Medications Administration - 25 responses 21 May10
POLICY TRAINING QUALITY
Click on the state name to go directly to that state's response:
Developmental Disabilities Nurses Association
18th Annual Education Conference
Keynote: Nancy Thaler
Williams, Jeff (DMH) [mailto:Jeff.Williams@mh.alabama.gov]
Attached is a PowerPoint presentation that I do that is an abbreviated version.
Meds Admin ALAB PowerPt
POLICY: The Alabama Board of Nursing (ABON) adopted regulations allowing Residential and Day programs to have their nurses delegate assistance with administering of medication to direct support professionals. TRAINING: The DSP's go through a 12 module training (Medication Assistance Certification) with proficiency tests for each module to become MAC workers. The training is conducted by a Medication Assistance Supervisor or MAS RN/LPN. MAS nurses go through a 1-day training with a proficiency test. This training is taught by a Medication Assistance Trainer RN or MAT Nurse. The MAT nurse started as a MAS nurse and received additional training through our Department. The MAT nurse must be an RN. The MAC workers and MAS and MAT nurses must receive 4 hours of additional or update training annually in order to remain certified. Much of the training for nurses is conducted by the Department by our Director of the Nurse Delegation Program. QUALITY: My office collects and analyzes data on Levels I, II, and III medication errors as part of our Incident Prevention and Management Plan. My certification staff reviews compliance with the NDP during their annual site visits.
I must say that this program is rather laborious and daunting. It is not popular with providers, nurses, or advocates. But hence, it was approved by the ABON. What we originally asked for was to allow our providers and their Direct Support Professionals to act as foster parents. In Alabama, foster parents have the same authority over medication assistance as parents or legal guardians. However, this was not approved and hence the Alabama NDP was born.
Director of Quality and Planning
Division of Intellectual Disabilities Services
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From: Lockyer, Laurie
Article 8 and 9 - for group homes- Rule Book attachment applies to Vendors as well as State Operated Group Homes
Article 10- Child Developmental Homes
Article 11- Adult Developmental Homes
Sent: Friday, May 07, 2010 4:07 PM
POLICY In Arkansas health maintenance activities may be provided by a designated care aide (supportive living worker). All health maintenance activities (to include oral medication administration/assistance, shallow suctioning, maintenance and use of intral-feeding and breathing apparatus/devices), except injections and IV's, can be done in the home by a designated care aide, such as a waiver worker. With the exception of injectable medication administration, tasks that consumers would otherwise do for themselves, or have a family member do, can be performed by a paid designated care aide at their direction, as long as the criteria specified in the Arkansas Nurse Practices Consumer Directed Care Act has been met. Health maintenance activities are available in the Arkansas Medicaid State Plan as self directed services. State Plan services must be exhausted before accessing waiver funding for health maintenance activities. The Arkansas Nurse Practice Act applies to all programs which administer medications. The act does not require a provider or their employees to perform any specific tasks, nor does it require a nurse to delegate tasks. Providers may at their discretion elect not to allow staff to perform any health maintenance activity. The training and education that non-medical waiver providers must have in order to administer medications to participants who cannot self-administer is determined and provided by the nurse or nurse consultant when nurse delegation is occurring, or by the physician when consumer directed care applies. Frequency of follow up is also determined by these professionals in accordance with the provisions in the Arkansas Nurse Practice Act. These provisions leave the training and monitoring frequency to the discretion of the professionals responsible and knowledgeable in this discipline.
The responsibility for ensuring that participant medications are managed appropriately is delegated to the direct care supervisor. The provider is required to have procedures and policies in place regarding medication management. QUALITY Annually, DDS Quality Assurance staff conducts a review of the providers policies, procedures and consumer files. Items reviewed include, but are not limited to, locked medication storage and medication logs. Any time there is a reported incident or concern; DDS Quality Assurance staff will investigate and follow up as needed. The supportive living direct care supervisor has on-going responsibility for monitoring participant medication regiments. Minimum components with monitoring activities for methods, frequency and effectiveness include:
POLICY According to the Consumer Directed Care Act, competent
adults or parents, guardians or caretaker (as defined in the Act) of a minor
or incompetent adult "may" now delegate all health maintenance activities
in a home to a paid caregiver, e.g. waiver staff, except
a. Physical, psychological, and social assessment which requires nursing judgment, intervention, referral, or follow-up;
b. Formulation of the plan of nursing care and evaluation of the client's response to the care rendered;
c. Tasks that require nursing judgment or intervention;
d. Teaching and health counseling;
e. Administration of any injectable medications (intradermal, subcutaneous, intramuscular, intravenous, intraosseous, or any other form of injection) or intravenous therapy.
f. Receiving or transmitting verbal or telephone orders.
Nurse delegation is not required, however a physician, Advanced Practice Nurse or Registered Nurse must determine a designated care aide under the direction of a competent adult or caretaker can safely perform the activity in the minor child's or adult's home. This may include the ability for waiver staff to do, for example: 1. Enteral feeding via G-tube/J-Tube; 2. Give medications, except by injection/IV to include monitoring an IV; 3. Suctioning; 4. Trach care; 5. Catherization; 6. Oxygen supplementation
The following five requirements are the only requirements that must be met (all five must be met):
DDS ACS Waiver Coordinator Arkansas
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Sent: Tuesday, May 11, 2010 6:27 PM
Medication administration to persons receiving services in Colorado are as follows:
POLICY 1) Licensed nurses can administer medications in any developmental disabilities service setting.
2) When the person receives services in an residential (ICF-MR or community group home)or day programs operated by the State of Colorado, medications are administered by licensed psychiatric technicians.
2) Authority for non-licensed staff to administer medication in non-state operated ICFs-MR and community programs is specifically allowed by state statute. When the person resides in a privately operated ICF-MR, in a community group home (4-8 residents) or an individual residential setting (1-3 residents),and/or receives services in day programs or supported living services program, medications can be administered by a Qualified Medication Administration Professional (QMAP). TRAINING All QMAPs must pass a medication administration class and practical test that has been approved by the Colorado Department of Public Health and Environment to serve as a QMAP. Staff are also able to administer G-tube/NG-tube feedings and administer medications via such tubes if they complete training from an RN and pass competency evaluations by the RN.
POLICY 3) State statutes also allow nurses to delegate certain function to non-licensed staff when certain specific requirements are met (e.g., j-tubes, IM insulin injection, etc.). Nurses may not delegate duties related to diagnosis or determining the person's need for a specific treatment.
CDHS - Division for Developmental Disabilities
Phone: (303) 866-7439
State of Connecticut Department of Developmental Services
POLICY In Connecticut non-licensed staff certified in medication administration by the Dept. of Developmental Services are allowed to administer medications medication in any residential facility operated, licensed, or funded by the department in which 15 or fewer persons reside. Medication administration is a delegated nursing activity and a registered nurse is responsible for supervising the delegation process.
In order to administer medication staff must successfully complete a department approved training program, which includes but is not limited to, instruction on the following areas:
(A) Medical Terminology
(B) Drug classifications, including controlled substances, dosage, measurement and forms
(C) Intended purpose and effects of medication
(D) Assessment of drug reactions, including but not limited to, known side effects, interactions and the proper course of action if a side effect occurs
(E) Correct and safe techniques of medication administration including, but not limited to, the correct methods to prepare, administer and chart medication
(F) Prohibited and dangerous techniques of medication administration
(G) Documentation of medication administered to each client, including but not limited to, evaluation, reporting and recording responses of clients to the medication administered
(H) Responsibilities associated with control and storage of medication
(I) Available medication reference texts or other written materials
(J) Lines of authority and areas of responsibility relative to certified unlicensed personnel, licensed personnel and others
(K) State and federal statutes and regulations pertaining to medication.
(2) Laboratory Practicum
The laboratory practicum consists of:
(3) Worksite practicum under the supervisor of a registered nurse
The on-site practicum consists of:
The medication administration certificate expires every two years. There
are two components to the recertification process: a written examination and
an on-site practicum which must be completed within 90 days prior to the employee's
certification expiration date.
QUALITY Supervision and Quality Assurance
The initial administration of medications is observed by the supervising registered nurse at the employee's worksite. The supervising registered nurse makes periodic observations of the administration of medications by certified unlicensed staff at least annually at the employee's worksite. At least four times a year on a quarterly schedule, the supervising registered nurse reviews documentation pertaining to the administration of medication including prescriber orders, medication records, and controlled drug counts. The supervising registered nurse reviews all incident reports related to medication errors and ensures corrective actions are taken as a result of staff noncompliance with agency regulations. Reports are submitted to Director of Health Services as needed for consideration of department sanctions including suspension or revocation of medication certification.
Romain Ramsuchit [mailto:firstname.lastname@example.org]
Sent: Friday, May 21, 2010 9:31 AM
POLICY Organizational policy stipulates that only licensed medical personnel can directly administer medication. Further, unlicensed personnel may supervise the individual with the self-administration of medication.
Changes to Georgia's Nurse Practice Act (NPA), scheduled to take effect July 1st, 2010, will allow for unlicensed, trained personnel to perform specific duties that would have otherwise been performed by a nurse. The changes in the NPA describes exceptions to the practice of licensed nursing, not delegation.
Romain Ramsuchit, M.A.
Residential Svcs. Administrator/Housing Dev.
Georgia Department of Behavioral Health and Developmental Disabilities
CONNIE SIMS [mailto:CONNIE.SIMS@illinois.gov]
Sent: Friday, May 07, 2010 5:15 PM
In response to your request below, please see our administrative rule on Medication Administration for selected DD community programs. The rule implements a section of the Illinois Nurse Practice Act. A link below is provided:
Medicaid Waiver Administration Section
Division of Developmental Disabilities
Dept. of Human Services
Sent: Friday, May 07, 2010 3:58 PM
TRAINING the Division of Intellectual Disabilities (DID), Supports for Community Living (SCL) Medicaid Waiver Program has partnered with the Department of Public Health to develop a medication administration curriculum for unlicensed assistive personnel (UAP). The curriculum has been approved by the Kentucky Board of Nursing for implementation in the SCL Waiver Program.
The curriculum will be required by all SCL Providers and will be the replacement for current medication curricula. The curriculum requires that each SCL provider designate a registered nurse to complete a one day face-to-face training with DID/SCL nurses. The SCL provider registered nurse will then be responsible for training of the Direct Support Professional staff for the provider according to the requirements in this curriculum. Multiple agencies could contract and/or share registered nurses in order to complete this requirement.
QUALITY Monitoring and oversight of the implementation process will be the responsibility of the DID Risk Management staff, Area Administrators, Certification Review Team and DID Nurse Consultant/Inspector.
Claudia J. Johnson, Acting Director
Division of Developmental and Intellectual Disabilities
Phone: 502-564-7702 Fax: 502-564-8917
One attachment Meds Admin LOUISIANA ACT 451.pdf
Louisiana has been struggling with this issue for a number of
years. Right now we have three methods for administering medications:
POLICY and TRAINING
In attempting to address the above ongoing issues with physician delegation and the undue complexity of the CMA course, the Department (Department of Health and Hospitals) worked with the Board of Nursing to provide another form of medication administration - we passed ACT 451 (attached) in 2005 but the final bill was more complicated in terms of what was wanted and the department could not agree with the Board of Nursing on rulemaking. The major source of contention was that the nurses' board insisted that physician delegation be eliminated completely and we indicated that the providers did not have the resources nor were there enough nurses to provide all of the person specific training that was required. We amended the bill in 2008 to allow a 3-year phase in so that we could get data to the Board of Nursing on the barriers to full implementation of this bill. So we finally came up with some rules and published a notice of intent earlier this year but there was so much provider push back to the rules and the resources it would have required (especially in light of budget cuts)- we ended up pulling the rule. Several of the provider groups have gotten an House Resolution proposed this session (HR94) which would put a moratorium on the statute until we figure out a better option for nurse administration. I am pretty confident this will pass. We still feel strongly that we need a more effective option than those listed above and would appreciate any information you have about options that have worked well in other states.
POLICY Maryland has several approaches to medication administration in the community setting. The Maryland Developmental Disabilities Administration's (DDA) regulations (COMAR 10.22) adopts the Maryland Board of Nursing (MBON) regulations and training requirements for unlicensed staff. MBON has regulations (COMAR 10.27.11) that guide Maryland in medication administration in the community setting. The most common model for administering medications in the community is the RN Delegation Model.
RN Delegation Model:
TRAINING The unlicensed staff who are being paid by a provider agency or others to provide for medication administration must be certified through the Maryland Board of Nursing. These individuals take a 20 hour Medication Administration Training Program developed by DDA in conjunction with the MBON. These staff are delegated medication administration privilege by the DD RN Case Manager/Delegating Nurse. Under this model:
1. The RNs are required to take a 16 hour training on Case Management and Delegation (CM/DN) in the DD community setting.
2. Delegation of medication administration by the DD RN Case Manager /Delegating Nurse to the Certified Medication Technician (CMT) requires the RN to provide initial and ongoing assessments minimally every 45 days, care planning and supervision of unlicensed staff.
3. Self administration of medication is encouraged for the individuals that are able to do so. The RN verifies through a screening the ability of the individual to self medicate. This skill is reevaluated minimally annually at the time of the Individual Planning meeting.
POLICY The MBON allows for exclusions to the Delegation Model. These exclusions include:
1. The cognitively capable adult living in their own home who can hire their own staff to provide medication of a routine nature.
2. Family Friends, Foster Family, Guardian who provide for medication administration without pay.
Additional information is available in the DDA regulations (COMAR 10.22.02) and at the MBON website at www.mbon.org.
Sent: Tuesday, May 11, 2010 7:50 AM
To: Nancy Thaler
Subject: FW: Medications administration
Sharon Oxx RN, CDDN
Director of Health Services, DDS
500 Harrison Ave.
Boston, MA 02118
From: Oxx, Sharon (DMR)
Sent: Tuesday, May 11, 2010 7:47 AM
Subject: RE: Medications administration
I have been asked to respond. I will be providing a brief overview of the program in Mass. at the same conference prior to your presentation. I have attached a brochure that gives a brief description of the program (called MAP) in Massachusetts.
In Massachusetts, we:
Use a standardized, mandated curriculum
Provide competency testing by a third party (American Red Cross) to provide Certification in MAP
Provide oversight by state agencies and ongoing support for MAP trainers and Providers
Provide clear guidance to the Providers via a MAP Policy Manual approved by DPH, DMH and DDS
Have a robust medication error reporting system (called Medication Occurrences or MORs)
Enforce competency criteria including revocation of Certification
For more detailed information cut and paste the following link:
See also attachment Meds Admin MINN 245B Consol Standards.doc See 245B.05 Consumer protection standards re QUALITY
This is from our current licensing standards for DD Service Providers (MN Statutes, Section 245B). However, we are beginning to develop a new set of standards.
Subd. 5. Consumer health. The license holder is responsible for meeting the health service needs assigned to the license holder in the individual service plan and for bringing health needs as discovered by the license holder promptly to the attention of the consumer, the consumer's legal representative, and the case manager. The license holder is required to maintain documentation on how the consumer's health needs will be met, including a description of procedures the license holder will follow for the consumer regarding medication monitoring and administration and seizure monitoring, if needed. The
medication administration procedures are those procedures necessary to implement medication and treatment orders issued by appropriately licensed professionals, and must be established in consultation with a registered nurse, nurse practitioner,
physician's assistant, or medical doctor.
TRAINING Requirements section:
(6) medication administration as it applies to the individual consumer, from a training curriculum developed by a health services professional described in section 245B.05,
subdivision 5, and when the consumer meets the criteria of having overriding health care needs, then medication administration taught by a health services professional. Staff may administer medications only after they demonstrate the ability, as defined in the license holder's medication administration policy and procedures. Once a consumer with overriding health care needs is admitted, staff will be provided
with remedial training as deemed necessary by the license holder and the health professional to meet the needs of that consumer.
For purposes of this section, overriding health care needs means a health care condition that affects the service options available to the consumer because the condition requires:
(i) specialized or intensive medical or nursing supervision; and
(ii) nonmedical service providers to adapt their services to accommodate the health and safety needs of the consumer;
From: Whelan, Shari [mailto:Shari.Whelan@dmh.mo.gov]
POLICY: The Missouri Division of DD policy is that all staff supporting individuals in community placement or other paid services who are responsible for the administration of medication must be either a licensed medical professional OR they must be trained and certified as a DD Medication Aide or a DHSS Level I Medication Aide as the minimal level of training (evidence of competency). In addition the certified medication aides (non-licensed staff) should have benefit of delegation and periodic supervision from a licensed medical professional associated with that service provider.
TRAINING At this time, the minimal level of medication aide certification includes no less than 16 hours of classroom instruction, self study, no less than 80% performance on a written exam and 100% performance on a practicum. Classes are instructed by certified and approved instructors. Once certified, the medication aide is required to participate in at least 4 hours of update training every 2 years to remain in good standing. The Division maintains a statewide registry for initial certification and tracking of the 2 year updates.
Each residential organization has a minimum of 1.25 hours per consumer of RN time for the purposes of delegation and oversight of medication administration and other delegated nursing tasks. They also serve as an oversight function to assure medical needs are supported adequately within that organization.
QUALITY Provider organizations are required to report
medication error events.
These events are shared with the RN providing delegation and oversight
and they are entered into the Division's data tracking system so that
QE reports can identify trends and patterns that can be addressed
through additional training, curriculum modification, or the identified
most appropriate intervention. The Division's Quality Enhancement
Nurses in each Region monitor the data, communicate with the providers,
their RN's, medication administration instructors, and assure that
interventions taken result in the desired outcome. They also provide
training to the Community RN providing the oversight.
The Division plans to revise and update the current curriculum
certification of medication aides in the near future. The following are
some supporting documents:
(CSR defining the certification process)
(Community RN program
provides the delegation and oversight function of med administration)
There are other supporting Directive related to Event Reporting
the DMH website: http://dmh.mo.gov/mrdd/new/provider1.htm
Please let me know if I can provide you with further information. Shari
Shari J Whelan RNIV BSN
MO Division of Developmental Disabilities
Consumer Health & Wellness Coordinator
Quality Enhancement Leadership Unit
Justad, Jean [mailto:JJustad@mt.gov]
Sent: Monday, May 10, 2010 12:48 PM
POLICY In 1977, the Montana State Legislature passed an amendment allowing nonmedical professionals to assist and supervise in the self-administration of medications by persons with developmental disabilities. The Board of Nursing is the legal entity authorized to define the medication assistance activities of direct care staff. The degree of assistance varies depending on the abilities of the individual served. Any medication, including over the counter medications, with which staff are assisting must be ordered by a physician. The physician must also order that assistance be given to each client served. Staff persons must document all medication given on a Medication Administration Record. Direct care staff are not certified to give insulin but may administer an epi pen in an emergency. Other medical tasks which may not be delegated to non-medical professionals are outlined in the Board of Nursing Rules.
TRAINING All staff persons that assist in medication administration must be medication certified. This is accomplished by studying the current manual (Health and Medication Administration Manual) which is designed as a self-study manual and was rewritten by me in 2009. The staff must then pass a written test with a score of 90% or higher. All staff must recertify every two years. The medication certification requirements are outlined in the Administrative Rules of Montana.
QUALITY The State Quality Improvement Specialists monitor the quality of work provided by the staff by reviewing all medication errors (incident reports) weekly as well as conducting inspections of providers yearly. They may require a staff person to recertify sooner than two years if a pattern of problems is discovered.
Sent: Monday, May 10, 2010 9:51 AM
POLICY New Hampshire Bureau of Developmental Services
Rule He-M 1201 Administration of Medications that was developed in 1982 in
conjunction with the NH Board of Nursing, with a state-mandated and
approved curriculum and test in place. This rule was last updated in 2003
and will be updated again in 2011. This rule has specific expectations for
unlicensed staff around training, competency (knowledge, skills, judgment),
ongoing supervision, and occurrence reporting. Medication occurrence
reports are reviewed monthly by a Medication Committee that is chaired by
an MD and includes community representation.
I have included a link to our Developmental Disabilities Nurses
(DDNNH) website, where a copy of the rules and the entire Training
Curriculum (except the tests) can be viewed.
TRAINING The New Hampshire Administrative Rule, He-M 1201- Administration of Medication, defines the qualifications of Nurse Trainers:
He-M 1201.05 Training and Authorization of Providers.
(a) Providers who request training to be authorized to administer medications shall complete a training program that:
(1) Consists of a minimum of 8 hours of classroom training, exclusive of testing or nurse trainer competency evaluation;
(2) Is conducted by a nurse trainer; and
(3) Covers the following topics:
a. The role, responsibilities and performance of the authorized provider in the medication administration process;
b. Effective health care coordination;
c. Rights regarding accepting or refusing medications;
d. Principles of infection control as they relate to medication administration;
e. Anatomy and physiology as it relates to medication administration;
f. Common reactions to medications;
g. Categories of medications and their effects;
h. Effective management of poisoning or medication overdose;
i. Storage and disposal of medications;
j. Communication with individuals and if applicable, their guardian about their medications; and
k. The 6 principles of medication administration including:
1. The correct medication;
2. The correct dosage of the medication;
3. The medication to the correct individual;
4. The medication at the correct time;
5. The medication to the individual by the correct method; and
6. The accurate documentation;
l. Methods of administration including:
10. Rectal; and
11. When indicated by the needs of the individual:
(ii) Enteral; and.... (b) To be authorized to administer medications, providers shall have:
(1) Completed a minimum of 8 hours of classroom training as set forth in (a) above;
(2) Scored 80% or higher on a written examination based on the information conveyed to them in the training referenced in (a) above;
(3) Demonstrated knowledge of the following pertaining to each individual's medication(s):
a. The name of the medication;
b. The reason for its use;
c. Any side effects or adverse reactions; and
d. Any special instructions such as giving certain fluids, checking pulse rate or monitoring blood levels; and
(4) Following direct observation by a nurse trainer, been found appropriate, pursuant to Nur 404.06(b)-(f), to be authorized to administer medications.
(c) Authorization pursuant to He-M 1201.05(b) shall be valid for a period of 12 months from the date of issuance.
(d) Whenever a change in an individual's medication occurs or a new individual begins to receive services, the nurse trainer shall educate the authorized provider according to He-M 1201.05(b)(3).
(e) Re-authorization of an authorized provider shall:
(1) Follow a nurse trainer's direct observation of the provider in the administration of medication;
(2) Be performed in accordance with Nur 404.06(b)-(f), as applicable; and
(3) Be valid for a period of 12 months from the date of issuance.
(f) Documentation of authorization pursuant to(b)(4) and (e) above shall be maintained by the nurse trainer for each authorized provider.
(g) Authorization of a provider to administer medication shall be rescinded pursuant to Nur 404.06(g)-(h). Authorization shall be reinstated pursuant to He-M 1201.05(b)(4).
QUALITY (from the above source)
m. Methods of documenting:
1. The administration of medications;
2. The use of controlled substances; and
3. Medication occurrences.
Ohio's approach to the administration of medications in community programs.
POLICY In Ohio, trained and certified unlicensed direct care staff can:
In most settings, these activities are performed through nursing delegation. However, in small community living arrangements (0 - 5 roommates) the supervision and oversight of medication administration and health-related activities can be done by non-nursing managers.
TRAINING Training and certification requirements:
Training of unlicensed staff must be done by an RN who has been
trained and certified by the Ohio Department of Developmental Disabilities
There are approved curriculums for all training courses for unlicensed direct care staff
Certification 1 covers medication administration and health-related activities and is a 14 hours course
Certification 2 covers G/J tubes and is a 4 hour course.
Certification 3 covers insulin injection and is a 4 hours course.
Certification 1 is a prerequisite for both Certification 2 and 3.
Other components of the process:
Individuals with developmental disabilities are assessed to determine their ability to self-administer medications.
In settings where nursing delegation is not required, a quality assurance review is conducted by an RN for each individual who receives assistance with medication administration at a minimum of once every 3 years.
DODD maintains a statewide database of all certified RN Trainers and direct care staff.
Ohio Department of Developmental Disabilities
Nancy, the first link is to our administrative rules for 24
hour service. Medication/Health starts on page 23. The next two links explains
the nurse delegation roles - this has been a critical tool to Oregon. Hope
POLICY 411-325-0120 Health: Medical
(1) Written policies and procedures. The program must have and implement policies and procedures that maintain and protect the physical health of individuals. Policies and procedures must address the following:
(a) Individual health care;
(b) Medication administration;
(c) Medication storage;
(d) Response to emergency medical situations;
(e) Nursing service provision, if provided ;
(f) Disposal of medications; and
(g) Early detection and prevention of infectious disease.
(2) Individual health care. The individual must receive care that promotes their health and well being as follows:
(a) The program must ensure each individual has a primary physician or primary health care provider whom he or she, the parent, guardian or legal representative has chosen from among qualified providers;
(b) The program must ensure each individual receives a medical evaluation by a qualified health care provider no less than every two years or as recommended by a physician;
(c) The program must monitor the health status and physical conditions of each individual and take action in a timely manner in response to identified changes or conditions that could lead to deterioration or harm;
(d) A physician's or qualified health care provider's written, signed order is required prior to the usage or implementation of all of the following:
(A) Prescription medications;
(B) Non prescription medications except over the counter topical;
(C) Treatments other than basic first aid;
(D) Modified or special diets;
(E) Adaptive equipment; and
(F) Aids to physical functioning.
(e) The program must implement a physician's or qualified health care provider's order.
(3) Required documentation. The program must maintain records on each individual to aid physicians, licensed health professionals and the program in understanding the individual's medical history. Such documentation must include:
(a) A list of known health conditions, medical diagnoses; known allergies and immunizations;
(b) A record of visits to licensed health professionals that include documentation of the consultation and any therapy provided; and
(c) A record of known hospitalizations and surgeries.
(4) Medication procurement and storage. All medications must be:
(a) Kept in their original containers;
(b) Labeled by the dispensing pharmacy, product manufacturer or physician, as specified per the physician's or licensed health care practitioner's written order; and
(c) Kept in a secured locked container and stored as indicated by the product manufacturer.
(5) Medication administration. All medications and treatments must be recorded on an individualized medication administration record (MAR). The MAR must include:
(a) The name of the individual;
(b) A transcription of the written physician's or licensed health practitioner's order, including the brand or generic name of the medication, prescribed dosage, frequency and method of administration;
(c) For topical medications and treatments without a physician's order, a transcription of the printed instructions from the package;
(d) Times and dates of administration or self administration of the medication;
(e) Signature of the person administering the medication or the person monitoring the self administration of the medication;
(f) Method of administration; Page 24 of 80
(g) An explanation of why a PRN (i.e., as needed) medication was administered;
(h) Documented effectiveness of any PRN (i.e., as needed) medication administration;
(i) An explanation of any medication administration irregularity; and
(j) Documentation of any known allergy or adverse drug reaction.
(6) Self-administration of medication. For individuals who independently self-administer medications, there must be a plan as determined by the ISP team for the periodic monitoring and review of the self-administration of medications.
(7) Self-administration medications unavailable to other individuals. The program must ensure that individuals able to self-administer medications keep them in a secure locked container unavailable to other individuals residing in the same residence and store them as recommended by the product manufacturer.
(8) PRN/Psychotropic medication prohibited. PRN (i.e., as needed), orders will not be allowed for psychotropic medication.
(9) Adverse medication effects safe guards. Safeguards to prevent adverse effects or medication reactions must be utilized and include:
(a) Obtaining, whenever possible, all prescription medication except samples provided by the health care provider, for an individual from a single pharmacy which maintains a medication profile for him or her;
(b) Maintaining information about each medication's desired effects and side effects;
(c) Ensuring that medications prescribed for one individual are not administered to, or self-administered by, another individual or staff member; and
(d) Documentation in the individual's record of reason why all medications should not be provided through a single pharmacy.....
POLICY - Delegation http://www.oregon.gov/DHS/spd/provtools/dd/nursing_manual/delegation.shtml
TRAINING - http://www.oregon.gov/DHS/spd/provtools/dd/nursing_manual/delegation_form2.pdf
TEACHING - WRITTEN INSTRUCTIONS - RATIONALE - TEACHING
The written instructions for the above task, including risks, side effects and the
appropriate response, have been reviewed with the unlicensed staff and can be
Teaching process used include (check methods used):
The rationale for determining that the skill of the unlicensed staff is appropriate
to the person's condition is based on the following (check all that apply):
These are searches Mary Lee did-tons of stuff in them!
Kauffman, David F [mailto:email@example.com]
Sent: Friday, May 07, 2010 6:37 PM
Pennsylvania's Medication Administration Program.
MEDICATION ADMINISTRATION FOR PEOPLE WITH INTELLECTUAL DISABILITIES IN PENNSYLVANIA
POLICY Pennsylvania has regulations addressing medication administration in a number of settings including small community homes (8 people or fewer), small ICF/MR (8 people or fewer) and Adult Training and Vocational Facilities.
TRAINING The Medication Administration Program teaching unlicensed staff to administer medication has been in use since 1981. It began as a self-taught course, but in 1995 became an instructor lead course in a Train the Trainer model. The current course was developed in 2002-2003 and first used in 2004. It provides medication administration training for multiple program offices including Aging, Children and Youth, and Personal Care Homes as well as for providers for people with IDD.
The Office worked with the Pennsylvania state nursing board to clarify jurisdiction over our licensed sites and the parameters of the course and activities related to medication administration that unlicensed staff can perform. The course teaches oral administration with guidance about other routes of administration that must be taught by a clinical, licensed professional such as a nurse or physician.
The course is structured around a Train the Trainer model where the Department instructors, who are all RNs, teach agency staff to become trainers. The trainers then teach unlicensed staff at their agency to administer medication. The requirements for the trainers are that they have passed the medication course at their agency, have worked for their agency for 6 months or longer, and are familiar with their agency policies and procedures around medication administration. Both trainers and students take competency examinations. As well those individuals administering medication are monitored on a regular basis through reviews of the Medication Administration Records (MAR) they complete and observations of medication passes. Trainers must recertify every 3 years and medication administrators must pass an annual practicum including 4 MAR reviews and observations of 2 medication passes.
A trainer extender was developed to assist the trainers in monitoring the direct support staff who administer medication. This individual called the practicum observer can review MARs and observe medication passes. They in turn are monitored by the trainers. All of the materials for teaching the course, testing, and monitoring of medication administrators are standard and there are standard strategies for remediation for those that have difficulty with the tasks.
POLICY Homes and ICF/MR that are larger than must use nurses or other licensed professionals for whom medication administration is allowed under their scope of practice through their respective State Boards. The use of trained, unlicensed staff to administer medication is optional and smaller homes may use nurses if they choose. Data measuring the reporting of medication errors primarily by trained, unlicensed staff show a very low rate of errors given the large number of medication passes. TRAINING Unlicensed staff are taught a simplified procedure for administration that differs slightly from that of nurses. As well they are not permitted to take verbal orders.
POLICY The Office is currently working on two other applications of unlicensed persons to give medication. The Family Living regulations (now referred to as Life Sharing) require that the family assure that the person receives all health care including medication. There is no requirement for a standard course to teach these individuals. The Office is developing a course that is more relevant to family life that can be used for those families participating in family living to learn the principles and practices of medication administration. In addition the Office is working with the nursing board to clarify the role of paid, unlicensed staff and administering medication in a private home. When looking at whether or not to teach someone how to give medication, it is always safer to teach people the principles so that they can use them to administer medication in the safest way possible.
From: Lacy, Kathi [mailto:KLacy@ddsn.sc.gov]
Sent: Friday, May 07, 2010 10:11 AM
POLICY In South Carolina, we distinguish between medication administration and medication assistance. The first is a nursing function in an ICF/MR or when performed by a person who has successfully completed the medication technician certification program (directive attached) for non-ICF/MR settings. The latter is paraphrased as helping a person to take their medication by handing them a pill, reminding them to take their medication, ensure they swallow their medication, etc.
DDSN has reviewed the Medication Technician Certification courses
of a number of states that have successfully implemented this program. Most
of these states' programs contain common elements that have been incorporated
into the DDSN approach.
In order to make this training available to as many staff as possible, the DDSN Medication Technician Certification course may be offered in one of three ways: 1) by selected technical or four year colleges; 2) by DDSN employed or contracted clinical staff; or 3) by community provider agencies themselves. Regardless of the forum, all Medication Technician Certification courses will be required to meet the standards enumerated below while adhering to pre-approved curriculum guidelines.
Two types of standards govern DDSN's Medication Technician Certification program: Program Standards and Curriculum Standards. The Program Standards outline the general requirements of the overall program. The Curriculum Standards outline the specific requirements of the units to be taught, the practicum experience, and the supervised medication passes.
1. Length of Program- The length of the initial medication technician training program, including classroom instruction, practicum experience, and supervised medication passes, shall not be less than 16 hours, but may be longer, if required to develop the necessary student competencies.
2. Approved Instructors- Instructors must be Registered Nurses with at least three years of clinical nursing experience. Instructors should have prior experience in training, supervision, and/or working with persons with disabilities. For those Nurse Instructors who do not work in an academic setting (i.e. DDSN employed or community agency employed), a "train the trainer" orientation class will be required by DDSN in order to enhance the consistency and the quality of the Medication Technician courses being offered.
NOTE: It is recommended that all instructors attend a "Train
the Trainer" course prior to teaching Medication Technician training
3. Instructor/ Student Ratio- For classroom instruction, no more than 1 to 24; for supervised practicum experience, no more than 1 to 8; for supervised medication passes, no more than 1 to 1. LPNs, under the direction of the RN Instructor, may be authorized to oversee the 1 to 1 supervised medication passes.
4. Testing- Competence testing will occur for each unit in the curriculum. Tests will measure the knowledge and all basic skills required for safe and effective functioning as a Medication Technician. A passing score of 85% will be required on each unit test with an opportunity to retake each test after additional tutoring has occurred.
5. Certificate- A certificate will be awarded to the employee upon successful completion of all components of the training program.
6. Roster- A roster of all currently employed Medication Technicians will be maintained by each DSN Board or other service provider.
7. CEUs- Each Medication Technician will be required to complete a standardized, annual refresher course on the administration of medication of not less than two hours duration.
8. Oversight- All Medication Technicians will have access to an RN or an LPN if questions arise in the course of the performance of their duties regarding appropriate medication administration practices. Either an RN or an LPN will also provide quarterly oversight, tailored to the specific needs of the agency and its Medication Technicians.
Medication error reporting- All DSN Boards or other community
providers who utilize Medication Technicians to administer medications will
be required to follow Policy Directive 100-29-DD "Medication Error/ Event
10. Sanctions- Provider agencies will track and appropriately follow up with Medication Technicians who commit medication errors. Appropriate follow up may include closer nursing supervision, re-training, progressive discipline or the removal of medication administration privileges.
11. Evaluation- Periodic review of the training being provided to prospective Medication Technicians by instructors will be conducted by DDSN staff and/ or consultants.
12. Records- Each RN instructor teaching a Medication Technician course will be required to maintain the following records: their qualifications, student attendance, lesson/ curriculum plans, all tests administered, student test results, a list of all graduates, and a copy of their course completion certificate.
Agencies employing Medication Technicians are required to maintain the following records: a roster of all Medication Technicians employed; Medication Technician certificates with date of award, record of quarterly oversight sessions, record of annual refresher class attendance, record of any medication errors committed, and corrective actions taken. These records will be available for review during DDSN's annual licensing and contractual compliance review processes.
TRAINING Curriculum Standards
1. Integrated- Classroom instruction that establishes a knowledge base will be integrated with practicum experiences that the student receives at a simulated (or real) treatment setting, and with the supervised medication passes that occur.
2. Objectives- Classroom instruction will be based on objectives for each unit that reflect the purposes of the training program and give direction to the instructor and the students. These objectives will be tied to the various competencies that the students will be tested on.
3. General Information- Classroom instruction shall include general information relevant to the administration of medication. Topics will include: relevant state & federal laws and regulations; terminology; forms of medication; routes of administration; abbreviations/ symbols; documentation guidelines, and medication reference works, etc. (See the attached curriculum outline.)
4. Body Systems- Classroom instruction shall include an overview of the general structure and function of body systems, and the pharmacological effect of medications on these systems.
5. Classes of Medication- Classroom instruction shall address the major categories of medications and how each category is related to a body system and its pathology.
Sent: Thursday, May 06, 2010 9:47 AM
South Dakota worked with the Board of Nursing and they gave us statutory authority for our community providers to administer medications. We then wrote administrative rules that require participant self-assessments, minimum training requirements, etc. I have attached the statute and the rules that apply.
One of the challenges we are facing now are people with medical needs that are not delegatable tasks such as insulin injections. The Board of Nursing is considering making this a delegatable task as it would help schools as well as our system.
POLICY The administration of medications, other than by the parenteral route, by staff of community support providers, group homes, and supervised apartments certified or approved by the Department of Human Services, when under the supervision of a licensed registered nurse. The Department of Human Services, in consultation with the South Dakota Board of Nursing, shall promulgate rules pursuant to chapter 1-26 for administration of medications by such staff;
POLICY In its comprehensive HCBS waivers prior to 2005,
Utah included nursing
services that included the administration of medications and other
nursing tasks including G-tube lavage and maintenance as a portion of
its bundled rate for residential services. However, in our efforts to
renew this service during our 5-year waiver renewal in 2005, this
service was challenged by CMS because it represented "bundling" in
opposition to 42 CFR 441.303(f)(10). Then, when we attempted to apply
for permission to operate a stand-alone nursing service that would
include medication administration, we were successfully challenged by
the State Plan office of CMSO on the grounds that meds administration
was covered under Utah's State Plan and therefore, could not be included
as a waiver service. We modified the service to include only the nursing
consultation and supervision of chronic medication maintenance regimens
and devices including reviewing compliance, efficacy and tolerance of
maintenance meds regimens and making sure that medication storage and
dispensing devices were properly stocked and maintained. Our
comprehensive waiver was approved with this restriction in the
definition of our nursing service. The service definition for our
current Professional Medication Monitoring service can be found at:
http://dspd.utah.gov/docs/mr_rcwaiver.pdf , Page B-14.
The subsequent years of operation of the waiver have been very
problematic with regard to meds administration though, particularly with
regard to administration of parenteral meds. While our State Plan does
provide for nursing administration of parenteral meds, it does so on a
very limited basis, limited to one administration a day.
TRAINING It is intended to train individuals or families
parenteral meds. However, in many cases, the individuals that we serve prove to be
incapable of being successfully trained in the self-administration of
parenteral meds such as insulin, and many require several doses a day,
rather than the single dose allowed by the State Plan. And, Utah's scope
of practice act bars those other than family members, nurses, doctors
and pharmacists from administering parenteral meds to individuals,
thereby eliminating staff at residential facilities from being
care-givers with regard to parenteral meds assistance.
This has pressured our providers to attempt to bill excessive
our approved Professional Medication Monitoring service in order to
recover the costs associated with having their staff nurses administer
parenteral meds without State Plan reimbursement to our individuals who
would not be able to survive without them. This has created financial
accountability assurance challenges for both the Division (operating
agency) as well as our SMA (contracting agency). We have reached
temporary accommodations with our SMA to permit individuals to receive
the parenteral meds assistance that they require, but no long-term
solution has been reached.
POLICY So, Utah has sought permission to include the
parental meds as a waiver service within the definition of Professional
Medication Monitoring in its pending application for renewal of its
comprehensive waiver and is prepared to make the argument that Utah's
State Plan, while offering nursing support for the administration of
parenteral meds, does so in a fashion that is not suitable for the needs
of the community of those we serve. We are also pursuing a State Plan
carve out for parenteral meds administration to the ID.RC community, in
order to fund this service for those enrolled in our comprehensive
The definition for Professional Medication Monitoring we have
in our pending application is:
Professional Medication Monitoring provides testing and nursing
necessary to provide medication management to assure the health and
welfare of the person. This service includes regularly scheduled, periodic visits by a nurse in order to conduct an assessment of the individual with regard to their health and safety particularly as it is
affected by the maintenance medication regimen that has been prescribed by their physician, to review and monitor for the presence and timely completion of necessary laboratory testing related to the medication regimen, and to offer patient instruction and education regarding this medication regimen. Nurses will also provide assistance to the individual by ensuring that all pill-dispensing aids are suitably
stocked and refilled. Nurses may assist persons in the administration of parenteral medications as part of a chronic medication maintenance regimen, and may assist with medication administration via a gastric tube route when specifically ordered by a physician, when such services
are not available for the person from the Medicaid State Plan or any other funding source.
Chuck Bruder, Ph. D.
Utah Community Supports Waiver
Division of Services for People with Disabilities
Utah Department of Human Services
195 N. 1950 West
Salt Lake City, UT 84116
Office: (801) 538-4202
Fax: (801) 538-4279
TRAINING In the Vermont DS system, Agency employees who will be administering any type of medication are required to first be trained and delegated by an RN. This requirement does not extend to home providers or respite providers. Home providers are to be directly trained by the ordering physician and respite providers are trained by the home provider or family member employing them.
Requirements for delegation of staff.
POLICY In 1994 the Vermont State Board of Nursing issued an advisory statement regarding delegation which stated in part, that a Registered Nurse may delegate any task within her scope of practice except - TASKS requiring nursing assessment or nursing judgment. In other words if an individual needs to make a judgment or assessment prior to performing a task it is not a task which should be delegated. This statement follows the National Council of State Board of Nursing Delegation: Concepts and Decision-Making Process and the Delegation Decision-Making Tree (1995).
TRAINING Vermont does not have a structured training program or requirements at this time. It is up to the delegating nurse to determine the type of delegation training and the time involved, following the guidelines stated above.
QUALITY Our current quality over sight consists of Quality Reviews to our agencies once in a 2 year cycle. A 10% sample of the agency clients are sampled and of that a smaller percentage are chosen for a medical review. At this 2 year review, delegation policy and procedure are reviewed as well as individual staff delegation training.
I have also attached 2 power point presentations I share with agencies regarding delegation if that is of any interest to you. It is not part of any mandatory training.
Joy Barrett, RN
Dept of Disabilities, Aging and Independent Living
Division of Disabilities and Aging Services
Clinical Services Unit
1 Scale Ave Suite 109
Rutland, Vermont 05701
From: Rolfe, Linda (DSHS\DDD) [mailto:RolfeLA@dshs.wa.gov]
Sent: Thu 5/6/2010 5:03 PM
POLICY In 1994, Washington State Legislature passed the
Nurse Delegation Law.
The law allows a registered nurse (RN) to delegate certain nursing tasks
to direct support staff (nursing assistant, NA) who are not nurses. The
law also describes the duties and responsibilities of the delegating RN
and those of the nursing assistant who would administer the medication
or apply the treatment. Initially the law contained a list of specific
nursing tasks that could be delegated. The revision of the law in early
2000 replaced the specific list with a short list of nursing tasks that
are prohibited from being delegated. The most recent revision of the law
allows insulin injection to be administered under delegation.
The State Board of Pharmacy also clarified its rules on medication
assistance. This clarification has helped providers and case managers in
making the distinction between the boundaries of assistance and
administration of medications.
Please find attached copy of the Washington State rules on nurse
delegation and DDD policy that describes medication assistance per board
of pharmacy rules.
If you have questions please feel free to contact me or
Saif Hakim, Program Manager
WA State Division of Developmental Disabilities
TRAINING from Meds
Admin Washington Nurse Delegation Rules.doc
(3)(a) Before commencing any specific nursing care tasks authorized under this chapter, the nursing assistant must (i) provide to the delegating nurse a certificate of completion issued by the department of social and health services indicating the completion of basic core nurse delegation training, (ii) be regulated by the department of health pursuant to this chapter, subject to the uniform disciplinary act under chapter 18.130 RCW, and (iii) meet any additional training requirements identified by the nursing care quality assurance commission. Exceptions to these training requirements must adhere to RCW 18.79.260(3)(e) (vi).
(b) In addition to meeting the requirements of (a) of this subsection, before commencing the care of individuals with diabetes that involves administration of insulin by injection, the nursing assistant must provide to the delegating nurse a certificate of completion issued by the department of social and health services indicating completion of specialized diabetes nurse delegation training. The training must include, but is not limited to, instruction regarding diabetes, insulin, sliding scale insulin orders, and proper injection procedures.
Stych, Judith A - DHS [mailto:Judith.Stych@dhs.wisconsin.gov]
Sent: Monday, May 10, 2010 10:29 AM
Medication Administration - Wisconsin
The most efficient general resource of WI medication administration information is located at: http://dhs.wisconsin.gov/rl_dsl/MedManagement/asstlvgMMI.htm - excerpts below
For WI training information/regulations - click on "Staff Training"; a new train-the-trainer model utilizing a standardized state-approved medication administration curriculum and state-approved trainers is being implemented in 2010
Medication Monitoring from http://dhs.wisconsin.gov/rl_dsl/MedManagement/asstlvgMMI.htm
Medication monitoring involves two questions:
POLICY Family Care is Wisconsin's Medicaid Managed Care Program which supports frail elders and individuals with physical and/or intellectual/developmental disabilities
An integral component of quality member care in WI's Family Care program is the interdisciplinary team (IDT) comprised of a social worker, registered nurse, the member and other support persons of the member's choice.
According to the WI Department of Health Services' contract with the state's managed care organizations (MCO), it is the responsibility of the registered nurse to complete a health assessment with each member within the first 10 days of enrollment, every six months thereafter, and whenever there is a change in the member's long term care or health care condition or situation. Medication assessment, which includes the member's ability to self administer as well as the reconciliation of medications taken with medications ordered, is an essential component of this health assessment.
State Policy for medication administration states:
"When a service provider [under contract with the MCO] is responsible for the administration of medications to a participant, there must be a written order from a physician and a properly labeled prescription, including the dosage. Medications given on an as needed basis require a clear definition of the circumstances under which the medication is given. A registered nurse affiliated with or employed by the provider is responsible to assure that staff who assist with administration of medications are appropriately trained in administration of the medications that are specific to each participant. Staff document each medication administration at the time of administration. Documentation of errors takes place as soon as discovered."
"The MCO is responsible for monitoring the performance of providers in the administration of medications to participants. The Division of Quality Assurance (DQA) regulates licensed and certified residential facilities including annual onsite monitoring and investigation of complaints and incidents with those facilities. Any findings related to health and safety including medication errors found in a facility where a participant resides are reported to the MCO and the Office of Family Care Expansion which oversees the contracts with MCOs. The external quality review organization (EQRO) evaluates the performance of MCOs for appropriate medication management as part of annual quality reviews."
RNs are authorized and licensed to delegate medication administration to Unlicensed Assistive Personnel (UAP). The limits of this authority are governed by the laws and rules that regulate nursing practice in WI and the type or facility or entity in which the RN works. The scope of duties of a UAP in regulated settings is defined by the requirements of their training and subject to the delegation of medication administration tasks to them by licensed health care professionals. It is the responsibility of the health care professional to know the extent of delegation permitted in any given setting and to exercise professional judgment in making the determination whether a task should be delegated to a UAP.
Jamie Staunton [mailto:firstname.lastname@example.org]
Sent: Thursday, May 06, 2010 11:14 AM
We just had to tackle this issue in Wyoming last May/June to get our waivers renewed. We had to implement a new system full of requirements and our Board of Nursing was okay with (for now) and planned on continuing to work on the issue until a better solution could be adopted by legislature and implemented in Wyoming.
POLICY: To ensure the health and safety of waiver participants, participant's medication regimens shall receive assistance, management and monitoring by providers in accordance with the Developmental Disabilities Division's standards. Effective July 1, 2009, all home and community-based waiver providers, who assist participants with medications, shall develop and implement policies and procedures in accordance to the standards listed herein and adhere to the specified timelines for compliance.
Medication Incident Reporting Errors reportable starting July 1, 2009
Providers shall develop policies and procedures to comply with the following Division's standards for reporting and tracking medication errors and tracking other medication incidents. The provider policies and procedures shall include:
Medication Errors reported to the Division do not have to be reported to Protection & Advocacy Systems, Inc., Department of Family Services, or police unless the medication error is considered suspected abuse, neglect, self-neglect, and/or a crime, such as medication diversion pursuant to Wyoming Medicaid rules Chapter 45, Section 30.
All Medication errors that meet the Division's criteria shall be reported to the Division via the Critical Incident Reporting process within 24 hours. The Division shall review:
TRAINING Medication Assistant Trainer
Compliance by December 31, 2009
To become a Medication Assistant Trainer, the Division shall use a "train-the-trainer" approach to assure providers can have qualified trainers available to train an adequate number of staff as Medication Assistants as to safely assist participants with medications.
Medication Assistant Trainers shall complete the required Medication Assistance training as well as:
The minimum qualifications to be a Medication Assistant Trainer shall be:
All providers who employ 20 full-time personnel
or more shall have at least two (2) trainers employed or available through
contract to keep an adequate number of staff trained as Medication Assistants
to meet the needs of the participants served.
Trainers will receive a trainer package from the Division, which will include the items necessary to complete the training.
Policy and Research Analyst
Wyoming Department of Health - Developmental Disabilities Division
6101 Yellowstone Road, Suite 186E
Cheyenne, WY 82002 ?
main: 307.777.7115?Fax: 307.777.6047