TX HHS Form 8007. ICF/IID RN Delegation Worksheet for 22 TAC Section 225 (Example Form)

The TX HHS Form 8007, ICF/IID RN Delegation Worksheet for 22 TAC Section 225, is a practical tool designed to help registered nurses (RNs) delegate nursing tasks to unlicensed personnel in the Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) setting. This form should be used when an RN needs to assess and document the delegation of specific nursing tasks, such as Health Maintenance Activities (HMAs), to ensure safe and effective care for individuals with intellectual disabilities.

The form highlights key features, including a list of HMAs that require delegation in the ICF/IID setting, such as administering oral medications, bowel and bladder programs, and skin care surrounding stoma areas. It also includes sections for documenting self-administration of medications, administration of medications by unlicensed personnel, and recording medication administration times and doses.

This form is specifically designed to address stable and predictable conditions, as defined in 22 TAC §225.4(11), and is intended to be completed by the RN and attached to a comprehensive assessment. The Black Box indicates that selection is not available per 22 TAC §225 for stable and predictable conditions.