What Is a Delegating Nurse? Nurse Delegation in I/DD Services

In many group homes and supported living settings, direct support professionals (DSPs) give medications, check blood sugar or help with tube feedings every day. In most states those are nursing tasks. A DSP can do them only because a registered nurse has delegated them, and that nurse stays answerable for how it goes.

This guide explains what a delegating nurse does in intellectual and developmental disability (I/DD) services, what can and can't be delegated, and how two states, Maryland and Washington, write the rules. It's written for nurses moving into community I/DD work, for DSPs who carry out delegated tasks, and for the managers who keep the paperwork straight.

What nurse delegation means

The national starting point is the National Guidelines for Nursing Delegation, adopted jointly by the National Council of State Boards of Nursing (NCSBN) and the American Nurses Association in 2019. They describe delegation as allowing someone to perform a specific nursing activity, skill or procedure that is beyond their traditional role, after they have received additional training and shown they can do it. The nurse who delegates keeps overall accountability for the patient, while the person who accepts the task is responsible for doing it correctly.

State law decides the details. The guidelines themselves say states have different delegation rules and that every licensed nurse must know what their own state allows. Maryland's Board of Nursing, for example, defines delegation as authorizing an unlicensed individual, a certified nursing assistant or a medication technician to perform acts of registered or practical nursing (COMAR 10.27.11.02).

The five rights of delegation

The national guidelines organize the delegating nurse's decision around five "rights":

1. Right task. The task fits the person's job description or the employer's written policies.
2. Right circumstance. The person's health is stable. If it changes, the staff member tells the nurse, who reassesses.
3. Right person. The nurse, the employer and the staff member together make sure the staff member has the skills and knowledge for the task.
4. Right directions and communication. Instructions are specific to the person, the nurse and the staff member, and the staff member agrees to accept the task.
5. Right supervision and evaluation. The nurse monitors the task, follows up and checks outcomes, and the staff member reports back.

The guidelines also give employers a role: they should name a nurse leader to oversee delegation and write policies that say what may and may not be delegated.

What a delegating nurse does

Across states, the delegating nurse's job follows the nursing process. Under Maryland's rule, before delegating, the nurse must assess the person's nursing care needs, instruct the staff member or verify their competency, supervise the task, evaluate how it's going and make sure outcomes are documented (COMAR 10.27.11.03). Washington's rule uses the same four steps, assess, plan, implement and evaluate (WAC 246-840-930).

Some work can never be handed off. Maryland lists the nursing assessment, the nursing diagnosis, setting nursing care goals, writing the nursing care plan, evaluating the person's progress, and any task that requires nursing knowledge, judgment and skill (COMAR 10.27.11.05). Washington says acts that require nursing judgment can't be delegated, and in community and in-home settings it also bars delegating injections other than insulin, sterile procedures and central line maintenance (RCW 18.79.260).

Maryland: delegation in DDA services

Maryland's Board of Nursing rules in COMAR 10.27.11 apply across settings. "Supervised group living settings" expressly include alternative living units for people with developmental disabilities.

The RN as case manager. A registered nurse may act as case manager and delegate nursing tasks, including medication administration, only after assessing and documenting that the person's health needs are chronic, stable, uncomplicated, routine and predictable, that the environment supports delegation, and that the person can't do their own care (COMAR 10.27.11.03F).

On-site visits. For a person who meets those criteria, the RN must make a supervisory on-site visit at least every 45 days to check the person's health, the delegated tasks, whether health goals are met, the staff member's continued competence and the environment. For a person who doesn't meet them, visits are required at least every 2 weeks (COMAR 10.27.11.04). The delegating nurse must also be "readily available," which outside structured settings means on the premises or reachable by phone.

Medications. Medication administration stays a nursing function, and the nurse keeps full responsibility for it. In settings such as supervised group living, supervised work settings and independent living, the nurse may delegate medication administration to certified medicine aides and to medication technicians, who complete a Board-approved 20-hour medication administration course and are certified by the Board (COMAR 10.27.11.02). The rule lists the routes allowed, including oral, inhaled, topical, eye, ear and nose drops, and suppositories. For liquids, tablet fractions, gastrostomy tube and subcutaneous medications, the nurse must calculate the dose or cut the tablet first (COMAR 10.27.11.05). Our guide to certified medication technicians covers that side of the role.

DDA nursing services. Maryland's Developmental Disabilities Administration (DDA) funds nursing through Nursing Support Services. At a January 20, 2026 statewide call for coordinators of community services, DDA described three options: Nurse Health Case Management and Delegation, Nurse Health Case Management, and Nurse Consultation. It said the delegation option is used when unlicensed staff, such as unlicensed assistive personnel, certified medication technicians or certified nursing assistants, are paid to give medications or provide other nursing services, and that to delegate, the RN must complete an assessment, create nurse care plans and train staff (DDA, January 2026 call slides).

DDA's proposed July 2025 service definition for Nursing Support Services adds provider qualifications for these nurses, including completing DDA's Registered Nurse Case Manager/Delegating Nurse (CM/DN) Orientation within 90 days of first providing services and staying active on DDA's registry of RN CM/DNs (DDA proposal, July 2025). That document is marked as a proposal, so confirm the current approved waiver language with DDA before relying on it.

Washington: delegation in community residential programs

Washington's nurse delegation law, RCW 18.79.260, names "community residential programs for people with developmental disabilities" certified by the Department of Social and Health Services (DSHS) as a community-based care setting where delegation can happen, along with adult family homes and assisted living facilities.

Who can accept a delegated task. In these settings, an RN may delegate only to registered or certified nursing assistants or certified home care aides, apart from simple care tasks the law exempts. The person's condition must be "stable and predictable," and the decision to delegate is up to the nurse. Before delegating, the RN delegator must verify that the staff member holds an unrestricted Washington credential and has completed basic caregiver training and nurse delegation core training, plus the special focus on diabetes training before insulin injections (WAC 246-840-930). For DSPs in community residential programs, the core training counts as nine hours of continuing education and the diabetes training as three, though neither counts toward basic training (WAC 388-829-0076).

Consent and written instructions. The nurse must get written consent from the person or their authorized representative the first time delegation is used. Documented verbal consent can work if written consent follows within 30 days. The nurse gives the staff member written instructions that are specific to one person and one staff member and can't be transferred to anyone else. They cover the purpose of the task, the steps, the risks, what to watch for and when to call the nurse (WAC 246-840-930).

Supervision. The nurse teaches the task and checks competency, for example with a return demonstration. Supervision and reevaluation happen at least every 90 days. With insulin injections, supervision happens at least every two weeks for the first four weeks, then at least every 90 days. Washington's delegation decision tree walks through the same questions in order.

No pressure to delegate. The law says no one may coerce a nurse into delegating when the nurse believes it would compromise patient safety, and nurses can't face employer reprisal for refusing (RCW 18.79.260).

For the rest of Washington's DSP training rules, see our guide to WAC 388-829.

What this means for DSPs

If you carry out delegated tasks, a few habits keep you and the people you support safe:

• Do only what was delegated to you. In Washington, a delegated task belongs to one person and one staff member. Covering a shift doesn't mean you can do a coworker's delegated task.
• Follow the written instructions exactly, and ask the nurse when something isn't clear.
• Report changes. If the person seems different, a reading is out of range or an order changes, tell the delegating nurse. Delegation depends on the person staying stable.
• Keep your credentials and training current. A lapse can stop you from doing delegated tasks until it's fixed.

What agencies should track

Delegation runs on dates and documents. For each person and each delegated staff member, keep:

Our guide to tracking employee training in a care agency covers how to keep these dates from slipping.

How TES helps

Delegation itself comes from your nurse and your state's rules, and no course replaces the nurse's person-specific teaching and competency check. TES courses can support the medication safety training around it. The Five Rights of Medication Administration, taught by a registered nurse, reviews the rights and builds them into a broader medication safety framework for community care.

If you work in Maryland, our Maryland DSP requirements page and the Maryland Community Pathways Waiver DSP compliance pathway show how required training fits together. In Washington, see our Washington DSP requirements page and the Washington DSP compliance pathway.

Training & eTracking Solutions has trained more than 200,000 professionals since 2010, and our catalog includes 400+ courses and programs. As an NADSP Accredited Education provider, our courses count toward the DSP-I and DSP-II credentials. Contact us to set up training and tracking for your team. For more on I/DD roles, see our guides to direct support professionals and DSP supervisors.

This article summarizes the NCSBN-ANA National Guidelines for Nursing Delegation (2019), Maryland Board of Nursing regulations in COMAR 10.27.11, Maryland DDA materials, and Washington's RCW 18.79.260 and related rules. It is not legal or nursing practice advice. Delegation rules differ by state and setting, so check your state board of nursing and Medicaid program before making decisions.