No violation of the Nursing Practice Act occurs when a certified medication technician, who does not hold himself out as a nurse licensed to practice in Missouri, provides care in an Adult Day Health Care Program that is also an Associated Adult Day Health Care Program, so long as the care associated with a licensed long-term care facility is restricted to the administration of medication, excluding injectables other than insulin.

DEPARTHENT OF SOCIAL SERVICES: NEDICAL TECHNICIANS: m.JRSES: No violation of the Nursing Practice Act occurs when a certified medication technician, who does not hold himself out as a nurse licensed to practice in :t-Jissouri, provides care in an Adult Day Health Care Program that is also an Associated Adult Day Health Care Program, so long as the care associated \vith a licensed long-term care facility is restricted to the administration of medication, excluding inject- abies other than insulin. May 14, 1984 OPINION NO. 14-84 Barrett Toan, Director Department of Social Services Broadway State Office Building Jefferson City, Missouri 65101 Dear Hr. Toan: This opinion is in response to your question: r r7 . ¥_i~-- ;~:~~·~. "·: . l ~ f L.,' :·, . 1 11 ..... .,_..,... __ . Is it a violation of the Nursing Practices Act for a certified medication"' technician who is not licens·ed as a professional or practical nurse to provide care, with periodic moni- toring by a licensed nurse, to persons in an Adult Day Health Care Program, as specified at 13 CSR 40-81.126? 13 CSR 15-11.010 (17) defines the phrase "Certified Medica- tion Technician" as follows: A certified medication technic ian srtall mean a nursing assistant who has completed a course in medication administration approved by the Division of Aging. Under Section 19R. 082 .1, P.Stvro Supp. 1983, anyone who is hired to 'vork as a nursing assistant in a skilled nursing or intermediate care facility must complete a nursing assistant training program approved by the Department of Social Services. Section 198.082.2, RSHo Supp. 1983, further defines "nursing assistant" to include: Mr. Barrett Toan [A]n employee, including a nurse's aide or an orderly, who is assigned by a skilled nursing or intermediate care facility to provide or assist in the prov1.s1.on of direct resident health care services under the supervision of a nurse licensed under the nursing practice law, chapter 335, RSMo. . .. The first question which must be answered is whether the care which a certified medication technician would provide under 13 CSR 40-81.126 falls within the scope of practical or profes- sional nursing as defined by Sections 335.016(7) and (8), RSMo 1978. Therefore, it is necessary to examine the types of acts which 13 CSR L:-0-81.126 would authorize a certified medication technician to perform. The types of care are described as follows beginning at (3)(H).8 thereof: 8. Observation. The health, functional and psycho-social status of each recipient shall be observed and documented by the licensed nurse and/or certified medication technician in the recipient's record at least monthly. In the case of the certified medica- tion technician the licensed consultant nurse must review and summarize, at least monthly, the notes on ·each recipient's health status. Therapy services provided must be summarized in the recipient record and progress noted at least monthly. Notes shall be made immedi- ately of any accident, injury or illness and emergency procedures taken;~ 9. l1edical consultation and treatment. The licensed nurse, certified medication tech- nl.cl.an and/or nurse consultant shall com- municate with each recipient's physician to report observed changes in health status, including reaction to medicine and treatment, and to obtain current medical recommendations regarding such items as diet, treatment and medications. Ordered medical services shall be recorded, signed and dated by the physi- cian; * * 10. Nursing services. A licensed nurse or certified medication technician with a nurse consultant shall be available at all times during the program's daily operating -2- Mr. Barrett Toan hours. Nursing services must be provided in accordance with the particular needs of each recipient and must include the following: A. Supervision of the administration of medication as prescribed by the recipient 1 s physician; B. Coordination of the development of the recipient care plan; C. On-going monitoring of each reci- pient's health status; D. Maintenance-therapy treatment as recommended by a therapist, and which has been prescribed by a physician; and E. Coordination among the recipient, his/her family, and program staff members of orders from the recipient's physician. 13 CSR 40-81.126(3)(H)l2.B and .C state: B. Medication may not be administered without a written order signed by a licensed physician. Injectable medications may only be given by a licensed nurse. A certified medi- cation technician who has been trained by the 1 icensed nurse may give .,insulin injections. Hedications are to be d'istributed by the licensed nurse and/or certified medication technician. The licensed nurse and/or certi- fied medication technician assigned the responsibility of medication distribution shall complete the procedure by personally preparing the dose, observing the act of swal- lowing oral medicines, and recording it in the recipient's record on a medication sheet; c. If a reaction to medications is observed by the licensed nurse and/or certi- fied medication technician, the recipient's physician shall be called immediately. If contact cannot be made with the personal phy- sician, emergency medical procedures shall be followed; The scope of the practice of practical and professional nursing is defined in Sections 335.016(7) and (8), RSMo 1978, as follows: -3- Mr. Barrett Toan (7) "Practical nursing" is the perfor- mance for compensation of selected acts for the promotion of health and in the care of persons who are ill, injured, or experiencing alterations in normal health processes. Such performance requires substantial specialized skill, judgment and kno·wledge. All such m .. rrsing care shall be given under the direc- tion of a person licensed in this state to prescribe medications and treatments or under the direction of a registered professional nurse; (8) "Professional nursing" is the per- formance for compensation of any act which requires substantial specialized education, judgment and skill based on Y~owledge and application of principles derived from the biological, physical, social and nursing sciences, including, but not limited to: (a) Responsibility for the teaching of health care and the prevention of illness to the patient and his family; or (b) Assessment, nursing diagnosis, nursing care, and counsel of persons who are ill, injured or experiencing alterations in normal health processes; or (c) The administration of medications and treatments as prescribed by a person licensed in this state to prescribe such medi- cations and treatments; or (d) The coordination and assistance in the delivery of a plan of health care with all members of the health team; or (e) The teaching and supervision of other persons in the performance of any of the foregoing. [Emphasis in original; revisor's note omitted.] Initially, we are assuming that the certified medication technicians will be performing the acts in question in exchange for compensation. vlith that assumption in mind, we conclude that the acts described in the rules as acts which may be performed by a certified medication technic ian fall within the scope of prac- tical or professional nursing. For example, observing a patient for signs of reaction to medication would fall within "selected -4- Mr. Barrett Toan acts for the promotion of health and in the care of persons who are ill, injured, or experiencing alterations in normal health processes. 11 Section 335.016 (7), RSNo 197 8. Such observation also appears to fall within "[a] sses sment, nursing diagnosis, nursing care, and counsel of persons who are ill, injured or experiencing alterations in normal health processes. 11 Section 335.016(8)(b), RSMo 1978. See Sermchief v. Gonzales, 660 S.U.2d 683 (Mo. bane 1983). - Having concluded that the acts which· may be performed by a certified medication technician under 13 CSR 40-81.126 include acts within the scope of practical or professional nursing, as defined in Section 335.016(7) and (8), RSMo 1978, the next issue is v1hether or not a certified medicat,ion technician is exempt from Section 335.076.3, RSMo 1978,11 by virtue of Section 335.081(2), RSMo Supp. 1983, "\vhich states: So long as the person involved does not represent or hold himself out as a nurse licensed to practice in this state, no provi- sion of sections 335.011 to 335.096 shall be construed as prohibiting: * * * (2) The services rendered· by techni- cians, nurses' aids or their equivalent trained and employed in public or private hospitals and licensed long-term care facil- ities except the services rendered in licensed long-term care facilities Shall be limited to administering medication, excluding inject- abies other than insulin; This exemption clearly covers certain acts of technicians performed in certain types of health care facilities. The type of facility in which the technician v.rill perform the acts 1.n question determines whether or not the acts of the technician will be exempt. In your question you have specified only that the care will be provided in an Adult Day Health Care Prqgrarn. 13 CSR 40-81.126(1) (G) defines the term "Free-Standing Adult Day Health Care Program" as: l/ Section 335.076.3, RSMo 1978, states in part: No person shall practice or offer to practice professional nursing or practical nursing in this state for compensation . . . unless he has been duly licensed under the provisions of sections 335.011 to 335.096. -5- Mr. Barrett Toan A program. of adult day health care services which does not share staffing or licensed space or any physical components of space, equipment, furnishings, dietary, security, maintenance or utilities utilized in the pro- vision of service with any hospital, licensed intermediate care facility or skilled nursing facility. 13 CSR 40-81.126(1) (H) defines the term·- "Associated Adult Day Health Care Program" as: An adult day health care program \vhich is connected physically with a licensed long-term care facility or hospital but has separate designated space for an adult day health care program which is above their licensed space requirement for their residents. An as so- ciated adult day health care program may share in part, staff, equipment, utilities, dietary and security with the connected long-term care facility. Recipients in the adult day health care program may participate with the resi- dents of the long term care facility or hospital for some activities and programs. The conclusion which v1e reach from these definitions is that a certified medication technician v1ho provides care in an Adult Day Health Care Program, may be providing care in a hospital, in a licensed long term care facility~, or in some other type of facility which is neither a hospita1 nor a licensed long-term care facility. Section 335.081 (2), RSMo Supp. 1983, only pro- vides an exemption for certain services of technicians which are performed in hospitals or licensed long-term care facilities. Therefore, it is a violation of the Nursing Practice Act for a certified medication technician to provide nursing care in an Adult Day Health Care Program which is a Free-Standing Adult Day Health Care Program. If the Adult Day Health Care Program in which the certified medication technician is providing care is in a public or private hospital, the services provided by the certified medication technician are exempt from the Nursing Practice Act. Therefore, as long as the certified medication technician does not hold himself out as a nurse licensed to practice in l'1issouri, see Section 335.081, RSt·tfo Supp. 1983, the certified medication tech- nician will not be in violation of the Nursing Practice Act by provic1ing nursing care in an Adult Day Health Care Program in a hospital. -6- Mr. Barrett Toan If the Adult Day Health Care Program is in a licensed long- term care facility, only certain types of services are exempt under the Nursing Practice Act. In a licensed long-term care facility, the only nursing care which may be provided by a certi- fied medication technician without violating the Nursing Practice Act is the administration of noninjectable medication and the administration of insulin. Generally, this restriction conforms to 13 CSR 40-81.126(3) (H)l2.B, quoted supra. No other forms of nursing care may be provided by the certified medication techni- cian in the Adult Day health Care Program ~n a licensed long-term care facility without violating the Nursing Practice Act. CONCLUSION It is the op~n1on of this office that no violation of the Nursing Practice Act occurs when a certified medication techni- cian, who does not hold himself out as a nurse licensed to practice in Missouri, provides care in an Adult Day Health Care Program that is also an Associated Adult Day Health Care Program, so long as the care associated with a licensed long-term care facility is restricted to the administration of medication, excluding injectables other than insulin. Very truly yours, JOHN ASHCROFT At torn.~y General .,. -7-