Raleigh Parks and Recreation Permission Form for Assisted Administration of Medication Parks and Recreation employees only administer medication to participants if: 1. The City of Raleigh Permission Form for Assisted Administration of Medication is completed and in the possession of the Parks & Recreation Staff. 2. A Parks & Recreation employee will not give medications unless it is in an original container with appropriate medicine contained within, with a visible label including the name of medication, the date of expiration, clear dosage amount and directions with the participant s name CLEARLY INDICATED on the bottle/box. The Parent/Guardian is responsible for the following with ALL medication: 1. Complete and sign the portion of the form below and return to the program staff. 2. Provide medication in an original container with visible label including the name of medication, the date of expiration, clear dosage amount and administration directions with the participant s name CLEARLY INDICATED. Note: Inhalers outside the original package, must be accompanied by a copy of the original package label noting the above information. 3. Provide new, labeled containers if/when medication changes are made. 4. Parents/Guardians must transport medication to program site and give directly to program staff. 5. Parent/Guardian must pick up medication at the end of each week/program from program staff. Medications not picked up at the end of 14 business days following the last day of participation in the program will be disposed of by program staff. 6. Recreation program employees will dispose of empty containers (unless otherwise instructed). 7. For Prescription medications: The pharmacy label will serve as the physician s authorization for the medication to be administered. Have the pharmacist label two containers: one for home use and one for use in the program, if the participant is to receive medication at both sites. 8. If the medication is an EPI pen or inhaler, it is recommended (not required) that the pharmacist label two containers to keep at the program site. The parent/guardian should check to ensure the medication does not exceed the printed expiration date. Program staff will not accept expired medication. 9. For Non-Prescription medications: The medication must be administered according to the dosage and administration instructions on the original container. **A physician s signature will be required as authorization IF medication is requested to be given in an alternate dosage, etc. 10. Parents/guardians should notify program staff as soon as possible if there are any changes to instructions for the administration of medication once this form has been submitted. A new form may be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Permission Form for Assisted Administration of Medication By completing the information below, the Parks & Recreation staff is authorized to administer any medication(s) that are provided as indicated above. Participant s Name: 1. Name of Medication: Prescription Non-Prescription Dosage: Times: Reason for medication: Side effects: 2. Name of Medication: Prescription Non-Prescription Dosage: Times: Reason for medication: Side effects: Physician Name: Signature: Date: *ONLY under special circumstances for NON-PRESCRIPTION medications (see #9 above). Parent/Guardian Signature: Date:
Medical Emergency Action Plan Participant Name: Parent/Guardian Name(s): Address: Phone (primary): Phone (secondary): Participants Medical Condition (parent/guardian to complete): Participant s History with condition, including known triggers (parent/guardian to complete): Preventative steps (parent/guardian to complete): 1. 2. 3. 4. 5. Any additional notes:
In the event of a medical emergency the following steps will be taken by the City of Raleigh Parks and Recreation Department. A medical emergency would include the following signs and/or symptoms (parent/guardian to complete): Steps to be Taken: Step 1: Call 911 and Parents/Guardians Step 2: Step 3: Step 4: *NOTE* City of Raleigh staff will not be able to administer invasive medication in the event of an emergency. Staff will notify EMS if emergency arises. Parent/Guardian signature City of Raleigh Staff Date Date For staff use only Once completed, this document should be forwarded to the program supervisor, who will forward it to the RPRD Risk Manager. RPRD Risk Manager will send it to the City Nurse for review. Once reviewed and approved by all of the above, the Recreation Superintendent, program supervisor, and program staff will be notified. A copy of this document should be kept with any medication stored on site for the participant; the original should be stored with the participant s registration form. A copy will be stored on the network in a password-protected file (for full-time staff access only) by the RBO. Date submitted to supervisor: Date approval received:
RALEIGH PARKS AND RECREATION Participant Medication Policy Subject: Participant medication protocols for minors 1.0 Purpose: To provide procedures for the variety of situations and methods involving administration of medicines that may be necessary for a participant s well-being to function in a Parks and Recreation setting and cannot be scheduled outside the program. 2.0 Definitions: 2.1 Self administration: Participant controls access, dosage and administration. 2.2 Assisted self administration: Staff controls access, dosage and participant self administers medication 2.3 External administration: Staff controls access, dosage and administers medication when the participant is either physically or mentally incapable of doing so. 2.4 Prescription medication: Medicine prescribed by a doctor post examination to treat a specific illness or medical condition that includes recommended dosage and intake schedule. Medicines that are filled by a pharmacist. 2.5 Non-prescription medication: Medicine one can purchase at a variety of stores to treat general symptoms that do not require medical exams and physicians prescription. 2.6 Diastat: This medication is used to treat episodes of increased seizures (e.g., acute repetitive seizures, breakthrough seizures) in people who are already taking medications to control their seizures. This product is only recommended for short-term treatment of seizure attacks. Be aware of the generic drug name as Diazepam. 2.7 Epinephrine (EPI): Epinephrine is a chemical that narrows blood vessels and opens airways in the lungs. Epinephrine injection is commonly used to treat severe allergic reactions (anaphylaxis) to insect stings or bites, foods, drugs, and other allergens. 2.8 Inhaler: An asthma inhaler is a handheld device that delivers asthma medication straight into the airways. 2.9 Severe allergic reaction: Allergic reaction that is restricting or preventing breathing. 2.10 Invasive treatment: Treatment that must be administered through the skin, such as injections or suppositories. 2.11 Insulin pump: An insulin pump is a small, computerized medical device (cell phone size) that allows a continuous flow of insulin to be released into the body. Pumps are worn on an individual s body, usually on the belt or in a pocket, with a tube that is inserted under the skin of the abdomen to deliver the insulin. The pump is programmed to a unique plan for each wearer and the dosage can be changed by the user. 3.0 Recreation division responsibilities: 3.1 Program staff may administer non-invasive medication to participants with authorization. Participants may need to take medication during the program day; if necessary, they may do so and have the medication administered as indicated on the current pharmacist s label. The pharmacist s Page 1
label and Assisted Administration of Medication Form; signed by a parent or guardian, will authorize the program staff to administer both prescription and non-prescription medications. 3.2 Program staff such as the program director or manager shall be responsible for receiving the request and for monitoring the administration and maintenance of medication. The following conditions apply when medication is to be controlled and distributed by program staff. 3.2.1 In the case of long-term medications, medication requests must be updated at the beginning of a program and any time there is a change in the prescribed dosage. 3.2.2 Only specific program staff (i.e. full-time staff, program/camp director or designee) will be responsible for overseeing the security and distribution of medications. 3.2.3 Program staff cannot be required to administer medication. However, each site must have at least one designated staff on site during program hours that will administer medication as indicated on Assisted Administration of Medication Form. 3.2.4 Program staff will not dispense medication unless it is in a current container dispensed by a pharmacy or commercial manufacturer. The medication label must match the name and dose of medication listed on Assisted Administration of Medication Form. 3.3 Sunscreen and Insect Repellent 4.0 General guidelines 3.3.1 All parents/guardians are encouraged to administer sunscreen and/or insect repellent to their participants prior to attending a Parks and Recreation sponsored program. Sharing is not permitted. Program staff will only apply sunscreen/insect repellent to areas that the participant physically cannot reach (i.e. the back). Program staff applying sunscreen/insect repellent should be of the same sex as the participant. Application should be done in a public area. Exceptions may be made for participants with special needs that require additional assistance for sunscreen/insect repellant application. 3.3.2 Program staff will provide frequent opportunities for participants to apply sunscreen and/or insect repellent as needed throughout the course of the program. Program staff will also provide supervision and verbal direction to participants during reapplication of sunscreen and/or insect repellent. 3.3.3 Participant may transport and keep sunscreen and/or insect repellent with their personal belongings while participating in a Parks and Recreation program. Sunscreen and insect repellent will not be kept at the program location overnight or on weekends. Licensed school-based programs also will require a signed parental permission form, to be kept on file at the program site. 4.1 Medication storage: 4.1.1 Medications, even those requiring refrigeration, must be kept LOCKED or SECURED. The term secured can mean a closed backpack under the direct supervision of a designated program staff. Medication containers must be kept separated by a zip-lock bag that is labeled appropriately with the participant s name. The perforated section of the Assisted Administration of Medication Form should be copied and placed in the zip lock bag. The original should remain with the participant s registration form. Page 2
4.2 Assisted self administration of medications 4.2.1 Program staff will assist with self administration of both prescription and nonprescription medications. Specific processes for administering and monitoring of participant medications are listed in 6.0 and 8.0 of this policy. 4.3 Documentation and record retention 4.3.1 The program staff responsible for distributing medication will keep a written record of dates and times of administration on the Medication Monitoring Form. 4.3.2 Medication monitoring forms should be kept in one location such as a program medication binder. 4.3.3 Records and monitoring forms will be kept secure and private. 4.4 Medication disposal: 1.0 Medication dosage should not extend past the end of the program the participant is registered for. Program staff should encourage parents to use the physician prescription to calculate dosage provided to program staff so that no extra medication remains at the end of the program. Program staff will remind parents of the recreation division s disposal guidelines. 2.0 The parent/guardian will pick up the medication directly from the program site on the last day of the program. Unclaimed medication will be turned into the designated full time staff member for disposal. If parent/guardian does not retrieve any remaining medication at the end of the program, they will have 14 business days to claim medication. After 14 business days the designated full time staff member will document and transfer possession of medication to the City nurse who will dispose of all medications. 3.0 Program staff will contact the participant s legal guardian until direct contact is made. Once contact is made program staff will confirm the remaining time frame for medication disposal or pick up. Documentation of attempted contact with the legal guardian as well as conversation with the guardian will be collected on the Contact and Disposal of Medication Form. 4.0 Prescription medication, EPI pens, inhalers and any other approved medication supplies can be held for a participant who is registered for back to back programs in the same location (site/facility). Back to back programs are defined as programs that have no more than 14 business days between programs. 5.0 Non-prescription medications 5.1 Non-prescription medications will be controlled by program staff supervising minors. Exceptions may be made for Teen, Adventure and SRS Adult programs. 5.1.1 Teen and Adventure participants middle school age and higher and SRS Adults may selfmedicate with non-prescription medicines. Should there be concern or question about the appropriateness of self-administered medication, program staff should consult with participant s parent/guardian. 5.2 An Assisted Administration of Medication Form must be completed and returned by the legal guardian. 5.3 Program staff will not dispense non-prescription medication unless it is in its original container. The medication must match medication listed on the Assisted Administration of Medication Form. Page 3
5.4 All non-prescription medications received by the program will be recorded on the registration/medical information form including the name and dose of the medication and the person receiving the medication and circumstances under which the participant should receive the medication. 5.5 It is the responsibility of the parent or legal guardian to bring the medication to the program and transfer possession to the appropriate program staff. The parent or legal guardian is also responsible for collecting medication for their participant at the end of a program. 5.6 Assisted administration of non-prescription medication 5.6.1 Make sure medication is given in the correct dosage according to the medication monitoring form. 5.6.1.1 Ask participant to state his or her name and check against form 5.6.1.2 Check container and verify that medication has not exceeded the expiration date. 5.6.1.3 Recheck dosage instruction then give the medication. 5.6.2 Avoid touching the medication. Pour tablets onto lid. 5.6.3 Observe the participant taking the medication. 5.6.4 Document and sign immediately that medication was given on Medication Monitoring Form. 5.7 Liquid medication 5.7.1 Parents/legal guardians must supply a method of measurement for liquid medication. Program staff is not responsible for supplying liquid medication measurement devices. 5.7.2 Liquid medication will follow all the guidelines listed above. All liquid medication dosage measurements will be double checked by a second program staff prior to distributing medication to the participant. 5.8 Documentation and record retention 5.8.1 Medication Monitoring Form should be kept in a single notebook, alphabetized by participant s last name. 5.8.2 A weekly updated list of participants on medications should be kept at the front of the medication notebook for the purpose of identifying participants and making sure they receive medication if it is to be given a specified times. This will give program staff quick review on a daily basis. 5.8.3 Records are to be kept confidential and are to be accessible only to authorized program staff. 5.8.4 If a participant fails to come to the designated person to receive the medication if required to be given at a specified time, program staff will verify and document the participant s absence. 6.0 Prescription medications 6.1 Prescription medications will be controlled by program staff supervising minors. Exceptions may be made for Teen, Adventure and SRS Adult programs. Page 4
6.1.1 Teen and Adventure participants middle school age and higher, and SRS adults, may selfmedicate with prescribed medication including but not limited to inhalers and EPI pens with proper documentation. Should there be a concern or question about the appropriateness of self-administered medication, program staff should consult with the participant s parent/guardian. 6.2 Program staff will not dispense prescription medication unless it is in a current container dispensed by a pharmacy with participant s name, name of medication, name of doctor, date the prescription was filled and directions clearly marked. The medication label must match the name and dose of medication listed on Assisted Administration of Medication Form. Note: Inhalers outside the original package must be accompanied by a copy of the original package label noting the above information. 6.3 All prescription medications received by the program will be recorded on the registration/medical information form including the name and dose of the medication, person receiving the medication, the doctor s name and time of administration. 6.4 It is the responsibility of the parent or legal guardian to bring the medication to programs and transfer possession to the appropriate program staff. The parent or legal guardian is also responsible for collecting medication for their participant at the end of a program. 6.5 Assisted administration of prescription medication 6.5.1 Make sure medication is given at the right time and in the correct dosage according to medication monitoring form and pharmacist s label. 6.5.1.1.1 Ask each participant to state his or her name and check medication 6.5.1.1.2 Check container prescription label with medication monitoring form and verify the medication has not exceeded the expiration date. 6.5.1.1.3 Recheck the label a 3 rd time then give the medicine. 6.5.2 Avoid touching the medication. Pour tablet onto lid. 6.5.3 Observe the participant taking the medication. 6.4.4 Document and sign immediately that medication was given on Medication Monitoring Form. 6.6 Liquid medication 6.6.1 Parents/legal guardians must supply a method of measurement for liquid medication. Program staff is not responsible for supplying liquid medication measurement devices. 6.6.2 Liquid medication will follow all the guidelines for prescription medication listed above. All liquid medication dosage measurements will be double checked by a second program staff prior to distributing medication to the participant. 6.7 Documentation and record retention 6.7.1 Medication Monitoring Form should be kept in a single notebook, alphabetized by participant s last name. 6.7.2 A weekly updated list of participants on medications should be kept at the front of the medication notebook for the purpose of identifying participants and making sure they receive medication daily as prescribed. This will give program staff quick review on a daily basis. Page 5
7.0 Inhalers and EPI pens: 6.7.3 Records are to be kept confidential and are to be accessible only to authorized program staff. 6.7.4 If a participant fails to come to the designated person to receive the medication, program staff will verify and document the participant s absence. 7.1 Adventure program staff has additional procedural and medical protocol concerning treatment of anaphylaxis and asthma. 7.2 All essential program staff will complete Epinephrine Administration (EPI) Training. Each program/facility will have an EPI trained staff. Assisted administration and administration of Epinephrine will comply with the required training. 7.2.1 Program staff may administer Epinephrine when: 7.2.1.1 The participant has a history of allergies or allergic reactions. 7.2.1.2 The participant is having a severe allergic reaction. 7.2.1.3 The participant asks for assistance in administering their epinephrine or is otherwise incapable of self administration. 7.2.1.4 The participant provides you with an auto-injector prescribed in their name. 7.3 Auto Injection EPI (Ana-pen, Ana-aid) pens are the only form of Epinephrine allowed at City of Raleigh recreation programs. Epinephrine that requires program staff to draw medication from a vial is not permitted as program staff is not trained for that type of injection. 7.4 All EPI pens require a completed Assisted Administration of Medication Form kept with the medication. 7.5 Both inhalers and EPI Pens will be kept by program staff if the Assisted Administration Form has been completed by participant s parent/guardian. Participants in Teen, Adventure and SRS Adult programs, of middle school age or older, may keep their personal inhaler or EPI Pen if the Participant Self Administration of Medication Form is completed by the participant s parent/guardian and on file with program staff. More than one EPI pen or inhaler is recommended to better equip both participants and program staff in case of an emergency. 7.6 If Inhalers/EPI Pens are kept with the program staff, rather than with the participant, the program staff must store these as they would any medication. 7.7 EPI Pens are not to be left in vehicles during field trips. Excessive heat will spoil/ruin EPI medication. 7.8 Use of EPI and Inhalers will be documented by program staff on the Prescription Medication Monitoring Form. 911 must be called in the event that epinephrine is administered. 8.0 Invasive Treatment 8.1 Program staff is not authorized to administer invasive treatments except Inhalers and Epi Pens. 8.2 A Medical Emergency Action Plan will be developed for any participant that, due to medical condition, requires invasive treatment to be kept on site. This plan will be developed between the program supervisors and the participant s parent or guardian. It will detail the participant s history as relates to their medical condition, warning signs or symptoms, and treatment that will be required upon onset of those signs and symptoms. The plan will also detail steps that program staff are Page 6
9.0 Appendix authorized to take (i.e. observe participant, call 911, provide EMT with medication, contact parents). It will be signed by both parents and program staff. A template will be provided (see Appendix). 8.3 Once a Medical Emergency Action Plan has been developed for a participant, it will be forwarded as soon as possible to the full-time program supervisor, who will then forward it to the RPRPD Risk Manager for review. The Risk Manager will forward it to the City Nurse for review and once all parties have reviewed it, will notify the Recreation Superintendent, program supervisor and program manager. This process should be completed within five (5) business days. The original document will be stored with the participant s registration form on site; a copy will be stored on the network in a password-protected file. 8.4 In the event that the need to administer invasive treatment to a participant arises, program staff will follow the Medical Emergency Action Plan for that participant. Once the event is over, staff will need to complete an Accident Report for documentation and debrief the incident with the immediate Supervisor, Superintendent & other appropriate City of Raleigh Personnel. 8.5 Participants that will need to self-administer invasive treatment on site (i.e. glucose testing or insulin) will be required to have all necessary paperwork (Self Administration of Medication Form and Specific Medication Administration Instructions) on file. 8.6 Participant will take full responsibility for their self-administration. 8.7 Staff will monitor and document through use of the Prescription Medication Monitoring Form. In the event that a disposable needle is used, the needle will be disposed of in the red Sharps container kept in each site s first aid kit. The Sharps container should be transported to the City Nurse s office so that they may dispose of the contents. 8.8 If the participant cannot self-administer necessary invasive treatment on site, a Medical Emergency Action Plan will be developed and followed. 9.1 General Medication Information Form 9.2 Assisted Administration of Medication Form 9.3 Self Administration of Medication Form (for use by Teens, Adventure & Adult SRS ONLY) 9.4 Specific Medication Administration Instructions 9.5 Allergy Information Form 9.6 Medication Monitoring Form 9.7 Contact and Disposal of Medication Form 9.8 Medication Emergency Action Plan Template Page 7
Contact and Medication Disposal Form Program name: Participant s name: Medication: Medication: Program end date: Guardian name: Medication: Medication: Attempts to contact parent/legal guardian Contact info used: Phone 1) Phone 2) Email: 1. Date Method: Phone 1/2, Email, Both. Contact: Yes/No 2. Date Method: Phone 1/2, Email, Both. Contact: Yes/No 3. Date Method: Phone 1/2, Email, Both. Contact: Yes/No 4. Date Method: Phone 1/2, Email, Both. Contact: Yes/No 5. Date Method: Phone 1/2, Email, Both. Contact: Yes/No 6. Date Method: Phone 1/2, Email, Both. Contact: Yes/No 7. Date Method: Phone 1/2, Email, Both. Contact: Yes/No 8. Date Method: Phone 1/2, Email, Both. Contact: Yes/No 9. Date Method: Phone 1/2, Email, Both. Contact: Yes/No 10. Date Method: Phone 1/2, Email, Both. Contact: Yes/No 11. Date Method: Phone 1/2, Email, Both. Contact: Yes/No 12. Date Method: Phone 1/2, Email, Both. Contact: Yes/No 13. Date Method: Phone 1/2, Email, Both. Contact: Yes/No 14. Date Method: Phone 1/2, Email, Both. Contact: Yes/No
Contact and Medication Disposal Form Multiple efforts have been made to contact to retrieve the medications for. In accordance with the City of Raleigh recreation division s medication policy, medications listed below will be turned over to the City nurse s office for disposal as of the date listed below. Medications (1), (2), (3), (4) were delivered to the City nurse s office on by. Program manager signature: Date: City nurse signature: Date:
Medication Monitoring Form Program Name: First name: Last name: Name of medication: Dosage: Prescription Non-Prescription Times: Program Dates (if applicable): Monday Tuesday Wednesday Thursday Friday Notes: Staff name / signature: Staff name / signature: *When administration form is completed, any staff who initialed to administer the medication must print and sign their name above. *A notation should be written on EVERY day the participant is scheduled to attend. *When administering the medication, note the time and your initials. *If the participant is absent, please note ABS and your initials. *If participant arrives late/leaves early, affecting administration of meds, note: TOA(time of arrival) or TOD(time of departure), the time and your initials.