CHAPTER XII.

XII. Medication Administration

Medications may be administered only by a physician, PA-C, nurse, or by direct-carestaff who have taken and passed a CMHOC Medication Administration training class.

1. Specific clinical programs will determine which non-Health Practitioner staffwill be trained and authorized to administer medications.

2. Training shall be provided for designated staff by the Training Center.This class will be taught by a qualified healthcare professional (RegisteredNurse, Pharmacist or his/her designee).

3. Documentation of dates and attendance will be kept by the site supervisorand the CMHOC training unit.

The minimum qualifications for unlicensed staff who administer medication are:

1. 18 years of age or older

2. High school graduate or G.E.D.

3. English language proficiency (which includes reading, writing and speaking)

4. Satisfactory references including criminal background checks

5. Successful completion of Medication Administration class that meets thecurriculum requirements of CMHOC, demonstration of safe medicationadministration practice and completion of a facility orientation program.

A. Injectable Medication

1. Injectable medications may be given by a physician, RN or LPN

2. Nurse will verify last physician, PA-C or NP's prescription on InfoScriber

3. Current order must be within the last 90 days.

A. Iniectable Medication (cont.)

4. Nurse will record all new orders on AVATAR Medication Injection Record.

5. Injection medication, dose, route & site will be documented by the Nurse onthe AVATAR Medication Injection Record.

6. Team nurses will schedule appointments for all injections when a prescriberis scheduled to be present in that building.

7. Team nurses may give injections one day earlier than ordered if the consumerpresents at the CMHOC office without requiring a change in prescriber's order.

8. If a consumer does not keep his/her appointment for an injectable medication,the RN will call the consumer to reschedule the appointment as soon aspossible.

Injectable Medication Inventory

Injectable medications are prescribed by the Psychiatrists and administered by the Nursesof Community Mental Health (CMH). The medications that are part of the inventory arepurchased with CMH Funding and do not include any medication that is purchased by anindividual and stored at any CMH site.

At the end of each month, the nurses or their designee at 3 different sites takes aninventory of all CMH Injectable medication:

MDT Team - HollandMDT Team - Grand HavenACT

The inventory is e-mailed to CMH Accountant I (Brenda Molendyk). The e-mail is thenforwarded to the CMH Account Clerk (Kelli Headley).

The Account Clerk researches the amount paid for the medications from the most recentinvoices and writes that amount on the inventory list that was provided from each site.The Account Clerk then returns the inventory to the CMH Accountant I for theprocessing of a month end Journal Entry.

2 times a year (March and September) a physical count and verification of inventory isrequired to comply with policy. The CMH Accountant I goes to each individual site andphysically confirms with the nurse or their designee, the inventory that is at each site.CMH Accountant I sets a time with each of the nurses from the individual sites to countthe medications that are in inventory. A medication inventory sheet is completed andthen signed and dated by the nurse or their designee and CMH Accountant I. (Seesample below} The sheet is then given to the CMH Accounts Payable Account Clerk forregular month end processing.

Balance as of (DATE)

Site Name Medication Quantity

Nurse Signature

Date

Fiscal Services Signature

Date

Duplicate Pharmacy Protocol

1. Some pharmacies are unable to obtain all injectable medications. Therefore,some consumers may require more than one designated pharmacy. Whenthis occurs, the treatment team nurse will:

• Designate on the Injectable Medication Schedule consumers whorequire a different pharmacy for injectable medications.

• Print a copy of the daily schedule for each prescriber on their team.

• Make a highlighted note of different pharmacy/location and name ofmedication next to each consumer name, when applicable.

• Provide prescriber with highlighted schedule for reference.

2. Prescribers will be responsible for e-Rx or faxing of all prescriptions toappropriate pharmacies.

COMMUNITY MENTAL HEALTH OF OTTAWA COUNTYOPERATIONAL GUIDELINE

Pagel of 2

TITLE: Administration of Zyprexa Relprevv

EFFECTIVE DATE:4/4/11

REVIEW DATES:

AUTHORED BY: Dr. Bruce Walters, Medical Director

I. SUBJECTUse of Zyprexa Relprew injections

II. SCOPEAll CMHOC directly operated and contractual providers

III. PURPOSETo ensure the safe administration and monitoring of individuals who receive ZyprexaRelprevv injections, to provide appropriate care in the vent of an adverse reaction, and tocomply with federally mandated monitoring requirements.

IV. PROCEDUREa) Registration

The following persons/facilities must receive required training and become registeredby the Zyprexa Relprevv Patient Care Program prior to the administration of theZyprexa Relprevv:

i) Facility where the medication clinic is locatedii) Prescriberiii) Pharmacyiv) RN administering injectionv) Individual receiving injection

b) ConsentPrior to prescribing Zyprexa Relprew, the recipient must have potential side-effects/risks and benefits explained by a health care professional and a CMHOCmedication consent completed. In addition, the consent required by Eli Lilly mustalso be reviewed and signed by the recipient.

c) Administrationi) Zyprexa Relprevv may be administered only in a healthcare facility that has ready

access to emergency response services and that can provide continuous patientmonitoring for at least 3 hours post-injection,

ii) Zyprexa Relprevv is administered by an RN or physician by deep intramusculargluteal injection only, using a 19 gauge, 1.5" needle. A 2" needle may be used forpersons who are obese. Zyprexa Relprevv cannot be administered in the deltoid,

iii) Zyprexa Relprevv is provided as a powder and must be reconstituted before use.Once reconstituted, the solution is stable for 24 hours without refrigeration.However, if not used immediately, the solution should be shaken to resuspendbefore being withdrawn into the syringe,

iv) The administrator of the injection must aspirate the syringe for several secondsprior to injection to ensure no blood is visible. Should blood be visible in the

Page 2 of 2

syringe, administration at that site must be aborted, a new syringe and vial be usedand administration switched to the other buttock. The injection site must not bemassaged.

d) Monitoringi) Locate the recipient of the injection where he/she can be seen and/or heard for 3

hours after the injection and where a health care professional is located nearby. Astaff who can see and/or hear the recipient(s) for the 3 hours and identify that therecipient is alert, oriented, and without signs or symptoms of Post-InjectionDelirium Sedation Syndrome (PDSS) shall be present at all times during themonitoring period.

ii) In the event that PDSS occurs, the monitor shall immediately notify the nearbyhealth care professional and call 911 for medical assistance.

iii) After the health care professional and/or emergency medical responders haveassumed care, the monitor shall complete an incident report.

iv) Recipients of a Zyprexa Relprew injection will be offered a Zyprexa Relprevv IDcard and a Zyprexa Relprevv wristband.

v) Ensure that someone is available to accompany the recipient to their destinationafter the 3-hour observation period. If no one is available, the injection will not beadministered. A bus or taxi may be used to transport a consumer home whenaccompanied by a responsible adult.

e) Standards:i) Zyprexa Relprevv Literature issued by Eli Lillyii) Physician's Desk Reference: Zyprexa Relprevv (Olanzapine)

Zyprexa Relprew - 040411

B. Self-Administration of Medication

1. Self-administration of medication is defined as the removal of the medication bythe consumer from the original pharmacy container and the taking of themedication as directed, or the placement of the medication in another containerto be taken at a later time or date after leaving the home or program.

2. Only consumers in a 24 hour setting and/or consumer's who have CMH staffpresent while taking medication(s) will have a written order from the prescribingprofessional to be considered competent to self-administer their medication.

3. Both prescription and nonprescription medication must be accompanied by awritten order from a licensed prescriber, be in the original pharmacy containeror packaging and include the full name of the consumer. This order will bevalid for one year from the date issued.

4. Consumers will be supported and trained in the safe self-administration ofmedication(s) and trained about the medication itself.

5. All medication brought into either the residential home, CBS site, or ACT willbe stored in a single locked area, including medications that are self-administered.The safety of all consumers is paramount.

6. Any consumer with a written authorization for self-administration of medicationswill be monitored by staff, which have successfully completed MedicationAdministration Class, to assure that safe administration occurs.

7. While receiving services from a CMH operated or contracted residential or dayprogram, a recipient may self-administer his/her medication only when approvedin a written order by the physician/PA-C/NP, specified in the recipient's Plan ofService, and monitored by trained staff. The physician/PA-C/NP must assess therecipient's capacity to self- administer medication and document that anappropriate level of competency exists at the time the order to self-administermedication is written.

8. When it is determined by a CMH Physician/PA-C/NP that a recipient receivingOutpatient services (i.e., therapy, case management, ACT) requires CMHassistance to learn to safely self-administer their medication, it must bedocumented in a psychiatric progress note and incorporated in the recipient'sPlan of Service. The nature and duration of CMH assistance must be specified.Once sufficient competency is acquired on the part of the recipient, assistance inself-administration of medication will be discontinued.

C. Consumers in Residential Settings and/or Community Based Education

Medication Administration Protocol for Ottawa County

Medication Administration Protocol Utilizing The Medication Administration Record

Routine Medication AdministrationWhen a medication is administered, the person who prepares and administers the medicationwill chart his initials on the MAR in the box that correlates with the time and date of thatdose of medication. He also will also sign his initials and full name on the back of the MAR.

WithheldWhen labs or tests are ordered, check with the lab or facility drawing the lab or doing thetests to see if medications must be held or delayed. If medications are withheld, and themeds would be considered late, check with the nurse and/or physician to see if any held medsshould be given late or skipped and given at the next regular dose time. If the medication isnot given and you wait until the next dose time, circle your initials on the front of the MARand write the reason on the back of the MAR in the nurse's notes. Notify other staff that willbe caring for the recipient.

Leave of Absence (LOAWhen a recipient is on LOA, in the appropriate space on the front of the medicationadministration record (MAR), for each medication not given while out on LOA, document"left on LOA" on the back of the MAR when the person leaves and in the nursing notes.Indicate on the back of MAR if meds were sent for the LOA. When the recipient returns,document that he/she has "returned from LOA". Note: when a recipient is scheduled to be ona leave of absence, notify the pharmacy 3-5 days in advance to have necessary medicationpackaged and labeled for the LOA. If there is not enough time for the pharmacy to send out asupply of medications for the LOA, staff should place each medication in a separate envelopewith a copy of the physician orders on the front as it appears on the MAR. You should alsowrite the recipient's name and times the meds are to be given on the envelope. Includeenough of the medications for the entire LOA. A copy of the MAR may be given to theperson taking the recipient out on LOA.

PRN MedicationsFor PRN orders, initial the front of the MAR in the space which most closely indicates thetime the medication was given. Document the date, time, name of PRN medication, dose andreason why this medication was given on the back of the MAR and in the nurse's notes. Alsodocument on the back of the MAR and nurse's notes the recipient's response to the PRNmedication. When PRN medications are given at CBE, home staff should copy that page inthe communication log that states what was given and attach it to the MAR in the home'smedication book.

Discontinued MedicationWhen a medication is discontinued, write D/C'd in bold letters where the next dose wouldhave been recorded. Then draw a wavy line to to the end date of the MAR. Document theD/C'd medication order in the nurse's notes and in the daily log.

Changed Dosage or FrequencyWhen a physician gives a medication order to change the dosage or frequency of a currentmedication, the present order must be D/C'd as above, and the new order transcribed onto theMAR. A second staff person must read the physician's order to verify the transaction, thenalso initial it.

Missed DocumentationWhen a staff person notices that there are no initials for a previous medication that shouldhave been given, that person should attempt to phone the responsible staff and clarify if themed was given (and just the initials were omitted) or if the med was not given. If themedication was given, but the initials were omitted, present staff person should document onthe back of the MAR that responsible staff was phoned and stated med was given. Nothingshould be written on the front of the MAR for the missed initials of another staff. Alsoinclude the information in that shifts nurse's notes. If the responsible staff was not able to bereached, present staff should continue with present schedule. Additional attempts to reachthe responsible staff person should be made for clarification. Do not assume the med wasmissed and give another dose. Fill out an Incident Report.

Late EntryWhen a staff person omits their initials for a passed medication, they should enter theirinitials upon their return to duty on the front of the MAR, as if they were giving it now. Onthe back of the MAR, the present date and time should be noted, immediately followed byLATE ENTRY, then a narrative should be written that they are now signing their initials latefor the medication given on the previous date and time.

New Medication OrderWhen the physician orders a new medication, put the original order in the physicians ordersection of the recipient's chart. Transcribe the medication order onto the MAR. Include startand stop dates if necessary, i.e. if ordered for short term 10 day therapy. The staff personmust date and initial the transcribed order on the MAR. A second staff person must reviewthe physician's order to verify the transcription is accurate, then initial it and sign the back ofthe MAR.

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OTTAWA COUNTY COMMUNITY MENTAL HEALTHCOMMUNITY BASED SERVICES

Protocol for Medication Administration

Physicians will be encouraged to prescribe medication(s) to be taken other than during CBS service hourswhen possible. If a consumer is able to independently manage their medication, and has written supportingdocumentation from the prescriber, they will be responsible for their own medication(s). When a consumeris unable to independently manage their medication(s), the following procedure will apply:

I. DOCUMENTATION REQUIREMENTS:

A. Medication Notification: A written order from a licensed prescriber (Dentist, MD, DO, NursePractitioner or Physicians Assistant) is required prior to administering any medication.This includes both prescription and over the counter (OTC) medication. A copy of theorder will be kept on file at each CBS site for medications that are to be administered on adaily or PRN basis.

This procedure applies to new, changed, or discontinued medications. The written ordermay be faxed or directly delivered to the CBS site. It must be received at CBS before anymedications will be administered.

B. Medication Log: Medications administered to a consumer will be documented by initialingthe log space corresponding to the correct date and time. A designated staff person(s) ateach CBS site will be responsible for keeping the Medication log current and identifying allconsumers at the site who are authorized to receive medication during CBS service hours.This person(s) will also confirm that written orders are present for all medications thatrequire CBS administration. The Medication Log will include the consumer's name,medication name, dosage, and directions for administration. Medication logs will beshredded after the information is transferred to individual Medication AdministrationRecords.

C. Standing Orders for PRN Medications: Standing orders for PRN medications (such asacetaminophen, ibuprofen, cough syrup, et.) must include dosage & specific directions forunder what circumstances the medication may be given. Each CBS site will maintain asupply of PRN medications prescribed for that individual. Staff will document on theMedication Log the time a PRN med is given, the reason, as well as the consumer's resultor response approximately 45-60 minutes following administration. This information will becommunicated to the home using a standardized memo (see attachment). PRNmedication will not be administered in emergency situations as a means of preventingharm to the consumer or others, or for behavioral control. These orders require annualwritten renewal by the prescribing medical professional.

D. Medication Administration Record: Each consumer receiving medications at a CMHOCCBS site will have an individual Medication Administration Record. Medication orders willbe transcribed from the prescriber's order and initialed by recording staff. A second CBSstaff person will review the medication order and transcribed order. He/she will also initialthe medication entry on the Medication Administration Record indicating confirmation of

Updated 3/1/10 SN

OTTAWA COUNTY COMMUNITY MENTAL HEALTHCOMMUNITY BASED SERVICES

correct transcription of the order. Weekly, all individuals who have administeredmedication(s) at CBS will record all entries of medications administered onto the individualmedication administration records of each consumer. This will include date, time and staffinitials for both routine and PRN medications. Additionally for PRN medications,documentation requirements include reason for administration and the consumer'sresponse to the medication approximately 45-60 minutes post administration. EachMedication Administration Record will also include both the initials and full name of all staffadministering medications. When completed, Medication Administration Records will befiled/scanned into the consumer's chart.

RECEIPT AND STORAGE OF MEDICATIONS:

A. A month's supply (or normal unit supply) of medication(s) for each consumer should beprovided to the CBS site by the consumer's guardian or group home. The medication wilbe in the original pharmacy container with pharmacy label attached. The label will includethe consumer name, medication name, dose, directions for administration & prescribingphysician. In some instances the home will transport consumer's medications on a dailybasis. In those instances the medication should be in a pharmacy labeled pre pack with allrequired information.

B. Transportation of med supply:1. Residential home staff who transport consumers to CBS will deliver medication directlyto the designated CBS staff person.2. For those individuals transported on Pioneer, staff have the availability of a locked medbox onboard each of those buses. Home providers are supplied with a key and will placethe medication supply in the lock box. CBS staff will remove the medication from lock box& deliver to designated CBS staff person.3. Those individuals transported on Public Transportation (MAX & Harbor TransitDirect-Response) do not have an available med lock box, thus necessitating thetransportation of medication by the home provider directly to the CBS site.

C. Medications will be stored in a locked receptacle at each CBS site, supervised by adesignated staff person. Medications will be administered in the appropriate dosage at theprescribed time. Topical medications and oral medications shall be stored separate fromeach other.

D. Unused medication(s), such as those that have been discontinued or expired, will bereturned to the home.

PROCEDURE FOR ADMINISTERING MEDICATION:

A. CBS staff who have successfully completed Medication Administration Training Class willbe responsible for administering medication at the prescribed times. Administration ofmedication will be documented daily on the Medication Log. This information will betransferred on a weekly basis to the consumer's individual Medication AdministrationRecord by the person(s) who administered the dose(s).

B. The designated staff person will:1. Prepare one recipient's medication(s) at a time.

Updated 3/1 /10 SN

OTTAWA COUNTY COMMUNITY MENTAL HEALTHCOMMUNITY BASED SERVICES

2. Verify a match between what the med log lists is prescribed and what is received.If both do not match exactly, the consumer's contact person will be notified and anIncident Report will be completed.

3. Pour capsules, tablets, pills, etc. into lid of med container and then into disposablemed cup (if med is pre pack/bubble pack, place directly into disposable med cup).

4. Explain to recipient why the physician ordered the medication.5. Administer the medication. Remain with the recipient until he/she swallows the

medication.6. Document that the medication was given by initialing the Medication Log

under the proper date & time.7. Monitor the consumer for side effects or adverse effects. Document the response

to PRN medication approximately 45-60 minutes following administration.

IV. REPORTING OF ERRORS:

Should a medication error occur, an Incident Report form will be completed and the home notified.

Reviewed & approved by the Medication Committee on

Bruce Walters, MD DateMedical Director

Updated 3/1/10 SN

3. Insulin Administration and Blood Glucose Monitoring of a Developmental^ DisabledCMH Consumer in a Residential Setting

a. RN will assess the clarity of the physician's orders and the recipient's abilityto self-administer insulin, to monitor blood glucose, to understand the physician'sorders, to prepare accurate amount of insulin and administer the insulin.

b. If CMH RN determines the recipient is not capable of all or some aspects ofself-administration of insulin, CMH RN or staff appropriately trained by CMHRN will monitor/assist with prescribed orders for insulin administration.

4. Recipients Receiving Medications Away from the Usual Facility (e.g., outings or Leavesof Absence (LOA) from residential settings or day program)

a. Duplicate labeled pharmacy containers must be requested for providingmedication to recipient away from the usual setting.

b. Such medication shall be recorded in the medication administration record/LOAform.

c. If medication not taken for any reason while away shall be secured in themedication storage area. Also:

• An Incident Report (IR) shall be completed and sent to the sitesupervisor.

• The medication sheet entry for the LOA medications shall be circled inblack ink.

• If authorized by the nurse, the missed medication should be given tothe recipient, with the time given noted on the medication administrationrecord.