SAFE MEDICATION ASSISTANCE AND ADMINISTRATION

A.    Medication setup

1. For the purposes of this subdivision, "medication setup" means the arranging of medications according to instructions from the pharmacy, the prescriber, or a licensed nurse, for later administration when the license holder is assigned responsibility in the coordinated service and support plan or the coordinated service and support plan addendum. A prescription label or the prescriber's written or electronically recorded order for the prescription is sufficient to constitute written instructions from the prescriber.

If responsibility for medication setup is assigned to the license holder in the coordinated service and support plan or the coordinated service and support plan addendum, or if the license holder provides it as part of medication assistance or medication administration, the license holder must document in the person's medication administration record: dates of setup, name of medication, quantity of dose, times to be administered, and route of administration at time of setup; and, when the person will be away a home med report will be printed and have person taking the medications sign and dat. Upon return if there are no discrepencies this form may be destroyed.

B.    Medication assistance

1. For purposes of this subdivision, "medication assistance" means any of the following:

• bringing to the person and opening a container of previously set up medications, emptying the container into the person's hand, or opening and giving the medications in the original container to the person under the direction of the person;
• bringing to the person liquids or food to accompany the medication; or
•  providing reminders, in person, remotely, or through programming devices such as telephones, alarms, or medication boxes, to take regularly scheduled medication or perform regularly scheduled treatments and exercises.

If responsibility for medication assistance is assigned to the license holder in the coordinated service and support plan or the coordinated service and support plan addendum, the license holder must ensure that medication assistance is provided in a manner that enables a person to self-administer medication or treatment when the person is capable of directing the person's own care, or when the person's legal representative is present and able to direct care for the person

C.    Medication Administration

1. For purposes of this subdivision, "medication administration" means:

• checking the person's medication record;
• preparing the medication as necessary;
• administering the medication or treatment to the person;
• documenting the administration of the medication or treatment or the reason for not administering the medication or treatment; and
• Reporting to the prescriber or a nurse any concerns about the medication or treatment, including side effects, effectiveness, or a pattern of the person refusing to take the medication or treatment as prescribed. 
• Adverse reactions must be immediately reported to the prescriber or a nurse.

If responsibility for medication administration is assigned to the license holder in the coordinated service and support plan or the coordinated service and support plan addendum, the license holder must implement medication administration procedures to ensure a person takes medications and treatments as prescribed. The license holder must ensure that the requirements in the requirements below:

• The license holder must obtain written authorization from the person or the person's legal representative to administer medication or treatment. 
  • This authorization shall remain in effect unless it is withdrawn in writing and may be withdrawn at any time. 
  • If the person or the person's legal representative refuses to authorize the license holder to administer medication, the medication must not be administered.
  • The refusal to authorize medication administration must be reported to the prescriber as expediently as possible.
• For a license holder providing intensive support services, the medication or treatment must be administered according to the license holder's medication administration policy and procedures.

D.    Injectable medication 

Injectable medications may be administered according to a prescriber's order and written instructions when one of the following conditions has been met:

1. A registered nurse or licensed practical nurse will administer the injection;
2. A supervising registered nurse with a physician's order has delegated the administration of injectable medication to an unlicensed staff member and has provided the necessary training; or
3. There is an agreement signed by the license holder, the prescriber, and the person or the person's legal representative specifying what injections may be given, when, how, and that the prescriber must retain responsibility for the license holder's giving the injections. 

*Only licensed health professionals are allowed to administer psychotropic medications by injection.

E.    Psychotropic medication use and monitoring

1. When Mains’l Services is responsible for administration of a psychotropic medication, the program develops, implements, and maintains the following documentation in the person's Support plan (Support Plan addendum) 

• Target symptoms are determined by the prescriber of the psychotropic medication and detailed by the expanded support team.
• A documentation method is identified for monitoring and measuring changes in target symptoms that are to be alleviated by the psychotropic medications; if required by the prescriber

2. Mains’l Services provide monitoring and reporting of Target Symptoms data to the expanded support team for review every three months, or as otherwise requested by the prescriber, person or the person’s legal representative

3.If the person receiving services or their legal representative refuses to authorize the administration of a psychotropic medication, the medication is held and is reported to the prescriber within 24 hours.

•  After reporting the refusal to the prescriber Mains’l Services follows and documents all directives and/or orders given by the prescriber.
• A court order overrides a refusal of psychotropic medication administration.
• A refusal to authorize administration of a specific psychotropic medication is not grounds for service termination and does not constitute an emergency.  A decision to terminate services will comply with the program’s service suspension and termination policy.

F.    Written Authorizations

Written authorization is required for medication administration or medication assistance, including psychotropic medications or injectable medications. 

1. The program must obtain written authorization from the person or the person’s legal representative before providing assistance with or administration of medications or treatments, including psychotropic medications and injectable medications.  
2. If the person or the person’s legal representation refuses to authorize the program to administer medication, the staff must not administer the medication.
3. The program must report the refusal to authorize medication administration to the prescriber as expediently as possible. 

G.    Refusal to Authorize Psychotropic medication 

1. If the person receiving services or their legal representative refuses to authorize the administration of a psychotropic medication, the program must not administer the medication and report the refusal to authorize to the prescriber in 24 hours. 
2. After reporting the refusal to authorize to the prescriber in 24 hours, the program must follow and document all directives or orders given by the prescriber. 
3. A court order must be obtained to override a refusal for psychotropic medication administration. 
4. A refusal to authorize administration of a specific psychotropic medication is not grounds for service termination and does not constitute an emergency.  A decision to terminate services must comply with the program’s service suspension and termination policy.

H.    Reviewing and Reporting medication and treatment issues

1. When assigned responsibility for medication administration, including psychotropic medications and injectable medications, the program must ensure that the information maintained in the medication administration record is current and is regularly reviewed to identify medication administration errors. 
2. At a minimum, the review must be conducted every three months or more frequently as directed in the Support Plan or as requested by the person or the person's legal representative. 
3. Based on the review, the program must develop and implement a plan to correct patterns of medication administration errors when identified.
4. When assigned responsibility for medication assistance or medication administration, the program must report the following to the person's legal representative and case manager as they occur or as otherwise directed in the Support Plan:

• any reports made to the person's physician or prescriber 
• a person's refusal or failure to take or receive medication or treatment as prescribed;
• concerns about a person's self-administration of medication or treatment.
• Medication errors include (but not limited to):
  • wrong person;
  • wrong route;
  • wrong dose;
  • wrong date;
  • wrong time;
  • wrong medication; or,
  • medication not given
  • Treatment errors include (but not limited to):
• treatment not being provided;
  • A treatment being done incorrectly
  • given to the wrong person
  • wrong route
  • wrong dose
  • wrong date
  • wrong time
• For the following type of errors contact a nurse. (Instructions will be given on how to respond to the error)  
  • person refusing to take the medication or treatment;
  •  wrong person;
  •  wrong time;
  • missed dose;
  • wrong dose;
  • wrong route;
  • failure to provide supervision/education or follow through in regard to medication or treatment, that resulted in a negative outcome to the person;
  • missing or stolen medication;
  • other (health or safety concerns)
• The employee who discovers a documentation error will fill out med error form and contact the employee to determine if the medication/treatment was given
  • Notify the manager of the error.
• The manager will follow up on all medication error report forms and complete an “Internal Review” form with the employee; making the error as soon as possible.  This form is to be provided to the employee in person and signed at the time of review.
  • The manager is responsible for keeping track of med errors.
•  Retraining is determined by the manager and the nursing manager and ranges from
  • assigning a co-worker to double check doses before administration
  • double check the medication administration records before employee leave shift
  • attending a medication refresher class
  • Receive training from the nurse.   
• If an employee’s error requires a person to seek intervention from a physician, the employee is immediately ineligible to administer medications or provide treatments. This employee’s ability to administer medication is reviewed..
• The ability of the employee to administer medications or provide treatments may be restricted at any time by the nursing manager if the safety of the person is at risk.
• Medication administration records will be reviewed a minimum of every 3 months or more often as directed in the Support Plan or the Support Plan addendum as requested by the person or the person’s legal representative. 
• Based on the review, Mains’l Services will develop and implement a plan to correct patterns of medication administration errors when identified. 

I.      Staff Training

1. When medication set up, assistance or administration has been assigned in the Service plan, staff will successfully complete: 

• Mainsl Medication Administration course develpped by a Registered Nurse.
  • The training curriculum incorporates an observed skills assessment.
  • This training curriculum incorporates written exam – exam must be passed with a score of 80% or higher
• Site Specific Training is taught by a Manager or a Support Coordinator
  • The site specific training includes a site specific test
  • The site specific training includes a medication home skills test

 2. Once the Manager and/or Support Coordinator ensure that the employee has completed these steps the training mailbox is notified.

3. Any time the safety of the people in the home is at risk or the employee demonstrates a pattern of difficulty with medication skills, a discussion occurs with the manager and the Nurse to determine if this employee needs to complete additional medication training.

4.  Employees may only administer injectable medications when the necessary training has been provided as indicated in the Person’s Support Plan (Support Plan and/or Support Plan addendum).

5. Medication refreshers are provided to the homes annually.

J.  Storage and disposal of medications

Storage
1.    Medications that are administered by employee are kept in a storage area (cabinet, closet, etc.) 

2.    Only employee authorized to administer medications have access to the key of the locked medication storage area.

3.    All medications are stored in an area that has proper control of sanitation, temperature (including refrigeration), light and humidity.

4.    Medication will not be stored near food or cleaners and poisons

5.    Topical or liquid medications are stored separately from other oral medications

6.    Controlled Substances will be counted in CaraSolva
Disposal of discontinued, expired or contaminated medications 
1.    Will be immediately placed in a container labeled MEDICATIONS TO BE DESTROYED in the medication cabinet

2.    Place contaminated medications in an envelope with the person’s name, name of medication, strength and reason medication is to be destroyed.  Put the envelope in the container to be destroyed container

3.    Medication is destroyed by the manager/support coordinator or designated employee and a witness within two months 

4.    Schedule II medications are destroyed by an RN and witnessed by another person (See Controlled Medications section)

5.    Destruction of medications is documented in the person’s health care progress notes with another employee  as a witness.

6.    Documentation should include 

• Date of the medication destruction
• The name of the medication
• Strength of the medication
• Signatures of the 2 people involved in the destruction of the medication

7.    Medication destruction procedure

• Place medication in a container such as a zip-top or sealable plastic bag
• Add water to the bag to begin disintegrating/dissolving the medication
• Add an unpalatable substance such as vinegar, liquid soap, kitty litter or used coffee grounds
• Place the container in the outside trash or trash that is not accessible to persons living in the house
• Before throwing out the empty pill bottle and/or bubble pack scratch or blacken out all the personal information on the prescription label to make it unreadable.

Procedures of Medication Administration 

• At the beginning of the shift, employee checks the medication administration record for medications to be administered on their shift and review the health care progress notes (HPN’s) and the communication book for any changes.
•  Employee does not give the medication if there is a discrepancy and, if any doubt, contact the manager, nurse, pharmacy, or the physician before giving any medication.
• Employee checks the label on the medication comparing to the Medication Administration Record (MAR) three (3) times:

1.    When removing medication from the container 

2.    Compare removed medication to medication administration record information

3.    While setting up medications

• Employee identifies the person by name, photo, or asking another employee and explains what will occur, to the person, and what is expected of them
• If there are no concerns, employee administers the medication according to the route direction
• If there are concerns about the medication or treatment, including side effects and effectiveness, notify the nurse or prescriber. 
• Adverse reactions must immediately be reported to the prescriber or nurse and document on the “Medication/Treatment Error/Refusal and Adverse Reaction Report” 
• The person’s legal representative and case manager will be notified of adverse reactions. 
• All notification is documented in the health care progress notes 
• Employee observes the person to ensure completion of medication administration (swallowed, dissolved, etc.).
• Employee cleans and replaces equipment used and secures medication in the locked area.
• Employee documents that the medication is given on the medication administration record immediately after the person takes it. 
• Employee checks the medication administration record one more time at end of their shift to make sure that all medications/treatments have been administered and documented properly.

Steps for administration of Oral Medications
Tablets or pills:

• Pour the correct number of tablet(s) into the lid of the medication bottle and then from the lid into a medication cup 
• Give the person the medication with a glass of water (unless another liquid is specified).
• Watch the person swallow the medication.       

 Lozenges:

• Lozenges are placed on the tongue and kept in the mouth until completely dissolved.
• Water is not given for at least 30 minutes after administering. 

Sublingual medications

• Sublingual medications are placed under the tongue to dissolve.
• Water is not given for at least 30 minutes after administering.

Intrabuccal 

• Intrabuccal medications are placed between the cheek and gum.
• Water is not given for at least 30 minutes after administering.

Liquid medications

• At eye level, carefully pour the liquid medication into a graduated plastic medication cup or Medication spoon
• Water is not given after many liquid medications.  Follow directions on the bottle.

Steps for Administration of Other Medication: 
Topical medication: 

• Employee washes their hands. 
• Apply gloves; never apply topical medications with your bare hands.  
• Explain to the person how the treatment will be done.
• Position the person accordingly. 
• When indicated the person/or employee washes the area with soap and warm water.           
• Topical medication to groin area: The person supported, will be encouraged to self-apply with training.  
• o    If not able to self-apply the employee will complete the application.

Eye drops

• Employee washes their hands, 
• Apply gloves.
• Explain to the person how the eye drops will be administered.                
• Have the person sit or lie down.
• Observe affected eye(s) for any unusual condition which should be reported prior to 
• If drainage is present, cleanse each eye with clean tissue, wiping from inner corner outward once. 
• Position the person with head back and looking upward.  Separate eye lids by raising the    
• Upper lid with forefinger and lower lid with thumb.  Approach the eye with the dropper from                  below the eye, outside of the person’s field of vision.  Avoid contact with the eye.
• Apply drop(s) gently near the center of the lower lid not allowing drop(s) to fall more than one (1) inch before striking eye.
• Ask the person to keep eyes gently closed for a few minutes.
• Gently dab off excess medication from the eye with a clean tissue, using a separate clean tissue for each eye if the medication is administered to both eyes.

Eye ointment                                                                                                                

• Employee washes their hands, 
• Apply gloves.
• Explain to the person what is to be done.
• Have the person sit or lie down.
• Observe affected eye(s) for any unusual condition which should be reported prior to
• Applying the medication.
• If drainage is present, cleanse the eye with a warm washcloth, wiping from inner corner outward
• Position the person with head back and looking upward.  Retract lower lid.  Approach the eye from below, outside the person’s field of vision.
•  Apply ointment in a thin layer along the inside lower lid.  Use care to avoid contact of the medication container with the eye.
• Position the person comfortably and ask him/her to keep eyes closed gently for a few minutes.  
• Gently dab off excess medication by wiping from inner corner outward.

Ear drops

• Employee washes their hands.
• Explain to the person what is to be done.
• Position the person:

                           i)   If lying in bed, put bed flat and turn ear to be treated facing up; or
                          ii)   If reclining in a chair, tilt head sideways until ear is as horizontal as possible.

• Clean entry to ear canal with a wash cloth, if wax or debris visible.                                                                                                                     
• Observe the affected ear for any unusual condition prior to ear drop instillation.                                                                                                                                                               
• Draw up the ordered amount of medication into the dropper, if applicable.
• Administer the eardrops by pulling the ear gently backward and upward and instilling the number of drops ordered into the ear canal.  Do not contaminate the dropper by touching any part of the ear.
• Have the person remain in the required position for two to three (2-3) minutes.
• If drops are ordered for both ears, wait at least five (5) minutes before putting drops in the second ear, repeating the procedure.
• Leave the person comfortably positioned.
• Rectal medication:  Suppository    
• Employee washes their hands.
•  Apply gloves
• Carry the medication to the person.
• Explain to the person what is to be done.  Provide privacy.
• Position the person on left side with right knee bent slightly and lying across left leg.
• Remove packaging.
• Lubricate the tip of the suppository with a water-soluble lubricant. Do not use Vaseline.
• Insert suppository into the rectum beyond the sphincter about  2", pushing it in gently with gloved finger. Stop if there is any resistance.
• Encourage relaxation by instructing the person to breathe slowly through his/her mouth.
• Withdraw finger. Press tissue against anus or press buttocks together until the urge to expel subsides.                                                                 
• Remove and discard gloves, and wash hands.
• Encourage the person to remain flat or on their side for five (5) minutes

Enemas

• Employee washes their hands.
• Apply gloves
• Explain procedure to person.
• Provide privacy.
• Position person on left side with right knee at 90 degree angle and lying across left leg.            
• Place waterproof pad under the person’s hips and buttocks.
• Insert lubricated tip of enema bottle gently into rectum.  Advance 3-4 inches for adults.
• Encourage relaxation by telling the person to breathe out slowly through their mouth.
• Squeeze entire contents of enema into rectum slowly over 1-2 minutes.
• Withdraw enema tip.  May need tissues to catch fluid.
• Gently hold buttocks together for few minutes.
• Remove gloves and wash hands.
• Encourage the person to lay flat and hold contents of enema for 5 minutes or as long able.
• Assist the person to the bathroom.  Enemas usually produce bowel movement in 15-60 minutes.

Nasal Spray 

• Employee washes 
• Apply gloves.
• Shake bottle if indicated on the label.
• In an upright position, instruct the person to inhale through the nose while bottle is squeezed.
• Wash off tip of bottle before recapping.

Inhalers

• Refer to the instructions that come with the inhaler. 

Vaginal medications: 
The person needs to wash vaginal area if indicated and insert/apply the vaginal medication with employee’s prompts if needed. 

• Explain procedure to the person.
• Ask the person to empty her bladder before beginning procedure.
• Wash hands and put on gloves (if the employee is assisting).
• Provide privacy.
• Position the person properly on the bed, lying on her back with knees flexed and legs apart.
• If discharge is noted, clean area using disposable wipes.  
• Working from front to back, clean the left side of the perineum, using a downward stroke
• Discard wipe.
• Using a clean wipe, repeat the procedure for the right side of the perineum and then the center of the perineum
• Be sure to use a clean wipe for each stroke
• Continue as necessary until the perineum is cleansed
• If you are administering a vaginal suppository, place the prescribed medication dose in the applicator. 

Note:  Encourage self-administration vaginal medications; which include vaginal jelly, ointment, cream, or tablet.
To make insertion easier, the suppository and applicator tip may be lubricated with water or water soluble lubricating jelly. Do not use Vaseline.    
        

• Instruct the person to separate labia with one hand.  Insert the applicator into the vagina with other hand and advance the applicator about two (2) inches, angling slightly toward the sacrum.
• Instruct to insert the medication by pushing the plunger.  Remove the applicator and discard it.
• Encourage the person to remain lying down for about 20 - 30 minutes so the medication can be absorbed.
• Instruct the person to wash hands.

Other routes, such as gastrostomy (g-tube, mic-Key) gastrostomy/jejunostomy (G/J tube) or nebulizers are individualized for the person in each home.
For training on these routes of administration and for injections consult a health professional.

CONTROLLED MEDICATION 

1.    Security of Controlled Medications                        
a.    Schedule (Class) I medications are not currently administered in the home.
b.    Schedule II medications may be administered in the home. Schedule II medications are stored with all other medications. 

• The Schedule II medication is counted during each shift (preferred at the beginning) 
• Schedule III, IV, and V medications are given at the home as all other medications.

2.    Receiving new and administering Controlled Medications
 a.    The employee receiving the medication will verify that the quantity listed on the medication label is the amount of medication received. 
b.    The employee receiving the medication will record this amount  on the ordered/received log.
c.    The home maintains a record of the administered Schedule II medications using the enable count in CaraSolva.
d.    These medications are documented as administered on the person’s medication administration record (MAR) per procedure.
f.    If a dose(s) of Schedule II medication was not administered to the person, a     Medication/treatment error form is completed and the designated prescriber and nurse are notified.
            
3.    Reconciliation of Controlled Medications

a.    When Schedule II medication is spilled or dropped, an explanatory notation is entered in the health progress notes, and signed by the employee responsible and one witness (if available). 
b.    Contaminated/discontinued medication is returned to the locked area with an attached note stating the name of the Schedule II medication, person’s name, dose, quantity, and the reason for necessary destruction. 
c.    This medication is placed in the bin labeled “MEDICATION TO BE DESTROYED”. Employee will continue to count until destroyed. 
d.    A Nurse destroys the Schedule II medication along with a witness. 
-When a nurse is not assigned to the site, the manager/support coordinator contacts the health services manager to make arrangements for the medication to be destroyed. 
e.    The procedure for medication destruction is documented in this policy.
f.    If during the count a discrepancy is discovered, the employee will notify the manager. 

• The manager will attempt to identify the error and may consult with a nurse for assistance
• If the manager is unable to reconcile the count, the administrative on call employee and the health service manager are to be notified.
• At this time an incident report will be completed 
• If this problem continues after the above steps are taken, the police may be notified

OFF SITE MEDICATION PROCEDURE

Physician’s Orders for Off Site Medication Administration
If a medication is ordered for a person who is not self-administering medication during school, day placement, or work hours, a copy of the order for the medication will be obtained and sent to the designated employee at the day placement.

Medication Labeling for Off Site Medication Administration
Medication procedure for short term (three days or less) off site medication administration, including medication to be given short-term
1.    The employee will transfer enough medication for the duration of the leave into labeled envelopes
2.    Each medication envelope will display the following information

•  Name of the person
• Name of the medication and strength
• Amount of medication
• Route of administration
• Date and time to be given
• Any special directions for administration
• Signature of employee who packaged the medication
• Name and phone number of the site may be written/stamped on the back of the envelope

3.    All medications to be administered at one time are to be placed in one envelope.
4.    Employee will have the person who the medication is given to sign the Leave of Absence Form

For long term (longer than 3 three days) off site medication administration including medications to be given at day placement: 
1.    Medications will be sent in a properly labeled container from the pharmacy
2.    Ensure that all new or changed orders are communicated properly
3.    Employee will have the person who the medication is given to sign the Leave of Absence Form