D.15 USE OF UNLICENSED ASSISTIVE PERSONNEL IN ADMINISTERING MEDICATION .pdf

D.15 USE OF UNLICENSED ASSISTIVE PERSONNEL IN ADMINISTERING MEDICATION

36C25922R0102

Department of Veterans Affairs VHA DIRECTIVE 2013-006

Veterans Health Administration

Washington, DC 20420 March 5, 2013

THE USE OF UNLICENSED ASSISTIVE PERSONNEL (UAP) IN

ADMINISTERING MEDICATION

1. PURPOSE: This Veterans Health Administration (VHA) Directive provides policy regarding the discretionary use of Unlicensed Assistive Personnel (UAP) for medication administration. AUTHORITY: 38 U.S.C. §7301(b). NOTE: Personnel certified by a recognized external authority to administer medications are excluded from this Directive.

2. BACKGROUND: VHA recognizes that medication administration by a UAP needs to be closely monitored. The administration of specific medications, based on local policy and documentation of the administered medication, can be delegated to a UAP, based on factors related to the training and competency of the individual, area of practice, the complexity of the medication to be administered and the availability of adequate supervision and oversight. The

Pharmacy Benefits Management Services office within the Office of Patient Care Services has the VHA organizational responsibility for managing the Department of Veterans Affairs (VA)

National Formulary (VANF). The Veterans Integrated Service Network (VISN) Formulary

Committees and facility Pharmacy and Therapeutics Committees are responsible for implementing VANF initiatives. UAP categories include, but are not limited to: nursing assistants, certified medical technician, health technicians, and dental assistants.

3. POLICY: It is VHA policy that a UAP, operating within a clearly-defined medication administration role and upon recommendation of the facility Pharmacy and Therapeutics

Committee, Medical Executive Committee, the Associate Director for Patient Care and

Associate Director for Nursing Services, Chief of Staff, and the Chief of Pharmacy and with the approval of the medical facility Director, may administer medications as described in this

Directive.

4. ACTION

a. VA Medical Facility Director. The VA medical facility Director is responsible for:

(1) The approval of UAP medication administration upon the recommendation of the appropriate facility medication management committees (typically the Pharmacy and

Therapeutics and Medical Executive Committees) and in collaboration with the Chief of Staff, Associate Director for Patient Care or Nurse Executive and the Chief of Pharmacy.

(2) Ensuring that written policies and procedures are in place. These must include the following:

(a) All UAPs are under the delegated authority and supervision of a Physician, i.e., Doctor of

Medicine (MD) or Doctor of Osteopathy (DO); Advanced Practice Registered Nurse (APRN);

Dentist (Doctor of Dental Surgery (DDS) or Doctor of Dental Medicine (DMD); Pharmacist

Supervisor; or Registered Nurse (RN).

THIS VHA DIRECTIVE EXPIRES MARCH 31, 2018

VHA DIRECTIVE 2013-006

March 5, 2013

(b) When medications are approved for administration by an UAP per local facility policy, appropriate medication specific training and competency evaluation of each UAP must be documented.

(c) Each UAP designated for medication administration must complete a formal medication administration course, Bar Code Medication Administration (BCMA) training, and must demonstrate competency. The UAP’s completion of a training course must be approved or authorized by the facility medication management committees.

(d) A copy of the course certificate and competency assessment must be placed in the employee’s competency folder.

(e) The medication course and competency checklist must include the following principles:

1. Proper patient or resident identification;

2. Procedures for routes of administration;

3. Symbols and descriptions for medication dosages, routes, and frequencies;

4. Documentation requirements;

5. Responsibility for reporting to an MD or DO, APRN, DDS or DMD, Pharmacist

Supervisor, or RN;

6. Knowledge of facility guidance on delegated actions;

7. Importance of timelines and adherence to medication schedules (e.g., right medication, dose, person, route, time);

8. Infection control and safe handling of medications;

9. VHA-approved abbreviations related to medication administration;

10. Responsibility for understanding indications and contra-indications for the medications administered;

11. Medication administration safety;

12. Adverse event reporting procedures;

13. Annual verification and evaluation of the UAP’s competency; and

14. Any requirements for the patient to remain in the clinic or VA Community Living

Center (CLC), post-medication administration, for a re-evaluation by a health care professional.

15. Knowledge of the side effects, drug interactions and dosage limits on administered medications.

16. Equipment and devices required for medication administration.

(f) The evaluation and competency of each UAP must be verified annually through direct observation of their medication administration. This competency verification must be conducted and documented by a licensed clinician (e.g., MD or DO, RN, APRN, Pharmacist Supervisor, DDS or DMD), who has the competency to perform such verification and competency evaluation and who supervises the UAP.

(g) There is a system in place to verify that an individual UAP is administering only those drugs that are approved for that UAP.

(3) Ensuring there is a list of drugs approved for medication administration for each individual UAP.

(a) Each UAP must have a clearly defined list of drugs approved for medication administration that is reflective of patient care needs within the identified environment including, but not limited to:

1. Identifying the patient or resident environment where the UAP may administer medications;

2. Listing medications that may be delegated to the UAP to be administered according to patient or resident care needs within the identified environment; and

3. Establishing conditions under which delegation of medication administration may occur.

(b) Drugs locally approved for medications administration for each UAP may include the following:

1. Oral, topical, suppository, eye drops, ear drops;

2. Single dose immunizations administered intramuscularly in the deltoid muscle; and

3. Intradermal injections for allergy testing.

(c) Drugs for medication administration by the UAP may not include the following:

1. Controlled substances;

2. Experimental or investigational drugs;

3. Medications requiring dosage adjustments based on clinical judgment or calculation of dosages;

4. Medications requiring specialized training for licensed clinicians (for example, chemotherapy);

5. Medications requiring specialized training as determined by external accreditation standards;

6. Intravenous (IV) Administration-IV Drips (infusions), IV Push (with the exception of certified radiology and nuclear medicine technologists); and

7. Medications contained on the VA medical facility’s list of High Alert Medications.

8. Administration of medications to patients who are deemed medically unstable.

b. Chief of Staff and Associate Director for Patient Care Services or Nurse Executive.

The Chief of Staff and Associate Director for Patient Care Services or Nurse Executive is responsible for:

(1) Collaborating with the Pharmacy and Therapeutics Committee, the Medical Executive

Committee, and the Chief of Pharmacy to create local policies and procedures and to make group recommendations to the medical facility Director, as needed, defining the scope of medication administration.

(2) Ensuring the compliance of clinical staff with the written policies and procedures;

(3) Ensuring the clinical area designated for the UAP meets all requirements for medication storage and is inspected monthly; and,

(4) Ensuring that all components of the UAP Program are in compliance with accrediting body standards.

c. Facility Chief of Pharmacy. The facility Chief of Pharmacy is responsible for:

(1) Collaborating with the Associate Director for Patient Care or Associate Director for

Nursing Services, the Pharmacy and Therapeutics Committee, the Medical Executive

Committee, and the Chief of Staff to create local policies and procedures; and

(2) Making recommendations to the facility medication management committees (typically the Pharmacy and Therapeutics and Medical Executive Committees) and in collaboration with the Chief of Staff and Associate Director for Patient Care Service or Nurse Executives for

Nursing Services, for defining the list of drugs suitable for UAP medication administration.

d. Pharmacy and Therapeutics Committee. The Pharmacy and Therapeutics Committee is responsible for:

(1) Reviewing and approving policies and procedures defining the scope of medication administration for the UAP;

(2) Reviewing and approving an approved list of medications; and

(3) Reviewing annual quality assurance data related to UAP medication administration.

e. BCMA Coordinators. The BCMA Coordinators at each facility are responsible for:

(1) Ensuring that each UAP administering medications completes initial and ongoing BCMA training;

(2) Redesigning all facility BCMA training documents to incorporate the elements of this directive for UAPs; and,

(3) Adding UAPs to the distribution lists of disseminated information related to BCMA policy and procedural changes as appropriate.

5. REFERENCES: None.

6. FOLLOW-UP RESPONSIBILITY: The Office of Nursing Service (10A1) is responsible for the content of this Directive. Questions may be referred to 202-461-6700.

7. RESCISSION: VHA Directive 2010-028, dated June 9, 2010 is rescinded. This VHA

Directive expires the last working day of March 2018.

Robert A. Petzel, M.D.

Under Secretary for Health

DISTRIBUTION: E-mailed to VHA Publications Distribution List 3/8/2013