Policy Manual sample

MDT Home Health Care Agency, Inc. POLICY ON VERIFICATION OF SELF-ADMINISTERED MEDICATIONS 1. New Patient Situations When the patient is under medical care on admission, prescription and non-prescription medications are to be reviewed with the patient and checked with the medical orders and/or referral; if no discrepancies are found, the nurse does not need to verify the current medication regimen with the patient's physician. If there are discrepancies between the referral and what the patient is taking, the nurse is to telephone the physician for clarification and will document this contact on the patient's record. The nurse will obtain written orders to verify the clarification. 2. Ongoing Patient Situations If the nurse has assessed that the patient or primary caretaker is reliable and has good memory retention, changes in medications do not have to-be verified with the physician. In such instances, the documentation contained in the record must give evidence of patient/family reliability and good memory retention. If patient or primary caretaker is not reliable, all medication changes must be verified by the physician. 3. CNA/Home Health Aides assisting with self-administered medication, must receive a minimum of 2 hours of training (which can be part of the 40 hour home health training), prior to assuming this responsibility. Training must cover state law and rule requirements with respect to the assistance with self-administration of medications in the home, procedures for assisting the patient /resident with self-administration of medication, common medications, recognition of side effects and adverse reactions and procedures to follow when patient/residents appear to be experiencing side effects and adverse reactions. CNA/home health aide Supervision of self-administered medication in the home limited to: obtaining medication container from the storage area for the patient, ensuring that the medication is prescribed for the patient, preparing necessary items such as juice, water, cups, spoons to assist patient in the self-administration of medication, remain the patient that is time to take the medication as prescribed, and observing the patient self- administering the medication. Also the CNA/home health aide may open and close the medication container or tear the foil of prepackaged medications, assist the patient/resident in the self-administration process, such as steadying of the arm, hand, or other parts of the patient’s body so as to allow the self-administration of medication, assist to the patient by placing unused doses of solid medication back into the medication container. A licensed health care professional shall inform the patient, or the patient’s caregiver that the patient may receive assistance with self-administered medication by an unlicenced person, and he/she must give consent for this arrangement. Home Health Agency - - Skilled Professional Services D-55