PDF- -Chapter NR 115 - Wisconsin - Administrative Rule 116

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Division of Developmental Disabilities Bureau of Clinical Services

Section 2

Administrative Rule 116 State Published Copy of Administrative Rule 116 Annotated Copy of Administrative Rule 116

Training Program for Authorized Non-licensed Direct Care Staff

PART 116 ADMINISTRATION OF MEDICATION IN COMMUNITY SETTINGS : Se...

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TITLE 59: MENTAL HEALTH CHAPTER I: DEPARTMENT OF HUMAN SERVICES PART 116 ADMINISTRATION OF MEDICATION IN COMMUNITY SETTINGS

The General Assembly's Illinois Administrative Code database includes only those rulemakings that have been permanently adopted.

This menu will point out the Sections on which an emergency rule (valid for a maximum of 150 days,

usually until replaced by a permanent rulemaking) exists.

The emergency rulemaking is linked through the notation that follows the Section heading in the menu.

Section 116.10 Purpose Section 116.20 Definitions Section 116.30 Master Nurse-Trainer and Nurse-Trainers Section 116.40 Training and Authorization of Non-Licensed Staff by Nurse-Trainers Section 116.50 Administration of Medications Section 116.60 Medication Self-Administration Section 116.70 Medication Administration Record and Required Documentation Section 116.80 Storage and Disposal of Medications Section 116.90 Individual Health Supports and Assessment Section 116.100 Quality Assurance Section 116.110 Administrative Requirements

AUTHORITY: Implementing and authorized by Section 15.4 of the Mental Health and Developmental Disabilities Administrative Act [20 ILCS 1705/15.4].

SOURCE: Emergency rule adopted at 23 Ill.

11988,

1999,

2656,

2000.

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TITLE 59: MENTAL HEALTH CHAPTER I: DEPARTMENT OF HUMAN SERVICES PART 116 ADMINISTRATION OF MEDICATION IN COMMUNITY SETTINGS SECTION 116.10 PURPOSE

Section 116.10 Purpose The purpose of this Part is to ensure the safety of individuals in programs funded by the Department of Human Services (DHS) by regulating the storage,

and administration of medications in specific settings

training of non-licensed staff in the administration of medications.

This applies exclusively to all programs for individuals with a developmental disability in settings of 16 persons or fewer that are funded or licensed by the Department of Human Services and that distribute or administer medications and all intermediate care facilities for the developmentally disabled with 16 beds or fewer that are licensed by the Illinois Department of Public Health.

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TITLE 59: MENTAL HEALTH CHAPTER I: DEPARTMENT OF HUMAN SERVICES PART 116 ADMINISTRATION OF MEDICATION IN COMMUNITY SETTINGS SECTION 116.20 DEFINITIONS

Section 116.20 Definitions The words and phrases used in this Part shall mean the following,

except where a different meaning is clearly intended from the context: "Administer" or "Administration." An act in which a single dose of medication is instilled into the body of,

or otherwise given to a person for immediate consumption or use,

exclusive of injection or other similar methods of transmission.

"Adverse drug reaction." A person's response to medication that has an undesirable effect and may be harmful to the health of a person.

The reaction may be temporary and resolve itself without lasting effects or it may require interventions to be resolved.

"Agency." Any organization that operates a residential program for persons with developmental disabilities.

"Authorized direct care staff." Non-licensed persons who have successfully completed a medication administration training program specified by the Illinois Department of Human Services (DHS) and conducted by a nurse-trainer.

This authorization is specific to an individual receiving services in a specific agency and does not transfer to another agency [20 ILCS 1705/15.4(b)] or individual.

"Community residence." Any residence funded by DHS and provided by a licensed agency,

or a residential setting certified or approved by DHS,

or an intermediate care facility for 16 or fewer persons with developmental disabilities,

licensed by the Illinois Department of Public Health (DPH) as an Intermediate Care Facility for the Developmentally Disabled (ICF/DD-16),

"Competency-based." Training which is tied to an identified set of skills and knowledge and requires documentation of an acceptable level of performance of a task or achievement of an outcome.

"Controlled substance." Any drug or other substance listed pursuant to a schedule in the Illinois Controlled Substances Act [720 ILCS 570].

"Days." Unless otherwise indicated,

all references to days within the text of this

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Part refers to working days.

"DD Clinical Director." The physician serving as the clinical director of the Office of Developmental Disabilities,

Division of Disability and Behavioral Health Services,

Illinois Department of Human Services,

"Delegation." The transfer of responsibility for the performance of selected tasks by the registered nurse (RN) to qualified,

competent assistive personnel in a selected situation,

based upon the RN's plan of care.

The RN retains professional accountability for the outcome of the delegated task and all the nursing care of the individual.

No redelegation by assistive personnel may occur.

"Department." The Illinois Department of Human Services (DHS).

"Distribute or distribution." The act of controlling access to medications and allowing access by individuals to their medications at prescribed times.

"DPA." The Illinois Department of Public Aid.

"DPH." The Illinois Department of Public Health.

"Functional literacy." An individual's ability to read,

compute and solve problems at levels of proficiency necessary to function on the job as assessed by standardized techniques.

"Guardian." The parent of a child under the age of 18 whose parental rights have not been terminated or a person appointed by a court to be guardian of the individual.

"Individual." Any person with a developmental disability receiving services from a program.

"Intermediate care facility for the developmentally disabled (ICF/DD-16)." A residence licensed by the Illinois Department of Public Health to provide health or habilitative care on a long-term basis for 16 or fewer individuals with developmental disabilities.

"Licensed person or personnel." A physician,

a registered professional nurse,

or a podiatrist licensed in the State of Illinois.

"Master nurse-trainer." An employee of DHS who is a registered professional nurse who has been designated by the DD Clinical Director to train/educate nurse-trainers.

"Medication." A drug prescribed for the individual by a physician,

including drugs to be taken on a PRN basis and over-the-counter drugs.

"Medication error." The administration of medication other than as prescribed resulting in the wrong medication being taken,

or medication being taken at the wrong time,

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It is meant to include a lack of documentation of medication administration or any error in that documentation.

Medication errors must be reported to the DHS Bureau of Quality Enhancement or to the Illinois Department of Public Health Regional Office (if the individual is a resident of an ICF/DD-16) in accordance with written instructions from the Department's Bureau of Quality Enhancement or DPH rules (77 Ill.

Code 350).

All medication errors are subject to review by DHS or DPH,

Medication errors that meet the reporting criteria pursuant to the Department's rules on Office of Inspector General Investigations of Alleged Abuse or Neglect or Deaths in State-Operated and Community Agency Facilities (59 Ill.

Code 50) shall be reported to the Office of Inspector General.

"Medication administration record." A written record of medications prescribed for,

"Non-licensed staff training program." A standardized competency-based medication administration training program approved by the Illinois Department of Human Services.

It is conducted by a nurse-trainer for the purpose of training persons employed or under contract to provide direct care or treatment to individuals receiving services to administer medications and implement selfadministration of medication training to individuals under the supervision and monitoring of the nurse-trainer.

It incorporates adult learning styles,

curriculum overview including ethical-legal aspects,

and standardized competency-based evaluations on administration of medications and self-administration of medication training programs.

"Nurse-trainer." A registered professional nurse and/or advanced practice nurse who has successfully completed the DHS nurse-trainer training program.

"Nurse-Trainer Training Program." A standardized competency-based medication administration program provided by the Illinois Department of Human Services and conducted by a DHS master nurse-trainer.

Nurse-trainers shall train persons employed or under contract to provide self-administration of medication training to individuals under the supervision and monitoring of the nurse-trainer.

It incorporates adult learning styles,

classroom management and a curriculum overview including the ethical and legal aspects of supervising those administering medication.

"Physician." A physician licensed to practice medicine in all of its branches.

"PRN." Prescribed medications,

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"Registered professional nurse." A person licensed as a professional nurse as defined in the Illinois Nursing and Advanced Practice Nursing Act [225 ILCS 65].

"Self-administration." An act in which an individual administers his or her own medications.

To be considered "capable of self-administering medications",

be able to identify prescribed medication by size,

or color and know when it should be taken and in what amount it should be taken each time.

except for variations from the strict and literal performance of such requirements that result in insignificant omissions and defects,

given the particular circumstances and the history of those omissions and defects.

Omissions that have an adverse impact on an individual's health and safety shall be considered significant and shall be considered substantial noncompliance.

"Supervision." An active process in which the Registered Professional Nurse monitors,

and evaluates the outcomes of an activity or task.

The registered nurse maintains the accountability for the tasks and responsibilities,

as subcomponents of total patient care,

delegated to qualified competent assistive personnel.

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TITLE 59: MENTAL HEALTH CHAPTER I: DEPARTMENT OF HUMAN SERVICES PART 116 ADMINISTRATION OF MEDICATION IN COMMUNITY SETTINGS SECTION 116.30 MASTER NURSE-TRAINER AND NURSE-TRAINERS

Section 116.30 Master Nurse-Trainer and Nurse-Trainers a)

The Department's master nurse-trainers are designated by the DD Clinical Director and shall meet the following criteria: 1)

Demonstration of competence to teach adult learners through: A)

evidence of previous teaching or training experience

completion of courses in teaching and instructing.

Possession of two years of clinical registered professional nursing experience within the last five years,

at least one of which shall have been in developmental disabilities.

All registered professional nurses seeking approval to be nurse-trainers to provide medication administration training to non-licensed staff shall: 1)

Be licensed as a registered professional nurse or advanced practice nurse in Illinois.

Possess two years of clinical registered professional nursing experience within the last five years,

at least one of which shall preferably have been in developmental disabilities.

Have successfully completed the DHS Nurse-Trainer Training Program.

Requests for approval as a Nurse-Trainer shall be submitted,

The DD Clinical Director shall approve all requests that show substantial compliance with the requirements.

The decision to approve or deny requests shall be on file with the Department,

which shall maintain a list of all approved Nurse-Trainers.

The DD Clinical Director shall,

grant conditional approval to a registered professional nurse who fulfills the requirements but has not completed the required nurse-trainer course of instruction.

Conditional approval shall be granted for no more than 90 days following the date of conditional approval.

The nurse given conditional approval shall not train or authorize non-licensed staff to administer medications,

previously authorized direct care staff on new medications or dosage changes as shall be required.

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TITLE 59: MENTAL HEALTH CHAPTER I: DEPARTMENT OF HUMAN SERVICES PART 116 ADMINISTRATION OF MEDICATION IN COMMUNITY SETTINGS SECTION 116.40 TRAINING AND AUTHORIZATION OF NON-LICENSED STAFF BY NURSE-TRAINERS

Section 116.40 Training and Authorization of Non-Licensed Staff by Nurse-Trainers a)

Only a nurse-trainer may delegate and supervise the task of medication administration to direct care staff.

Prior to training non-licensed staff to administer medication,

each nurse-trainer shall perform the following for each individual to whom medications will be administered by non-licensed staff [20 ILCS 1705/15.4(c)] once they are trained and authorized direct care staff:

An assessment of the individual's physical and mental status and medical history.

An evaluation of the medication orders and medications prescribed.

Non-licensed direct care staff who are to be authorized to administer medications under the delegation of the registered professional nurse shall meet the following criteria: 1)

complete high school or its equivalency (G.E.D.)

demonstrate functional literacy

satisfactorily complete the Health and Safety component of the Direct Support Persons Core Training Program or a DHS approved equivalent Developmental Disabilities Aide Training Program

be initially trained and evaluated by a nurse-trainer in a competency-based,

standardized medication curriculum specified by DHS

receive specific additional competency-based training and assessment by a nurse-trainer as deemed necessary by the nurse-trainer whenever a change of medication or dosage occurs or a new individual that requires medication enters the program

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pass the written portion of the comprehensive examination furnished by DHS based on the information conveyed to them

score 100% on a written or oral competency-based evaluation specifically pertinent to those medications that such staff are responsible to administer.

Initial competency-based training toward delegation for medication administration shall include: 1)

Best practice standards related to the rights of individuals,

legal and ethical responsibilities,

agency procedures and communication pertaining to medication administration.

Best practice nursing techniques associated with medication administration.

Classes of drugs and their effects and common side-effects.

Specific information regarding the individuals to whom the staff will administer medication and the medication the staff will administer.

Techniques to check,

report and record vital signs when those skills are necessary for the safe administration of medication to that individual.

A final,

competency-based evaluation performed by a nurse-trainer for each medication administered to persons at the program for whom the staff provide supports.

Authorized direct care staff shall be re-evaluated by a nurse-trainer at least annually or more frequently at the discretion of the registered professional nurse.

Any retraining shall be to the extent that is necessary to ensure competency of the authorized direct care staff to administer medication [20 ILCS 1705/15.4(c)],

Direct care staff who fail to qualify for competency to administer medications shall be given additional education and testing to meet criteria for delegation authority to administer medications.

Any direct care staff person who fails to qualify as an authorized direct care staff after initial training and testing must,

be given another opportunity for retraining and retesting.

A direct care staff person who fails to meet criteria for delegated authority to administer medication,

failure of the written test on two occasions,

shall be given consideration for shift transfer or reassignment,

No employee shall be terminated for failure to qualify during the three month time period following initial testing.

Refusal to complete training and testing required by this Section may be grounds for immediate dismissal.

No authorized direct care staff person delegated to administer medication shall be subject to suspension or discharge for errors resulting from the staff person's acts or omissions when performing the functions unless the staff person's actions or omissions constitute willful and wanton conduct [20 ILCS 1705/15.4(i)].

Authorization of staff to administer medication shall be revoked if,

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the registered professional nurse-trainer,

the authorized direct care staff person is no longer competent to administer medication [20 ILCS 1705/15.4(c)].

The degree of retraining and reassessment of competency should occur at the discretion of the nurse-trainer.

Clear documentation of training,

and evaluation shall be kept in each staff or contractual person's personnel file by each agency where authorized direct care staff are employed.

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TITLE 59: MENTAL HEALTH CHAPTER I: DEPARTMENT OF HUMAN SERVICES PART 116 ADMINISTRATION OF MEDICATION IN COMMUNITY SETTINGS SECTION 116.50 ADMINISTRATION OF MEDICATIONS

Section 116.50 Administration of Medications a)

Medications shall be administered in accordance with the Mental Health and Developmental Disabilities Administrative Act [20 ILCS 1705] and the Illinois Nursing and Advanced Practice Nursing Act [225 ILCS 65].

Non-licensed staff shall not administer any medication in an injectable form.

A registered professional nurse,

physician licensed to practice medicine in all of its branches,

or physician assistant shall be on duty or on call at all times in any program covered by this Part [20 ILCS 1705/15.4(j)].

Authorized direct care staff shall not administer PRN medications unless there is a written protocol approved by a nurse-trainer and prescribing practitioner for each individual and for each medication.

A written protocol shall include the following information: 1)

and dosage form of the medication

dosage or quantity to be taken

frequency or times of administration

conditions for which the medication may be given

contraindications for the medications

any necessary special directions and precautions for the medication's preparation and administration

common severe side or adverse effects or interactions and the action required if they occur

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A facility may stock for use as PRN medications,

and in accordance with subsection (d) above,

only drugs that are regularly available without prescription at a commercial pharmacy,

such as: uncontrolled cough syrups,

These shall be given to an individual only upon the written order of the physician,

shall be administered from the original containers

and shall be recorded in the individual's medication administration record (MAR).

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TITLE 59: MENTAL HEALTH CHAPTER I: DEPARTMENT OF HUMAN SERVICES PART 116 ADMINISTRATION OF MEDICATION IN COMMUNITY SETTINGS SECTION 116.60 MEDICATION SELF-ADMINISTRATION

Section 116.60 Medication Self-Administration a)

As part of the normalization process,

in order for each individual to attain the highest possible level of independent functioning,

all individuals shall be permitted to participate in their total health care program [20 ILCS 1705/15.4(d)].

Every program shall include,

individual training in promoting wellness,

prevention of disease and medication self-administration procedures.

Every program shall adopt written policies and procedures for assisting individuals in obtaining preventative health and medication selfadministration skills in consultation with the registered professional nurse [20 ILCS 1705/15.4(d)].

Individuals shall be evaluated to determine their self-administration of medication capabilities by a nurse-trainer through the use of DHS required,

standardized screening and assessment instruments.

When the results of the screening and assessment indicate an individual not to be independently capable to self-administer his or her own medications,

programs shall be developed in consultation with the Community Support Team (CST) or Interdisciplinary Team (IDT) to provide individuals with [20 ILCS 1705/15.4(d)] medication self-administration training as identified in each individual's treatment/service plan.

Each individual shall be presumed to be competent to self-administer medications if he or she has been determined to be: 1)

capable by a registered professional nurse or advanced practice nurse

approved to self-administer medication by the individual's Community Support Team (CST) or Interdisciplinary Team (IDT)

authorized by a written order of a physician licensed to practice medicine in all of its branches.

Training of individuals to self-administer medication shall minimally include instruction,

for each medication prescribed,

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name of medication or identification within the existing agency pharmacy protocol

dosage or quantity to be taken

frequency or times of administration

common side-effects and potential consequences of not taking the medication or of not taking the medication properly

when to seek medical assistance and any action to be taken in the event of a missed dose,

When requested to do so by an individual,

authorized direct care staff may assist an individual in the self-administration of medications by taking the medication from the locked area where it is stored and handing it to the individual.

If the individual is physically unable to open the container,

a staff member may open the container for the individual.

Agency staff may also assist physically impaired individuals,

such as those who have arthritis,

in the removal of the medication from the container and in consuming or applying the medication.

Each individual shall remain under observation by authorized direct care staff and be assisted by the staff to correct or prevent medication errors and to safeguard against adverse drug reactions.

All observation and assistance shall be noted in the progress section of the individual's clinical record.

Individuals specifically determined to be competent,

by a physician who has issued a written order,

to self-administer their own medications may maintain possession of the key or combination of the lock to their own medication storage area.

A duplicate key or a copy of the combination shall be kept by the program in a secure location for emergency use,

such as if the individual should lose or misplace the key or forget the combination.

A medication administration record need not be kept for those individuals for whom the attending physician has given permission to have access to their own medications and to be fully responsible for taking their own medications.

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TITLE 59: MENTAL HEALTH CHAPTER I: DEPARTMENT OF HUMAN SERVICES PART 116 ADMINISTRATION OF MEDICATION IN COMMUNITY SETTINGS SECTION 116.70 MEDICATION ADMINISTRATION RECORD AND REQUIRED DOCUMENTATION

Section 116.70 Medication Administration Record and Required Documentation a)

All medications,

including patent or proprietary medications (e.g.,

but not limited to those) shall be given only upon the written order of a physician,

Rubber stamp signatures are not acceptable.

All orders shall be given as prescribed by the physician and at the designated time.

Telephone orders may be taken by a registered professional nurse or licensed practical nurse.

All orders shall be immediately written on the individual's clinical record or a "telephone order form" and signed by the nurse taking the order.

These orders shall be countersigned or documented by facsimile prescription by the physician within ten working days.

Medication Administration Record 1)

An individual medication administration record shall be kept for each individual for medications administered and shall contain at least the following: A)

the name and dosage form of the drug

the name of the prescribing physician,

frequency or times of administration

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The medication administration record for the current month shall be kept with the medications or in the individual's clinical record.

If logs are kept in the individual's clinical record,

the record shall be present when and where the medications are taken so that the appropriate notation can be made in the log.

The medication administration record shall be completed and initialed immediately after the medication is administered by the authorized direct care staff.

Each medication administration record shall have a section that contains the full signature and title of each individual who initials the medication administration record.

All changes in medication shall be noted on the medication administration record by a licensed practical nurse,

registered professional nurse,

or certified optometrist and reported to the registered professional nurse in charge of the program prior to the next dose.

Individual refusal to take medications shall be noted in the medication administration record.

A progress note by authorized direct care staff shall be written in the individual's clinical record indicating the reasons for refusal and the registered professional nurse shall be noti

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