DMH Nurse Delegation 101

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Nurse Delegation 101

• Why, What, Who, How and When of the Nurse
  Delegation Program

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OBJECTIVES

• Upon completion, participants will know
• Why DMH developed NDP
• What NDP requires
• Who is impacted by NDP
• How to get more information
• When agencies must be in compliance

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WHY???
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DMH AND NDP, WHY?

• Federal Law requires that State Agencies,
• such as the Department of Mental Health
• (DMH), that receive Federal funds MUST be in
  compliance with all State Laws.

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DMH AND NDP, WHY?

• The Alabama Board of Pharmacy (ABOP) and the
• Alabama Board of Nursing (ABON) direct and
• control the provision, storage and administration
  of
• medications.
• Programs regulated by DMH must comply with not
  only
• DMH regulations, but also those of the ABOP and
  ABON
• with respect to their specific guidelines for the
  handling
• and administration of medications by individuals
• other than the consumers who receive the
  medications.

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DMH AND NDP, WHY?

• Alabama Board of Nursing (ABON) Regulation
• Code of Alabama (1975) Section 34-21-20
• (Statutory Law)
• Any person practicing or offering to practice
  professional/practical nursing in Alabama for
  compensation shall be required to submit evidence
  that he/she is qualified so to practice and shall
  be licensed. It shall be unlawful for any person
  not licensed to practice or offer to practice
  professional/practical nursing for compensation
  in this State.

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DMH AND NDP, WHY?

• Alabama Board of Nursing Regulation
• Code of Alabama (1975) Section 34-21-26
• The Practice of professional/practical nursing by
  any person who has not been issued a license or
  whose license has been suspended, revoked or has
  expired, is hereby declared to be inimical to the
  public welfare and to constitute a public
  nuisance. The ABON may apply to any court of
  competent jurisdiction for any injunction to
  enjoin any person from practicing
  professional/practical nursing who has not been
  issued a license.

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DMH AND NDP, WHY?

• Alabama Board of Nursing Regulation
• Administrative Code 610-X-6-.02(10)
• The RN/LPN shall accept responsibility and
  accountability for timely reporting of illegal,
  substandard, unethical, unsafe or incompetent
  nursing practice directly to the Board of Nursing

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DMH AND NDP, WHY?

• SB 428
• Under existing law, the ABON employs
  investigators who investigate alleged violations
  involving drugs or controlled substances. This
  bill grants investigators of the ABON the
  authority to exercise the powers of peace
  officers in investigating alleged violations of
  the Nurse Practice Act by persons licensed by the
  ABON.

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DMH AND NDP, WHY?

• Alabama Board of Nursing Regulation
• Administrative Code 610-X-6-.15(1)
• The RN/LPN who provides care in residential
  community mental health programs certified by the
  ADMH is accountable and responsible for the
  nursing care delivered to patients in those
  settings

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DMH AND NDP, WHY?

• Alabama Board of Nursing Regulation
• Administrative Code 610-X-6-.15(2)
• RN/LPNs who provide nursing in the residential
  community mental health setting and the community
  extensions including day habilitation programs,
  may delegate specific limited tasks to designated
  unlicensed assistive personnel.

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DMH AND NDP, WHY?

• Department of Mental Health Administrative Code
  Regulations
• Intellectual Disabilities 580-5-32-.16
• Mental Illness 580-2-12(6)
• Substance Disorders 580-9-46(14)
• All require 24/7 nursing coverage

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DMH AND NDP, WHY?

• ABOP and NDP
• NAKED PILL SYNDROME
• Carter English, R. Ph.

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DMH AND NDP, WHY?

• ABOP and NDP
• Pillboxes
• Blister Packs type (labeled at top each
  blister labeled
• Stock medications
• OTCs
• Controlled Substances
• Current Pharmaceutical Companies assisting with
  NDP Requirements

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DMH AND NDP, WHY?

• New DMH NDP Administrative Code Regulations
• Anticipated completion 2009
• Will address at a minimum the 4 components of
  NDP
• Administrative Requirements
• Education/Training
• Quality Assurance
• Compliance

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WHAT???
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ACRONYMS

• NDP Nurse Delegation Program
• DMH Department of Mental Health
• MAC Medication Assistant Certified
• Unlicensed Nursing Individuals
• MAS Medication Assistance Supervisor
• (RN/LPN)
• MATT Medication Assistance Train-
• The-Trainer (RN ONLY)

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ACRONYMS

• MAR Medication Administration Record

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Definitions

• Delegation
• The act of authorizing a competent
• individual to perform acts supportive to
• RN/LPNs in selected situations.
• ABON Administrative Code

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Definitions

• Competency
• Outcomes assessed through academic
• standing, clinical performance and
• certification examination that demonstrates
• the ability to perform a particular task.

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Definitions

• Supervision
• Periodic monitoring by direct observation on
• site, by the MAS Nurse to visualize MAC
• Workers skill and ability to perform
• delegated task(s).

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LPN Supervision

• 610-X-6-.04 Practice of Practical Nursing
• (1) The practice of practical nursing includes,
  but is not limited to
• (a) Acts designed to promote and maintain health
  
• (b) Prevention of illness and injury
• (c) Provision of care using standardized
  procedures including administering medications
  and treatments under the direction of a licensed
  professional nurse or a licensed or otherwise
  legally authorized prescriber and
• (d) Exercise of appropriate nursing judgment.

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Supervision

• Physically present or accessible within a
  reasonable time to the immediate area and is
  available to intervene if necessary

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Definitions

• Self Administration
• A consumer can self administer if he/she is
• able to
• Recognize medication(s)
• Understands purpose/reason for taking the of
  medication(s)
• Ability to report major side effects and knows
  when to notify nurse, doctor, etc.
• (RN MUST PERFORM ASSESSMENT)

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Consumer Assessment

• Self Administration
• Limited Self Administration
• Unable to Self Administer

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Definitions

• Drug/Medication
• Substances recognized as drugs in the
• official US pharmacopoeia.
• Substances intended for use in the
• diagnosis, cure, mitigation, treatment or
• prevention of disease in man or animals

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Definitions

• Drug/Medication
• Substances other than food intended to affect the
  structure or any function of the body of man or
  animals
• Code of AL Section 20-2-2

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Definitions

• Medication Administration
• Removal of an individual dose of
• medication, from a previously dispensed,
• properly labeled container, verifying it with
• the M.D./CRNPs order, giving the individual
• dose to the proper consumer at the proper
• time by the proper route and promptly
• recording the time and dose given.

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Definitions

• Administer
• The direct application of a controlled
• substance, whether by injection, inhalation,
• ingestion or any other means to the body of
• a recipient.
• Administrative Code Section 20-2-2

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Definitions

• Assisting with Medication Administration
• Helping the consumer
• with one or more steps in the process of
  administering medication

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What is NDP?

• The Nurse Delegation Program (NDP) was
• developed by the Department of Mental Health
• (DMH), with guidance from the Alabama Board
• of Nursing (ABON), in response to changes
• made to the Alabama Nurse Practice Act, which
• allows non-licensed persons to assist with
• medication administration in residential
• programs, day programs and other community
• extensions in programs regulated by DMH.

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What is NDP?

• The NDP defines the respective authority and
  responsibility for agencies and nurses related to
  delegation of medication administration in DMH
  certified programs.

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What is NDP?

• NDP is managed by the DMH in conjunction with the
  ABON to assure that all individuals who receive
  services from programs certified by the DMH
  receive appropriate care.

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What is NDP?

• Consumers have a right to health care that
• meets legal standards of care regardless of
• the setting. The Safety and well-being of the
• consumer must be the central focus of all
• decisions regarding delegation of nursing
• tasks to MAC Workers (unlicensed
• personnel)
• NCSBN, 1997

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What is NDP?

• Let whoever is in charge keep this simple
  question in her head, not, how can I always do
  this right thing myself, but how can I provide
  for this right thing to be always done?
• Florence Nightingale

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What is NDP?

• Four Components of the NDP
• 1. Administrative Requirements
• 2. Education/Training
• 3. Quality Assurance
• 4. Compliance

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Administrative Requirements

• There is both individual accountability and
  organizational accountability for delegation.
• Organizational accountability relates to
  providing sufficient resources, staffing,
  appropriate staff mix, implementation of policies
  and position descriptions, opportunity for
  continuing education and creating an environment
  conducive to teamwork, collaboration and
  client-centered care.

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Administrative Requirements

• The organization is accountable for assuring
  that documentation of competencies for ALL
  personnel is maintained
• The organization is responsible for the
  development and enforcement of policies on
  delegation with active participation from nurses

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Administrative Requirements

• Organizations are responsible for assuring that
  educational needs/requirements are met through
  the implementation of the NDP
• Organizations are responsible for assuring
  compliance with all DMH Regulations

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Personnel Issues

• MAC Workers Must
• Have a HS Diploma/GED
• Be responsible
• Be able to read with understanding
• Be knowledgeable of agency operations
• Be respectful
• Be able to work independently
• Be able to monitor consumers

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Personnel Issues

• MAS Nurse Must
• Be an LPN/RN in good standing
• Attend MAS Training and pass competency test
• Understand disease and symptoms management
  related to MI/MR/SA
• Be able to teach and supervise others
• Practice according to the Nursing Standards of
  Practice
• Practice within the NDP guidelines

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Documentation

• Job Descriptions
• Training MAC, MAS, MATT
• Supervision MAC, LPN
• MAR
• Communications
• Observations/Actions
• Self Administration Assessment

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Documentation

• IF IT IS NOT DOCUMENTED
• IT WAS NOT DONE!

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Policies and Procedures

• Compliance with ABON Regulations
• Compliance with NDP
• Documentation MAR, communications, observation,
  actions
• MAC Supervision quarterly
• LPN Supervision
• Training and Updates MAC, MAS
• Self Administration Assessment - annually

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Policies and Procedures

• How to handle medications when on home visits, MD
  visits, trips
• How to handle telephone orders
• Reporting a Nurse to the NDP Director/ABON
• Medication Errors documentation, reporting
• Medication security/disposal

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Administrative Requirements

• The DMH Certification Process includes NDP
  Regulations. Certification Surveyors will assess
  compliance with NDP Regulations.

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Education and Training

• MAC Worker
• 24 hours of training
• 12 hours Level I classroom education
• Take a written test and pass with 90
• Three attempts
• 12 hours Level ll assessment of competencies
• 4 hours update/refresher annually

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Education and Training

• MAS RN/LPN
• Any RN/LPN licensed in Alabama, employed or
  contracted by an Agency certified by DMH is
  eligible for training and certification as a MAS
  Nurse

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Education and Training

• MAS RN/LPN
• A four (4) hour training program, taught by a
  MATT
• RN is required
• The RN/LPN must pass a written test with a score
• of 90 or better
• Three (3) attempts to pass written test
• Certification updated every two (2) years

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Education and Training

• MATT RN
• RN ONLY
• At least one (1) year residential/community
  experience
• Specific trainers certified by the DMH to train
  MAS
• Nurses
• Must complete a self study module and take a
  written test
• passing with a score of 90 or better

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Education and Training

• MATT RN
• Two attempt to pass test
• Update every two (2) years
• Appointed to DMH NDP Advisory Council

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Education and Training

• NEXT SCHEDULED MAS TRAINING
• JANUARY 2009
• (Watch for announcement of date and location)
• NEXT SCHEDULED MAS UPDATE TRAINING
• DECEMBER 5, 2008 Montgomery
• DECEMBER 17, 2008 Tuscaloosa
• JANUARY 14, 2009 - Mobile

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Education and Training

• 2nd Annual Update for MAC Workers due
• prior to April 1, 2009

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Quality Assurance

• Medication Errors
• A medication error occurs when the
  correct/incorrect recipient receives an incorrect
  drug, dose, form, quantity, route, at the
  incorrect time.
• Failure to administer a drug (missed dose) at
  the scheduled time constitutes a medication error

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Quality Assurance

• Medication Errors
• Medications may be given one (1) hour before OR
  one (1) hour after the scheduled/ordered time.
  Administration within this acceptable range does
  not constitute a medication error.
• Medication errors by licensed and unlicensed
  personnel must be reported to the DMH.

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Quality Assurance

• Severity of Medication Errors
• Level I incidents in which the recipient
  experienced NO or MINIMAL adverse consequences
  AND NO TREATMENT or INTERVENTION other than
  monitoring or observation was required.

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Quality Assurance

• Severity of Medication Errors
• Level II incidents in which the recipient
  experienced SHORT TERM, REVERSIBLE adverse
  consequences AND TREATMENT(S)/INTERVENTION(S) in
  addition to monitoring and observation was
  required.

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Quality Assurance

• Severity of Medication Errors
• Level III incidents in which the recipient
  experienced LIFE THREATENING and/or PERMANENT
  adverse consequences

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Quality Assurance

• ABON DATA REQUIREMENTS
• of programs with 24/7 on call coverage
• Programs that participate in NDP
• Programs that do not participate in NDP
• Programs with Nurses 24/7
• Programs with Nurses on call

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Quality Assurance

• ABON DATA REQUIREMENTS
• Method used to comply with 24/7 coverage
• Turnover
• Training
• Medication Errors
• Areas of non-compliance
• How non-compliance was addressed

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Data Collection Suggestions

• Nurse Case Load (MAC/MAS)
• Calls received after 5P
• Calls received on weekends/holidays
• Times of Calls
• Location of calls
• Self Medication Assessments completed

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Compliance

• ABON requires that the DMH provide an Annual
  Report addressing the required data
• Failure to comply with all NDP Regulations may
  result in decertification

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MAR

• All medications must be listed on the MAR
• The MAR must be recopied by a licensed nurse if
  not pre printed by the pharmacy
• MAC Workers CANNOT change, add or deleted any
  medications from the MAR
• MAC Workers CANNOT take verbal orders

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PRNs

• MAC Workers CAN give PRNs
• MAC Workers MUST call the MAS Nurse prior to
  giving a PRN
• Effectiveness of the PRN MUST be documented
• MAS Nurse MUST be notified of outcome

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WHO???
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Who is Impacted?

• This regulation applies to any DMH certified
  residential program, day programs and/or other
  community extensions that provide services to
  minors UNLESS ALL medications are administered by
  nurses licensed in the State of Alabama

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Who is Impacted?

• This regulation applies to any DMH certified
  residential program, day programs and/or other
  community extensions that provide services to
  individuals who are unable to self medicate as
  defined and assessed by a RN according to NDP
  guidelines.

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Who is Impacted?

• This regulation does not apply to programs where
  ALL INDIVIDUALS SELF MEDICATE as defined and
  assessed by an RN as required by NDP

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Who is Impacted?

• This regulation does not apply to individuals
  residing at home and receiving CARE FROM
  FAMILY/SIGNIFICANT OTHER(S)

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HOW???
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How can I get a MAS Nurse?

• Employ a RN/LPN licensed in Alabama
• Discuss Delegation with the nurse and
• review Position Description
• Contact me for training dates and scheduling
• [phone]
• Contact me with problems/questions
• Vanessa.Prater_at_mh.alabama.gov

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How can I get more information?

• DMH Website
• www.mh.alabama.gov
• Click on the NDP link
• OR
• CONTACT Vanessa B. Prater, BSN, RN, Director,
  Nurse Delegation Program
• RSA Union Building
• 100 S. Union Street
• P. O. Box 301410
• Montgomery, AL 36130-1410
• [phone] Office
• Vanessa.Prater_at_mh.alabama.gov

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How can I get Technical Assistance?

• CONTACT
• Vanessa B. Prater, BSN, RN, Director,
  Nurse Delegation Program
• RSA Union Building
• 100 S. Union Street
• P. O. Box 301410
• Montgomery, AL 36130-1410
• [phone] Office
• Vanessa.Prater_at_mh.alabama.gov

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ABON

• Practice Consultant
• Carolyn Morgan, MSN, RN
• cmorgan_at_abn.state.al.us
• Executive Officer
• Genell Lee, MSN, RN, JD
• Genell.Lee_at_abn.alabama.gov

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WHEN???
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When do I have to comply?

• NOW!

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Historical Overview

• Regulation initially effective December 05
• Program Development/Training
• Jan 06-Apr 1, 07
• Full Implementation began April 1, 07
• Certification Compliance Nov 1, 07

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QUESTIONS