W. Va. Code R. § 64-60-7 - Minimum Policy and Procedure Requirements for AMAP Programs

7.1. Policy Development and Approval Procedures.

7.1.1. The facility or single specific agency must develop policies and procedures for the implementation of the AMAP program, including, but not limited to, the minimum requirements within the provisions of this rule and the applicable provisions of W. Va. Code §§ 16-50-1, et seq., and §§ 16-5AA-1, et seq.

7.1.2. An authorized registered professional nurse shall participate in development and revision of AMAP program policies and procedures.

7.1.3. Facilities are not permitted to implement an AMAP program prior to the authorizing agency's approval of the AMAP program's policies and procedures.

7.1.4. Facilities or single specific agencies must submit proposed policies and procedures to the authorizing agency at least 60 days prior to the proposed implementation date of the AMAP program.

7.1.5. Facilities or single specific agencies with approved policies and procedures must review the policies and procedures at least once a year for any needed revisions or updates.

7.1.6. Facilities or single specific agencies with approved policies and procedures must submit any proposed changes to the authorizing agency 30 days prior to implementing proposed changes.

7.1.7. The authorizing agency may require alterations to the facility's or single specific agencies policy when a determination is made that the delegated tasks are not being monitored or performed in a safe manner or under unsafe conditions.

7.1.8. Failure by the facility or single specific agencies to develop and implement an effective policy and procedure for the AMAP program, as required by this rule may result in penalties, including the suspension or denial of participation in the AMAP program.

7.2. Personnel Records. Requirements for documentation in the personnel record must include at least the following related to the AMAP program:

7.2.1. Applications for participating as an authorized registered professional nurse;

7.2.2. Training records for all AMAP training received by the AMAP and the authorized registered professional nurse;

7.2.3. Competency testing attempts and successful completion;

7.2.4. Monitoring and supervision reviews by the authorized registered professional nurse;

7.2.5. Retraining records for the AMAP and authorized registered professional nurse;

7.2.6. Any disciplinary action taken related to AMAP or authorized registered professional nurse performance in carrying out duties and responsibilities; and

7.2.7. For nursing homes, proof of one year of full-time experience as a nurse aide in a long-term care facility.

7.3. Resident medical records. Requirements for documentation in the resident medical record must include at least the following related to the AMAP program:

7.3.1. Each facility shall maintain a medication administration record (MAR) for each resident, to be maintained as a part of the permanent medical record. This record must be available for review by the authorized registered professional nurse, representatives of the authorizing agency, and other authorized persons. This record shall include:

7.3.1.a. The name of the resident to receive the medication;

7.3.1.b. Listing of each medication, to include at least the following:

7.3.1.b.1. The name of the medication;

7.3.1.b.2. The dosage to be administered;

7.3.1.b.3. The time and frequency for administration;

7.3.1.b.4. The diagnosis for which the medication was ordered;

7.3.1.b.5. The route of administration;

7.3.1.b.6. The date the medication was ordered; and

7.3.1.b.7. The date the medication is to cease, if indicated on the physician's order;

7.3.1.c. Legible identification of the name and title of the individual who administered the medication;

7.3.1.d. Name and phone number of the physician;

7.3.1.e. A listing of allergies the resident may have;

7.3.1.f. Space for each day of the month to record the administration of medication;

7.3.1.g. Any special instructions for handling or administering the medication, including instructions for maintaining aseptic conditions and appropriate storage;

7.3.1.h. Written, signed, and dated orders by the physician or authorized health care professional shall be present in the medical record for each medication to be administered, including over-the-counter medications. Verbal orders may only be taken by a registered professional nurse or licensed practical nurse and must be countersigned by the physician or authorized health care professional within the designated timeframe not to exceed 14 days; and

7.3.1.i. Written, signed, and dated verification of physician or authorized health care professional collaboration in the decision to allow medication administration shall be present in the medical record of each resident.

7.3.2. Each facility must maintain a treatment administration record (TAR) for each resident, to be maintained as a part of the permanent medical record. This record must be available for review by the authorized registered professional nurse, representatives of the authorizing agency, and other authorized persons. The TAR must include:

7.3.2.a. The name of the resident to receive the health maintenance task or medication to be administered;

7.3.2.b. Listing of the specific health maintenance task or medication to be administered to include at least the following:

7.3.2.b.1. Instructions for performing the specific health maintenance task or medication to be administered;

7.3.2.b.2. The time or intervals at which the health maintenance task or medication to be administered is to be administered or performed;

7.3.2.b.3. The date the health maintenance task or medication to be administered is to begin; and

7.3.2.b.4. The date the health maintenance task or medication to be administered is to cease, if indicated on the physician's order;

7.3.2.c. Any special instructions for performing health maintenance task or medication to be administered, including but not limited to, instructions for maintaining aseptic conditions and appropriate storage;

7.3.2.d. Legible identification of the name and title of the individual who performed the health maintenance task;

7.3.2.e. Name and phone number of the physician;

7.3.2.f. A listing of allergies the resident may have;

7.3.2.g. Space for each day of the month to record the performance of the health maintenance task or medication to be administered;

7.3.2.h. Written, signed, and dated orders by the physician or authorized health care professional for each authorized health maintenance task to be performed or medication to be administered. Verbal orders may only be taken by a registered professional nurse or licensed practical nurse and must be countersigned by the physician or authorized health care professional within the designated timeframe not to exceed 14 days; and

7.3.2.i. Written, signed, and dated verification of physician or authorized health care professional collaboration in the decision to allow health maintenance tasks or medication to be administered by an AMAP must be present in the medical record of each resident.

7.4. Monitoring and Supervision. Requirements for the monitoring and supervision of the AMAP by the authorized registered professional nurse employed or contracted by the facility shall include at least the following:

7.4.1. The authorized registered professional nurse or designated registered professional nurse must be available onsite or on-call 24-hours per day, seven days per week, to respond to questions or concerns related to any aspect of the delegation process from the AMAP. In an emergency situation, a physician or physician extender may respond to questions or concerns related to any aspect of the delegation process from the AMAP;

7.4.2. The number of AMAPs, residents, and sites the authorized registered professional nurse will supervise, including their location;

7.4.3. The number of residents and sites for which the AMAP will perform delegated tasks;

7.4.4. The furthest distance the authorized registered professional nurse will be expected to travel to a site and between sites; and

7.4.5. Periodic and ongoing observation and supervision, not less frequently than quarterly, of the AMAP performing delegated tasks to ensure quality of care is provided to the individual and to identify any areas for further training and technical assistance.

7.4.6. Video conferencing for completing observation and supervision may be used when an emergency situation, including inclement weather or other declared emergency limits the authorized registered professional nurse from being on-site. Video conferencing permitted in these limited situations when:

7.4.6.a. It offers the same access for observations and communication with the AMAP as face-to-face interaction;

7.4.6.b. It protects the privacy and confidentiality of the resident;

7.4.6.c. It is not used for consecutive monitoring events; and

7.4.6.d. Used to provide more frequent monitoring and supervision than the required quarterly events.

7.5. Multiple Site Coverage. The facility shall have policies and procedures for the training and approval process for AMAPs to perform authorized and permitted delegated tasks at different sites within a specific agency.

7.6. Review of Physician Orders. The facility shall have policies and procedures for ongoing review of the prescribing practitioner's orders, MARs, TARs, and medication labels for consistency and documentation of such; and ongoing review of medication error reports and medication related incident reports by the authorized registered professional nurse and the prescribing practitioner.

7.7. Withdrawal of Approval. The facility shall have policies and procedure for the withdrawal of approval for an AMAP to perform authorized and permitted delegated tasks, including the reasons for the withdrawal of approval and the date of the withdrawal.

7.8. Communication. Requirements for communication and monitoring between the AMAP and the authorized registered professional nurse shall include at the following situations:

7.8.1. Any change in a resident's condition;

7.8.2. Any discrepancy between the pharmacy label and the MAR;

7.8.3. Any discrepancy between the physician or health care provider's order and the TAR;

7.8.4. Any deviation from the six rights of medication administration;

7.8.5. Any doubt or question about the performance of any delegated task;

7.8.6. Any resident refusal of the delegated task;

7.8.7. Any change in the prescribing practitioner's order;

7.8.8. Any need for the disposal of medications; and

7.8.9. The type and frequency of additional monitoring and training in response of these occurrences will be determined by the authorized registered professional nurse.

7.9. Medication Delivery System. The authorized registered professional nurse must provide AMAPs with the possible risks, side effects, and contraindications for each medication prescribed to the resident. The medication delivery system policy used by the facility must include at least the following:

7.9.1. The type of medication packaging;

7.9.2. The method of medication storage;

7.9.3. How the six rights of medication administration are implemented;

7.9.4. The process for resident identification;

7.9.5. The process to prevent drug diversion;

7.9.6. The disposal method used;

7.9.7. The procedures used to handle, monitor, protect, store, and track controlled substances; and

7.9.8. The infection control prevention and mitigation program, including, but not limited to, universal precautions, use of personal protective equipment, and medical aseptic practice.

Notes

W. Va. Code R. § 64-60-7