MAP Policy Manual
3/1/24
TABLE OF CONTENTS
01 DEPARTMENT GUIDANCE ........................................................................................................... 5
01-1 Department Guidance Requirements .............................................................................................. 6
Definition of Terms Used at MAP Registered Sites .............................................................................. 7
01-2 DPH MAP Waiver Request .......................................................................................................... 10
02 Youth Community Programs........................................................................................................... 11
02-1 Medication Administration to Youth ............................................................................................ 12
02-2 Role of MAP Quality Assurance Monitor (MAP Monitor) .......................................................... 13
03 SITE REGISTRATION REQUIREMENTS ................................................................................. 17
03-1 Criteria for Site Registration with DPH ....................................................................................... 18
03-2 Massachusetts Controlled Substances Registration (MCSR) ....................................................... 19
03-3 Preparation for Site Registration .................................................................................................. 21
03-4 Application Forms for a MAP Massachusetts Controlled Substances Registration (MCSR) ...... 23
04 TRAINING AND CURRICULUM ................................................................................................. 24
04-1 MAP Trainer Requirements.......................................................................................................... 25
04-2 Training Direct Care Staff ............................................................................................................ 26
04-3 Completion of MAP Certification Training ................................................................................. 27
04-4 Revocation of MAP Trainer Approval Status .............................................................................. 28
05 STAFF CERTIFICATION .............................................................................................................. 29
05-1 MAP Certification Eligibility and Guidelines .............................................................................. 30
05-2 MAP Certification Testing Process .............................................................................................. 31
05-3 Acceptable Proof of MAP Certification ....................................................................................... 32
DCP MAP Policy Manual 3/1/24 Page 1 of 273
, 05-4 MAP Recertification ..................................................................................................................... 33
05-5 MAP Recertification Testing Processes ....................................................................................... 34
05-5.1 MAP Recertification Process Through State Contracted Testing Vendor ................................ 35
05-5.2 MAP Recertification Process Through the Service Provider .................................................... 36
05-5.3 MAP Recertification Evaluation Guide .................................................................................... 38
05-6 Revocation of MAP Certification ................................................................................................. 41
06 ROLE OF NURSING ....................................................................................................................... 43
06-1 Board of Registration in Nursing Guidance ................................................................................. 44
06-2 Role of Nursing in MAP ............................................................................................................... 45
06-3 Role of Nurses: Registered Nurse (RN) and Licensed Practical Nurse (LPN) Advisory Ruling 47
07 MAP CONSULTANTS .................................................................................................................... 48
07-1 Role of the MAP Consultant ........................................................................................................ 49
08 HEALTH CARE PROVIDER (HCP) ORDERS .......................................................................... 50
08-1 Required Components of Health Care Provider Medication Orders ............................................ 51
08-2 Health Care Provider Orders Received by Fax, Email, Telehealth, and Telephone .................... 54
08-3 PRN Health Care Provider Medication Orders ............................................................................ 56
08-4 Transcribing, Posting and Verifying of Health Care Provider Orders ......................................... 57
08-5 Monthly Accuracy Check of Health Care Provider Orders .......................................................... 59
08-6 Medication Reconciliation and Discharge Health Care Provider Orders ..................................... 60
09 SAMPLE MEDICATION ............................................................................................................... 62
09-1 Labeling Guidelines of Sample Medication ................................................................................. 63
10 PHARMACY ..................................................................................................................................... 64
10-1 Acceptable Prescription Medication Packaging ........................................................................... 65
10-2 Receiving Medication from the Pharmacy ................................................................................... 68
10-3 Components of a Pharmacy Label ................................................................................................ 69
10-4 Exhausting the Current Supply of Medication ............................................................................. 70
10-5 Maintaining a Sufficient Supply of Medication ........................................................................... 72
10-6 Over-the-Counter (OTC) Medications and Dietary Supplements ................................................ 74
10-7 Labeling of Pre-filled Syringes Received from the Pharmacy
..................................................... 77 11 MEDICATION ADMINISTRATION RECORD
......................................................................... 78 11-1 Required Components of a Medication
Administration Record .................................................. 79
11-2 Transcribing Required Information onto the Medication Administration Record ....................... 80
11-3 Service Provider Transcription of Medication Management System ........................................... 81
11-4 Medication Administration Record Documentation..................................................................... 83
12 MEDICATION SECURITY ............................................................................................................ 85
12-1 Medication Storage .......................................................................................................................
86
12-2 Schedule II-V Medication Security Measures .............................................................................. 88
12-3 Countable Controlled Substance Book ......................................................................................... 90
12-4 Transfer of Medication ................................................................................................................. 91
12-5 Transportation of Medication ....................................................................................................... 94
12-6 Syringe Security and Storage ....................................................................................................... 95
12-7 Drug-Tampering and Suspected Drug-Tampering ....................................................................... 96
DCP MAP Policy Manual 3/1/24 Page 2 of 273
, 12-8 Drug Loss ..................................................................................................................................... 97
12-9 Biometric Medication Security ..................................................................................................... 98
13 MEDICATION ADMINISTRATION ......................................................................................... 100
13-1 Medication Administration .........................................................................................................
101
13-2 Medication Refusals ................................................................................................................... 103
13-3 Day Program Medication Requirements .................................................................................... 104
14 POLICIES, PROCEDURES AND RECORD KEEPING .......................................................... 106
14-1 Service Provider MAP Policies .................................................................................................. 107
14-2 Site Record Keeping Requirements ............................................................................................ 110
14-3 Retention Period for MAP Program Records ............................................................................. 113
14-4 Electronic Reference Materials .................................................................................................. 114
14-5 Allergies...................................................................................................................................... 115
15 MEDICATION DISPOSAL .......................................................................................................... 116
15-1 Medication Disposal Guidelines .................................................................................................
117
15-2 Disposal Form............................................................................................................................. 119
16 OFF-SITE MEDICATION ADMINISTRATION, CERTIFIED/LICENSED STAFFED
VACATION, LEAVE OF ABSENCE, BACKPACKING ................................................................ 120
16-1 Medication Administration at Locations other than MAP Registered Sites .............................. 121
16-2 Off-Site Administration of Medication ...................................................................................... 122
16-3 Vacation Accompanied by Certified/Licensed Staff .................................................................. 124
16-4 Definition and Criteria for a Leave of Absence ......................................................................... 126
16-5 Preparation of Medication for a Leave of Absence .................................................................... 128
16-6 Documentation of a Leave of Absence....................................................................................... 129
16-7 Transporting Medications to Administer to Individuals Living at a Location Other than the MAP
Registered Site; ‘Backpacking’ ........................................................................................................... 131
17 MEDICATION OCCURRENCES ................................................................................................
133 17-1 Definition of a Medication Occurrence
...................................................................................... 134
17-2 Hotline Event Medication Occurrences ...................................................................................... 136
17-3 Requirements for Reporting and Follow-Up of Medication Occurrences ................................. 137
17-4 Instructions for Completion of Medication Occurrence Report (MOR Form) ........................... 139
17-5 Medication Occurrence Report (MOR Form) ............................................................................
142
17-6 Pharmacy Errors ......................................................................................................................... 143
17-7 Health Care Provider Errors ....................................................................................................... 144
18 ANCILLARY PRACTICES BY CERTIFIED STAFF .............................................................. 145
18-1 Vital Signs Monitoring Related to Medication Administration by Certified Staff .................... 146
18-2 Blood Glucose Monitoring by Certified Staff ............................................................................ 149
19 SPECIALIZED TRAINING RELATED TO MEDICATION ................................................... 154
19-1 Specialized Training Programs ................................................................................................... 155
19-2 Oxygen Therapy ......................................................................................................................... 156
19-3 Epinephrine Administration via Auto-Injector Device(s) .......................................................... 162
Epinephrine Auto-Injector Disposal Guidelines ................................................................................ 168
DCP MAP Policy Manual 3/1/24 Page 3 of 273
, 19-4 Administration Via Gastrostomy (G) or Jejunostomy (J) Tube Route ....................................... 169
19-5 Medication Administration and Water Flushes via Gastrostomy (G) or Jejunostomy (J) Tubes171
19-6 High Alert Medications-Medications Requiring Additional Monitoring of An Individual ....... 182
19-7 High Alert Medication-Warfarin Sodium (Coumadin)Therapy .................................................
183
19-8 High Alert Medication-Clozapine (Clozaril) Therapy ............................................................... 196
20 LEARNING TO SELF-ADMINISTER MEDICATION ........................................................... 202
20-1 Definition and Criteria for Self-Administration of Medication.................................................. 203
20-2 Definition and Criteria for Learning to Self-Administer Medication ......................................... 204
20-3 Self-Administration of Medication Skills Determination/Assessment ...................................... 205
20-4 Development of a Learning to Self-Administer Medication Teaching/Support Plan ................ 207
20-5 Learning to Self-Administer Medication and the Appropriate Use of Pill-Organizers .............. 209
20-6 Documentation of the Learning to Self-Administer Medication Process................................... 211
20-7 Ongoing Supports for Individuals Learning to Self-Administer their Medication .................... 213
20-8 Change in Individual’s Status Warranting a Reevaluation ......................................................... 214
21 DPH CLINICAL REVIEW AND INSPECTIONS ..................................................................... 215
21-1 DPH Clinical Reviews and Inspections ......................................................................................
216
21-2 DPH Clinical Review Process .................................................................................................... 217
22 HOSPICE CARE SERVICES ...................................................................................................... 218
22-1 Hospice Care Services: Protocol for Instituting .........................................................................
219
22-2 Hospice Care Services: MAP Policies Exemptions ................................................................... 222
22-3 Hospice Care Services: Sample Record Keeping Forms ............................................................ 224
23 ADMINISTRATION OF INJECTABLE MEDICATION ........................................................ 232
23-1 Administration of Injectable Medication .................................................................................... 233
24 RESOURCES ................................................................................................................................. 234
24-1 Contacts ......................................................................................................................................
235
DPH, State Agencies, and Other Contacts for MAP .......................................................................... 236
DCP MAP Policy Manual 3/1/24 Page 4 of 273
3/1/24
TABLE OF CONTENTS
01 DEPARTMENT GUIDANCE ........................................................................................................... 5
01-1 Department Guidance Requirements .............................................................................................. 6
Definition of Terms Used at MAP Registered Sites .............................................................................. 7
01-2 DPH MAP Waiver Request .......................................................................................................... 10
02 Youth Community Programs........................................................................................................... 11
02-1 Medication Administration to Youth ............................................................................................ 12
02-2 Role of MAP Quality Assurance Monitor (MAP Monitor) .......................................................... 13
03 SITE REGISTRATION REQUIREMENTS ................................................................................. 17
03-1 Criteria for Site Registration with DPH ....................................................................................... 18
03-2 Massachusetts Controlled Substances Registration (MCSR) ....................................................... 19
03-3 Preparation for Site Registration .................................................................................................. 21
03-4 Application Forms for a MAP Massachusetts Controlled Substances Registration (MCSR) ...... 23
04 TRAINING AND CURRICULUM ................................................................................................. 24
04-1 MAP Trainer Requirements.......................................................................................................... 25
04-2 Training Direct Care Staff ............................................................................................................ 26
04-3 Completion of MAP Certification Training ................................................................................. 27
04-4 Revocation of MAP Trainer Approval Status .............................................................................. 28
05 STAFF CERTIFICATION .............................................................................................................. 29
05-1 MAP Certification Eligibility and Guidelines .............................................................................. 30
05-2 MAP Certification Testing Process .............................................................................................. 31
05-3 Acceptable Proof of MAP Certification ....................................................................................... 32
DCP MAP Policy Manual 3/1/24 Page 1 of 273
, 05-4 MAP Recertification ..................................................................................................................... 33
05-5 MAP Recertification Testing Processes ....................................................................................... 34
05-5.1 MAP Recertification Process Through State Contracted Testing Vendor ................................ 35
05-5.2 MAP Recertification Process Through the Service Provider .................................................... 36
05-5.3 MAP Recertification Evaluation Guide .................................................................................... 38
05-6 Revocation of MAP Certification ................................................................................................. 41
06 ROLE OF NURSING ....................................................................................................................... 43
06-1 Board of Registration in Nursing Guidance ................................................................................. 44
06-2 Role of Nursing in MAP ............................................................................................................... 45
06-3 Role of Nurses: Registered Nurse (RN) and Licensed Practical Nurse (LPN) Advisory Ruling 47
07 MAP CONSULTANTS .................................................................................................................... 48
07-1 Role of the MAP Consultant ........................................................................................................ 49
08 HEALTH CARE PROVIDER (HCP) ORDERS .......................................................................... 50
08-1 Required Components of Health Care Provider Medication Orders ............................................ 51
08-2 Health Care Provider Orders Received by Fax, Email, Telehealth, and Telephone .................... 54
08-3 PRN Health Care Provider Medication Orders ............................................................................ 56
08-4 Transcribing, Posting and Verifying of Health Care Provider Orders ......................................... 57
08-5 Monthly Accuracy Check of Health Care Provider Orders .......................................................... 59
08-6 Medication Reconciliation and Discharge Health Care Provider Orders ..................................... 60
09 SAMPLE MEDICATION ............................................................................................................... 62
09-1 Labeling Guidelines of Sample Medication ................................................................................. 63
10 PHARMACY ..................................................................................................................................... 64
10-1 Acceptable Prescription Medication Packaging ........................................................................... 65
10-2 Receiving Medication from the Pharmacy ................................................................................... 68
10-3 Components of a Pharmacy Label ................................................................................................ 69
10-4 Exhausting the Current Supply of Medication ............................................................................. 70
10-5 Maintaining a Sufficient Supply of Medication ........................................................................... 72
10-6 Over-the-Counter (OTC) Medications and Dietary Supplements ................................................ 74
10-7 Labeling of Pre-filled Syringes Received from the Pharmacy
..................................................... 77 11 MEDICATION ADMINISTRATION RECORD
......................................................................... 78 11-1 Required Components of a Medication
Administration Record .................................................. 79
11-2 Transcribing Required Information onto the Medication Administration Record ....................... 80
11-3 Service Provider Transcription of Medication Management System ........................................... 81
11-4 Medication Administration Record Documentation..................................................................... 83
12 MEDICATION SECURITY ............................................................................................................ 85
12-1 Medication Storage .......................................................................................................................
86
12-2 Schedule II-V Medication Security Measures .............................................................................. 88
12-3 Countable Controlled Substance Book ......................................................................................... 90
12-4 Transfer of Medication ................................................................................................................. 91
12-5 Transportation of Medication ....................................................................................................... 94
12-6 Syringe Security and Storage ....................................................................................................... 95
12-7 Drug-Tampering and Suspected Drug-Tampering ....................................................................... 96
DCP MAP Policy Manual 3/1/24 Page 2 of 273
, 12-8 Drug Loss ..................................................................................................................................... 97
12-9 Biometric Medication Security ..................................................................................................... 98
13 MEDICATION ADMINISTRATION ......................................................................................... 100
13-1 Medication Administration .........................................................................................................
101
13-2 Medication Refusals ................................................................................................................... 103
13-3 Day Program Medication Requirements .................................................................................... 104
14 POLICIES, PROCEDURES AND RECORD KEEPING .......................................................... 106
14-1 Service Provider MAP Policies .................................................................................................. 107
14-2 Site Record Keeping Requirements ............................................................................................ 110
14-3 Retention Period for MAP Program Records ............................................................................. 113
14-4 Electronic Reference Materials .................................................................................................. 114
14-5 Allergies...................................................................................................................................... 115
15 MEDICATION DISPOSAL .......................................................................................................... 116
15-1 Medication Disposal Guidelines .................................................................................................
117
15-2 Disposal Form............................................................................................................................. 119
16 OFF-SITE MEDICATION ADMINISTRATION, CERTIFIED/LICENSED STAFFED
VACATION, LEAVE OF ABSENCE, BACKPACKING ................................................................ 120
16-1 Medication Administration at Locations other than MAP Registered Sites .............................. 121
16-2 Off-Site Administration of Medication ...................................................................................... 122
16-3 Vacation Accompanied by Certified/Licensed Staff .................................................................. 124
16-4 Definition and Criteria for a Leave of Absence ......................................................................... 126
16-5 Preparation of Medication for a Leave of Absence .................................................................... 128
16-6 Documentation of a Leave of Absence....................................................................................... 129
16-7 Transporting Medications to Administer to Individuals Living at a Location Other than the MAP
Registered Site; ‘Backpacking’ ........................................................................................................... 131
17 MEDICATION OCCURRENCES ................................................................................................
133 17-1 Definition of a Medication Occurrence
...................................................................................... 134
17-2 Hotline Event Medication Occurrences ...................................................................................... 136
17-3 Requirements for Reporting and Follow-Up of Medication Occurrences ................................. 137
17-4 Instructions for Completion of Medication Occurrence Report (MOR Form) ........................... 139
17-5 Medication Occurrence Report (MOR Form) ............................................................................
142
17-6 Pharmacy Errors ......................................................................................................................... 143
17-7 Health Care Provider Errors ....................................................................................................... 144
18 ANCILLARY PRACTICES BY CERTIFIED STAFF .............................................................. 145
18-1 Vital Signs Monitoring Related to Medication Administration by Certified Staff .................... 146
18-2 Blood Glucose Monitoring by Certified Staff ............................................................................ 149
19 SPECIALIZED TRAINING RELATED TO MEDICATION ................................................... 154
19-1 Specialized Training Programs ................................................................................................... 155
19-2 Oxygen Therapy ......................................................................................................................... 156
19-3 Epinephrine Administration via Auto-Injector Device(s) .......................................................... 162
Epinephrine Auto-Injector Disposal Guidelines ................................................................................ 168
DCP MAP Policy Manual 3/1/24 Page 3 of 273
, 19-4 Administration Via Gastrostomy (G) or Jejunostomy (J) Tube Route ....................................... 169
19-5 Medication Administration and Water Flushes via Gastrostomy (G) or Jejunostomy (J) Tubes171
19-6 High Alert Medications-Medications Requiring Additional Monitoring of An Individual ....... 182
19-7 High Alert Medication-Warfarin Sodium (Coumadin)Therapy .................................................
183
19-8 High Alert Medication-Clozapine (Clozaril) Therapy ............................................................... 196
20 LEARNING TO SELF-ADMINISTER MEDICATION ........................................................... 202
20-1 Definition and Criteria for Self-Administration of Medication.................................................. 203
20-2 Definition and Criteria for Learning to Self-Administer Medication ......................................... 204
20-3 Self-Administration of Medication Skills Determination/Assessment ...................................... 205
20-4 Development of a Learning to Self-Administer Medication Teaching/Support Plan ................ 207
20-5 Learning to Self-Administer Medication and the Appropriate Use of Pill-Organizers .............. 209
20-6 Documentation of the Learning to Self-Administer Medication Process................................... 211
20-7 Ongoing Supports for Individuals Learning to Self-Administer their Medication .................... 213
20-8 Change in Individual’s Status Warranting a Reevaluation ......................................................... 214
21 DPH CLINICAL REVIEW AND INSPECTIONS ..................................................................... 215
21-1 DPH Clinical Reviews and Inspections ......................................................................................
216
21-2 DPH Clinical Review Process .................................................................................................... 217
22 HOSPICE CARE SERVICES ...................................................................................................... 218
22-1 Hospice Care Services: Protocol for Instituting .........................................................................
219
22-2 Hospice Care Services: MAP Policies Exemptions ................................................................... 222
22-3 Hospice Care Services: Sample Record Keeping Forms ............................................................ 224
23 ADMINISTRATION OF INJECTABLE MEDICATION ........................................................ 232
23-1 Administration of Injectable Medication .................................................................................... 233
24 RESOURCES ................................................................................................................................. 234
24-1 Contacts ......................................................................................................................................
235
DPH, State Agencies, and Other Contacts for MAP .......................................................................... 236
DCP MAP Policy Manual 3/1/24 Page 4 of 273
