Mr Douglas and memebers of the Virginia Board of Nursing,

   I have been a nurse for almost 10 years and 5 of those years have been in assisted living as an Assistant Administrator, Director of Nursing and Staff Educator. I applaud the new regulations in consideration to register our med aides. They need to understand the seriousness of thier role and there has to be some accountability for negative actions. I have had the responsibility of teaching medication aide classes for many years to my employees. I enjoy this and feel that I have done an excellent job of producing med aides who are capable and confident. I am deeply disturbed that this may no longer be something that I am able to do. While I agree with the proposed legislation, I do not agree that an LPN who has been more than capable of teaching this course and has done so for years, will now only be allowed to be a secondary instructor dealing with the skills portion of the class. I feel that there should be some way of "Grandfathering" current LPNs who are instructors. I take pride in how I conduct my classes and encourage students to continue their learning after leaving my class. The current curriculum has no Pharmacology, but I ask my students to start learning about the medicines that they administer on a daily basis, and even have inservices about medications they should be aware of.

Since Medication Aides are limited in what medications they administer, I feel curent LPNs who have been trained, should be allowed to continue training as primary instructors. I would be more than happy to take some type of advanced teaching class that will focus on the new curriculum. Please don't take good teachers who can and know how to relate to their students away from this class simply because they don't have an RN after their name. Let's work together and continue putting knowledgeable Medication Aides into the system.

                                                                   Thank You,

                                                           Rebecca S. Mils, LPN

This regulation assumes a "one size fits all" Assisted Living Facility as licensed by the Department of Social Services. In fact, some ALFs are NOT typical in that they:

*do not work with an increasingly older and frailer population

*do not have a high turn over of residents

*do not mirror a nursing home population

For our community (and you note I say community, NOT facility) this new regulation will be cumbersome, unnecessary and costly. We work with a stable group of remarkably healthy adults with mental retardation who come to live most of their adult lives together with us. The care providers are full-time live in VOLUNTEERS, people who choose to make their home here with the residents...In fact we call them co-workers to stress the reality that we are more alike than we are different.

We currently provide the required 32 hour course in medication administration. The changes proposed for the registration of medication aides will impose an undue hardship on our community. For example, in our community the 8 hour insulin module is unnecessary. Not one of our coworkers takes insulin and never has in 35 years. Clearly if someone developed diabetes and needed insulin injections, it would be appropriate to teach those working with that individual. But to propose 8 hours of instruction for every Volunteer on how to administer something that has never been a prescribed medication in the history of our community would be costly and time consuming and inappropriate.

Even some of the more benign aspects of this regulation are inappropriate in our community. One of the regulations requires that Medication Aides who are still in training wear a badge stating that they are a Student-in-Training. The Volunteers who come to our community make this their home and live side-by-side the coworkers in the same household. It would be inappropriate for them to wear a badge in their own homes. Assuredly, every one in the house knows who is living with them, who is new, who has been here for years.

There needs to be room for Variances to this proprosed regulation for situations where it is clearly inappropriate.

This regulation will have enormous- and unnecessary- consequences for our community. Ours is a stable group of healthy adults who live most of their adult lives at Innisfree. The care providers are live in volunteers who choose to make their homes with the residents.We currently provide these full-time volunteers with the required 32 hours of medication administration training. The changes proposed would impose non-value added requirements which would impact the very quality of life in our community (e.g., the eight hour insulin module which would undoubtedly be appropriate for a volunteer working with a diabetic resident, if we had one, but not for all volunteers in our community, etc.). Somehow this regulation seems to assume that assisted living facilities share certain features completely in common. Ours does not. We hope this regulation can be rewritten to achieve the goals it aims to and should achieve without imposing penalties on those it does not, or should not, aim to adversely impact. Thank you.

Our son requires medication, is developmentally disabled and lives at Innisfree Village. He lives an amazing and fulfilled life engaged in a variety of therapeutic activities in a wonderful community along with Staff, Volunteers and other developmentally disabled co-workers.

While he needs help with the dispensing of his prescription drugs, this is accomplished professionally and safely under a very well controlled and supervised system using trained aides.

Although the goal of the proposed regulations is sound, there needs to be flexibility allowed so as not to unnecessarily impact the quality of life of this active community.

The proposed regulation should allow Variance if necessary to accomodate the special circumstances of communities such as Innisfree Village.

Forcing major increases in training will unnecesarily increase costs, negatively  affect the viability of the community and impact the ability of the volunteers and staff to provide all of the other therapeutic activities provided. We simply request that the special circumstances of this great community are respected so that the superb quality of life afforded the residents is not jeopardized by regulations inappropriate to their needs.We would of course expect and welcome the structuring of appropriate variances approved by Innisfree and the HHS professionals.

I'm the recruiter, trainer and supervisor for the volunteer staff at Innisfree Village. We currently have adults with disabilities (coworkers) from the age of 24 until 84 and they lead active and productive lives here in our community. Our volunteers are dedicated individuals of all ages and many backgrounds who live and work in the home with our coworkers. One of the new regulations that seems especially unnecessary and inappropriate concerns requiring us to wear a name badge while living in our own homes.  I started as a volunteer 14 years ago and lived and worked alongside most of our residents at some point. In 1992 we were required to take a  Medication Training that lasted half a day and now we are required to take a 32 hour training. An increase from a couple of  hours was important and necessary. Adding 8 more hours for something we have never used in 35 years of operation (giving insulin), seems to me an added burden in terms of time and money. We would much rather spend our time in getting to know each individual, whether working in the gardens, the bakery or making dinner together at home.

The current regulations seem more than adequate to serve our community's needs for safe and healthy lives. Please do not paint all ALF's with one brushstroke.

          What seems like a simple, elegant solution – requiring medication aides to wear badges – is for the Innisfree community a bizarre intrusion. Our population is not the frail elderly who may see three different shifts of caregivers who may not be around for the long term. Our caregivers live and work with our residents (whom we call co-workers to emphasize that they are not clients or patients) and get to know them very well.

 

          The living conditions in individual houses are like people’s homes. Would a mother or father wear a badge? Most of our caregivers are volunteers who choose to live and work in a life sharing community. In the thirty-five years that I have been associated with Innisfree, as president and as a parent, it has been the sense of community among everyone who resides here that has above all sustained Innisfree’s uniqueness.

 

          To you, a badge may seem like a minor matter in the face of compelling problems of large-scale institutions. To us, it is symptomatic of the Procrustean problem -  stretching or shortening every way of life to fit one model of an assisted living facility. We don’t claim to be the only or the right model. We ask that you give us and other groups the breathing space to enrich the community of assisted living facilities and the lives of the people we serve.

 

 

                                                          Barbara J. Fried

My name is Linda Krongaard-DeMong, RN, MSN. I am a retired C-ANP ( certified adult nurse-practitioner). I have been closely involved with Innisfree Village for the past 30 years. For many of those years I worked with a physician providing the majority of the villagers (both the co-workers with metal disabilities and the volunteers who live and work with the co-workers) with their primary health care. In all of those years, I cannot remember any medication errors. The volunteers are very consciousnesses. Before you add more and more requirement on the volunteers that assist with medication, you have to understand that Innisfree is not an assisted living facility. If it belongs under any title, it’s a home or a village for 36 functional mentally handicapped adults. They live in a village on 500 beautiful acres up next to the Blue Ridge Mountains. They live no more than five co-workers to a house with two or three volunteers who assist them in any way necessary and supervise when necessary. The volunteers always supervise medication just as a family member would do. They are like family member who are sharing their lives together with the co-workers. The co-workers have been taking most of the same medicines over their adult life. The volunteers diligently help with all daily living activities, including meals, cleaning, and workstations, which include bread making, gardening, weaving and woodwork. To add new requirement to the volunteers is in my estimation frankly unneeded and an unnecessary burden that may undermine the perfect harmony that is Innisfree Village, a life sharing community where volunteers and co-workers live and work together to make this wonderful village a home. It is a home, not an assisted living faculty. It is a place where those with mental handicaps can live and be productive in a normal, quiet, non-medical setting. I hope this explains my reasons that I hope reconsider the policy on more medication requirement or add a waiver to Innisfree Village. Please do not require an additional medication requirement, which will not help the co-workers and might undermine the conscientious volunteer system that has works so well in allowing these mentally challenged adult co-workers to live a productive life.

I strongly support the regulation of medication aides, by the Board of Nursing. My concern is the proposed renewal fee for medication aides. If this is in addition to the CNA certification renewal, it is not appropriate. This will act as a deterrent for qualified CNA candidates to further their education and take on additional reponsibilities. I have been in nursing for over 30 years and was skeptical regarding the role that unlicensed personnel would have, administering medications. I now know that, with proper training and monitoring, these personnel are quite professional and dedicated, when fulfilling their duties regarding medication administration. In fact they are diligent regarding their documentation and take their role very seriously.

I urge you to reconsider the fees, as outlined in the proposed regulatory changes.

The intent of these proposed regulations is admirable, but the effect on a community like Innisfree could be devastating.  This seems to clarify why classifying Innisfree in the same category as nursing homes just doesn't work, in so many ways.  Innisfree Village is a treasure and should be protected and championed as a model life-sharing community - I don't know of another quite like it in the U.S. - and cumbersome regulations like these could weigh it down beyond its ability to comply.  I ask that you, please, before adding another layer of regulation, come visit Innisfree Village.  It seems clear that what is missing is a separate category which would apply to a village where people are not in a medically-fragile state at the end of their lives, but rather living, thriving, working, playing, eating, dancing - in short, sharing their lives.

As a practicing physician heavily involved in the care of individuals residing in a variety of assisted living settings, I would like to voice my strong opposition to the proposed legislative changes. This legislation fails to take into account the broad diversity in assisted living settings that currently exist in Virginia. The legislation is clearly geared toward facilities that care for the oldest, most seriously ill individuals who are on multiple medications, including insulin. I understand the rationale for some of the regulations as they apply to this type of setting, though agree with one of the other respondents that there is no reason an experienced LPN could not oversee the training of medication aides. More important, I have cared for a number of individuals at the Innisfree Village in Crozet, Virginia for over a decade. I cannot call this a "facility" because it is truly a village, a community, serving the needs of mentally handicapped individuals who are generally in excellent physical health. The community is served largely by volunteers who have received appropriate training, in accordance with existing law, and have provided truly outstanding care to my patients. As Ms. Carolyn Ohle has noted in a separate public comment, not ONE "co-worker" (we do not call them residents, as that would belie their superb functional status) has been on insulin in the past 35 years. You could easilty amend the legislation to require insulin training if there is, in fact, an individual ON insulin. Another example: I have an octogenerian under my care at Innisfree, who has been there much of his adult life - he is on NO REGULAR MEDICATIONS. Many of the co-workers are physically healthier than the average Virginia citizen. Finally, it would be a great disservice to make the volunteers in a community such as Innisfree wear name badges - if you were being cared for by your family members at home, would you want your loved ones to be forced to wear name badges? That is effectively what you are asking of the volunteers at Innisfree. This is an intimate community, where coworkers and volunteers know each other intimately. It would only serve to place an "institutional" veneer on what is currently a loving community, where the care of the villagers is nothing short of remarkable.

In summary, it simply does not make sense to make assisted living settings such as Innisfree Village (and I suspect there many others in a similar situation) adhere to such inflexible and "one size fits all" regulations. This legislation MUST be reworded to allow more flexibility and exceptions for the variety of assisted living settings in Virginia. Imposing such restrictions will be sufficiently costly to imperil the financial solvency of such facilities, and I assure you that these negative consequences FAR outweigh the potential benefits in terms of patient safety - if we lose a place like Innisfree, countless individuals will be deprived of the best care and nurturing available in the world. I would strongly recommend that the crafters of this legislation spend a day working and living alongside the co-workers and volunteers of Innisfree Village. Not only will it allow you to revise this overly proscriptive legistlation to reflect the broad diversity of assisted living settings in Virginia, it will give you a glimpse of a model of care that should be disseminated throughout the state, nation, and world.

The deadliest weapon we, medication administrators have , are the medications we give, if we do not have sufficient information of the drugs' action or reaction.  Insulin should receive more attention in this course module because our country in seeing newly diagnosed diabetics in alarming numbers. The population that medication aides work with are usually geriatric and/or mentally impaired.  This does not mean that any body with little training should give them medications.   The person that gives a medication is the last safety net between and the patient, therefore appropriate training is required. We, society, should be their advocates and ensure that proper training is mandated for those that administer medications to them.  A name badge should always be worn by a caregiver as a form of identification.  The "Nurse's uniform" is nolonger restricted to the nursing profession, so it does not, in any form, identify the med aide or nurse. Wouldn't any pt want to know the name and title of the person taking care of them in the hospital or other setting?  It creates some sense of ease to know who is taking care of a person. 

The Virginia Dept of Health Professions has held a high standard for anybody that is certified in any of the health fields in this State and should strive relentlessly to maintain that.  Any training that increases the safe practice of health care employees should be made a requirement for certification in that field.

Thank you

kadi

 

 

I am writing to offer an Operator's perspective on what the effects of the proposed Med Aide regulations will be.  As President of Commonwealth Assisted Living, I oversee the operation of five Assisted Living facilities with approximately 300 beds.  We have over 200 employees, a majority of which are nurse’s aides, CNAs, and Medication Technicians.

 

As I am sure you are aware, our biggest problem in the long term care industry is the availability of labor.  There are simply not enough trained individuals for all of the positions that are available.  Three major forces drive the shortage of Med Techs:

 

1.      There are not enough classes available.  While our pharmacy offers monthly classes, they are often booked up months in advance.  Technical schools offer the class, but typically only once a semester.

2.      The cost of the classes deters staff from taking them.  Again, our pharmacy offers an inexpensive training, but we have trouble getting our staff in these classes.  Currently, technical schools are charging around $400 for tuition. 

3.      Aides cannot afford to miss the current 32 hours of work without pay.  Due to the high turnover in the industry, facilities are reluctant to pay employees for their time off, and due to staffing shortages, they generally end up paying overtime in order to provide the employee with the time off for training.

 

While well intentioned, we do not feel that the proposed regulations are going to achieve the desired results, and further, they will have a negative impact on the industry.  First, they will shrink an already undersized labor pool.  It appears that nothing has been done to address the availability of classes.  An increase in required training hours will serve to increase tuition that already has affordability issues, an increase in the economic cost to the student (who must miss work to attend the class), and increase of economic costs to the facility in the form of overtime while the staff is training, as well as increased labor costs inherent of a further shrunken labor pool.

 

The most frequent medication errors in our facilities fall into two categories:

 

1.      Med Techs do not follow up to document the effects of a PRN medication one hour after it is given.

2.      Holes in the MAR, where a medication is given but not documented on the MAR.

 

It is our opinion that our top medication errors are not education related, but rather they are related to management and oversight, and are a result of an inherently flawed documentation system.  In one instance, we replaced all of the Medication Technicians in one facility with LPNs, who receive more training than that proposed in the new regulations.  The result was disappointing in that med errors did not go down, and the nurses did not participate in the care of the resident.  The forms are simply hard to read and document, and they are subject to human error.

 

We support solutions that will make a real difference in the quality of care our residents receive.  We support:

 

1.      A state registry for Medication Technicians similar that currently in existence for CNAs.  This will improve accountability and serve to keep unqualified aides out of the position.

2.      Leaving the curriculum at 32 hours and requiring state licensing agencies to ensure that the class is available monthly at a low cost basis.  This will serve to improve two major problems, accessibility and affordability.

3.      A requirement for all Aides to take the refresher course on an annual basis, bringing them up to date on any technical changes to the industry.

4.      The mandatory computerization of the Medication Administration Record.  This technological change is long overdue and would virtually eliminate our two most prevalent medication errors.  The technology is available, and if it were used on a widespread basis, would come down to a price that is affordable. 

 

We support the idea of improving the care our residents receive.  However, we do not feel that the proposed regulations are going to have a positive impact on our residents or our industry.  The effect of more hours will reduce our labor pool, drive up wages, and not have a positive effect on resident care.  From an operator standpoint, we would rather invest in the solutions above, which we feel would work and would improve the services we offer. 

 

I look forward to working with all interested parties in the future to improve the quality of care in the Assisted Living industry.

The proposed regulations regarding the education and training of medication aides is convoluted and does not address what happens to aides who already hold a certificate of training approved by the Board of Nursing. Many or these individuals have already received refresher courses in medication administration. The proposed regulations appear to support the training of a medication aide to the training of an LPN without ample opportunity to recieve the training nor compensation comparative with an LPN salary. My experience of 12 years indicate that the problem with errors in medication administration is not in the education or training of staff, but rather in mechanisms in place in the facility to reduce error such as supervision, the ratio of staff to resident per shift, and hourly wages. The present education and training for medication aides is sufficient for the population we serve. The proposed regulations would cause cruel  and undue hardship to aides who presently work in difficult situations with little pay. The reading of the proposed regulations would lead one to believe that effective July 1, 2008 a majority of aides who presently administer medication in Assisted  Living Facilities will be fired and replaced by LPNs.