(D) Medication Orders.

1. (1) The school nurse shall ensure that there is a proper medication order from a licensed prescriber which is renewed at the beginning of each academic year and as clinically necessary. A telephone order or an order for any change in medication shall be received only by the school nurse. Any verbal order must be followed by a written or electronic order within three school days. Whenever possible, the medication order shall be obtained, and the medication administration plan specified in 105 CMR 210.005(E) shall be developed before the student enters or re-enters school.

   1. (a) In accordance with standard medical practice, a medication order from a licensed prescriber shall contain:

      1. 1. the student's name;
      2. 2. the name and signature of the licensed prescriber and business and emergency phone numbers;
      3. 3. the name, route and dosage of medication;
      4. 4. the frequency and time of medication administration;
      5. 5. the date of the order;
      6. 6. a diagnosis and any other medical condition(s) requiring medication, if not a violation of confidentiality or if not contrary to the request of a caregiver or student to keep confidential;
      7. 7. specific directions for administration.

   2. (b) Every effort shall be made to obtain from the licensed prescriber the following additional information, as appropriate:

      1. 1. any student-specific side effects, contraindications and adverse reactions to be observed;
      2. 2. any other medications being taken by the student;
      3. 3. the date of return visit, if applicable.

2. (2) Special Medication Situations.

   1. (a) For short-term medications, i.e., those requiring administration for ten school days or fewer, the pharmacy-labelled container may be used in lieu of a licensed prescriber's order. If the school nurse has a question, they may request a licensed prescriber's order.
   2. (b) For "over-the-counter" medications, i.e., non-prescription medications, the school nurse shall follow the Board of Registration in Nursing's Advisory Ruling 92-05: Medication Administration of Over the Counter Drugs.
   3. (c) For medications administered under a standing order, the school nurse shall follow the Board of Registration in Nursing's Advisory Ruling 9324: Accepting, Verifying, Transcribing and Implementing Medication Orders. Unlicensed school personnel can only administer a medication under a standing order that is specific to an individual patient (with the exception of an emergency rescue opioid antagonist) and under the delegation model.

   4. (d) Investigational new drugs may be administered in the schools with:

      1. 1. a written order by a licensed prescriber;
      2. 2. written consent of the caregiver; and
      3. 3. a pharmacy-labelled container for dispensing. If there is a question, the school nurse may seek consultation and/or approval from the school physician to administer the medication in a school setting.

3. (3) The school nurse shall ensure that there is a written authorization by the caregiver which contains:

   1. (a) the caregiver’s printed name and signature and phone number;
   2. (b) a list of all medications the student is currently receiving, if not a violation of confidentiality or contrary to the request of the caregiver or student that such medication not be documented;
   3. (c) approval to have the school nurse or unlicensed school personnel designated by the school nurse administer the medication;
   4. (d) persons to be notified in case of a medication emergency if the caregiver is unavailable.

(E) Medication Administration Plan: The school nurse, in collaboration with the caregiver whenever possible, shall establish a medication administration plan for each student receiving a medication. Whenever possible, a student who understands the issues of medication administration shall be involved in the decision-making process and their preferences respected to the maximum extent possible. If appropriate, the medication administration plan shall be referenced in any other health or educational plan developed pursuant to St. 1972, c. 766 the Massachusetts Special Education Law (Individual Education Plan under Chapter 766) or federal laws, such as the Individuals with Disabilities Education Act (IDEA) or Section 504 of the Rehabilitation Act of 1973.

1. (1) Prior to the initial administration of the medication, the school nurse shall assess the student's health status and develop a medication administration plan which includes:

   1. (a) the name of the student;
   2. (b) a medication order from a licensed prescriber, which meets the requirements of 105 CMR 210.005(D)(1);
   3. (c) the signed authorization of the caregiver, which meets the requirements of 105 CMR 210.005(D)(3);
   4. (d) any known allergies to food or medications;
   5. (e) the diagnosis, unless a violation of confidentiality or the caregiver or student requests that it not be documented;
   6. (f) any possible side effects, adverse reactions or contraindications;
   7. (g) the quantity of medication to be received by the school from the caregiver;
   8. (h) the required storage conditions;
   9. (i) the duration of the medication order;
   10. (j) the designation of unlicensed school personnel, if any, who will administer the medication to the student in the absence of the school nurse, and plans for back-up if the designated personnel are unavailable;
   11. (k) plans, if any, for teaching self-administration of the medication;
   12. (l) with caregiver permission, other persons, including teachers, to be notified of medication administration and possible adverse effects of the medication;
   13. (m) when appropriate, the location where the administration of the medication will take place;
   14. (n) a plan for monitoring the effects of the medication;
   15. (o) the school nurse has final decision-making authority for the provision of medication administration in the case of field trips and other short-term special school events, which may include nursing staffing, delegation of medication administration, or a combination of nursing staffing and delegation of medication administration.

(F) Developing Procedures for Administration of Medications.

1. (1) The medication program manager shall develop procedures for the administration of medications which shall include the following:

   1. (a) A procedure to ensure the positive identification of the student who receives the medication;
   2. (b) A system for documentation and record-keeping which meets the requirements of 105 CMR 210.009.
2. (2) The medication program manager shall develop a system of documenting observations by the school nurse or unlicensed school personnel and communicating significant observations relating to medication effectiveness and adverse reactions or other harmful effects to the student’s caregiver and/or licensed prescriber;
3. (3) The medication program manager shall develop and implement procedures regarding receipt and safe storage of medications in accordance with 105 CMR 210.008;
4. (4) The medication program manager shall develop procedures for responding to medication emergencies, i.e., any reaction or condition related to administration of medication which poses an immediate threat to the health or well-being of the student. This includes maintaining a list of persons, with their phone numbers, to be contacted as appropriate, in addition to the caregiver, school nurse, licensed prescriber and other persons designated in the medication administration plan. Such persons may include other unlicensed school personnel, the school physician, clinic or emergency room staff, ambulance services and the local poison control center;

5. (5) The medication program manager shall develop procedures and forms for documenting and reporting medication errors. The procedures shall specify persons to be notified in addition to the caregiver and school nurse, including the licensed prescriber or school physician if there is a question of potential harm to the student. A medication error includes any failure to administer medication as prescribed for a particular student, including failure to administer the medication:

   1. (a) within appropriate time frames;
   2. (b) in the correct dosage;
   3. (c) in accordance with accepted practice; and
   4. (d) to the correct student.
6. (6) The medication program manager shall develop procedures to review reports of medication errors and take necessary steps to ensure appropriate medication administration in the future.

(G) Delegation/Supervision. When a School Committee or governing body, in consultation with the Board of Health where appropriate, has registered with the Department of Public Health and authorized unlicensed school personnel to administer medications, such personnel shall be under the supervision of the school nurse for the purposes of 105 CMR 210.000. The School Committee or governing body, in consultation with the Board of Health where appropriate, shall provide assurance that sufficient school nurse(s) are available to provide proper supervision of unlicensed school personnel. Responsibilities for supervision, at a minimum, shall include the following:

1. (1) After consultation with the principal or administrator responsible for a given school, the school nurse shall select, train and supervise the specific individuals who may administer medications. When necessary to protect student health and safety, the school nurse may rescind such selection.

2. (2) The number of unlicensed school personnel to whom responsibility for medication administration may be delegated is to be determined by:

   1. (a) the number of unlicensed school personnel the school nurse can adequately supervise, as determined by the school nurse; and
   2. (b) the number of unlicensed school personnel necessary, in the school nurse's judgment, to ensure that the medications are properly administered to each student.
3. (3) The school nurse shall support and assist persons who have completed the training specified in 105 CMR 210.007 to prepare for and implement their responsibilities related to the administration of medication.
4. (4) The first time that an unlicensed school personnel administers medication, the delegating school nurse shall provide supervision at the work site. In extenuating circumstances, as determined by the school nurse, the skills competency for p.r.n. emergency rescue medications administered through inhalation or through the mucous membranes of the nose, digestive tract, or lungs (such as inhalers and nasal preparations of glucagon and diazepam) or, in the case of injectable glucagon, an FDA-approved, pre-dosed autoinjector, may be demonstrated without administration of the medication to the student. When a p.r.n. emergency rescue medication is administered, the medication plan shall address notification of the local emergency medical services system, followed by notification of the student's caregiver.

5. (5) The degree of supervision required for each student shall be determined by the school nurse after an evaluation of the appropriate factors involved in protecting the student's health including, but not limited to, the following:

   1. (a) health condition and ability of the student;
   2. (b) the extent of training and capability of the unlicensed school personnel to whom the medication administration is delegated;
   3. (c) the type of medication; and
   4. (d) the proximity and availability of the school nurse to the unlicensed school personnel who is performing the medication administration.

6. (6) For the individual student, the school nurse shall:

   1. (a) determine whether or not it is medically safe and appropriate to delegate medication administration;

   2. (b) administer the first dose of the medication, if:

      1. 1. there is reason to believe there is a risk to the student as indicated by the health assessment; or
      2. 2. the student has not previously received this medication in any setting. In extenuating circumstances, as determined by the school nurse, p.r.n. emergency rescue medications administered through inhalation or through the mucous membranes of the nose, digestive tract, or lungs (such as inhalers and nasal preparations of glucagon and diazepam) or, in the case of injectable glucagon, an FDA-approved, pre-dosed autoinjector, are not required to be administered previously. When a p.r.n. emergency rescue medication is administered, the medication plan shall address notification of the local emergency medical services system, followed by notification of the student's caregiver;
   3. (c) review the initial orders, possible side effects, adverse reactions and other pertinent information with the unlicensed school personnel to whom medication administration has been delegated;
   4. (d) provide supervision and consultation as needed to ensure that the student is receiving the medication appropriately. Supervision and consultation may include record review, on-site observation and/or assessment;
   5. (e) review all documentation pertaining to the delegation of medication administration on a weekly basis or more often if necessary.