Sample Assisted Living Delegating Nurse Agreement

Assisted Living

Welcome to Senior Service Maps. We are a company that sends referrals to Assisted Living facilities with no referral fees. We also offer free support. Below is a copy of a sample delegating Nurse agreement; We strongly encourage you to let your attorney review this before you use it. If you are interested in receiving clients from us please click (here). Thank you

Click here to start your own Assisted living facility!


Case Manager!

Delegating Nurse Agreement




This Agreement is made by and between ____________________________ (Facility)

_____(Delegating Nurse)________, RN. (Nurse)

_____(Delegating Nurse)_________, RN has agreed to act as Case Manager/Delegating Nurse for ______________ Assisted Living Home and is willing to provide delegating nurse services.


The following services will be provided:

1. Review with the Director, the Health Care Practitioner form of all potential residents for accuracy, completeness, and ability to safely care for the residents.

2. Within 14 days of a new resident’s admission assess the resident, review the resident’s current medical profile, including all prescription and nonprescription medications and make appropriate recommendations to the Director. Also assess the medication assistant’s ability to administer medications to that resident, or the resident’s ability to self-administer medications.

3. At least every 90 days reassess residents and the medications of all residents who are capable of self-administering, or who self-administer with reminders, supervision, or physical assistance to determine their continued ability to sell medicate.

4.Perform on-site reviews every 45 days for all residents who require that medications be administered by non-licensed personnel. This review shall include reviews of the Physicians Order Sheet, the Medication Administration Record, an assessment of the resident and the non-licensed person’s continued ability to administer medications.

5. Be available to the Director to answer questions concerning resident’s medical issues and/or medication issues.

6. Teach the Medication Administration Course and the Review Course to unlicensed personnel.

7. Conduct In-Services as appropriate.

8. Consult with families, physicians and pharmacy personnel as requested.

9. ____(Backup DN)__________, RN will be in the back-up position if_____(DN)_________ is not available.

10. Payment in the amount of $________ per resident for initial assessment and $______ per resident for the 45day review is due at the time of service.

11. __________(DN)_______, RN has the right to terminate services immediately, but not limited to the following reasons.

12 .________(DN)__________ will serve as ALF alternate manager until _________________________.


  • Three (3) consecutive late payments and/or not paying the late fee
  • If recommendations have been strongly given regarding patient’s
  • safely and/or patient’s safety is compromised, If continuous severe medication errors are made by the same individual, which jeopardizes the patient’s well-being;
  • If abuse is suspected; or
  • Falsification of documentation




(owner)_________________________            Delegating Nurse________________________





Comments are colsed