Medication Assistance and Administration Policy and Procedures *

MEDICATION ASSISTANCE AND ADMINISTRATION POLICY AND PROCEDURES *

Policy:

PossAbilities requires written authorization from the participant or their legal representative in order to provide assistance with administration of prescription or over the counter medications or treatments.
To protect the health and safety of participants only staff who have successfully completed medication administration training provided by a registered nurse, nurse practitioner, physician’s assistant or medical doctor will be allowed to administer medications or treatments.
PossAbilities staff will not be responsible for medication setup for participants receiving services.

*Medication assistance and administration includes, but is not limited to medication administration, medication storage and security, medication documentation and charting, coordination and communication with participant homes regarding medications and monitoring effectiveness of procedures related to medication handling and administration

Definitions:

Medication means a prescription drug or over-the-counter drug and includes dietary supplements.
Medication administration means following the procedures in this policy to ensure that a person takes their medications and treatments as prescribed.
Medication assistance means to enable the 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.
Medication setup means arranging medications, according to the instructions provided by the pharmacy, prescriber or licensed nurse, for later administration.
Over-the-counter drug means a drug that is not required by federal law to bear the statement "Caution: Federal law prohibits dispensing without prescription."
Prescriber means a person who is authorized under section 148.235; 151.01, subdivision 23; or 151.37 to prescribe drugs.
Prescriber’s order and written instructions means the current prescription order or written instructions from the prescriber. Either the prescription label or the prescriber's written or electronically recorded order for the prescription is sufficient to constitute written instructions from the prescriber.
Prescription drug has the meaning given in section 151.01, subdivision 16.
Psychotropic medication means any medication prescribed to treat the symptoms of mental illness that affect thought processes, mood, sleep, or behavior. The major classes of psychotropic medication are antipsychotic (neuroleptic), antidepressant, antianxiety, mood stabilizers, anticonvulsants, and stimulants and non-stimulants for the treatment of attention deficit/hyperactivity disorder. Other miscellaneous medications are considered to be a psychotropic medication when they are specifically prescribed to treat a mental illness or to control or alter behavior.

Staff Training Requirements:

Before administering medications staff must successfully complete medication administration training developed and taught by a registered nurse, clinical nurse specialist in psychiatric and mental health nursing, certified nurse practitioner, physician's assistant, or physician. The training will include observed skill assessment conducted by the trainer to ensure staff demonstrate the ability to safely and correctly follow medication procedures.
Only staff who have been trained by a health professional may administeremergency injectable medications (Epi-Pen or Gluc-Gun).
Staff must review and receive instruction from the Program Director or their designee on individual medication administration procedures established for each participant for whom they are responsible for medication administration.

Procedures for Obtaining Consent to Administer Medications:

When PossAbilities is assigned responsibility for medication administration, during the initial admissions meeting, and on an annual basis, the Program Director, Coordinator or Specialist assigned to the participant, will obtain written authorization to provide assistance with or administration of medications or treatmentsfrom the participant and/or their legal representative on the Emergency Treatment and Medication Administration Release.
The Program Director, Coordinator or Specialist assigned to the participant will assure a copy of theEmergency Treatment and Medication Administration Release is placed in the participant’s individual program file.
If the participant or the person’s legal representative refuses to authorize medication administration the staff must not administer the medication.
The Program Director must report the refusal to authorize medication administration to the prescriber within 24 hours.
After reporting the refusal to authorize to the prescriber the Program Director will inform staffof all directives or orders given by the prescriber. Staff must follow and document those directives or orders.
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.
Staff may not override the refusal to authorize the administration of a psychotropic medication without a specific court order.

Procedures for Maintaining Current Medication and Treatment List:

Upon admission to services, whenever medications or treatments are changed and annually the Program Director, Coordinator or Specialist assigned to the participant will complete the Medication and Treatment List for each participant. The Medication and Treatment List must include:

Name of the medication;
Date the medication or treatment started, changed or stopped;
Dose and instructions;
Time(s) to be administered;
Information on any risks or other side effects that are reasonable to expect, and any contraindications to its use;
The possible consequences if the medication or treatment is not taken or administered as directed;
Prescriber name and contact information,
Timeframe prescriber would like to be contacted if a dose of medication is not administered or treatment is not performed as prescribed, whether by error by the staff or the participant or by refusal by the participant; and
Possible adverse reactions to the medication or treatment.

The Program Director, Coordinator or Specialist assigned to the participant will assure a copy of the Medication and Treatment List is placed in the participant’s individual program file.
The Program Director, Coordinator or Specialist assigned to the participant will complete a Medication and Treatment Administration Record for each medication or treatment to be administered while receiving supports through PossAbilities. The Medication and Treatment Administration Record will be placed in the Medication Record three ring binder.

Procedures for Transportation and Storage of Medication and Treatments:

All medicationsor treatments must be sent with the participant each day with a single dose in a childproof bottle inside a lockbox. The bottle must be marked with the following information:

Name of participant;
Name of medication;
Quantity of dose;
Time(s) to be administered; and
Route of administration.

Individual participant lockboxes containing medications will be kept in the following manner once participants begin services with PossAbilities for the day:
For all participants with medications the lockbox and lockbox keywill be kept with the participant or with the staff responsible for supervising the participant.
For participants with PRN medications the lockbox, lockbox key and, if applicable, the protocol for administering the PRN medication, will be kept with the participant or with the staff responsible for supervising the participant.
Life-saving emergency medications such as Epi-Pens or Gluco-Guns will not be locked and kept with the participant or the staff responsible for supervising the participant.

Procedures for Medication Assistance:

When staff are responsible for medication assistance they may:

Bring to the participant and open a container of previously set up medications;
Empty the container into the participant’s hand;
Open and give the medications in the original container to the participant;
Bring to the participant liquids or food to accompany the medication; and
Provide reminders to take regularly scheduled medication or perform regularly scheduled treatments.

After providing medication assistance staff must document that the medication was taken on the Medication and Treatment Administration Record for the individual participant by using the appropriate code and initialing the record for that date.
The Medication and Treatment Administration Record for each individual participant will be kept in a three ring binder in a locked container. When the Medication and Treatment Administration Recordis completed the Coordinator or Specialist assigned to the participant will place the form in the participant’s individual program file.
If the medication or treatment is not taken staff will complete a Medication/Treatment Error/Refusal and Adverse Reaction Report. Staff completing the form will notify others as indicated on the form and place a copy in the participant’s individual program file.
If the participant has an adverse reaction to a medication or treatment staff will complete a Medication/Treatment Error/Refusal and Adverse Reaction Report. Adverse reactions must be immediately reported to the prescriber or a nurse. Staff completing the form will notify others as indicated on the form and place a copy in the participant’s individual program file.
Staff will report any concerns about medication or treatments, including side effects, effectiveness or a pattern of the participant refusing to take the medication or treatment as prescribed to the Program Director or Coordinator. The Program Director or Coordinator will report this information to the prescriber or nurse.

Procedures for Medication Administration:

When administering medication or treatment for a participant staff must:
Check the label on the medication bottle against the Medication and Administration Record to assure it is the correct medication;
Prepare the medication or treatment as necessary;
Administer the medication or treatment according to the prescriber’s orders (correct dose, correct time, correct route);
After administering a medication or treatment staff must document that the medication was administered on the Medication and Treatment Administration Record for the individual participant by using the appropriate code and initialing the record for that date.
The Medication and Treatment Administration Record for each individual participant will be kept in a three ring binder in a locked container. When the Medication and Treatment Administration Record is completed the Coordinator or Specialist assigned to the participant will place the form in the participant’s individual program file.
If the medication or treatment is not taken staff will complete a Medication/Treatment Error/Refusal and Adverse Reaction Report. Staff completing the form will notify others as indicated on the form and place a copy in the participant’s individual program file.
If the participant has an adverse reaction to a medication or treatment staff will complete a Medication/Treatment Error/Refusal and Adverse Reaction Report. Adverse reactions must be immediately reported to the prescriber or a nurse. Staff completing the form will notify others as indicated on the form and place a copy in the participant’s individual program file.
Staff will report any concerns about medication or treatments, including side effects, effectiveness or a pattern of the participant refusing to take the medication or treatment as prescribed to the Program Director or Coordinator. The Program Director or Coordinator will report this information to the prescriber or nurse.

Procedures for Administration of PRN Medications:

Prior to administering a PRN medication or treatment for a participant staff must first check the written protocol/criteria for the PRN medication or treatment to determine if administration is necessary.
After administering a PRN medication staff must document that the medication was administered on the PRN Medication and Treatment Administration Record for the individual participant.
The PRN Medication and Treatment Administration Record for each individual participant will be kept in a three ring binder in a locked container. When the PRN Medication and Treatment Administration Record is completed the Coordinator or Specialist assigned to the participant will place the form in the participant’s individual program file.
If the medication or treatment is not taken staff will complete a Medication/Treatment Error/Refusal and Adverse Reaction Report. Staff completing the form will notify others as indicated on the form and place a copy in the participant’s individual program file.
If the participant has an adverse reaction to a medication or treatment staff will complete a Medication/Treatment Error/Refusal and Adverse Reaction Report. Adverse reactions must be immediately reported to the prescriber or a nurse. Staff completing the form will notify others as indicated on the form and place a copy in the participant’s individual program file.
Staff will report any concerns about medication or treatments, including side effects, effectiveness or a pattern of the participant refusing to take the medication or treatment as prescribed to the Program Director or Coordinator. The Program Director or Coordinator will report this information to the prescriber or nurse.

Procedures for Use and Monitoring Psychotropic Medications:

When responsible for administering psychotropic medication to participants the Program Director, Coordinator or Specialist assigned to the participant will assure the following information is documented in the individual participant’s file:

A description of the target symptom(s) the psychotropic medication is prescribed to alleviate; and
Documentation methods used to monitor and measure changes in target symptom(s) if required by the prescriber.

The Program Director, Coordinator or Specialist assigned to the participant will collect and report medication and symptom related data as instructed by the provider to the expanded support team for review every three months or as otherwise requested by the participant or their legal representative.

Procedures for Reviewing and Reporting Medication and Treatment Issues:

Every three months, or more frequently as directed in the CSSP or as requested by the participant or their legal representative, aProgram Director, Coordinator ordesignee will complete the Medication and Administration Review Record. This must include the following:

Medications and treatments listed in the Medication Administration Record are current; and
Review of Medication/Treatment Error/Refusal and Adverse Reaction Reports to determine if there is a pattern of errors or refusals.

Based on the review, the Program Director, Coordinator or Health and Safety Work Group will develop and implement a plan to correct any patterns of medication administration errors identified.

Revised 9/15/14 Medication Administration Policy Page 1 of 6