Licensed Home Care Agencies and Nursing Scope of Practice: Impacts on Persons Needing Assistance in Community Living

Unlicensed assistive personnel who help people in their homes might be employed by a licensed home care agency or can be employed directly by the person who requires assistance. State nurse practice acts and medication aide laws determine who can perform common tasks such as managing catheters, tube feeding, and medication management. Variations in state laws and regulations mean that aides working through agencies may have a more limited scope of practice than if they were hired independently. This could mean that some community-dwelling older adults and people with disabilities might not be able to get the help they need or be forced to enter institutions solely to have access to licensed personnel who can provide the required help. This study examined how state laws affect the scope of practice of unlicensed assistive personnel and investigated if such laws and policies act as barriers, facilitators, or best practices to support community living for seniors and people with disabilities receiving home care through a licensed home care agency. This project informs HRSA’s workforce programs and policy related to the certification and education of those employed in LTSS. It also provides important guidance to the Centers for Medicare and Medicaid Services, which establishes regulations and recommendations regarding LTC programs. The study was conducted in partnership with the Disability Rights Education and Defense Fund.


Key Questions

  • What health maintenance tasks do licensed home care agencies allow non-licensed personnel to perform? What tasks are these personnel barred from performing?
  • How do agencies interpret and implement nursing delegation provisions of state law?
  • How do agencies handle provision of care involving tasks that cannot be delegated to non-licensed personnel? What is the impact on clients and families?
  • How do agency policies and practices regarding health maintenance tasks act as barriers or facilitators for community living?
  • What are the strengths and weaknesses of the current system of nurse delegation from the perspective of home health care workers and their clients?


Journal Article

Dudley, N, Miller, J, Breslin, ML, Chapman, SA, Spetz, J. The Impact of Nurse Delegation Regulations on the Provision of Home Care Services: A Four-State Case Study. Medical Care Research and Review, 2020, online September 23.


The objective of this study was to explore how home care workers and the agencies that employ them interact with their state’s nurse practice act in the provision of care. Using a qualitative case study approach, we selected four states with varying levels of restrictiveness in their nurse delegation regulations. We conducted interviews (N = 45) with state leaders, agency leaders, and home care workers to learn how these policies affect the home care workforce’s ability to perform care tasks for their clients in order to allow clients to remain in their own homes. We found that increased training and input from registered nurses is needed to identify appropriate health maintenance tasks to delegate to home care workers and support development of training strategies. The federal government could support the development of evidence-based guidelines for training and competency testing as well as for appropriate delegation of health maintenance tasks.

For questions, contact: Joanne Spetz, PhD FAAN, Director, UCSF Health Workforce Research Center, [email protected]