MINUTES BOARD FOR LICENSING HEALTH CARE FACILITIES MEDICATION ADMINISTRATION SUBCOMMITTEE MEETING FEBRUARY 24, 2011

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1 MINUTES BOARD FOR LICENSING HEALTH CARE FACILITIES MEDICATION ADMINISTRATION SUBCOMMITTEE MEETING FEBRUARY 24, 2011 The Medication Administration Subcommittee meeting was called to order by Ms. Ann Rutherford Reed on February 24, 2011 at 9:10 a.m. Members of the Medication Administration Subcommittee Present: Mr. Luke Gregory Mr. John Marshall Ms. Carissa Lynch-arrived 9:14 a.m. Present and representing the Office of General Counsel: Ms. Diona Layden Also present: Ms. Ann Rutherford Reed, Director, Board for Licensing Mr. Vincent Davis, Director, Health Care Facilities Ms. Wanda Hines, Board Administrator Ms. Reed provided a summary on the establishment of the subcommittee. Several questions were brought before the Board at its January 19, 2011 meeting from the industry as well as the surveyors from the Department. The questions related to medication administration in the Assisted Care Living Facilities regarding who can administer medications and what degree of assistance may be provided by nonlicensed staff. This subcommittee meeting is to get more of a handle on the regulatory language that is currently in place and compose an interpretation of the language and/or determine if more rule language may be needed. The subcommittee s objective is to determine which is needed and then present to the full Board at the May meeting. Mr. Gregory and Mr. Marshall were co-chairs of this subcommittee. Ms. Layden stated at the January Board meeting there was discussion regarding medication administration and cognition levels of the residents to determine if what was being provided was assistance or administration of medications. The Board also wanted to look at the physical ability of the residents relative to arthritis and things of that nature with respect to their ability to open bottles and a basic overall standard of care. The rules being looked at specifically are (2) which speaks of administering medication and (32) which speaks of self-administration of medication. Mr. Marshall explained his main concern was centered on self-administration of medication. There are many different types of medications a resident may have which if not monitored and taken as prescribed may lead to harm of residents in the ACLF. Mr. 1

2 Marshall referenced regulation (2) which define administering medication including injections and topical applications that it would be understood licensed personnel should be administering these meds. He felt the pushing of the medication out of a bubble wrap or opening a medicine bottle would not take licensed personnel. When speaking of hospice patients and the types of medicine they are on like morphine, protection and safety of delivering the meds i.e. overdose of the resident or to ensure they receive their medication a licensed professional would be needed. Mr. Gregory opened the floor to the audience to speak regarding these issues. Ms. Mitzi Maddox from Tennessee Hospice Organization Regulatory Committee explained to the subcommittee the role of hospice in the ACLF and the different levels of hospice care. Ms. Maddox stated hospice provides training of medication administration for the caregiver or family member of the hospice patient in the home and these caregiver and/or family members are not licensed professionals. She explained that to hospice home is home ; it is an assisted living; it is a nursing home facility. The patients are paying rent to be in that facility and that is where the patient resides so hospice considers an ACLF the home. Ms. Maddox stated hospice trains the residential assistant, certified nursing assistant or LPN that may be there to administering needs. Hospice is not allowed to be a sitter service. Hospice is available to the staff 24/7 if there is a crisis. In a crisis, hospice will send someone or the crisis care nurse will go to the facility. Hospice can also place the patient in general inpatient, in a hospital or a nursing home that has 24 hour R.N. or a hospice facility. Dialogue and questioning ensured between Ms. Maddox and subcommittee members regarding deliverance of medications and the application of the ACLF rules per hospice. Ms. Maddox indicated the current rules are complete and no changes are needed. The subcommittee was briefed by Ann R. Reed on the issue also brought to Health Care Facilities of medication administration to hospice patients and who can be trained and who can administered in an ACLF. Ms. Carrie Ermshar, Carrington Senior Health Services and former Executive Director of the Tennessee Association of Homes and Services for the Aging (TNAHSA) which represents aging service providers across the state, stated she had the opportunity when working with TNAHSA to be exposed to the grayness and challenges within the regulations. Ms. Ermshar explained she went back to the statute and the definition of assisted living which states the purpose of assisted care living facilities services is to promote the availability of residential alternatives to institutional care and for persons who are elderly and have disabilities to be cared for in the least restrictive and home like environment appropriate to enhance the person s ability to age in place. She emphasized the need with aging in place to look at the individual needs of the residents and not to box in methods for administering of medications which really prevents the aging in place philosophy and those individuals defining assisted living as their home environment was meant to be. Ms. Ermshar stated that TNAHSA highly recommends that the State leave the rules as is with the understanding that individualized care plans must be in place for those residents that need it. She states she has had many scenarios brought to her 2

3 attention for medication administration such residents with Parkinson unable to open bottles/packaging, but able to partake in all other aspects of ACLF life. Ms. Ermshar medication references to quadriplegic patients as well as Alzheimer s/dementia patients in ACLFs and the need of supervisory staff. Aging in place forces ACLFs and the state to be more flexible and at the same time not taking responsibility away from the providers and licensed caregivers. The rules clearly states as long as the physician signs off on the medical needs and the resident needs can be safely and effectively met in that facility that person can stay in an ACLF. It is up to the providers, the family, the partners within that care plan as well as the surveyors when they come into the facility to work together when they view the individualize care plan and make sure it is being met. Ms. Gloria Densmore, administrator for home care for Alive Hospice, gave examples of what she deals with on a day-to-day basis. Ms. Densmore stated the challenges that she has seen in assisted livings in relation to hospice and medication administration is the care plan is significantly important. The care plan is how we provide care to patients in an assisted living and in their home. From a surveyor s standpoint, you have a care plan as a start point and then proceed to medication administration. ACLFs usually have a licensed professional in their building as well as med techs and some other ACLFs have neither of these. Generally, what happens from a hospice standpoint is these people are brought together, family and professionals, within the ACLF and we discuss what s going to happen. A patient is doing quite well then at some point they decline and it s not only medication administration and who is going to be there to assist the patient, but also how we are going to get the patient out of the building in 13 minutes. Lock boxes have come into use in ACLFs where there is an agreement between hospice, the caregivers in the building, and the family on how medication is to be managed. There have also been challenges for hospice. For instance, hospice has been called in the middle of the night to come and give medication, this routine for emergency care as part of the conditions of participation to receive crisis intervention for patients who are actively having issues. The collaboration between families, assisted living, and the patient if able to administer medication is just like any home setting whether it s an ACLF, nursing home or independent living there has to be some type of agreement that says okay the patient can administer medication and when the patient no longer can administer the medication then you have to pull all pertinent people together, the family and caregivers in the facility and discuss how this patient s plan of care is going to be managed in regard to medication. Ms. Densmore indicated she desired the ACLF regs to stay as is. Patti Killingsworth, Assistant Commissioner of TennCare, spoke to the subcommittee regarding the regulations and was supportive of them remaining as they are and wanted to make sure that any interpretation will not make this benefit less accessible to people and make it less likely that people can age in place while trying to make ACLFs more flexible when the resident s needs change. She understand there are times when skilled care is required and a nurse is needed but this is still that resident s home and a family member should be able to do in their ACLF home as they would be able to do in their own home if all of that is planned out as part of the plan of care. This is not an institution but a community based setting and it needs to be treated that way. 3

4 Mr. Marshall commented even though the assisted care living facilities are the resident s home these facilities are licensed and there is still some level of responsibility and liability to the State. Ms. Killingsworth agreed, but indicated the State does license and regulate services in this type setting but the State should not reach into what a family caregiver can do for a family member. The State would be reaching beyond the bounds of the scope of that licensed entity s responsibility. She feels that the State doesn t have the authority or a need to license what individuals and family members can do in their own home. Mr. Marshall asked clarification from legal counsel on this matter. Ms. Layden emphasized that in the ACLF regulations this is a mandate to assure that medication shall be self-administered in accordance to the resident s plan of care. She reminded the subcommittee that in paragraph (b) of the regulation it states medication must be administered by a licensed professional and according to the resident s plan of care. The authority s requirement is it has to be a licensed professional and this is mandated by legislation the Board does regulate these types of facilities. Patti Killingsworth reiterated her thought that the Board does not have the right to regulate what the patient or family members do in the facility, but to regulate the services provided by the ACLF. Carrie Ermshar re-emphasized the importance and role of care plan in medication administration and service provision to ACLF residents. Patients and situations vary and the care plan is to be individualized for this reason. Mr. Marshall wants clarity and direction for surveyors on this issue such policies and procedures as hospitals have for how to handle medications brought in from home. Ms. Kara Holston, Executive Director of Rose Terrace-Emeritus Senior Living, Memphis, requested clarification from the subcommittee and the Department regarding medication administration by medication aides. What can they do legally as far as pushing through the bubble pack, placing medications on table, in hands, or in a cup? Ms. Holston stated they had been told different things and been cited for different things and she wanted to make sure their medication aides are doing the right thing legally. Mr. Marshall stated according to the ACLF regulation (32) self-administration of medication is assisting in reading labels, opening dosages packaging, reminding residents of taking their medications and observing the resident in accordance to the plan of care as long as it is according to their plan of care and you have a policy in place. Audience members were adding comments and responses to Ms. Holston s question. Luke Gregory sought response from the Department. Ms. Reed did not feel comfortable with that statement due to the need for consideration of the Board of Nursing Standards of Practice and what this may state about administration of medication. Mr. Gregory responded to Ms. Holston that the State could not respond to her question without more clarification. 4

5 Ms. Linda Jennings, Director of Clinical Services for the Tennessee Health Care Association (THCA), stated to the subcommittee that THCA felt that the assisted living facility rules clearly outline self-administration of medications. As such, THCA feels the rules also clearly state that medication administration must be done by licensed personnel. If a caregiver is taking the medication out of its packaging and placing it in a resident s hand this would be medication administration because it s a direct application of a single dose of medication to a resident s body which clearly falls outside the definition of self-administration. To look at it differently, if a paid unlicensed caregiver in any other health care facility took that action the facility would be cited for improper administration of medication. Ms. Jennings confirmed THCA s position is the current ACLF rules and regulations are self-explanatory. Ms. Martha Gentry on behalf of Assisted Living Federation of America (ALFA), Tennessee Chapter, stated ALFA supports all that has been presented and feels the existing rules and regulations are flexible enough. It is felt the discussion of the role of the patient care plan and the existing definition of self-administration is adequate. Luke Gregory summarized all participants in the subcommittee discussions and summarized their position statement that the rules should stand as written. He also indicated direction would be obtained from the Board of Nursing on the term administration. Mr. Gregory asked for input from the Board of Nursing representative if present, no response and input from surveyors on their issue with the current rule language. Mr. Vincent Davis, Director of Health Care Facilities spoke on behalf of the surveyors. He stated this issue medication administration was initially brought before the Board in January in the context of three (3) different scenarios. Mr. Davis presented each again to the subcommittee and asked in these three scenarios if self-administration or administering medication was occurring? There were different opinions by the surveyors in regards to these scenarios so they were brought to the Board for guidance. Ms. Pam Donahue, Director of Nursing, LPN, Stones River, Murfreesboro, explained that resident assistants do assist on a daily basis with the residents medications. The assistants go in and help open the pack that is pre-packaged and ordered by the physician, observe the resident taking the medication and make sure the medicine and review record is exactly what is in the medicine pack. Ms. Donahue questioned the role of sitters in the facility and administration of medication primarily for hospice residents. Mitzi Maddox once again spoke regarding the training of family in the administration of medications in the home. She stated the ACLF is the home and if it s a part of the Home and Community Based Service then the patient should be allowed to age in place. The family or sitters are pulled in if staffing is not available just as would occur in the patient s home. These services fall under the plan of care as dictated by the regulations. Ms. Theresa Cole, LPN, Director of an ACLF in Cordova, TN. She has been an administrator in two communities in the last 5 years and the other being in Memphis, TN. 5

6 Ms. Cole recalled the experience of inconsistencies with surveyors regarding selfadministering of medication. At one facility, they are cited and at the other facility there are no citations yet both were doing the same thing, the same way regarding selfadministration. Ms. Cole stated they do have policies in place but they had concerns with the inconsistencies and the information they had received regarding medication administration by patients and the documentation requirements. With further discussion amongst the subcommittee, attending industry members, and Department staff regarding self-administration of medication, administration of medication including family members and caregivers administering in assisted care living facility, the subcommittee came to the decision that the consensus regarding the rules and regulations are they fine as written and any interpretation of the role of other providers including the family would be addressed in the plan of care. The subcommittee s responsibility from this meeting and from the information received the conclusion is to propose a statement that would be an interpretative guideline which should include the core statement around the plan of care. Due to time constraints for two (2) subcommittee members, a second meeting is needed to be able to complete the task at hand. The subcommittee acknowledged appreciation for everyone s suggestions and invited everyone back to the next schedule meeting that will be announced at a later time. The meeting was adjourned. 6