FACT SHEET FOR RECOMMENDED CODE CHANGES Chapter 16. Article 5O. Medication Administration by Unlicensed Personnel Updated: January 25, 2012

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1 FACT SHEET FOR RECOMMENDED CODE CHANGES Chapter 16. Article 5O. Medication Administration by Unlicensed Personnel Updated: January 25, 2012 The Fair Shake Network, the West Virginia Developmental Disabilities Council, the West Virginia Olmstead Council, and the West Virginia Statewide Independent Living Council has made recommendations to amend the Medication Administration by Unlicensed Personnel Act. Extensive research was conducted and numerous meetings were held with regulators. Research on all 50 states Chapter 16, Article 5O Fact Sheet Page 1

2 was conducted with more in-depth research done on Washington, Oregon, Ohio, Texas and Kansas. Washington and Oregon were chosen primarily due to having the longest history of implementing flexible medication administration statutes and regulations for home and community-based services. All of these states had extensive materials for review available on-line. All the recommendations listed below are being implemented in other states. RATIONALE FOR RECOMMENDATIONS Chapter 16, Article 5O Fact Sheet Page 2

3 In the 10 years since Chapter 16, Article 5O was enacted, areas have been identified that inhibit people with disabilities from interacting in their home and community to the fullest extent possible. Advocates and others have observed the need to make some quality improvements to the statute and the regulations covered in Chapter 16, Article 5O. The recommendations presented here are common sense approaches to ensure people with disabilities are able to receive the supports they need in the most integrated setting in their community. Chapter 16, Article 5O Fact Sheet Page 3

4 GENERAL BACKGROUND What is the Nurse Practice Act State regulations that govern the practice of registered professional nurses often affect the extent to which individual autonomy is permitted by the State Board of Nursing. There are two broad statutory/regulatory options available to authorize unlicensed personnel, or Approved Medication Assistive Personnel (AMAP) to perform health maintenance tasks: delegation and exemption. What is Delegation? Chapter 16, Article 5O Fact Sheet Page 4

5 Delegation is transferring the authority to an AMAP to perform a selected health maintenance task in a selected situation. The nurse has the responsibility for authorizing the delegation. All 50 states have language in their statutes or regulations permitting some form of delegation. What is Exemption? Exemption allows the individual directing his or her own care to be responsible for that care. The nurse does not have responsibility for authorizing the exemption. Forty-four states allow some form of exemption Chapter 16, Article 5O Fact Sheet Page 5

6 within their home and communitybased service programs. What is an AMAP? Authorized Medication Assistive Personnel or AMAP is an unlicensed personnel who is otherwise providing direct care that is trained and certified/authorized under an organized program to provide specific services for medication administration. This is the person the registered nurse trains and delegates to provide specific services for medication administration to specific persons. The registered nurse Chapter 16, Article 5O Fact Sheet Page 6

7 provides training, monitoring and supervision of the AMAP. ISSUE #1: LOCATION OR SETTINGS FOR MEDICATION ADMINSTRATION Chapter 16, Article 5O restricts the location where unlicensed personnel, or Approved Medication Assistive Personnel (AMAP) may perform tasks. Personal Example Carol receives services through the I/DD Waiver Program and has a job at a local printing company. Carol has staff with her 24-hours per day that are also an Approved Medication Assistive Personnel (AMAP). While Chapter 16, Article 5O Fact Sheet Page 7

8 Carol is in her home her AMAP staff can administer her medications. However, when Carol goes to work the AMAP staff cannot administer her medications. Carol has two options: 1) a nurse can come to her job and administer her medications, or 2) her AMAP staff can take her home and administer her medications and take her back to work. Recommendation Code language needs to reflect that an AMAP can administer services in the location most appropriate to the needs of the individual taking into Chapter 16, Article 5O Fact Sheet Page 8

9 consideration the safeguards that need to be in place. State Examples Most states have broad language in their statutes with the implementation addressed through regulation. However, states with language that does not limit the location: Arkansas, Colorado, Delaware, Florida, Hawaii, Idaho, Nebraska, New Jersey, New Mexico, North Carolina, North Carolina, Ohio, South Carolina, South Dakota, Texas, Virginia, Washington and Wyoming. ISSUE #2: TASKS PERMITTED Chapter 16, Article 5O Fact Sheet Page 9

10 Chapter 16, Article 5O does not address two specific tasks: medication administration and feeding through a g-tube or j-tube; and administering insulin through subcutaneous injections or an insulin pump. Personal Example Jane receives services through the I/DD Waiver and has stable diabetes and is insulin dependent. A nurse administers her insulin via a preloaded syringe. Due to the stable nature of Jane s diabetes, an unlicensed person could be trained to Chapter 16, Article 5O Fact Sheet Page 10

11 provide Jane with her routine insulin treatment. Carl receives services through the I/DD Waiver and has a g-tube for feedings and medication administration. A nurse administers his feedings and medications six times per day. Due to the routine nature of the g-tube, an unlicensed person could easily be trained to provide this service. Recommendation Code language need to reflect that unlicensed personnel may be trained to provide routine insulin injections to Chapter 16, Article 5O Fact Sheet Page 11

12 individuals with stable and predictable diabetes, and g-tube/jtube feedings. This is highly relevant for a state with a very high rate of diabetes among its citizens, and due to the lack of available and qualified nurses in the field. State Examples Insulin Treatment: Colorado, Hawaii, Maryland, Minnesota, Missouri, Nebraska, New Jersey, North Dakota, Ohio, Oklahoma, Oregon, South Carolina, Texas, Utah, Vermont, Washington, Wisconsin Chapter 16, Article 5O Fact Sheet Page 12

13 G-Tube/J-Tube Treatment: Arkansas, Connecticut, Delaware, Florida, Hawaii, Idaho, Iowa, Kentucky, Louisiana, New Hampshire, New Jersey, Ohio, Oregon, South Carolina, South Dakota, Texas, Utah, Vermont, Washington ISSUE #3: SELF-ADMINSTRATION Chapter 16, Article 5O restricts the level of assistance that may be provided to support people with disabilities to self-administer their own medications. Personal Example Chapter 16, Article 5O Fact Sheet Page 13

14 Mark receives services through the I/DD Waiver Program and needs physical assistance to self-administer his medications. Mark cannot place the dosage of medication in his mouth due to his cerebral palsy. Mark can identify each medication he takes and why he takes it. Mark uses an assistive device to remind him the time he takes his medication. Current law prevents an Approved Medication Assistive Personnel (AMAP) from assisting Mark to selfadminister his medications. Recommendation Chapter 16, Article 5O Fact Sheet Page 14

15 Code language needs to reflect that an AMAP can assist the individual to self-administer by using sanitary measures to place the dosage of medication to Mark s mouth to facilitate self-administration. State Examples States address this in many different ways through statutory and regulatory means. The following states define assisting or assistance with selfadministration of medication: Arkansas, Florida, Illinois, Minnesota, North Carolina, New Jersey, Ohio, Oregon, South Dakota, Texas, Wisconsin, and Wyoming. Chapter 16, Article 5O Fact Sheet Page 15

16 ISSUE #4: EXEMPTION AND SELF- DIRECTION Chapter 16, Article 5O does not permit exemption for people directing their own supports and services through self-directed options under the I/DD Waiver Program. Personal Example Michelle receives services through the I/DD Waiver Program and participates in the self-directed option with the assistance of her guardian/mother. Michelle and her mother are able to hire/train/fire the direct care staff that work for Chapter 16, Article 5O Fact Sheet Page 16

17 Michelle. However, they cannot hire/train/fire direct care staff to administer medications. Recommendation Code language needs to reflect the ability for people who desire and are capable of directing their own supports to do so with respect to health maintenance tasks or medication administration. State Examples With the development of formal selfdirected options for state programs and services, the issues surrounding nursing services and exemptions Chapter 16, Article 5O Fact Sheet Page 17

18 began to arise in home and community-based programs. Examples of states that define exemptions within statute are: Alabama, Alaska, Arizona, Colorado, Connecticut, Delaware, Florida, Idaho, Illinois, Kansas, Kentucky, Louisiana, Maine, Maryland, Montana, Nebraska, New Hampshire, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, South Dakota, Tennessee, Vermont, and Washington. COST CONSIDERATIONS There is a considerable cost factor when registered or licensed practical Chapter 16, Article 5O Fact Sheet Page 18

19 nurses administer medications versus trained and certified AMAP. The following details the Medicaid reimbursement rates for paid service providers to administer medications through the I/DD Waiver Program: Trained and Certified AMAP $20.04/hour ($5.01 per 15 minute unit) Licensed Practice Nurse $44.08/hour ($11.02 per 15 minute unit) Registered Nurse $65.12/hour ($16.28 per 15 minute unit) Chapter 16, Article 5O Fact Sheet Page 19

20 The above rates are based on a 1:1 staff ratio. The direct care staff person (who is also an AMAP) is billing for their services regardless of whether they perform medication administration or a registered nurse performs this task for them. The AMAP is the direct care staff that is providing support to the individual. When a registered nurse performs medication administration, this is an additional cost to the program. OTHER CONSIDERATIONS Changes were made to include liability language and general language cleanup to reflect current Chapter 16, Article 5O Fact Sheet Page 20

21 best practices. The intent is define the liability of the registered nurse to cover the decision to delegate and the requirements to provide training and oversight to the unlicensed personnel. This would eliminate liability for the occurrence of the unlicensed personnel performing in a manner that is not consistent with the training provided by the registered nurse. State Examples Montana, Oregon, Washington have language that hold the nurse accountable for the act of delegating Chapter 16, Article 5O Fact Sheet Page 21

22 and supervision, but not accountable for the outcome. Chapter 16, Article 5O Fact Sheet Page 22

TABLE 3c: Congressional Districts with Number and Percent of Hispanics* Living in Hard-to-Count (HTC) Census Tracts**

TABLE 3c: Congressional Districts with Number and Percent of Hispanics* Living in Hard-to-Count (HTC) Census Tracts** living Alaska 00 47,808 21,213 44.4 Alabama 01 20,661 3,288 15.9 Alabama 02 23,949 6,614 27.6 Alabama 03 20,225 3,247 16.1 Alabama 04 41,412 7,933 19.2 Alabama 05 34,388 11,863 34.5 Alabama 06 34,849 4,074