Agency for Persons with Disabilities State Curriculum January 2009

1. Medication Administrationand Assistance with Self-Administration of MedicationFlorida Administrative Rule 65G-7 Agency for Persons with Disabilities State Curriculum January 2009

2. Medication Administration Rule • Allows unlicensed staff who are working with clients of the Agency for Persons with Disabilities to • Administer medication or • Supervise the self administration of medication • Gives specific training/validation guidelines • Discusses the do’s and don’t of the Medication Assistant Provider (MAP) • Explains the documentation process Florida Administrative Rule 65G-7

3. Florida Statutes 393.506 • Section (5) • “ The agency shall establish by rule standards and procedures that a direct service provider must follow when supervising the self-administration of medication by a client and when administering medication to a client” Direct Authority

4. Will understand both training and validation requirements • Will demonstrate ability to complete and maintain all required forms • Will understand how to document and communicate determination of need • Will state the six rights of medication administration • Will understand the difference between fully capable of self administration, supervision of self administration and administration of medication • Will understand the importance of information on symptoms of adverse reactions and side effects of prescribed or over the counter medications, and how to locate it • Will understand health care practitioner orders, prescriptions and prescription labels • Will understand how to complete a Medication Administration Record (MAR) • Will be able to discuss safe handling of medications and sanitary conditions • Will understand the allowed routes of medication administration • Will have knowledge of proper preparation and positioning of the client • Will have knowledge of medication errors, disposal of medication and safe storage • Will understand steps that need to be taken when medication is taken off-site Outcome of Training Course

5. After attending a minimum 4 hour class and passing the exam with 80% or above • Once you have completed this course and pass the course exam, you will be issued a certificate of successful completion • After on-site Validation with 100% competency by a RN, ARNP, or MD (APD form 65G7-04) • You will receive a Validation Certificate, with each route you are validated for signed off on the back. • Once you receive a client assignment you will need to make sure the next 2 items are in place: • Authorization for Medication Administration signed by client’s MD, PA, or ARNP (APD form 65G7-01) • Informed Consent for Medication Administration form, signed by client or their legal representative (APD form 65G7-02) When can I give medications?

6. Must be done on-site, with real client • Must be done by a RN, ARNP, or MD • Must validate with 100% competency • Each Route of medication administration must be individually validated (signed on back of form) • Revalidation must occur yearly • Employer, if any, must also keep a copy available for review On-site validation by route

7. The ways that medications can be delivered to the body • MAP’s can administer medication for only approved routes of delivery. • MAP’s can only administer medication via a route that they have been validated for Approved Routes of Delivery: • Oral • Topical • Transdermal • Ophthalmic • Otic • Rectal • Inhaled • Enteral What are “routes?”

8. Informed Consent • (APD form 65G7-02) • Signed by client or client’s authorized representative • May be filled out with the agency (ie: abc group home) or individual MAP’s name in the provider space • Kept in client record readily accessible for review Client/guardian Informed Consent

9. The Authorization Form Three levels of “ABILITY” Must be completed by an MD, PA, or ARNP for clients annually or with any changes to health status or ability Keep with clients record, easily accessible for review • Fully capable of self administering own medication without supervision • Requires supervision while administering own medication • Requires medication administration Authorization for Medication Administration 65G-7.01

10. These clients may take their own medications by themselves, without supervision • A MAR is not kept (document only what you do) • The client may need a little help with reminding, reordering or getting medication from the pharmacy • Not required to lock up medication in own home • Storage: • May use pill minder • Keep in locked container if client lives in GH or multi-person SL • Under certain circumstances medication may need to be centrally stored • Medication threatens health, welfare or safety of the client or others • Client does not keep medication in locked place • Physical arrangements or habits of other clients makes it unsafe • Client or their authorized representative asks for the medication to be centrally stored “Fully capable of Self Administration” What does this mean?

11. Will need properly trained and validated MAP complete this task • Tasks will not be the same for every client • MAP may complete the following duties • Prompt and observe client taking medication • Confirm the client is taking dosage as prescribed • Assist clients when there is something they can’t do • Document on MAR • Medication must be centrally stored Supervision of self administration

12. Supervision of Self Administration of medication includes instructions orany other assistance necessary to ensure the correct self administration of medication. Client may be able to take oral medications – but cannot give themselves eye drops, or insert a rectal suppository Client may be able to identify the medications needed, and the route…but may be unable to remove the medication from the container, or put the medication in their mouth without help • Client may be able to self administer a topical medication in an easy to reach area, but need the MAP to apply it on a less easy to reach area • MAP must assist with every scheduled medication delivery • MAP documents on MAR that they observed the client appropriately received the scheduled medication Supervision of Self Administration

13. Clients are not yet able to safely give their own medications • MAP must prepare and give medications • MAP must document immediately on a Medication Administration Record (MAR) • Medication must be centrally stored Administration of Medication

14. Goal is Independence • Training and encouragement for clients to become independent is central to the views of this agency. • Your input can be very helpful to health care practitioners when deciding on the client’s capabilities. • Reviews must be done annually and/or upon health status change

15. Does Administrative Rule 65G-7 Apply to EVERYONE? NO, it does not.

16. Health care practitioners whose licenses include medication administration-LPN’s RN’,s, etc. • A client’s family members or friends who provide assistance with medication with out compensation • Providers employed by or under contract to: Intermediate Care Facilities for the developmentally disabled, home health agencies, hospices, health care service pools, or assisted living facilities. • Clients who are authorized to self administer their medications without supervision. Who is exempt?

17. Six Rights of Medication Administration

18. Safely give medication by practicing the Six Rights of Medication Administration • Right Client • Right Medication • Right Dosage • Right Time • Right Route • Right Documentation What rights do clients have?

19. Prescription is ordered for your client What happens next?

20. Health care practitioner writes the prescription • MAP makes copy of the prescription for the client record and takes original to pharmacy • Current copies in the MAR for reference • Archive discontinued prescription orders • Write prescription order on the client MAR • When medication is picked up or delivered from pharmacy • Compare label with copy of prescription and with MAR • All information must match • Medication should be started in a reasonable time frame (within 24 hours) • Medication is given as prescribed • Document on MAR Tracking and Documentation

21. Medical Physician or Psychiatrist (MD) • Osteopathic Physician (DO) • Advanced Registered Nurse Practitioner (ARNP) • Physician Assistant (PA) • Dentist (DDS or DMD) • Optometrist (OD) • Podiatrist (DPM) Who can write a medication order?

22. Dispenses • Labels • Packages • Only pharmacist can change a label • Only pharmacist can write on a label • Only pharmacist can transfer from one container to another Pharmacist duties

23. Label Example (PRN) • Name • Strength • Route • Amount • Time • Reason for use • Condition to notify MD • Maximum number of doses • Tylenol • 325mg • By mouth • 2 tablets (650mg) • Every 4 hours • Fever> 101F • Fever> 102F • 3 days What is on a prescription label?

24. Will contain • Name of medication • Strength of medication • Purpose of medication • Amount of medication included in container • Directions for use • Active and inert ingredients • Possible side effects • Warning- possible drug interactions, maximum dosage • Storage conditions • Name and address of the manufacturer • Expiration Date • Lot number Manufactures Labels for OTC medications

25. All medication must be properly labeled • Sample Medication: • Must be accompanied by a prescription • Maintained in original container • Labeled by dispensing healthcare practitioner • Clients name • Practitioners name • Directions for administering the medications • The MAP must initial the label and add the date the medication was opened What you need to know!

26. The physician may • Change the dose or time of medication • All changes must be in writing on a prescription and taken to the pharmacy to dispense the appropriate medication with the appropriate label • Write “as directed” on the prescription • You will need to get more specific directions in writing before medication can be given • Try to give you verbal order • You must ask the physician to fax the order since all orders must be in writing. You can not change a prescription label.

27. Healthcare Practitioner must provide written directions that include: • Then name of the medication • The prescription number, if applicable • The prescription dosage • Specific directions for use, including medical reason for the medication, the time intervals for administration, the maximum number of doses, the maximum number of days that the medication should be administered and conditions under which the health care practitioner should be notified PRN medication

28. Medication that is regulated under the jurisdiction of the Controlled Substance Act of 1970 • Abuse is the highest with schedule I drugs • Five groups (scheduled I thru V) • Example: • Schedule II: • Ritalin, Codeine, Demerol, Duragesic patch, Percocet • Schedule IV: • Phenobarbital, Valium, Ativan Controlled Medications

29. When do I document? • Pharmacy provided form stamped with “C” • On the MAR immediately after administration • Control Medication Count Sheet (APD form 65G7.07) • To verify count accuracy • Must be signed by two providers • Your responsibility to count and document as directed by rule • Must report any medication discrepancies to supervisor Documentation of Controlled Drugs

30. Stored separately from other prescriptions or OTC drugs • Double Locked • A locked container • A locked enclosure How to store controlled drugs

31. Labeled Bottles • Bubble packs or bingo cards • Color coding on packaging for different time periods (only developed by the Pharmacy) • Unit dose dispensing systems Forms of Packaging

32. Abbreviations • a.c. before meals • ad lib as directed • BID twice a day • cap capsule • d/c or D/C discontinue • gtt drop • H.S. or h.s hour of sleep • mg milligram • ml milliliter • od right eye • os left eye • ou both eyes po by mouth p.c. after meals prn as needed QD every day QOD every other day Tab tablet Q3h every 3 hours QID or qid four times per day sig label TID or tid three times per day U units

33. When writing on a MAR it is best NOT to use the abbreviations. While many health care practitioners use them, abbreviations have been identified as the main cause of many medication errors. VERY CONFUSING QD, QID, QOD (look similar) PO, pc, pr, prn (look similar) CAN YOU SEE WHY IT IS BEST NOT TO USE ABBREVIATIONS? Abbreviations - continued

34. Procedures for Routes of Medication Administration How to give medications

35. Wash your hands. • Gather equipment – medication spoon or syringe, medicine cup, pill cutters or crushers, paper towels, glass of water or other liquid with which to take or follow medication. • Verify first five Rights of Medication Administration. • Unlock the medication storage area and remove one client’s medication at a time. • Select the needed medications, making sure to compare the label to the order or prescription to the MAR and check expiration dates. • Make sure you follow any special instructions, for instance “take on empty stomach,” “take with food,” “check pulse and hold for pulse less than 60,” “do not give if client is having diarrhea.” Medication Administration for Oral Route

36. Place a dot on the MAR. • Pop or pour the medication into a medication cup – remember to pour a pill from the container into the lid, then into the medication cup. If you pour too many into the lid, you can pour them back into the bottle and try again. Do not touch with fingers. • For liquid medications, shake bottle before pouring (as directed by label), make sure that the cup is on a level surface for accurate measuring, pour away from the label. Wipe the lid and neck of the bottle with a dampened paper towel before returning to storage. Read the amount of medication at the bottom of the curve of the liquid in the medication cup at eye level. • Crush medications if directed to do so, and mix with applesauce, pudding, or ordered substance. • Compare the label on the medication to the directions on the MAR again. Oral Medication

37. Return the medication to the storage area and lock. • Hand the medication cup to the client, followed by glass of liquid with which to swallow the pills. Verify that the client swallows the medication. Give pills first, liquids last. If giving a medication for cough, it should be given last to coat the throat. • Again check the label against the MAR. Sign the MAR and blister pack, if used. • Wash your hands. • Document on the MAR. Controlled substances requires additional documentation on the Controlled Drug Count Form (see attached) • Check on client and assist to comfortable position, if needed. • Check client for response to medication, especially if PRN medication. Oral Medications - continued

38. Wash your hands. • Gather equipment-medication cup, gloves, glass of water or other liquid with which to take or follow medication. • Verify first five Rights of Medication Administration. • Unlock the medication storage area and remove one client’s medication at a time. • Select the needed medications, making sure to compare the label to the order or prescription to the MAR and check expiration date. • Make sure you follow any special instructions, for instance “take on empty stomach.” “take with food,” “check pulse and hold for pulse less than 60,” “do not give if client is having diarrhea.” • Place a dot on the MAR. • Pop or pour the medication into a medication cup-remember to pour a pill from the container into the lid, then into the medication cup. If you pour too many into the lid, you can pour them back into the bottle and try again. Do not touch with fingers. • Compare the label on the medication to the directions on the MAR again. Buccal or Sublingual

39. Return the medication to the storage area and lock. • Hand the medication cup to the client and instruct them to place the medication under their tongue if sublingual, or between cheek and gum if buccal. If the client is unable to do this, carefully place the medication in the appropriate spot yourself. • Instruct the client not to drink liquids until the medication has dissolved and been absorbed. • Tell the client not to swallow the pill, and to let it dissolve Again check the label against the MAR. Initial the MAR and blister pack, if used. • Wash your hands. • Document on the MAR. Controlled substances require additional documentation on the Controlled Drug Count Form (see attached). • Check on client and assist to comfortable position, if needed. • Check client for response to medication, especially if PRN medication. (if PRN medication document response on back of MAR) Buccal or Sublingual - continued

40. Wash hands. • Gather equipment – spacers, glass of water, tissue, • Verify first five Rights of Medication Administration. • Unlock the medication storage area and remove one client’s medication at a time. • Select the needed medications, making sure to compare the label to the order or prescription to the MAR. • Place a dot on the MAR. • Remove the cap from the inhaler and ensure that mouthpiece is clean; shake if indicated. • Ask the client to exhale and then place the mouthpiece, tilted slightly upward, into his/her mouth. Instruct the client to close lips around mouthpiece. • Use a spacer attached to the mouthpiece as instructed if the client is unable to close lips around mouthpiece. • Ask the client to inhale slowly as you push the cylinder of the medication down against the mouthpiece one time. Inhaled (such as albuterol)

41. Ask the client to hold his/her breath for several seconds. • Remove the mouthpiece from the client’s mouth. • Ask the client to exhale slowly through pursed lips. • If a second puff is required, wait at least one minute between each puff, and then repeat above instructions. • Ask the client to rinse out his/her mouth. • Rinse the mouthpiece with warm water, dry with a paper towel, and recap. • Wash hands. • Store medication in proper locked area. • Document on the MAR. • Have the client use any inhalers first and then take oral medications. Inhaled - continued

42. Follow the steps above for inhalers through step 6. • Pull back the dose lever until it clicks into place. Do not tilt the inhaler, and ask the client not to breath into the inhaler. • Ask the client to exhale. • Place the mouthpiece into the client’s mouth, and instruct the client to close his/her lips around it. • Instruct the client to inhale forcefully and deeply. • Continue with steps 11-18 for inhalers, above. • Document on the MAR. • Have the client use any inhalers first and then take oral medications. Dry powder inhalers (such as Advair)

43. Wash hands • Gather paper towels or tissues and gloves • Verify the first five Rights of Medication Administration • Unlock the medication storage area – remove one client’s • medication at a time • Select the needed medications, making sure to compare the label • to the order or prescription to the MAR • Place a dot on the MAR • Put on gloves • Ask the client to blow his/her nose gently to clear the nasal • passages • Ask the client to tilt his/her head backwards, making sure the neck • is supported • Elevate the nostrils slightly by pressing the thumb against the tip • of the nose Nose spray

44. Hold the spray just above the client’s nostril, without touching it. • Use spray as directed by the prescription or order • Ask the client to inhale slowly and deeply through the nose, hold breath for several seconds and then exhale slowly. • Client may blot nose with tissue, but ask client not to blow nose for several minutes following instillation • Rinse the tip of the spray bottle with hot water or wipe with an alcohol pad and dry with tissue before recapping • Remove gloves and dispose of properly • Place medication back in locked storage area • Wash hands • Document on the MAR Nose spray - continued

45. Follow the directions for nasal sprays above, making sure to use the correct number of drops. • Do not touch the nostrils with the dropper. • Document on the MAR. Nose drops

46. Wash hands. • Gather equipment – gloves, washcloth and towel. • Verify first five Rights of Medication Administration. • Unlock the medication storage area and remove one client’s medication at a time. • Select the needed medications, making sure to compare the label to the order or prescription to the MAR. • Place a dot on the MAR. • Provide for privacy for client. • Wear gloves; check client for latex allergies if using latex gloves. • Remove old patch and dispose of appropriately. Transdermal – self adhesive patches

47. Make sure site for new patch is clean and dry. If needed, clean area with soap and warm water and then pat area dry. Do not apply over a bony prominence such as the collarbone or shoulder blade. Do not apply the patch over a pacemaker site. Apply in a hairless area. Apply the patch to a different site with each new patch application. Avoid areas of increased warmth (such as the back if bed-ridden) which would promote faster absorption. Do not apply to areas with redness, rash, or broken skin. Report these areas to your supervisor. • Open the package and remove the patch. • Date and initial the patch. • Remove the backing from the patch. • Apply the patch to the chosen spot, pressing firmly around the edges to adhere. • Apply, and cover patch, if applicable, making sure it is dated and initialed. • Remove gloves and dispose of properly • Place medication back in locked storage area. • Wash hands. • Document on the MAR. Transdermal patches - continued

48. Wash hands. • Gather equipment – gloves, applicators, wash cloth and towel, water. • Verify first five Rights of Medication Administration, making sure you understand where on the client’s body the medication is to be applied. • Unlock the medication storage area and remove one client’s medication at a time. • Select the needed medications, making sure to compare the label to the order or prescription to the MAR. • Place a dot on the MAR. • Provide for privacy for client. • Wear gloves: check client for latex allergies if using latex gloves. • Make sure site for medication is clean and dry. If not, cleanse gently with soap and warm water and pat dry, unless the prescription directions say otherwise. Previous medications are usually removed before applying additional medication, except for lotions which are used for soothing the skin). Topical (ointments, lotions, creams, sprays)

49. Squeeze a small amount of medication (if a cream, ointment, or lotion) onto the applicator. Always shake lotions to activate ingredients. If applying to a large surface area, warm lotions/creams in hands before use so the client does not chill. Keep powder away from the nose and mouth to keep the client from inhaling it. If applied to the face, apply while the client exhales. If applying nitroglycerin ointment, measure in centimeters or inches on special provided paper or applicator. Do not apply to areas with redness, rash, or broken skin unless you are treating that area (rash). • Apply gently to correct site. • If a spray, hold the can about 6” away from site and spray. • Discard applicator. • Gently lay dressing over site, if applicable, and secure. MAP may only apply simple dressings which are intended to cover and protect, such as Band-Aids, Telfa or gauze pads. • Discard gloves and dispose of properly. • Place medication back in locked storage area. • Wash hands. • Document on the MAR. Topical - continued

50. Wash hands. • Gather equipment – gloves, cotton balls or gauze, tissues, wash cloth, towel, warm water, simple dressing, if ordered. • Verify first five Rights of Medication Administration. • Unlock the medication storage area and remove one client’s medication at a time. • Select the needed medications, making sure to compare the label to the order or prescription to the MAR. Check number of drops and eye (right, left, both). • Place a dot on the MAR. • Wear gloves: check client for latex allergies if using latex gloves. • Assist the client to a comfortable position either sitting or lying down with head tilted back. May turn the head slightly toward the affected side to prevent medication or tears from flowing toward the opposite eye. If using both drops and ointment, administer the drops first and wait 5 minutes before applying the ointment. Eye medications (ointments and drops)