1. Medication Management: MANAGING THE MEDICINE CABINET ON CENTER MARCH 9, 2016 SHANNON BENTLEY, RN GARY STROKOSCH, MD LIZZY DROBNICK, MPH, MA

2. Goals Provide students’ medications safely and within the scope of your state’s professional practice laws Ensure safety and monitoring precautions are in place Teach students self management skills within the boundaries of maintaining student safety Have medication readily available just like a medicine cabinet 2

3. DISCLAIMER* The National Office is taking an interest in medications on center, and there will be more information shared in the near future Professional practice laws vary tremendously from state to state These laws apply to Pharmacy, Nurse, Physician, Dentist, and other healthcare professions Know your state’s practice acts, as well as other applicable statutes and regulations Practice within your scope of care 3

4. Pharmacy Laws 4

5. Cover pharmacies, pharmacists, pharmacy technicians, pharmacy practice, and medication management Statutes or Acts Written laws passed by legislative body Broad scope Regulations or Rules Written laws issued and adopted by executive agencies Provide the details to implement the statute Usually adopted through state board of pharmacy Both statutes and regulations are laws Slide adapted from ASHP 5

6. Pharmacy Laws Statute Examples Pharmacy Practice Act of the State of Illinois (State – Illinois) Controlled Substances Act (CSA) (Federal) Regulation Examples TITLE 68: PROFESSIONS AND OCCUPATIONS, CHAPTER VII: DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION, SUBCHAPTER b: PROFESSIONS AND OCCUPATIONS, PART 1330 PHARMACY PRACTICE ACT (State – Illinois) Title 21 United States Code (USC) Controlled Substances Act (Federal) 6

7. Rules and Regulations Agencies(2013) Light Purple – Division of Occupational Professional Licensing Yellow – Board of Pharmacy & Department of Licensing and Regulatory Affairs Dark Green – Board of Pharmacy & Division of Public Health Light Green – Pharmacy Examining Board Blue – Board of Regents Gray – Board of Pharmacy & General Assembly Blue – Board of Regents Turquoise –Board of Pharmacy Orange – Board of Pharmacy & Department of Health Dark Pink – State Board of Pharmacy & Department of Financial and Professional Regulation Light Pink - Department of Financial and Professional Regulation & Department of Consumer Protection Dark Purple – Board of Registration in Pharmacy 7

8. Pharmacy Laws: Key Lessons Both statutes and regulations are laws Your center must be aware of and in compliance with all laws So what? Why does this matter to me? I’m not a pharmacist? 8

9. Common Center Issues Does your center: Stock prescription medications for dispensing? Repackage medications for evening or weekend doses? Use bubble packs that, when broken apart, do not contain all of the labeling information? Allow residential or security staff to administer medications on evenings and weekends? Dispose of medications by throwing them in the trash or flushing them? Not dispose of medications after a student has left Job Corps? If you answered yes to any of these questions, your center may be violating your state’s pharmacy laws 9

10. State Pharmacy Laws State pharmacy laws include, but are not limited to: Dispensing Labeling Repackaging Monitoring and record keeping Administering Educating / Counseling (consumer medicine information) Disposing Please note that other laws, such as the Nurse Practice Act or Physician Practice Act, also cover administration and pharmaceutical management 10

11. Commonalities Between State Pharmacy Laws If state pharmacy law or federal law has stricter requirements on the same issue, the stricter requirement must be followed Practice laws outline information to be included on the label, although labeling differs greatly between states While physician or dentist dispensing is permitted in most states, it is often carefully regulated and restricted to samples or conditions of immediate need Some states require dispensing doctors to have a special permit or license, or they need to be registered with their state’s Board of Pharmacy Prescriptive authority varies widely by state and practitioner type; for example, clinical nurse specialists have prescriptive authority in 26 states 11

12. Did you know?: Example of State Pharmacy Laws No chain pharmacies allowed in North Dakota The North Dakota’s Pharmacy Ownership Law from 1963 states that only a licensed pharmacist or group of pharmacists can own and operate a pharmacy within the state All prescriptions are supposed to be submitted electronically in New York starting in March 2016 Federal institutions are currently exempt from this law, but please follow up with your regulatory agency in NY to confirm The 2005 federal Combat Methamphetamine Epidemic Act (CMEA) was established to regulate OTC pseudoephedrine (PSE) sales; but, Oregon and Mississippi have sticker state laws that classify PSE as a Schedule III substance, requiring a prescription 12

13. ROCA Examples: Concerns Example 1: For weekends, the nurses repackage medications on Friday afternoons into separate envelopes for each dose. The medications are in labeled envelopes with the date and time of administration written on the envelope. This violates state law as the envelope labels do not contain all of the required information. Example 2: LPNs in this state are not allowed to dispense or administer OTC medications in accordance with their practice act. However, the LPNs on center regularly dispense OTC medications to students. Example 3: When a student separates from the center and is not provided with their medication, the center keeps the medication on center and does not dispose of it, given cost concerns. Medication prescribed for a former student is then used for current students so the center does not have to purchase more medications. This violates state law. 13

14. ROCA Examples: Promising Practices Example 4: The center has a pharmacy license. Under state law, licensed nurses are allowed to dispense medication, and trained non-medical personnel are allowed to observe medication self- administration. Weekend medications are stored on an open medication cart, which is placed in the hallway of the locked HWC. A security staff member trained in medication self- administration opens the HWC and observes the students taking their medication. Example 5: All scheduled medications and most other medications are sent to the center in bubble packs. The center has a stock supply of some frequently used antibiotics that, under the CP’s direction, can be dispensed by the center nurse. State pharmacy act 65-1635 (c) permits this activity. 14

15. Assessing Compliance: PIN 15-27 Make sure you keep current copies of your pharmacy and nursing practice acts and applicable regulations According to PIN 15-27, each center must have printed copies of the pharmacy and nursing acts. It should be available for review by assessor(s) during an assessment Compliance will be reviewed during ROCA, and if a copy of the pharmacy act is not available for review, it will be cited as a concern under 6.12 R5: Professional Standards of Care: All center health staff and providers shall follow accepted professional standards of care and are subject to prevailing state laws 15

16. Medication on Center KEY INFORMATION FOR HWMS, WELLNESS STAFF, CENTER DIRECTORS, AND OTHER APPLICABLE STAFF 16

17. In the Health & Wellness Center 17

18. Managing Medication In the Health & Wellness Center New students’ medications should be brought to the Health and Wellness Center (HWC) to be logged in; evening doses should be made available for students if the HWC is closed Each student medication should have a medication administration record (MAR) to track medication and compliance Each student initially should come into the HWC daily for their prescription medications For psychotropic medication, the CMHC should collaborate with center physician and Health-and-Wellness staff on psychotropic medication monitoring of stable students and document monitoring in the SHR All prescription medications must be documented in the student health record via a center created medication administration (MAR)sheet with additional notes taken on the SF-600, Chronological Summary of Medical Care, if necessary All OTC medications must be documented on the SF-600 18

19. Controlled Substances Centers shall comply with all state and federal regulations regarding controlled medications Controlled substances include narcotics and psychostimulants Know the PRH requirements outlined in Chapter 6, 6.12 R6 Check your state pharmacy laws, state police and local pharmacies on the available ways to dispose of left over or expired medications Any miscounts or missing medications identified during the inventory shall be immediately reported to the Regional Office by the Center Director 19

20. On Center Outside the Health & Wellness Center 20

21. Personal Authorizations for Non-Health Staff Monitor students’ use of prescription medications Make available prescription medication for self-administration Make available over-the-counter medications and devices (e.g., Tylenol, Maalox, condoms) Obtain and record vital signs including: Temperature Pulse Respiration Blood pressure 21 Give basic first aid for major problems including: Cardio-pulmonary resuscitation Treatment of shock Control of bleeding Splinting or stabilizing of fractures Conduct alcohol testing based on suspicious behavior Call HWM or Officer of Day, who will contact RN or MD Call the RN or MD directly Send the student to the ER

22. Medication Management in Residential Living Prescriptions are packaged according to state laws Medication is made readily available like a medicine cabinet Students self-administer all medication Sign-out sheets must be used to monitor and track all medications that are made available to students All student prescription medications must be secured in a lock box in the residential advisor office RAs should not handle or administer any medication 22

23. Residential - Prescription Medication Observation Records MORs should include: 1) Student’s name at top 2) Place for student signature 3) Place for staff name 4) Place for staff signature 5) Date 23

24. Examples of Making Prescriptions Available Outside HWC Hours Example 1: Students have mailboxes with locks in HWC for weekend and evening doses. Trained security staff let students into the HWC where the student unlocks their own mailbox and self-administers their medication. Observation is recording on a Med Observation Record (MOR). Example 2: A filled and locked medication cart is set up in the HWC or Safety after hours and trained security staff makes the medication readily available for student self-selection. Observation is recorded on a MOR. Non-medical staff should only observe medication self-administration; non- medical staff should not administer medication 24

25. Examples of Making Prescriptions Available Outside HWC Hours Example 3: Medications are sent to residential in secure lock box. The RA opens, makes available, and observes the student self-administer their medication; this is similar to a medicine cabinet. Observation is recorded on a MOR. Example 4: Daily dosing made available during HWC open hours. Assigned nurse works evenings and weekends to make available individual dosing for all students on prescribed medications. 25

26. Managing OTC Supplies in Classrooms, Dorms, & Other Areas Process: Have a student sign-out sheet Student self-selects Goals: Help students learn to manage minor conditions Teach employability skills 26

27. Over-the-Counter (OTC) Sign Out Sheets for Dorms, Classrooms, & Other Areas Should include: 1. Slot for name of OTC medication 2. Place for student name 3. Place for student signature 4. Place for staff name 5. Place for staff signature 6. Date and time 27

28. First Aid Kits in Dorms and Classrooms Acetaminophen and/or Ibuprofen Tweezers Alcohol wipes Antiseptic hand cleaner Medical adhesive tape Sterile gauze (four inch squares are best) Elastic bandages Several sizes of adhesive bandages Insect bite swabs Triple-antibiotic ointment Hydrogen peroxide Bandage scissors Triangular bandages Instant cold packs Exam gloves Barrier device for CPR Important contact numbers- nurse on call, duty officer, emergency numbers, 911 28

29. Leaving the Center 29

30. Student Travel and Medications Prescription medications should be available to students when they travel on weekend pass or on break Travel packaging must comply with your state’s labeling laws Students may self-prepare their medications for travel in a travel-friendly container if it complies with state laws 30

31. Separated Students and Medications If a separation occurs when the HWC is open, all separated students should be provided with their medications when they leave If a separation occurs when the HWC is closed, students should be provided with their medications through: Mail: All prescribed medications should be sent overnight to the student if allowed by sending and receiving states’ laws Pharmacy in student’s home town: Call in an order for a supply until the student can see a new provider; this can be done by the CP, referred prescriber, or personal physician Communication is key between center departments to ensure Wellness is aware that a student has departing and medications can be made available when student leaves 31

32. Ideas for Medication Management on Center Disclaimer: The National Office is looking at medications on center, and there may be more coming out from them in the near future. For now, please be sure you know your state professional practice laws, and it is suggested each center have written medication policies to ensure the safe delivery of medications to students. 32

33. SOPs Each center is recommended to have the following SOPs: 1. Prescribed Medications 2. Controlled Substances 3. OTC Medications 33

34. Know the Statutes Example: A center discovered that in their state the center could get a limited pharmacy license with the CP named as the responsible professional. Under these circumstances, the nurse can act as a pharmacy tech under the supervision of the CP and dispense medications, as long as their CP is on center. They can also train residential advisors to administer medications under the supervision and training of the nurse and CP. SOPs have been written to describe these policies. The center invited a pharmacist to inspect their program and policies for consistency with state statutes. 34

35. SOPs Most center have no SOPs regarding the prescription, dispensing, and administration of OTC or prescription medications Although required in the disability program, NONE are currently required in the HW program, except for a rarely read instruction in PRH Change Notice 12-06 (Job Corps Health History Form) from Nov 26, 2012: “Each center should have an SOP for handling alert questions” It is suggested that each center have SOPs for medication management 35

36. Examples of Medication Management Language for SOPs Pre-packaged bubble packs or punch packs by local or mail order pharmacies Applying for pharmacy license (if applicable) to be able to dispense stock doses of certain medications, such as antibiotics Local pharmacies “take back” unused or expired medications to dispose of properly Utilizing local law enforcement that set aside several days a year for medication disposal Using mailboxes kept in locked area for prescription doses when HWC is closed with individual student keys; students self-administer doses Allowing students to self-package their medications for travel or weekend doses 36 Disclaimer: Laws vary by state; Be in compliance with your state and federal laws.

37. Example: Medicine Administration Record (MAR) 37

38. Example: Prescription Medication Observation Record (MOR) 38

39. Example: Controlled Substance Medication Observation Record (CMOR) 39

40. Over-the-Counter (OTC) Sign Out Sheet 40

41. Questions shall be answered in a forthcoming document. Please submit questions electronically via chat or email to be included in the Q & A document. Thank you! 41