Review/Guidance for RN QA Review form: Reminder that the Review is of locations/sites not of people. The Review tool looks at agency

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1 Review/Guidance for RN QA Review form: Reminder that the Review is of locations/sites not of people. The Review tool looks at agency processes/procedures to determine if they are effective in making sure individuals are receiving their medication safely. When conducting the Reviews, there will be a meeting with agency supervisor to gather information about processes/procedures relating to medication administration and then a site visit will be scheduled. Included in the site visit is an observation of medication pass and/or performance of any health related activities (HRA), review of current months MARs and any other documentation not kept at the main office and interview with staff working. They will be asked the same questions as were asked of the supervisor and hopefully the same answer will be given by staff. The Reviewer has 10 business days (from the date of the site review) to send the completed tool to the agency. Areas that will be reviewed: Certification & Provider Supervision - It is no longer necessary for the provider to make copies of staff members Medication Administration certificates. - The Reviewer will check MAIS for certification dates along with any lapses in certification. If there are lapses found, the Reviewer is going to check to make sure no medications were administered and no HRA were performed during that time. - Ensure you have a plan for verifying that newly hired staff have medication administration certification. - Ensure your agency has a way to track your staff member s medication administration certification to make sure everyone remains current. I will ask staff at the site how they know they need to renew their certification. - Ensure your agency has a system for ensuring that Individual Specific Training (IST) is completed prior to certified staff administering medications or performing HRA to any individual. I will ask staff at the site if they have had IST, what kinds of health problems individual(s) at this site have. ***I will need to see evidence that IST was completed at the site that is being reviewed. - Ensure your agency s IST conforms to rule (5123: (U)). - What is the agency process for ensuring that staff have had annual skill checks completed for all routes of medication being administered at the site and for any HRAs being performed at the site. **Reviewer will check MAIS to verify that staff have completed necessary annual skill checks.

2 - What is the agency process for how the employer provides oversight/supervision for medication administration or performance of HRA? Reviewer will confirm the answer with staff at the site. - Is a VNS being utilized at this location? If yes, Reviewer will need to verify that DODD approved training has been completed and that IST has been completed. What is the agency s method of tracking dates for renewal for this training? Reviewer will ask staff at site what the protocol is for using VNS. - Does someone who lives at this site use an EpiPen? If yes, Reviewer will need to verify that DODD approved training has been completed with staff and that IST has been completed. What is the agency s method of tracking dates for renewal for this training? Reviewer will ask staff at site why they would use an Epipen and how would they administer it. Preparation: There - The self-administration assessment and the ISP. Reviewer will review this. is nothing the agency will need to have ready. - What is the agency process for storage of medication at individual sites? - What is the agency process for accounting for controlled substances? Reviewer will ask staff at site what the process is and will check controlled substance count forms to ensure accuracy. Reviewer will ask staff at site what they would do if the count did not come out right. - What is the agency process for training staff on Universal Precautions? When are Universal precautions implemented? Is there personal protective equipment (PPE) at the site? How do staff get more PPE? Reviewer will ask staff at site where PPE is, when do they use it, how do they get more PPE? Reviewer will be looking to ensure that staff who administer medications wash their hands prior to preparing medications. - At site visit, Reviewer will be checking all prescription labeled containers against the MAR to ensure they match. Reviewer will need to see a current, within 12mos, written physician order for any OTC medication that does not have a prescription label on it. HRAs that are being performed, will need to have a current, within 12mos, corresponding written physician order. Staff at the site will be asked what happens when there is a medication change or a change in a HRA. Observation: - Are there step by step directions present at the site for all routes of medication (routine and PRN) being administered or for any HRAs being performed? Reviewer will ask staff at the site where the directions are.

3 - During observation of administration of medications or performance of HRA, Reviewer will be watching to ensure that staff at the site are following the step by step directions. - Reviewer will be asking staff at the site what the purpose of the medications are. Note: if staff do not know the purpose of medication(s), Reviewer will ask where they could go to get the information. Per rule, all staff should know what the purpose of the medication they are giving is. - Reviewer will be asking staff at the site where they would go to find information about potential side effects of each medication. - What is the agency process for ensuring that ordered parameters are followed when administering PRN medications? Reviewer will be checking the MAR (current month and 2 months prior) to ensure that PRN medications have been administered by following the parameters established by the physician. - Are there current parameters (within the last 12mos) ordered by the physician for any HRAs ordered? Are these parameters listed on the MAR? Are staff at the site following the parameter orders (i.e. reporting an elevated blood sugar or an elevated BP)? - Do staff at the site understand what parameters are and what to do if readings fall outside the ordered parameters? Documentation: - What is the agency have a process/procedure for how to transcribe medications and/or HRA onto the MAR? What about for discontinuing a medication from the MAR? - Reviewer will be asking staff at the site how medications and/or HRA are transcribed onto the MAR and how medications are discontinued. - Reviewer will be checking the MAR (current months and 2mos. Prior) to see if any medications and/or HRA have been transcribed onto the MAR if it was done per agency procedures and also if medications and/or HRA have been discontinued from the MAR per agency procedures. - What is the agency procedure for documentation of medications administered or for HRAs completed? What is the procedure for medications that are missed/held or refused? - Reviewer will be checking the MAR to ensure that staff are following agency procedures for documentation of medications and HRAs that are administered, held, missed or refused.

4 - What method is the agency using to identify the initials of staff who have documented on the MAR? (I.e. Master Signature log or staff have to sign the back of the MAR) - Reviewer will check to ensure that each staff member who has initialed the MAR has a corresponding signature (either on a Master Signature Log or on the MAR). Coordination of Care/Communication: - What is the agency process for reporting situations/symptoms as defined in the Training manual for Cert. 1? - Reviewer will ask staff at site who they report situations/symptoms to and how they document the situations/symptoms. - What is the agency process for reporting a medication or HRA error? - Reviewer will ask staff at the site what a medication error and to give examples. Reviewer will ask staff what they should do if they find a medication error. - Reviewer will look check to see if there has been any medication errors during the last 12mos. that could be a trend and/or pattern. Reviewer will check to see if agency completed any follow up to the error. - Reviewer will site a deficiency if undocumented medication errors are found during the QA Review process. This will include making a notation in MAIS for the individual staff member who committed the error. - What is the agency process for packaging medications for LOA or outings with staff? - Reviewer will ask staff at the site what the process is for packaging medications for when an individual is not going to be home for a med pass. Make sure that staff understand that they are unable to administer medications packaged by another staff member. - What is the agency process for provision of medication administration or performance of HRA if the scheduled staff member is not available? - Reviewer will ask staff at the site what they would do if they could not administer medications or perform HRAs. - What is the agency process for addressing urgent/emergency situations, who is called first, second etc. Where can emergency phone numbers be located and how often are they updated/reviewed? whom - Reviewer will ask staff at the site what an emergency is (give examples) and would they call first, second etc.? - Reviewer will ask staff at the site where emergency phone numbers are located.

5 - What is the agency process for scheduling routine and as needed appointments in a timely manner? Who is responsible for scheduling these? How does agency train staff to know what type of information needs communicated to healthcare providers (i.e. how do you train your staff to run a medical appointment?)? - How does the agency track when annual/semi annual/bi-annual/screening appointments are due? Who is responsible for keeping this up to date? - Reviewer will ask staff at site how they know when a medical appointment is coming up or is due. If they have run an appointment are they prepared (i.e. do they know why they are there, do they know what to communicate to the healthcare providers etc.). - What is the agency process for communicating information from appointments or medication/hra changes to the staff working at the site? - Reviewer will ask staff at the site how they are informed about what occurred at a medical appointment or if there is a medication/hra change. - What is the agency process for ensuring ample amount of medications are present at the site, there are refills on medications? - Reviewer will ask staff at the site who is responsible for ordering more medications or making sure there are refills on medications. - What is the agency process for starting a new medication how long does one have to implement a new medication order? Delegation of Nursing Tasks: - Any task that is not taught in the initial 14hour Medication Administration class must be delegated by a Registered Nurse (RN) using Ohio Bd. of Nursing rules OAC A RN must complete a documented assessment prior to the start of delegation and reassessed at a minimum annually. - There must be current (within the last 12mos) physician orders in place. - Staff performing the task must be trained by the delegating nurse and the training must be documented. This training must include IST. - There must be a delegation statement in place. - The delegating nurse must provide written step by step instructions on the task including how to document that the task was done. - The delegating nurse must be the one contacted for ANY questions about the task. Supervisors cannot be the contact because they cannot advise/direct the delegated staff on what to do only the delegating nurse can advise.

6 - Reviewer will be asking staff at the site how and when to contact the delegating nurse. - The Reviewer will be observing staff at the site performing the delegated task and will be referencing the step by step directions to ensure that staff are completing the task as they were taught. - Only the delegating nurse can make changes to the MAR regarding the delegated task. Exception to this is when the delegating nurse delegates not only the task to unlicensed staff but also delegate s transcription of new orders onto the MAR for the nursing task. NOTE: the delegation statement must identify that MAR transcription and the task are being delegated. Delegation of G-tube, J-tube Medications/Nutrition/Fluids: - A RN must complete a documented assessment prior to the start of delegation and reassessed at a minimum annually. - The Assessment must indicate that the tube is stable and labeled. - What is the agency process to ensure that current physician orders (within the last 12 months) are in place and only transcribed by a nurse? - A delegation statement must be in place. - Staff must be trained by the delegating nurse and the training must be documented. This training must include IST. - The delegating nurse must provide written step by step instructions for all actions to be taken with G/J tube including applicable parameters. - The Reviewer will be observing staff at the site performing G/J tube medications/nutrition/fluids and will be referencing the step by step directions to ensure that staff are completing this intervention the way they were taught. - Reviewer will be asking staff at the site how and when to contact the delegating nurse. Delegation of Insulin and/or injectable treatments for Metabolic Glycemic Disorders: - A RN must complete a documented assessment prior to the start of delegation and reassessed at a minimum annually. - What is the agency process to ensure that current physician orders (within the last 12mos.) are in place and only transcribed by a nurse. - A delegation statement must be in place. - Staff must be trained by the delegating nurse and the training must be documented. This training must include IST.

7 - The delegating nurse must provide written step by step instructions for all actions to be taken for the administration of insulin or injectable treatments for metabolic glycemic disorders. - The Reviewer will be observing staff at the site insulin or injectable treatments for metabolic glycemic disorders and will be referencing the step by step directions to ensure that staff are completing this intervention the way they were taught. - Reviewer will be asking staff at the site how and when to contact the delegating nurse. Outcomes on the QA Review tool: - Each section reviewed will be color coded and a number will show up in the far right hand column. - 0=No process, 1 = incomplete or ineffective process, 2 = effective process. - Any section receiving a 0 or a 1 will require a plan of correction. RN Findings & Recommendations section of tool: - This is the summary area. - Detailed description of what the concerns are in any area will be noted here. Also listed will be the possible root cause for the concern and recommendations on how to improve the process. - Agency s do not have to use the recommendations given. They can come up with their own. - If a plan of correction is requested, the agency has 30 calendar days from the date they received the Review tool, to develop and send the plan of correction back to the Reviewer. - If a plan of correction is not received by the Reviewer within 60 calendar days of receiving the completed Review tool, the OPSR at DODD will be notified.