The purpose of this policy is to establish guidelines to promote the health and safety of persons served by ensuring the safe assistance and administration of medication and treatments or other necessary procedures.
The DAC is responsible for meeting health service needs including medication-related services of persons as assigned in the Coordinated Service and Support Plan (CSSP) and/or CSSP Addendum.
Persons served will be encouraged to participate in the process of medication administration to the fullest extent of their abilities, unless otherwise noted in the Coordinated Service and Support Plan and/or CSSP Addendum. The following procedures contain information on medication-related services for the administration of medication as well as the assistance staff may provide to a person who self-administers their own medication.
All medications and treatments will be administered according to this policy and procedure and the DAC’s medication administration training curriculum.
A. When medication set up and/or or administration has been assigned to the DAC as stated in the Coordinated Service and Support Plan and/or CSSP Addendum, staff who will set up or administer medications to persons served will receive training and demonstrate competency as well as reviewing this policy and procedure.
B. Unlicensed staff, prior to the set up and/or administration of medication, must successfully complete a medication set up or medication administration training course developed by a registered nurse or appropriate licensed health professional. The training curriculum must incorporate an observed skill assessment conducted by the trainer to ensure staff demonstrate the ability to safely and correctly follow medication procedures. The course must be taught by a registered nurse, clinical nurse specialist, certified nurse practitioner, physician’s assistant, or physician, if at the time of service initiation or any time thereafter. This may occur if the person has or develops a health care condition that affects the service options available to the person because the condition requires specialized or intensive medical or nursing supervision and nonmedical service providers to adapt their services to accommodate the health and safety needs of the person.
C. Upon completion of this course and prior to the setting up and/or administering medications, staff will be required to demonstrate medication set up and/or administration established specifically for each person served at their location, if this has not already been completed.
D. This training will be completed for each staff person during orientation, within the first 60 days of hire. Staff who demonstrate a pattern of difficulty with accurate medication administration may be required to complete retraining at a greater frequency and/or be denied the responsibility of administering medications.
E. Documentation for this training and the demonstrated competency will be maintained in each staff person’s personnel file.
Medication set up
A. Medication setup means the arranging of medications according to instructions from the pharmacy, the prescriber, or a licensed nurse, for later administration when the DAC is assigned responsibility in the Coordinated Service and Support Plan or the CSSP 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.
B. Staff will document the following information in the person’s served medication administration record:
1. Dates of medication set up.
2. Name of medication.
3. Quantity of dose.
4. Times to be administered.
5. Route of administration at the time of set up.
6. When the person will be away from the service location,
7. To whom the medication was given.
A. There may be occasions when the DAC is assigned responsibility solely for medication assistance to enable a person served to self-administer medication or treatments when the person is capable of directing their own care or when the person’s legal representative is present and able to direct care for the person.
B. If medication assistance is assigned in the Coordinated Service and Support Plan and/or CSSP Addendum, staff may:
1. Bring to the person and open a container of previously set up medications, empty the container into the person’s hand, or open and give the medication in the original container to the person under the direction of the person.
2. Bring to the person food or liquids to accompany the medication.
3. Provide 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.
A. Medication may be administered within 60 minutes before or after the prescribed time. For example, a medication ordered to be given at 7:00 am may be administered between 6:00 am and 8:00 am.
B. Medications ordered to be given as an “AM medication” and/or “PM medication” may be administered at a routine daily time. The routine time may fluctuate up to two hours in order to accommodate the person’s schedule. For example, if a person typically receives their medication at 7:00 am, then on the weekends, the medication may be given between 5:00 am and 9:00 am.
C. Staff administering medication must know or be able to locate medication information on the intended purpose, side effects, dosage, and special instructions.
D. General and specific procedures on administration of medication by routes are included at the end of this policy. Routes included are:
1. Oral tablet/capsule/lozenge.
2. Liquid medication.
3. Buccal medication.
4. Inhaled medication.
5. Nasal spray medication.
6. Eye medication.
7. Ear drop medication.
8. Topical medication.
A. Prior to administering medication for the person served, the DAC will obtain written authorization from the person served and/or legal representative to administer medications or treatments, including psychotropic medications.
B. This authorization will remain in effect unless withdrawn in writing and it may be withdrawn at any time.
C. If authorization by the person served and/or legal representative is refused, the DAC will not administer the medication or treatment. This refusal will be immediately reported to the person’s prescriber and staff will follow any directives or orders given by the prescriber.
A. Injectable medications may be administered to a person served according to their 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 injections.
2. A supervising registered nurse with a prescriber’s order can delegate the administration of an injectable medication to unlicensed staff persons and provide the necessary training.
3. There is an agreement that must be signed by the DAC, the prescriber, and the person served and/or legal representative will be maintained in the service recipient record. This agreement will specify:
a. What injection may be given;
b. When and how the injection may be given;
c. That the prescriber retains responsibility for the DAC to give the injection.
B. Only a licensed health care professional is allowed to administer psychotropic medications by injection. This responsibility will not be delegated to unlicensed staff.
A. When a person served is prescribed a psychotropic medication and the DAC is assigned responsibility for the medication administration, the requirements for medication administration will be followed.
B. The DAC will develop, implement, and maintain the following information in the person’s CSSP Addendum according to MN Statutes, sections 245D.07 and 245D.071. This information includes:
1. A description of the target symptoms that the psychotropic medication is to alleviate.
2. Documentation methods that the DAC will use to monitor and measure changes to these target symptoms, if required by the prescriber.
3. Data collection of target symptoms and reporting on the medication and symptom-related data, as instructed by the prescriber, a minimum of quarterly or as requested by the person and/or legal representative. This reporting will be made to the expanded support team.
C. If the person and/or legal representative refuse to authorize the administration of a psychotropic medication as ordered by the prescriber, the DAC will not administer the medication and will notify the prescriber as expediently as possible. After reporting the refusal to the prescriber, the DAC must follow any directives or orders given by the prescriber. A refusal may not be overridden without a court order. Refusal to authorize administration of a specific psychotropic medication is not grounds for service termination and does not constitute an emergency.
Documentation requirements on the Medication Administration Record (MAR)
The following information will be documented on a person’s medication administration record
1. Information on the current prescription labels or the prescriber’s current written or electronically recorded order or prescription that includes the:
a. Person’s name
b. Description of the medication or treatment to be provided
c. Frequency of administration
d. Other information needed to safely and correctly administer medication or treatment to ensure effectiveness
2. Easily accessible information on risks and other side effects that are reasonable to expect and any contraindications to the medications use.
3. Possible consequences if the medication or treatment is not taken or administered as directed.
4. Instruction on when and to whom to report:
a. If a dose of medication is not administered or treatment is not performed as prescribed, whether by staff error, the person’s error, or by the person’s refusal
b. The occurrence of possible adverse reactions to the medication or treatment
5. Notation of any occurrence of a dose of medication not being administered or treatment not performed as prescribed, whether by staff error, the person’s error, or by the person’s refusal, or of adverse reactions, and when and to whom the report was made.
6. Notation of when a medication or treatment is started, administered, changed, or discontinued.
Medication documentation and charting
A. Staff will transcribe a prescriber’s new, changed, and discontinued medication/treatment orders to the monthly medication sheet by:
1. Comparing the label on the medication with the prescriber’s to ensure they match. Any discrepancy must be reported to the pharmacy immediately.
2. Copying any new medication/treatment or change from the original prescriber’s orders to the monthly medication sheet.
3. When there is a change in a current medication/treatment, the revision is written on the MAR in order to implement the medication change.
4. Entering the medication/treatment name, dose, route, frequency, and times to be administered.
5. Drawing an arrow to the start date for each assigned time.
6. Writing the date the medication is to start, the name of the prescriber who ordered the medication, and the initials of the person making the entry, on the line just below the arrows or under the order on a separate line.
7. Discontinuing a medication/treatment as ordered by writing “D/C” or “Discontinued,” the date, the prescriber’s name, and the initials of the person making the entry on the line just below the arrow.
8. Completing any applicable health documentation regarding the entry and notifying the necessary personnel.
B. Staff will document administration of medications/treatments on the monthly medication sheet by:
1. Ensuring the person’s name, allergies, prescriber’s name, month, and year are on the monthly medication sheet.
2. Completing documentation on the monthly medication sheet in black ink.
3. Ensuring white-out, erasing, or disfigurement, such as scratching out are not used at any time.
C. Each month, staff administering and documenting medication/treatment administration will enter their initials, full name, and title initials in the designated location on the monthly medication sheet.
Medication storage and security, including Schedule II medication storage; Medication Destruction
A. The medication storage area/container will be appropriate for the person served, which may include being locked by the person or by the DAC, when unattended by staff and will be kept clean, dry, and within the appropriate temperature range.
B. Each person served will have a separate container for their internal medications and a separate container for their external medications. External standing order medications will be in a separate container from internal standing order medications.
C. Medication will not be kept in the same area as food or chemicals (in the case of refrigerated medications, they will be kept in a locked container and separated from food).
D. Schedule II controlled substances, names in MN Statutes, section 152.02, subdivision 3, will be stored in a locked storage area permitting access to the person served and staff authorized to administer medications.
E. Medications will be disposed of according to the Environmental Protection Agency recommendations.
Verification and monitoring of effectiveness of systems to ensure safe medication handling and administration (reporting and reviewing)
A. The designated person will be responsible for reviewing each person’s medication administration record to ensure information is current and accurate. This will include a review of the monthly medication sheets, referrals, medication orders, etc.
B. At a minimum, this review will occur quarterly or more frequently if directed by the person and/or legal representative or the Coordinated Service and Support Plan or CSSP Addendum.
C. Based upon this quarterly or more frequent review, the reviewer will notify the manager, as needed, of any issues. Collaboratively, a plan must be developed and implemented to correct patterns of medication administration errors or systemic errors when identified. When needed, staff training will be included as part of this plan to correct identified errors.
D. The following information will be reported to the legal representative and case manager as they occur or as directed by the Coordinated Service and Support Plan or CSSP Addendum:
1. Concerns about a person’s self-administration of medication or treatment.
2. A person’s refusal or failure to take or receive medication or treatment as prescribed.
3. Any reports as required, regarding:
a. If a dose of medication is not administered or treatment is not performed as prescribed, whether by staff error, the person’s error, or by the person’s refusal
b. Occurrence of possible adverse reactions to the medication or treatment
Coordination and communication with prescriber
A. As part of medication set up and administration, the DAC will ensure that clear and accurate documentation of prescription orders has been obtained by the prescriber in written format.
B. Initiations, dosage changes, or discontinuations of medications will be coordinated with the prescriber and discussed as needed to ensure staff and/or the person served has a clear understanding of the order. If the order has only been done verbally, staff will request a written or electronically recorded copy from the prescriber. Staff will not make any changes to medications or treatment orders unless there is a written or electronically recorded copy.
C. All prescriber instructions will be implemented as directed and within required timelines by staff and/or the person served and documented in related health documentation.
D. Concerns regarding medication purpose, dosage, potential or present side effects, or other medication-related issues will be promptly communicated to the prescriber by staff, the manager, assigned nurse, or nurse consultant.
E. Any changes to the physical or mental needs of the person as related to medication will be promptly made to the prescriber in addition to the legal representative and case manager.
Coordination of medication refills and communicating with the pharmacy
A. The manager or other assigned staff person will be responsible for checking medication supply routinely to ensure adequate amount for administration.
B. Some pharmacies may automatically refill prescriptions of persons served. If this is the case, staff will contact the pharmacy if a medication or treatment is discontinued.
C. The DAC will ensure that the pharmacy has the contact information for the service location and the main contact person who can answer questions and be the primary person responsible for coordinating refills.
Handling changes to prescriptions and implementation of those changes
A. All written instructions regarding changes to medications and treatments are required to be documented through a prescription label or the prescriber’s written or electronically recorded order for the prescription.
B. Changes made to prescriptions will be immediately communicated to the manager and nurse, as applicable.
C. Any concerns regarding these changes and the order will be resolved prior to administration of the medication to ensure safety and accuracy.
D. Staff will implement changes and document appropriately on the monthly medication sheet.
E. Discontinued medications or medications that the dosage is no longer accurate due to the changes will be discarded appropriately.
IV. GENERAL AND SPECIFIC PROCEDURES ON ADMINISTRATION OF MEDICATION BY ROUTES
A. General procedures completed before administering medication by any route
1. Staff must begin by washing their hands and assembling equipment necessary for administration.
2. The person’s monthly medication sheet is reviewed to determine what medications are to be administered and staff remove the medication from the storage area.
3. Staff will compare the medication sheet with the label of each medication for the following:
a. Right person
b. Right medication
c. Right date
d. Right time
e. Right route
f. Right dose
g. Expiration date
4. If there is a discrepancy, the medication will not be administered. Instructions will be verified by contacting the nurse, pharmacist, or prescriber.
5. Staff will compare the label with the medication sheet for the second time.
6. Immediately prior to the administration of any medication or treatment, staff will identify the person and will explain to the person what is to be done.
7. Staff will compare the label with the medication sheet for the third time before administering it, according to the specific procedures below, to the person.
8. After administration, staff will document the administration of the medication or treatment or the reason for not administering the medication or treatment.
9. Staff will contact the nurse, or prescriber regarding 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.
10. Adverse reactions will be immediately reported to the nurse, or prescriber.
B. Additional procedures for administration of oral tablet/capsule/lozenge
1. If medications are in a bottle, staff will pour the correct number of tablets or capsules into the lid of the medication container and transfer them to a medication cup.
2. If medications are in bubble packs, staff will, beginning with the highest number, push the correct dose into a medication cup, and write the date and their initials on the card next to the dose popped out.
3. If medication is in lozenge form, staff will unwrap the lozenge and transfer it to a medication cup.
4. Staff will administer the correct dosage by instructing the person to swallow the medication. If the medication is in lozenge form, staff will instruct the person not to chew or swallow the lozenge so it is able to dissolve in their mouth.
5. If the medication is to be swallowed (tablet/capsule), staff will offer at least 4 ounces of a beverage and remain with the person until the medication is swallowed.
6. If the medication is in lozenge form, staff will stay in the vicinity until the lozenge is completely dissolved; checking periodically to ensure the lozenge has not been chewed or swallowed.
C. Additional procedures for the administration of liquid medications
1. Staff will shake the medication if it is a suspension (staff will check the label if in doubt).
2. Staff will pour the correct amount of medication, at eye level on a level surface, with the label facing up, into a plastic medication measuring cup or measuring spoon.
3. Staff will wipe around the neck of the bottle with a damp paper towel, if sticky, and replace the cap.
4. Staff will dilute or dissolve the medication if indicated on the label or medication sheet with the correct amount of fluid.
5. Staff will administer the correct dose according to the directions in an appropriate container.
6. Staff will remain with the person until the medication is swallowed.
D. Additional procedures for the administration of buccal medication
1. Buccal medications are usually given in a liquid form and administered into the cheek.
2. Staff will open the container and measure the correct dose of liquid medication into a syringe or dropper.
3. Staff will position the person on their side.
4. Staff will administer the medication by squeezing the syringe or dropper into the person’s cheek, with gloved hands, avoiding going between the teeth.
5. Staff will remain with the person to ensure that the medication has been absorbed into the cheek and that they have not drank any liquids.
E. Additional procedures for the administration of inhaled medications
1. If more than 1 inhaled medication is to be given, staff will state which one is administered first.
2. Staff will position the person sitting, if possible.
3. Staff will gently shake the spray container (Diskus style inhalers do not require shaking).
4. Staff will assemble the inhaler properly, if required, and remove the cover (Diskus style: staff will slide lever to open inhaler, then cock internal lever to insert dose into mouthpiece).
5. Staff will instruct the person to exhale through their mouth completely.
6. Staff will place the mouthpiece into the person’s open mouth and instruct the person to close their lips around the mouthpiece.
7. Staff will press down the canister once, while instructing the person to inhale deeply and slowly through the mouth (Diskus style: staff will instruct the person to inhale the powdered medication).
8. Staff will wait 1 minute and repeat steps 5-7, if more than one puff is ordered.
9. Staff will instruct the person to rinse their mouth with water if directed.
10. Staff will return the medication to the locked area.
11. Staff will wash the inhaler mouthpiece daily with soap and warm water and dry it with a clean paper towel (Diskus style: staff will wipe the mouthpiece with a clean dry cloth).
F. Additional procedures for the administration of nasal spray medications
1. Staff will ask the person to blow their nose or will gently wipe the nose with gloved hands.
2. Staff will gently shake the spray container.
3. Staff will ask the person to tilt their head slightly forward.
4. Staff will remove the cap from the nozzle and will insert the nozzle into one nostril, aiming away from the septum (middle of the nostril).
5. Holding the other nostril closed, staff will instruct the person to inhale and squeeze once to spray.
6. Staff will repeat steps 4 and 5 to deliver the correct dosage to the other nostril.
7. Staff will rinse the nozzle with warm water, dry it with a clean paper towel, and replace the cap.
G. Additional procedures for the administration of eye medications
1. Staff will open the medication container.
2. Staff will position the person in a sitting or lying down position.
3. Staff will observe the eye(s) for any unusual conditions which should be reported to the nurse or prescriber prior to administration.
4. Staff will cleanse the eye (unless otherwise noted) with a clean tissue, gently wiping from the inner corner outward once (if medication is used in both eyes, staff will use a separate tissue for each eye).
5. Staff will assist or ask the person to tilt their head back and look up.
6. With gloved hands, staff will pull correct lower eyelid down to form a ‘pocket’ or ask the person to pull down their lower eyelid and will administer the correct dose (number of drops/strand for ointments) into the correct eye(s).
7. If different eye medications are prescribed, staff will five (5) minutes before administering the second medication.
8. Staff will avoid touching the tip of the dropper or tube to the person’s eyelid or any other object or surface and replace the cap.
9. Staff will offer the person a tissue for each eye or blot the person’s eye with separate tissues.
H. Additional procedures for the administration of ear drop medication
1. Staff will have the person sit or lie down with the affected ear up.
2. If sitting, staff will have the person tilt head sideways until the ear is as horizontal as possible.
3. If lying down, staff will have the person turn their head.
4. Staff will observe ears and notify the nurse or prescriber of any unusual condition prior to administration of the medication.
5. Staff will administer the correct number of drops, that are at room temperature, into the correct ear by pulling the ear gently backward and upward. For children, under 3 years of age, staff will pull the ear gently back and down.
6. Staff will have the person remain in the required position for one (1) to two (2) minutes.
7. Staff will have the person hold their head upright while holding a tissue against the ear to soak up any excess medication that may drain.
8. Staff will repeat the procedure for the other ear if necessary.
9. Staff will replace the cap on the container and will avoid touching the tip of the dropper to the person’s ear or any other surface.
I. Additional procedures for the administration of topical medications
1. Staff will position the person as necessary for administration of the medication.
2. Staff will, prior to administering the medication, observe for any unusual conditions of the affected area of the body which should be reported to the nurse or prescriber.
3. Staff will wash and dry the affected area unless otherwise indicated.
4. Staff will administer medication to the correct area, according to directions, with the appropriate applicator or with gloved hands.
5. If the topical is in powder form, staff will instruct the person to avoid breathing particles in the air that may result from the application.
6. If the topical is a transdermal patch, staff needs to be aware of the appropriate site location to place the transdermal patch.
7. If the topical is a transdermal patch, staff will remove the old patch and select a new patch site (new patch should be applied to clean dry skin which is free of hair, cuts, sores, or irritation on upper torso unless otherwise directed).
8. If the topical is a transdermal patch, staff will unwrap the new patch, sign and date the patch, remove the backing, and apply it to the new patch site.
9. Staff will replace the cap on the container, if needed, avoiding contact with any other surfaces.
J. Staff will throw away all disposable supplies and place all medications in the locked medication storage area/container prior to leaving the area.
K. Staff will wash their hands.
This policy and procedure was established in consultation with and approved by:
Name: Cindy Winter
Title: Registered Nurse
DAC: STAR Services
Date of consultation and final approval: July 31, 2015