1. Can the Medication Technician draw up insulin?
The RN delegating nurse is the primary decision maker and is the only person who can determine whether insulin administration can be delegated to the CMT, including the drawing up of insulin. The DDA MTTP Training Program permits the RN to exercise judgment to permit delegating insulin administration (including drawing up of insulin) to a CMT. There was an error in the original DDA - MTTP manual, however, corrected information and replacement pages for the MTTP have been provided to each DDA RN who completed the RN, CM/DN Training Program. These replacement pages permit the RN, CM/DN to delegate drawing up and administration of insulin to the CMT
2. Can the monitoring of insulin pumps be delegated?
The monitoring of insulin pumps cannot be delegated because nursing judgmentand interpretation of the readings is required.
3. Can glucagon injections be given by the CMT?
In the event of a hypoglycemic emergency, a glucagon injection may be delegated to the CMT to administer, if essential requirements have been met. These requirements include, but are not limited to the following:
Current HCP order;
The glucagon injection must be prepared utilizing a single dose, self
contained, pharmacy dispensed kit with a subcutaneous needle;
The preparation procedure may not include the calculating or wasting of the dose (the kit must have the exact amount of medication and dilutant to be used);
Training on use of the glucagon kit;
Procedure for checking the expiration date of the glucagon kit;
Documentation of staff competency in medication preparation and injection technique (e.g., practice demonstration and ongoing competency checks);
Protocol/directions to include when to give the injection, and a check list of yes or no questions detailing the presence or absence of the signs/ symptoms of hypoglycemic reaction;
Emergency notification protocols; and,
Documentation of occurrence and administration.
4. Must the individual client’s vital signs be documented in the Initial Nursing Assessment and the 45 day Reviews?
Yes, the assessment and evaluation process should include blood pressure, pulse, respiration checks, and temperature.
5. What is required when an Automatic External Defibrillator (AED) is available?
If an agency has an AED available for use in the event of a cardiac arrest, the agency needs to have a policy addressing the use of the AED. Documentation of staff training in the use of the AED must be accessible and retrievable.
6. What is suggested for handling disposable/single use devices (SUDs) (e.g., Toomey syringes, etc.) at the agency level?
The use and reuse of Single Use Devices (SUDs) was discussed with Dr. Brenda Roup, PhD, RN, CIC, and DHMH Nurse Epidemiologist. The following DDA guidelines were developed by the DDA regional nurses with Dr. Rupp’s guidance.
- SUDs (e.g., Monojet 60cc syringes/Toomey syringes, etc) are sterile and intended for single use. However, SUDs may be reused, when appropriate, for Clean Procedures (e.g., Toomey syringes for tube feedings, etc.). When used for Clean Procedures each individual’s SUD must be washed in soap and water, then rinsed and dried. They must be stored individually in a clean, dust free environment; and the SUDs must be labeled with the date of opening and the individual’s name. The recycled SUD may be used for up to one week. After one week, a new SUD must be used. Feeding bags must be labeled with the date and time the bag was hung and with the initials of the staff person who hung the bag. Feeding bags need to be changed every 24 hours.
- The reuse of SUDs for Sterile Procedures may be done if the reprocessed SUDs meet the same standards used by the original manufacturer. The reprocessed SUD must be Sterile and as safe and as effective as it was when originally manufactured. If an agency reprocesses SUDs for Sterile use, the manufacturer’s guidelines for sterilization must be available for review.
- SUDs are considered durable medical equipment and procurement should be investigated with the individual’s insurance carrier.
7. Can the RN select and recommend the use of Over-the-Counter (OTC) topicals and mouthwashes?
There are many products that are available OTC that the RN may select and recommend for use. In addition, the Board has an educational document addressing the conditions that permit an RN to select and recommend the use of an OTC. In order for the RN to make recommendations on the use of the OTC the conditions referenced in the Board’s document must be complied with. The following examples are intended as a guide for the RN but are not all inclusive. The use of the OTC would be incorporated in the Client’s care plan and in the training for staff. Selection of the OTC’s and recommendations for use must be permitted by the agency’s written policies. Training must include all staff.
- Lotions/Moisturizers: OTC lotions/skin moisturizers may be selected and recommended for use by the RN as part of the NCP (e.g., aloe vera containing lotions for dry skin). Therefore, these lotions/skin moisturizers may be applied as directed by the RN by any unlicensed individual. Document the use of these OTC’s per NCP directions.
- Shampoos/Conditioners: OTC shampoos/conditioners, particularly for dandruff, may be selected and recommended by the RN as part of the NCP. Therefore, these shampoos may be applied as directed by the RN by any unlicensed individual. Document the use of these OTC’s per NCP directions.
- Soaps: OTC soaps may be selected and recommended by the RN based on the nursing assessment (e.g., dry skin, oily skin, acne, etc.). These directions should appear in the nursing care plan. Therefore, the use of these soaps may be applied as directed by the RN by any UAP. Document the use of these OTC’s per NCP directions.
- Sunscreens and Insect Repellants: Sunscreens and insect repellants may be selected and recommended by the RN as part of the NCP. Therefore, sunscreens and insect repellants may be applied as directed by the RN by any UAP. Document the use of these OTC’s per NCP directions.
- Mouthwashes: OTC mouthwashes may be selected and recommended by the RN as part of the NCP. Therefore, UAPs may assist an individual as directed by the RN in the use of mouthwash. Document the use of the mouthwash per NCP directions.
8. Does it matter if the Health Care Provider (HCP) renewing an order is not the same HCP who initiated the order?
Very often renewal orders in DD are signed by a HCP who did not write the original order. The implication for any HCP who signs renewal orders is that the HCP is responsible for the orders for which the HCP signs. It continues to be a “Best Practice” recommendation that a HCP within a designated sub-specialty sign for the medications specific to that sub-specialty. For example, the ordering and management of psychotropic medications is best handled by psychiatrists.
9. Is it a Maryland law that 911 must be called for a seizure lasting 5 minutes or longer?
There is no law requiring 911 to be called for a seizure. The DDA MTTP Training Program does however require that 911 be called for a seizure lasting 5 minutes or longer. One need not call 911 as stipulated in the DD-MTTP training program if a healthcare protocol for that DD-client is developed in conjunction with and signed by the HCP. The protocol would need to be specific and well documented.
10. How are medical wastes to be handled in the DD community?
The following guidelines were developed by the DDA regional nurses with Dr. Brenda Roup, PhD, RN, CIC, DHMH Nurse Epidemiologist; and, following review of COMAR 10.06.06 which defines medical waste. The following items may be placed in regular trash:
- Used gloves, gowns and masks;
- ventilator, and urinary drainage tubing;
- Containers used for draining urine;
- Dressings that are not saturated with blood or body fluids;
- Adult diapers containing urine and feces not visibly contaminated by blood; and,
- Any item that is not dripping with blood.
- For someone on isolation precautions, ONLY items considered “special medical waste” are “red bagged.” Special medical waste means “the article must be dripping with blood or other body fluids.”
11. Is there a requirement that the RN utilize the Health Risk Screening Tool (HRST)?
The HRST is not a required tool. However, it is highly recommended as a reliable tool that has been very effective in helping to identify individuals who may require an RN initial nursing assessment; or a nursing care plan; or nursing delegation of a nursing function.
12. Can an Epipen be administered by a NON-CMT staff?
An Epipen is an emergency intervention and anyone can be trained to administer it. The person does not have to be a CMT. Training documentation should be accessible and retrievable.
13. Do individuals attending a day or vocational program need a nursing assessment and a nursing care plan (NCP)? Is there a need for a nursing assessment and NCP if there is no nursing delegation?
Clients attending a day or vocational program should be screened by the provider agency to identify the need for nursing intervention. It is recommended that a formal screening tool, such as the HRST, or another professionally accepted health screening tool, be completed by a licensed nurse or other appropriate provider representative to make a preliminary determination of the need for:
- an initial nursing assessment
- nursing care plan (NCP)
- health education
- nursing delegation
When utilizing the HRST, the results, (along with the individual’s medical history), should be reviewed by the RN for a final decision as to whether or not a nursing assessment is indicated. Individuals with chronic health conditions, while not requiring on-site nursing delegation, may still require individual education. Therefore, the nurse may determine that there is a need to provide health teaching or counseling to the unlicensed care provider, employer, or client. Subsequently, the educational health instructions by the nurse may be supplemented by providing standardized information (see COMAR 10.27.11.06) via pamphlets, video, handouts, etc. It is recommended that educational instructions/directions be accessible to the unlicensed care provider and reviewed on a routine basis. This may be completed in collaboration with other interdisciplinary members (nutritionist, OT/PT, speech, etc). Training must be documented, accessible and retrievable.
14. Some day programs have chosen not to have a RN delegate medication administration in the program. How do we handle individuals who receive medications during the day or have other nursing needs?
- COMAR 10.22.02 A (1) states that in the development of the Individual Plan for
the Client (IP), the personal well-being of the individual client must be considered including “Receiving health care services that respond to the client’s needs...” and COMAR 10.22.02 A (5) “having one’s basic needs met.” The client’s healthcare needs must be assessed and if medications or other nursing interventions are needed, those services must be provided.
- If medications are prescribed for day time administration to a client at a day program (and the day rogram does not have a RN delegating to a CMT possible arrangements could include:
- Have the client assessed to determine if the client can be taught to self-administer
- Consult with the prescribing HCP to determine if the time for medication administration, or the form (long-acting vs. short-acting) could be adjusted.
- Investigate whether the delegating RN from the individual’s residential agency could either come to the day program to administer the medications.
- Explore an alternative day program to meet the needs of the client
- Regardless of what resources the day program has or does not have the client must have his/her healthcare needs met including medication administration.
15. Can an LPN take “On Call” responsibilities?
The LPN may not triage. The LPN may serve as “On Call” IF protocols are in place which specify disposition of common routine calls. The designated decision maker for all triage calls must be either an RN or MD.
16. When a nurse assumes a caseload as a delegating RN, what are his/her
responsibilities in assuming the previous nurse’s clients?
Consistent with the Standards of Practice for the Registered Nurse COMAR 10.27.09 the RN assuming care of the individual MUST perform an “initial” assessment on each individual in their caseload. In addition, the new RN,CM/DN assuming the caseload must review the individual’s care plan to assure the care plan is complete and accurate and to assure staff are aware of how to care for the individual.
17. When an individual is discharged from the hospital back to the provider agency what is the status of the orders for medications and treatments that were in place prior to the hospitalization?
At the time of discharge from the hospital, all orders for medications/treatments must be re-ordered by the HCP. If medication and treatment orders for the client are to be continued as they were at the time of the admission to the hospital, an order authorizing the continuation of all pre-hospital orders must be written. For example, “resume previous medication and treatment orders”.
18. When an individual client is discharged from the hospital, is there a requirement that the individual client be seen by the RN within 24 hours of discharge?
There is no regulation that specifies that a RN must see an individual client upon discharge from a hospital. However, under COMAR 10.27.11.03 D, when delegating a nursing task, the nurse shall “make an assessment of the patient’s nursing care needs before delegating the task”. In addition, the RN Standards of Practice COMAR 10.27.09 (I)(1) states the RN may delegate nursing tasks to individuals who are competent to perform the nursing tasks. The RN is accountable for practicing nursing in compliance with all Board statutes and regulations and exercising reasonable prudent judgment. The clinical status of the client, the reason for the hospital admission, and the discharge orders and instructions for the client’s care -will dictate the timeliness with which the RN needs to see the client. An example may be – a client returns to the agency at 7PM after having a bowel resection and hospital stay of 10 days with orders for tube feedings. A prudent nurse would assess the client for bowel sounds before delegating tube feedings or delegating medication administration through the G-Tube.
19. Is there a 30 day grace period for the completion of the CMT recertification process?
Yes, the MBON permits a 30 day grace period for the renewal of the CMT certificate beyond the expiration date of the CMT’s certificate. For example, the certificate expires February 28, 2007, then the CMT has until March 28, 2007 to complete the renewal process (including submission of the online clinical update and the renewal form).
20. When a CMT is expired on the MBON website and repeats the 20-hour MTTP class, what is the process for renewal?
The “expired” CMT contacts the Maryland Board of Nursing (MBON) at 410-585-1918 and requests a renewal application. The CMT gives the renewal application to the RN, CM/DN approved to teach the 20 Hour CMT training program. After completing the training program and the renewal application, the renewal application is sent to the MBON with the required renewal fee and a Class List. It is recommended that a copy be retained for the agency’s record. It will take approximately 30 days for the updated information to appear on the MBON website. This information should be verified by the RN/agency’s designee by checking the MBON website. The “expired” CMT does not complete a second initial application form.
21. When a CMT, whose original CMT training was done under a different discipline (School Health, DJS, or Assisted Living), is employed by a DD agency, what training is the DD agency responsible for providing?
When a CMT trained in another Board approved CMT program, is hired by a DD agency, it is up to the agency RN’s discretion to determine what training will be necessary for the new CMT employee to safely function as a CMT in the DD agency. While it is not required that the CMT repeat the entire DDA-MTTP, the delegating RN must ensure that the CMT has received training that is specific to the DD population and the employer’s policy/procedures (e.g. high risk drugs, common disease process, regulations applicable to DDA etc). Training documentation must be accessible and retrievable.
22. Can the newly trained medication technician administer medications prior to receiving their certification as a CMT?
The medication technician may work up to 60 days following the medication technician course completion. If the MT does not receive notification of certification within 30 days of submission of the application, the MBON should be contacted at 410-585-1918 or 410-585-2051.
23. What is the procedure that the RN Trainer should follow in submitting information to the Board for the MT Training Program when a student reports a past criminal offense?
Applications for MT certification along with the Class List are to be submitted in the following manner:
- The students who have answered “no” to all disciplinary questions should be submitted together as a separate class, by sending a Class List with their applications.
- Any group of students who have answered “yes” to any of the disciplinary questions should be submitted together as a separate class, by sending a separate Class List with their applications.
- For example, there is a class of 15 students, 12 answered “no” to the discipline question and 3 answered “yes”. The instructor should prepare 2 Class Lists. For the 12 that answered “no” to the discipline questions, a Class List should be prepared and sent to MBON, along with applications. For the 3 that answered “yes” to the discipline questions, a Class List should be prepared and sent to MBON, along with applications.
- Any questions regarding disciplinary issues should be directed to the MBON at 410-585-1936. Questions pertaining to other CMT issues should be directed to the MBON at 410-585-1918 or 410-585-2051.
24. Is there a special procedure to be followed when a CMT is repeating the DDA-MTTP training and it is not time to renew the CMT certificate?
If the person is repeating the training at the request of the delegating nurse or the employer, (for example, errors in medication administration and it is not time to renew the CMT certificate), no information is sent to the MBON. The information is simply placed in the individual’s personnel folder, etc. If the individual can not be remediate and their performance as a CMT does not meet safety standards then a complaint may need to be filed with the Board. The complaint form is available on the Board’s web page at www.mbon.org