ࡱ > > A = bjbj 8 y R - - - - - 4 a a a h T a . 9 9 9 9 9 x z z z z z z $ ' - - - 9 9 X - 9 - 9 x x 9 P[| a l d 0 $ & - 8 , : Documentation for Verification of Staff Authorized to Administer Medications (Rev. September 14, 2011)
This form can be used in two ways: 1) by the provider agency, to document for agency quality assurance and training purposes that a staff person is authorized to administer medications to specific individuals and/or 2) upon request of the Division of Developmental Disabilities Bureau of Quality Management (BQM) in response to cited deficiencies regarding medication administration.
Note: Complete one form for each staff for whom the agency is documenting and/or requesting authorization to administer medication. If required by BQM, submit completed forms with supporting documentation listed in Part B to Bureau of Quality Management via fax (217-782-9444) or mail (319 East Madison, Suite 4J, Springfield, IL 62701). Submission via email may also be an option. Call BQM at 217-782-9438 if you have questions. PLEASE PRINT INFORMATION BELOW:
Date:______________________________________ Agency Name:_____________________________
Staff Name:________________________________ Soc. Sec. No. (last 4 digits only):______________
Agency Contact:_____________________________ Contact Email:_____________________________
Agency/Contact Fax:_________________________ Agency Phone:_____________________________
Part A. PRINT Full Names of Persons to Whom this Staff Person will Administer Medications: (Attach additional pages, if neededif so, clearly indicate that the attachment is associated with this document.) 1. ______________________________
2. ______________________________
3. ______________________________
4. ______________________________
5. ___________________________
6. ___________________________
7. ___________________________
8. ___________________________
Part B. Information Needed: (Check each item provided and include documentation as noted.)
_____Proof of High School Education and Age of 18 or Older (copy of high school diploma or General Educational Development {GED} high school equivalency certificate recognized by Illinois State Board of Education; high school diplomas earned outside of the U.S. must be translated into English and have their U.S. equivalency verified); copy of birth certificate, passport, government-issued drivers license or ID as proof of age
_____Literacy Test (original {copyrighted}TABE or equivalent test must be maintained by agency, copy of TABE or equivalent test if submitting documentation to BQM; documentation must include, test, test version, employee name, date, name of test administrator and score which must indicate reading level of 8th grade or higher)
_____8-hour Medication Administration Course (copy of class roster with date of training, sign-in/sign-out by employee, instructors {RN Nurse-Trainer} name and course start/end times)
_____DHS Medication Test (copy of test completed by employee; test must be administered after the 8-hour medication administration course has been completed; include employees name, test date and score which must indicate score of 80% or higher)
_____Medication CBTA (copy of the CBTA for each person receiving services who will receive medication; date of initial CBTA or re-authorization must be within the last 12 months)
_____First Aid Certification (copy of current American Red Cross {ARC} or American Heart Association {AHA} card; official ARC or AHA class sign-in sheet will be accepted for 60 calendar days from date of class in lieu of card) Note: For instructors, evidence of ARC or AHA instructor credentials will be accepted.
_____CPR Certification (copy of current American Red Cross {ARC} or American Heart Association {AHA} card; official ARC or AHA class sign-in sheet will be accepted for 60 calendar days from date of class in lieu of card) Note: For instructors, evidence of ARC or AHA instructor credentials will be accepted.
_____Health Care Worker Registry (HCWR) Verification (copy of website printout with Social Security number verified; if not DD Aide, designation as a Certified Nurse Aide {CNA} on the HCWR or, if not on HCWR, documentation of satisfactory completion of the Direct Support Persons basic health and safety classroom curriculum and completion of basic health and safety on-the-job training) Note: Must successfully complete an approved DSP training program within 120 calendar days of hire.
______Nursing Assessment, inclusive of SAMA (Self-Administration of Medication Assessment) (Copy of assessment completed within past calendar year which includes signature of the same RN Nurse-Trainer who completed the Medication CBTA. The date of the signature by the RN Nurse-Trainer for the nursing assessment inclusive of the SAMA must be on or before the date of the Medication CBTA.
If a review by BQM is required, BQM will review the documentation submitted and a determination of approval or non-approval to administer medications will be faxed to the agency. Until the agency receives a notice of approval, the staff named above may not administer medications.
For agency administrative quality assurance or BQM use only
_______Meets requirements to administer medication to person(s) listed above.
_______Does not meet requirements to administer medications to person(s) listed above.
Reason(s):
Reviewed by: ____________________________________ Date: __________________
Division of Developmental Disabilities
Bureau of Quality Management
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