Medication Administration Program
Residential Program
Medication System Overview
Spring 2015
Company
LOGO
Objectives
To become familiar with a
medication system

Technical Assistance Tool sections
To know how to access MAP
resources



Required
Informational
Training
MAP Monitoring Tool
Tech Assist Tool

Evaluates a medication system
 Sections within the tool

Correspond with MAP Policies
MAP Technical Assistance Tool
Provider:
Address:
DPH MCSR:
Contact(s):
Date of Visit:
MAP Coordinator/Reviewer:
A. HEALTH CARE PROVIDER (HCP) ORDERS & TRANSCRIPTIONS (SECTIONS 13 & 06) YES
NO
COMMENTS
1. There is a HCP order for all prescription meds, OTCs and herbal supplements or
products
2. HCP orders are valid with HCP signature on the same page as orders and dated within
1 year
3. All HCP orders (including new orders and telephone orders) are posted and verified
(includes signature, date and time) below HCP signature
4. Changes in medication orders are handled as new HCP orders
5. Staff are not using outdated HCP orders which have been superseded by newer orders
or superseded by hospital discharge orders
6. On HCP order forms listing multiple meds, after med(s) are DC’d; staff indicate in the
margin - DC, date, initials and see new order, if applicable
7. PRN orders have the specific reason for use and instructions (including hours apart
from any regularly scheduled doses ordered) and guidelines when to notify HCP, if
applicable.
8. Prescriptions are not substituted for HCP orders
9. HCP orders, pharmacy labels and medication sheets agree
10. HCP orders are correctly transcribed on the medication sheets
11. Telephone orders for med changes are documented on a HCP telephone order form
and cosigned by HCP within 72 hours
12. Monthly med sheet accuracy check by 2 Certified and/or licensed staff
13. There is an internal MAP monitoring system
B. VITAL SIGNS (SECTIONS 03 & 08)
1. Each HCP is consulted to determine if vital signs are required for medication
administration
YES
NO
COMMENTS
MAP Resource
mass.gov/dph/map
MAP Resource
2
Health Care Provider (HCP) Orders
Health Care Provider Orders
 Telephone/Fax Orders
 Hospital Discharge Orders
 PRN Orders
MAP Policy Sections 06 & 13
Tech Assist Tool Section A
Telephone/Fax Order
Hospital Discharge Order
MAP Resource
3
mass.gov/dph/map
2
Transcriptions
Transcriptions
• Agree with HCP Orders and Pharmacy Labels

Monthly Med Sheet accuracy check
MAP Monitoring System
MAP Policy Section 13
Tech Assist Tool Section A
Vital Signs
HCP is Consulted

If required, HCP order includes
 Specific written parameters
 What to do if outside parameters


Documentation
HCP Notification
Staff Training & Competency

At Site and Provider main office
MAP Policy Sections 03 & 08
Tech Assist Tool Section B
Sample Med Sheet
Medication Sheet
Month and Year: DECEMBER (year)
Medication or Treatment
Start:
Generic:
11/1/yr Brand:
Lanoxin
Stop:
Strength:
125mcg
Cont.
Amount:
1 tab
Start:
Hour 1
Digoxin
3
4
5
6
7
8
9
10 11 12 13 14
8am CW CW DS
DS DS DS
Pulse 62 68 60 54 52
Dose: 125mcg
Frequency: daily am
Route: by mouth
Special Instructions:
If pulse is less than 56 hold the dose. Notify
NotifyHCP
HCPisis
ifdoes
doseare
is held
held22days
daysininaarow.
row,
Hour 1
Generic:
Brand:
Stop:
2
Strength:
Amount:
Dose:
Frequency:
Route:
Special Instructions:
2
3
4
5
6
7
8
9
10 11 12 13 14
Sample Progress Note
Date
Time
Medication Reason
Response
Signature
12/5/yr
9:30a
Notified Dr. Jones that Digoxin was held for the
second day in a row. Pulse was 54 yesterday
and 52 this morning. Dr. Jones said to continue
with the med as ordered. He said if the pulse is
less than 56 tomorrow morning to call back. He
may change the dose at that time. Don Stevens
Medication Documentation
Medication Sheets


Organized
Boxes initialed that meds are given
 No blank spaces

Corresponding signature of staff
MAP Policy Sections 06; 08 & 13
Tech Assist Tool Section C
Sample Med Sheet
Medication Sheet
Month and Year: DECEMBER (year)
Medication or Treatment
Start:
Generic:
Hour 1
Digoxin
2
3
4
5
6
7
11/1/yr Brand:
Lanoxin
8am CW CW DS DS DS CW CW
Stop:
Strength:
125mcg
Pulse 62 68 60 54 52 62 62
Cont.
Amount:
1 tab
Start:
8
9
10 11 12 13 14
DS DS CW CW
68 72
60
Dose: 125mcg
Frequency: daily am
Route: by mouth
Special Instructions:
If pulse is less than 56 hold the dose. Notify
NotifyHCP
HCPisis
ifdoes
doseare
is held
held22days
daysininaarow.
row,
Hour 1
Generic:
Brand:
Stop:
2
Strength:
Amount:
Dose:
Frequency:
Route:
Special Instructions:
2
3
4
5
6
7
8
9
10 11 12 13 14
Medication Documentation
2
Progress Note

Examples of when to use
 Med is not given as ordered
 PRN med given
 Leave of absence
 Refusal
 Held
Medication Documentation
3
Allergies
Data
PRN bowel meds
 PRN seizure meds

Seizure record
Staff Certification
On Site
Current
All Staff Administering Meds


Regular
Relief
Acceptable Proof

Master list
 MAP Certification expiration dates

Certification letter
 www.hdmaster.com
MAP Policy Section 02
Tech Assist Tool Section D
Certification Letter
www.hdmaster.com
Ancillary Practices
Blood Glucose Testing

Certified Staff training
 Documentation is on site

HCP Order Requirements
 Upper/lower parameters
 Steps to take when outside parameters
MAP Policy 08
Tech Assist Tool Section E
CLIA Waiver
Required if monitoring
Blood Glucose
 Urine [dipstick]

 Ketones, glucose, blood, etc.
 Pregnancy
MAP Policy 08 & 17
Tech Assist Tool Section E
mass.gov/dph/map
3
mass.gov/dph/map
4
mass.gov/dph/clp
CLIA Waiver
2
Required if monitoring

PT/INR
Licensed staff
MAP Policy 08 & 17
Tech Assist Tool Section E
High Alert Medication
Warfarin sodium
Clozapine
Buprenorphine/naloxone
MAP Policy Section 08
Tech Assist Tool Section E
mass.gov/dph/map
5
Training Resource
Training Resource
2
Ancillary Practices
2
G/J Tube med administration

Certified Staff training
 Documentation is on site
Training is Individual specific
MAP Policy Section 14
Tech Assist Tool Section E
Ancillary Practices
3
Injectable Epinephrine

Certified Staff training
 Documentation is on site
Training is Individual specific
MAP Policy Section 14
Tech Assist Tool Section E
Insulin
Administered only by licensed staff

Unless Individual is self-administering
 Defined in MAP policy Section 07

“Self-injecting” does not automatically mean
self-administering
MAP Policy Section 07; 14-1
Sample Med Sheet
Medication Sheet
Month and Year: DECEMBER (year)
Medication or Treatment
Start:
Generic:
Insulin glargine
12/1/yr Brand:
Lantus
Stop:
Strength:
100U/mL
Cont.
Amount:
50 Units
Start:
7am
2
3
4
5
7
8
9
10 11 12 13 14
ADMINISTERED BY VNA NURSING STAFF
Frequency: daily am
Route: SC
Special Instructions:
ADMINISTERED BY VNA NURSING STAFF
Hour 1
Generic:
Strength:
Amount:
Dose:
Frequency:
Route:
Special Instructions:
6
Dose: 50 Units
Brand:
Stop:
Hour 1
2
3
4
5
6
7
8
9
10 11 12 13 14
3
Insulin
2
MAP Certified Staff may NOT
Administer Insulin
 Dial a dose on an Insulin pen
 Double check

 A dose dialed by an Individual
 The amount of insulin drawn up into a
syringe by an Individual
“Sharps” Disposal
Disposal
Needle
 Syringe
 Lancet

Ancillary Practices
4
Oxygen Therapy

All methods of delivery including
 Oxygen cylinders
 Oxygen concentrators
MAP policies apply
Oxygen training guidelines
MAP Policy 08-4
Countable Substance Packaging
Schedule II-V meds must be


Received from pharmacy
In tamper resistant packaging
 Blister pack
 OPUS
 Opti-Pak
MAP Policy Section 10
Tech Assist Tool Section F
OPUS Medication System
Countable Substance Packaging
Schedule II-V meds must be


Received from pharmacy
In tamper resistant packaging
2
Schedule VI
DPH recommends

Two Schedule VI meds
 Add to count
Fioricet
 Gabapentin (Neurontin)

MAP Policy Section 10
Tech Assist Tool Section F
Blister Pack Monitoring
Tracking method to determine
meds are given as prescribed

Not required
 Staff
Initial
 Date
 Time

 Backside of package
Blister Pack Monitoring
2
Countable Substance Documentation
Count Book

Index
 Complete
 Accurate

Count Sheets
 Countables subtracted as removed
 Entries not squeezed in between lines

Shift Count Sheets
 Reflect meds are counted

Each time key changes hands
MAP Policy Section 10
Tech Assist Tool Section G
Countable Substance Documentation
2
Signature Requirements

Two signatures when
 Beginning a new count sheet
 Adding a refill onto a count sheet
 Transferring from
Bottom of old page/top of new
 An old count book to a new count book

 Disposal
MAP Policy Section 10
Tech Assist Tool Section G
mass.gov/dph/map
6
MAP Resource
4
Drug Loss (Schedules II-VI)
Include


All prescription meds
Written prescriptions
Reported to DPH


First business day after discovery
Drug Incident Report form required
MAP Policy Section 10
Tech Assist Tool Section G
mass.gov/dph/dcp
mass.gov/dph/map
7
MAP Resource
5
Self-Administration
Achieved only when

Medication is under complete
control of individual
 With no more than minimal
assistance from staff
MAP Policy Section 07
Tech Assist Tool Section H
Transitioning to Self-Administering
Self-administering assessment
ISP reflects status
Pill organizer preparation

Only by
 Pharmacist
 Individual
Documentation
MAP Policy Section 07
Tech Assist Tool Section H
mass.gov/dph/map
8
Off-Site Medication Administration
Preparation
Documentation

Med sheet
 Acceptable Codes





DP-day program
W-work
H-hospital, skilled nursing facility,
rehabilitation center
S-school
Med-Release document
 Signatures

Releasing/Accepting
MAP Policy Section 11
Tech Assist Tool Section I
Leave of Absence
Preparation
Documentation

Med sheet
 Acceptable code

LOA-leave of absence
 Med progress note

LOA form
 Signatures

Releasing/Accepting
MAP Policy Section 11
Tech Assist Tool Section I
Leave of Absence
2
Certified staff may prepare if
Unexpected
 Pharmacy is unable
 LOA is less than 72hrs

MAP Policy Section 11
Tech Assist Tool Section I
mass.gov/dph/map
9
MAP Resource
6
Medication Ordering/Receiving
Prescription Deliveries

Tracking
 Pharmacy Receipts

Maintained for 90 days
MAP Policy Section 10
Tech Assist Tool Section J
Cleanliness and Security
Contains only med
administration supplies


Internal/External separated
No more than 37 day supply of
prescription meds
 Unless prescription plan requires otherwise

Documentation
Locked

Countable meds are double locked
MAP Policy Section 10
Tech Assist Tool Section K
Medication Disposal
“Expired” or “discontinued”

Disposal completed with

2 Certified staff present

1 must be a Supervisor
MAP Policy Section 10
Tech Assist Tool Section L
Medication Disposal
2
“Dropped” or “refused”

Disposal is with 2 MAP
Certified staff present
 If unavailable, a Supervisor is
not required to be present

Unless your agency requires it
MAP Policy Section 10
Tech Assist Tool Section L
DPH Disposal Form
mass.gov/dph/map
10
MAP Resource
7
Policies & Resources
Must be on site
MAP policy manual
 Med Info sheets
 Drug reference
 MAP training manual
 Provider policies

MAP Policy Sections 01; 06; 08; 10 & 11
Tech Assist Tool Section M & N
Policies & Resources
2
Staff Education
Training Binder

Ongoing med education
Documentation is on site
MAP Policy Section 06
Tech Assist Tool Section O
mass.gov/dph/map
11
MAP Resource
8
MOR System Principles
Opportunity to improve

Procedures or systems
 That put people at risk
Focus on “cause”

Rather than “who”
 Made the mistake
MAP Policy Sections 09 &10
Tech Assist Tool Section P
Medication Occurrence Process
Tracks Certified staff only
One of five rights went wrong




Individual
Medication
Dose
Time
 Omission

Route
MAP Policy Sections 09 &10
Tech Assist Tool Section P
MOR Process
Self reporting system

Staff must immediately contact
MAP Consultant
 Follow recommendation
• Document recommendation
MAP Policy Sections 09 &10
Tech Assist Tool Section P
Medication Occurrence Reporting
Emergency numbers include
 911
 Poison Control
 MAP Consultant(s)

Available 24/7
MAP Policy Sections 09 & 10
Tech Assist Tool Section P
Reporting Requirements
MORs reported to MAP Coordinator
 Within 7 days of discovery

Via HCSIS
“Hotline” MORs reported
 Within 24 hours of discovery
DPH Clinical Reviewer
 MAP Coordinator

MAP Policy Sections 09 & 10
Tech Assist Tool Section P
DPH Hotline Form
mass.gov/dph/map
12
MOR Follow-Up
Retraining (usually)

Should occur
 Each time a med occurrence happens

Can be determined jointly
 Supervisor
 MAP Consultant
Documentation
MAP Policy Sections 09 &10
Tech Assist Tool Section P
MOR Follow-Up
2
Tech assist visit
Hotline
 Multiple MORs

Revocation

Occasionally
MAP Policy Sections 09 & 02
Tech Assist Tool Section P
DPH Registered Programs
Massachusetts Controlled
Substance Registration Number
(MCSR)


Issued by DPH
Original or copy stays on site
 Where medication is stored
MAP Policy Section 01
Tech Assist Tool Section Q
MAP Coordinators
Carolyn Whittemore, RN
Central/West
 413.205.0914
carolyn.whittemore@state.ma.us

Mary Despres, RN
Metro
 781.314.7506
mary.despres@state.ma.us

MAP Coordinators
Gina Hunt, RN
Northeast
 978.774.5000 x354
gina.hunt@state.ma.us

Susan Canuel, RN
Southeast
susan.canuel@state.ma.us

2
MAP Resource
9
mass.gov/dph/map
13