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NY State Intellectual Disabilities/Developmental Disabilities Nurses Association (nysidddna) was founded to promote Intellectual and Developmental Disability Nursing as a specialty area of practice. The Association continues to support its members' activities in nursing law, education, research and practice.

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Subject: Important: ICFs and PRN medications 

Hi Everyone,

For those of you who have oversight responsibilities for ICFs in State Operations:  As a follow up to a meeting we had yesterday with Dr. Pettinger and our Division of Quality Improvement, I need to draw your urgent attention to a change in the ICF Interpretive Guidelines, Guidelines to Surveyors (published last year, see attached) in regard to the use of PRN medications to manage behavior.

While the ICF 483 regulations themselves have not changed, the interpretive guidelines do get updated on occasion and become the standards that surveyors follow when reviewing ICF programs for compliance.

The new guideline related to PRN medication for behavior reads as follows: “Drugs for behavior management must not be ordered on a PRN basis for a client.  The facility staff must contact a physician to obtain a one-time order if the situation necessities the use of medication.” (Tag number W312, page 89 of the attached document).
This has very important implications for behavior plans and medication administration procedures within ICFs. 

In order to comply with the regulation, a physician (we have clarified physician to mean “anyone who has the authority to prescribe medication: Physician, Nurse Practitioner, Physician's Assistant, Dentist”) must be contacted to write a one-time order for each and every medication given in response to behavior, essentially becoming a stat medication order.

Behavior Plans will need to be updated and any language related to “PRN” as it applies to medications should be removed.  It is acceptable to include in the behavior plans that the person has had behavioral challenges that have necessitated the use of emergency medication administration and that the person has responded well to _______ medication at ____ dosage.  However, the plan should direct the staff to contact the covering physician/prescriber in the event that specific behavioral criteria (spelled out) are reached for the prescriber to determine whether the situation warrants the use of stat medication.  The prescriber would need to follow up any verbal order with a written one-time order.
My understanding is that agencies are already being cited for this.  It may be helpful to review all the individuals who currently have PRN orders, the frequency of their use, and the effectiveness of the PRN medication in emergency situations, to determine whether the PRN medication might be able to be removed from the plan and/or if other methods of intervention may be employed in such situations.

We are working with DOH to do some training on the new interpretive guidelines in the near future.

Please share this information with ICF clinicians, administrators, Human Rights Committees, and the medical staff, especially prescribers who may be called regarding stat medications.

Please let me know if you have any questions or concerns.  We will be discussing this further at the monthly psychology teleconference next week.

Paul A. H. Partridge, Ph.D.
Chief Psychologist