HD11 - Expansion of the Use of Medication Aides into Nursing Homes [HJR 90 (2010)]


Executive Summary:
Background & Authority

The 2010 General Assembly adopted House Joint Resolution 90 (See Appendix A) directing the Department of the Health Professions to study the advisability of expanding medication aides into nursing homes. This study was conducted by the Regulatory Research Committee of the Board of Health Professions on behalf of the Department.

Major Findings

1. Medication administration is a regulated nursing activity.

Medication administration by unregulated personnel poses a risk of harm to patients. Medication administration is a regulated nursing activity usually performed by RNs and LPNs and denied to CNA and other personnel. In 2004, the Commonwealth discovered that unregulated personnel were administering medications in Assisted Living Facilities (ALFs) and created a new regulated occupational class with lesser qualifications-the Registered Medication Aide (RMA)-to perform this nursing task in ALFs. The current study examines whether a reduction in qualifications for this regulated activity is appropriate in nursing homes.

2. The RMA program in ALFs is new in Virginia, and there are questions about its appropriateness.

The current Virginia RMA program does not include some of the key provisions used to ensure patient safety in other states. These include a requirement for supervision by licensed clinicians and more stringent eligibility requirements. Although we only have one year of data, RMAs currently had a high discipline rate of 12 per 1,000 registrants for FY2010. The program has not been in place long enough to determine if the program as it exists is appropriate for ALFs.

3. Medication administration in Nursing Homes is categorically different than medication administration in ALFs.

Although there is some overlap in their populations, nursing home patients tend to suffer from more physical and cognitive deficiencies that prevent patient participation in administration and patient communication of errors or adverse reactions, etc. A significant number of patients in nursing homes are recovering from surgery or other acute conditions and do not have stable drug regimens. In addition, nursing home patients tend to take more medications and have more complex drug regimens. These factors increase the potential for error in administration and increase the need for professional evaluation and assessment skills.

4. Medication error rates in nursing homes are "unacceptable."

A 2007 report by the Institute of Medicine described medication error rates in nursing homes as "unacceptable." The report suggests that 12 to 14 percent of doses are administered incorrectly and that there are over 800,000 preventable Adverse Drug Events in nursing homes in the US annually. The report suggests that wrong-time errors are rampant in nursing homes due to the length of medication passes.

5. Organizational factors are the main causes of medication errors.

Poor communication, fragmented medication use systems, nurse interruptions and staffing shortages are some cited causes of medication errors. There is little evidence on medication error rates by credential, and none of it suggests a difference in medication error rates by credential. One study found a significant correlation between nurse interruptions and error rates. However, if a facility has not made the necessary staffing or organizational investments necessary to lower medication errors, staff qualification requirements may be the last line of defense for patients.

6. Medication aides may help reduce interruptions and wrong-time errors in specific circumstances by increasing overall staffing; however, increased employment of LPNs would also address these concerns.

Medication aides may help to relieve administration errors caused by interruptions and wrong-time errors caused by staff shortages. Improvement would only occur if medication aides are used to increase overall staffing ratios.

7. Medication aides may be used as a substitute for nurses.

Virginia currently has no staffing ratio requirements in nursing homes. Although evidence is sparse, one national cross-sectional study suggests that nursing facilities with lower overall staffing levels are more likely to employ medication aides.

8. In the short-term, Virginia does not suffer from a shortage of LPNs; however, some rural areas may face a shortage.

Virginia is not projected to suffer from a shortage of LPNs and may have a slight surplus over the long-tem. Recent economic conditions have caused a pause in a looming RN shortage; however, this is expected to be temporary and an overall shortage of nurses (LPN & RN combined) is projected. As with all health professions, uneven distribution often causes local shortages-particularly in l1lral areas.

9. Twenty states allow medication aides to administer medications in nursing homes.

Twenty states allow medication aides to administer medications in nursing homes. Many of these states have separate eligibility, training and registrations for medication aides in nursing homes. Most allow medication aides to administer PRN (as needed) medications. Some allow them to administer by tube or rectally/vaginally while other states specifically prohibit this practice. Some states specifically prohibit administration of Schedule II drugs or narcotics.

10. Most states require nurse delegation or supervision of medication aides in nursing homes.

Virginia is in the minority in that it does not require nurse delegation or supervision of RMAs in ALFs. By requiring nurse delegation, states ensure that nurses retain responsibility for medication administration.

11. Certified Nurse Aide (CNA) credentials are a widely-recognized eligibility standard for medication aides in nursing homes.

In most states that allow medication aides in nursing homes, only CNAs are eligible. The National Council of State Boards of Nursing includes a CNA eligibility requirement in its model curriculum for medication aides regardless of setting. Comments from the public and from a stakeholder roundtable suggest that this would be an assumed pre-requisite for medication aide training for nursing home practice in Virginia.

12. States use a variety of other eligibility requirements.

Some states require experience as a CNA-up to two years in some cases. Some states require that CNAs have experience with a specific population. Some states require that each applicant be employed by the facility in which he intends to administer medications or to have a recommendation from a facility.

13. Training requirements vary; the NCSBN has created a model curriculum.

Training requirements vary based on a variety of factors, including the specific eligibility requirements of each state, the nature of the registration (broad or facility-type specific) and the scope of practice of medication aides. Training requirements range from 20 hours to 140 hours of specific medication aide training and usually include a significant clinical portion. The National Council of State Boards of Nursing has developed a model curriculum based on a thorough job analysis of medication aides in all settings. The model curriculum includes 60 hours of didactic training and 40 hours of clinical training.

14. ALFs face the prospect of losing their medication aide workforce; facilities may be reluctant to train new medication aides if they cannot ensure a return on training investments.

Virginia's ALFs have spent the last few years creating medication aide training programs and training close to 4,000 RMAs to meet new requirements. Just over half of RMAs are also CNAs and the proportion of RMAs who are also CNAs appears to be increasing. Unless specific measures discourage it, ALFs may lose a significant proportion of this workforce to nursing facilities should they be allowed to use medication aides. Over the long term, facilities may be reluctant to invest in training and training programs unless they can secure a return on that investment. Public investment in education is the usual solution to this common problem.

Recommendation

At its September 29, 2010 morning meeting, the Regulatory Research Committee recommended against expanding medication aides into Nursing Homes. This recommendation was adopted by the Board of Health Professions (seven in favor, three opposed and one abstention) at its meeting the same day. During discussion, Committee and Board members considered the findings and added the following comments. They were concerned about high medication error rates in nursing homes currently, when only licensed nurses are permitted to administer medication. Those opposed to the recommendation indicated that a pilot program may be beneficial; however, the majority opined that no demonstration project was warranted at this time. Greater experience with RMAs in Virginia and elsewhere may lead to a different conclusion, but concerns about patient safety at this time preclude piloting.