Cindy Leach RN, BSHA, NHA, AL Manager Vice President of Operations CopperSands

Cindy Leach RN, BSHA, NHA, AL Manager Vice President of Operations CopperSands

Objectives Address important checks and balances for QA in medication management Discuss care giver training best practices Discuss do s and don ts of survey processes

Medication Management Who s Managing your Medications? ADHS? Physicians? Pharmacists? Nurse? Caregiver? AL Manager?

ADHS Top three deficiencies as of April 30, 2014 R9-10-803.C.1.a. R9-10-816.B.2.b. R9-10-816.A, B, E. Policies and Procedures Meds administered as per order Medication P&Ps

Definitions Administer: AZ Statues: means the direct application of a controlled substance, prescription-only drug, dangerous drug or narcotic drug, whether by injection, inhalation, ingestion or any other means, to the body of a patient or research subject by a practitioner or by the practitioner s authorized agent of the patient or research subject at the direction of the practitioner.

Definitions Assistance in the Self-Administration of Medication: Article 1: means restricting a patient s access to the patient s medication and providing support to the patient while the patient takes the medication to ensure that the medication is taken as ordered.

Definitions Medication Administration: Article 1: means restricting a patient s access to the patient s medication and providing the medication to the patient or applying the medication to the patient s body, as ordered by a MP Immediate: Article 1: means without delay.

Article 8 R9-10-816 Medication Services A manager shall ensure that: P&P for medication services include: Procedures for preventing, responding to, and reporting a medication error; Procedures for responding to and reporting an unexpected reaction to a medication; Procedures to ensure that a resident medication regimen and method of administration is reviewed by a medical practitioner (MP) to ensure the medication regimen meets the resident s needs.

Article 8 Procedures for: Documenting, as applicable, medication administration and assistance in the self-administration of medication; and Monitoring a resident who self-administers medication; Procedures for assisting a resident in procuring medication; and If applicable, procedures for providing medication administration or assistance in the self-administration of medication off the premises; and

Article 8 If a verbal order for a resident s medication is received from a medical practitioner by the ALF: The manager or caregiver takes the verbal order from the MP, The verbal order is documented in the resident s medical record, and A written order verifying the verbal order is obtained from the MP within 14 calendar days after receiving the verbal order.

Article 8 If an ALF provides medication administration, a manager shall ensure that: Medication is stored by the ALF; P&P for medication administration: Are reviewed and approved by a MP, RN or pharmacist;

Article 8 A manager shall ensure that: Include a process for documenting an individual, authorized, according to the definition of administer in A.R.S. 32-1901, by a MP to administer medication under the direction of the MP.

Article 8 A manager shall ensure that: Medication is administered to a resident only as prescribed; and Cover the documentation of a resident s refusal to take prescribed medication in the resident s medical record; and

Article 8 A medication administered to a resident: Is administered by an individual under the direction of a MP, Is administered in compliance with a medication order, and Is documented in the resident s medical record.

Article 8 If an ALF provides assistance in the selfadministration of medication, a manager shall ensure that: A resident s medication is stored by the ALF; The following assistance is provided to a resident: A reminder when it is time to take the medication; Opening the medication container or medication organizer for the resident; Observing the resident while the resident removes the medication from the container or medication organizer;

Article 8 Except when a resident uses a medication organizer, verifying that the medication is taken as ordered by the resident s MP by confirming that: The resident taking the medication is the individual stated on the medication container label, The resident is taking the dosage of the medication stated on the medication container label or according to an order from a MP dated later than the date on the medication container label, and The resident is taking the medication at the time stated on the medication container or according to an order from a MP dated later than the date on the medication container label;

Article 8 For a resident using a medication organizer, verifying that the resident is taking the medication in the medication organizer according to the schedule specified on the MP s order; or Observing the resident while the resident takes the medication;

Article 8 P&P for assistance in the self-administration of medication are reviewed and approved by a MP or nurse; and Assistance in the self-administration of medication provided to a resident: Is in compliance with an order, and Is documented in the resident s medication record.

Article 8 A manager shall ensure that: A current drug reference guide is available for use by personnel members, and A current toxicology reference guide is available for use by personnel members.

Article 8 A manager shall ensure that a resident s medication organizer is only filled by: The resident; The resident s representative; A family member of the resident; A personnel member of a home health agency or hospice services agency; or The manager or a caregiver who has been designated and is under the direction of a MP, according to subsection (B)(2)(b).

Article 8 When medication is stored by an ALF, a manager shall ensure that: Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage; Medication is stored according to the instructions on the medication container; and

Article 8 P&P are established, documented, and implemented for: Receiving, storing, inventorying, tracking, dispensing, and discarding medication including expired medication: Discarding or returning prepackaged and sample medication to the manufacture if the manufactured requests the discard or return of the medication; A medication recall and notification of residents who received recalled medication; and Storing, inventorying, and dispensing controlled substances.

Article 8 A manager shall ensure that a caregiver immediately reports a medication error or a resident s unexpected reaction to a medication to the MP who ordered the medication or, if the MP who ordered the medication is not available, another MP.

Article 8 If medication is stored by a resident in the resident s bedroom or residential unit, a manager shall ensure that: The medication is stored according to the resident s services plan; or If the medication is not being stored according to the resident s service plan, the resident s service plan is updated to include how the medication is being stored by the resident.

Physicians? When they order a medication, do they review all the other meds for potential side effects and adverse reactions? Are they getting an accurate observation/assessment to determine the type of medication for maximum effect?

Pharmacist? When the AL orders medications, is a review being completed by a pharmacist for drug interactions? When does a pharmacist review the medications?

Nurse? There are no requirements to have a nurse in AL unless: Review of service plan for a resident requiring intermittent nursing services or medication administration (could use a MP too)

Caregiver? How much training do they receive in medications to obtain their certificate? Do they read the PDR or drug manual?

AL Manager? Receive the same amount of medication training as caregiver Only if they had to take caregiver course, otherwise, none.

Title 4 Profession and Occupation. Chapter 33. Board of Examiners for Nursing Care Institutions. Administrators and Assisted Living Managers. Article 7 Assisted Living Facility Caregiver Training Programs: R4-33-703 Curriculum for ALF Caregiver Training Program

Caregiver Training C. 14. Medication management (at least 16 classroom hours). Determining whether a resident needs assistance with medication administration and if so, the nature of the assistance; Assisting a resident to self-administer medications; Observing, documenting, and reporting changes in resident condition before and after medication is administered;

Caregiver Training Knowing the five rights of a resident in medication administration; Knowing classifications of and responses to medications; Taking, reading, and implementing physician medication and treatment orders; Storing medication properly and securely; Documenting medication and treatment services; Maintaining records of medication and treatment services;

Caregiver Training Using medication organizers properly; Storing and documenting use of narcotic drugs and controlled substances; Understanding how metabolism and physical conditions affect medication absorption; Knowing the proper administration of all forms of medication; Using drug-reference guides (PDR); and Preventing, identifying, documenting, reporting, and responding to medication errors.

CMA Compare this to Certified Medication Assistants in long term care settings through the Arizona State Board of Nursing. Besides the 120 hours required becoming a C.N.A, to pass meds they have to: Work as a C.N.A for at least 6 months; have no outstanding complaints or restrictions on a C.N.A. certification Pass a screening math and reading comprehensive test

CMA Earned a high school diploma, GED, or US college or US military credits or 12 years of education in a fording county; The total program length is a minimum of 100 clock or contact hours. 45 of those in didactic study inclusive of 4 unit tests 15 hours of skills lab experience Minimum of 40 hours of clinical practice utilizing the guidelines of progressive clinical practice and principles of supervision as detailed in the requirements.

Course Goals Explain the role of the CMA in AZ including allowable acts, conditions, and restrictions. Discuss principles, terminology, laws, and drug references as they apply to administration of medications. Explain principles of medication action. Explain principles of medication administration and nursing assistance care considerations when administering medication to clients of all ages. Accurately calculate medication dosages Promote safe medication administration

Course Goals Discuss medication properties, uses, adverse effects, administration, and nursing assistant care of residents receiving the following types of medications: Vitamins, minerals, and herbs Antimicrobials Eye and Ear medications Skin medications Cardiovascular medications Respiratory medications Gastrointestinal medications Urinary system medication and medication to attain fluid balance Endocrine/reproductive medications Musculoskeletal medications Nervous system/sensory system medications Psychotropic medications

CMA Even after all the training, there are multiple limitations. The CMA cannot: Give the first dose of medication including if the previous med dosage changed Give PRN meds Count controlled substances Give any medication delivered by a needle Give inhalant medications Apply topical patches and topical medications requiring a sterile dressing or assessment Give sublingual medications

Quality Management A Manager shall ensure that: A plan is established, documented, and implemented for an ongoing quality management program that, at a minimum, includes: A method to identify, document, and evaluate incidents; A method to collect data to evaluate services provided to residents;

Quality Management A method to evaluate the data collected to indentify a concern about the delivery of services related to resident care; A method to make changes or take action as a result for the identification of a concerns about the delivery of services related to resident care; and The frequency of submitting a documented report required in subsection (3) to the governing authority.

Quality Management ADHS has a Sample Quality Management Program on their website: ADHS has provided training. Is provided as a courtesy providers are NOT required to use sample.

Systems for Improvement Additional training to caregivers re: medication management Initially, audit medication records daily, then weekly to ensure residents are receiving medications. Develop systems at change of shift for caregivers to review the MARs to ensure there are no holes. Only have specific people assigned to take MP orders and order from pharmacy. Ensure there is a policy for times of administration

Systems for Improvement Have list of ordered meds available for when medications are delivered to ensure all medications have arrived. Count medications with delivery driver to ensure all medications have arrived. If doing recap of physician orders, do monthly as this will decrease errors. Ensure PO s match the MAR. Evaluate the difference between multi-dose packaging and unit does packaging. Ensure processes in place to prevent borrowing of medication.

Survey Do s and Don ts Do s Inspect med carts/room/storage for expired meds Audit frequently the MARs/TARs Have a pharmacist review the PO s, MARs, and TARs at least quarterly Conduct frequent med pass audits Review and update P&P Don ts Have new caregivers pass medications Allow interruptions to the caregiver during med pass

Resources Arizona Dept of Health Services Article 8 http://www.azdhs.gov/als/residential/documents/article-8.pdf AZNCIA http://www.aznciaboard.us/new%20rules%20effective%208-3-13.pdf Arizona State Board of Nursing http://www.azbn.gov/educationcmaprograms.aspx