date of verification:
5. Notes
6. RND SIGNATURE
7. DATE
NURSE DELEGATION: CREDENTIAL AND TRAINING VERIFICATION
DSHS 10-217 (REV. 04/2018)
Nurse Delegation:
1.
LONG TERM CARE WORKER’S (LTCW) NAME (PRINT)
Credentials and Training Verification
2. Credential Verification
Attach a copy of internet Provider Credential Search
http://www.doh.wa.gov/LicensesPermitsandCertificates/ProviderCredentialSearch.
OR COMPLETE THE FOLLOWING
Washington State Certificate / Registration Number for
NAR
NAC
HCA – C
Expiration Date:
3. Training Verification
NAR
NAC and HCA-C
Non-exempt LTCW
9 hour ND for nursing assistants
(employed after January 7, 2012 (HCS) and January 1, 2016 (DDA)):
Date:
9 hour ND for nursing assistants
Date:
3 hour special focus on diabetes
3 hour special focus on diabetes
Date:
Date:
Basic training:
HCS – 40 hours basic training
Date:
DDA – 40 hour CORE basic
Date:
Exempt LTCW
(employed one day from January 1, 2011 – January 6, 2012 (HCS) or
employed prior to January 1, 2016 (DDA)):
9 hour ND for nursing assistants
Date:
3 hour special focus on diabetes
Date:
Basic training:
HCS – Fundamentals of Care (FOC)
Date:
HCS – Revised Fundamentals of Care (RFOC)
Date:
DDA – 32 hour letter
Date:
4. Exempt Long Term Care Workers
The HCS LTCW employed one day between January 1, 2011 and January 6, 2012 and the DDA LTCW employed any
time prior to January 1, 2016 should have a letter from the employer who employed them stating they have completed the
basic training requirements in effect on the date of his or her hire. The Registered Nurse Delegator must obtain proof of
employment prior to delegation of an exempt LTCW.
Letter of employment verification type:
Date of verification:
5. Notes
6. RND SIGNATURE
7. DATE
NURSE DELEGATION: CREDENTIAL AND TRAINING VERIFICATION
DSHS 10-217 (REV. 04/2018)
Instructions – Nurse Delegation: Credentials and Training Verification
All fields are required unless indicated “OPTIONAL”.
1. Long Term Care Worker’s (LTCW) Name: Enter name of Long Term Care Worker (print).
2. Credential Verification: If you use the internet site, print a copy of the results of this caregiver’s credential search. Mark
the box with an “X” and fasten copy to this form. If you do not use the internet site, identify certification type (NAR,
NAC, HCA-C) and the expiration date of the credential.
3. Training Verification:
a. If the LTCW is an NAR, verify the following:
i. Employment dates
ii. Nurse delegation training. The LTCW must complete the 9 hour nurse delegation for nursing assistance prior to
delegation. If the LTCW will also be administering or drawing up insulin, they must also complete the 3 hour
special focus on diabetes prior to delegation.
iii. Basic training certificate (the 40 hour basic training/CORE basic training is part of the 75 hour Home Care Aide
training. The LTCW may present 40 or greater hours of approved training).
b. If the LTCW is certified as a Home Care Aide (HM) or Nursing Assistant (CNA) verify the following:
i. Nurse delegation training. The LTCW must complete the 9 hour nurse delegation for nursing assistance prior to
delegation. If the LTCW will also be administering or drawing up insulin, they must also complete the 3 hour
special focus on diabetes prior to delegation.
4. Exempt LTCW: If the HCS LTCW was employed one day between January 1, 2011 and January 6, 2012 they are
considered an exempt LTCW, not requiring the LTCW to complete the Home Care Aide Certification curriculum.
If the DDA LTCW was employed any time prior to January 1, 2016 they are considered an exempt LTCW, not requiring
the LTCW to complete 75 hours of Home Care Aide training.
Each exempt LTCW must provide proof of employment to the Registered Nurse Delegator. Proof may be in the form of
a letter from a past employer, or any other documentation the Nurse Delegator approves.
5. Notes: The notes section may be used for any form of notes useful to the Nurse Delegator.
6. RND Signature: The delegating nurse must sign verifying they have observed approved training and credentials for the
LTCW.
7. Date: The delegating nurse dates on the day of verification of training and credentials.
NURSE DELEGATION: CREDENTIAL AND TRAINING VERIFICATION
DSHS 10-217 (REV. 04/2018)
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