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Supervision of Licensed Practical Nurses in Methadone Treatment Programs

PDF Version of DQA 09-013  (PDF, 42 KB)

Date: April 8, 2009
To: Area Administrators/Assistant Administrators
Bureau Directors
County Departments of Human Services Directors
County Mental Health Coordinators
Tribal Chairpersons/Human Service Coordinators
Certified Mental Health and AODA CMHA 03
Community Substance Abuse Providers
Certified Outpatient Mental Health Clinics
From: Cremear Mims, Director
Bureau of Health Services
Division of Quality Assurance

Joyce Allen, Director
Bureau of Prevention, Treatment and Recovery
Division of Mental Health and Substance Abuse Services

Via:

Otis Woods, Administrator
Division of Quality Assurance

John Easterday, Administrator
Division of Mental Health and Substance Abuse Services

Supervision of Licensed Practical Nurses in Methadone Treatment Programs

Background

The purpose of this memo is to provide clarification regarding the role of the supervising physician or registered nurse when a licensed practical nurse (LPN) administers methadone in basic and complex nursing situations in Certified Narcotic Treatment Service.

Wisconsin Administrative Code DHS 75 (http://www.legis.state.wi.us/rsb/code/dhs/dhs075.pdf) governs Wisconsin certified Community Substance Abuse Services. Section DHS 75.15 provides requirements for Narcotic Treatment Service for Opiate Addiction. Section DHS 75.15 (4)(b) states, "The service shall have a registered nurse on staff to supervise the dosing process and perform other functions delegated by the physician." In addition, s. DHS 75.15(4) (c) states, "The service may employ nursing assistants and related medical ancillary personnel to perform functions permitted under state medical and nursing practice statutes and administrative rules."

A certified narcotic treatment service for opiate addiction may employ LPNs as a member of the treatment service that provide for the management and rehabilitation of selected narcotic addicts through the use of methadone or other FDA-approved narcotics and a broad range of medical and psychological services, substance abuse counseling and social services.

Chapter DHS 75 does not provide detail about the LPN's scope of practice in narcotic treatment service for opiate addiction. The rule does not clearly specify if/when the supervising physician or registered nurse must be "on site" to supervise the LPN.

Collaboration with the Wisconsin Board of Nursing

The scope of practice for the LPN is set forth in Chapter N6.04, Wis. Admin. Code. The Department of Health Services (DHS) requested an opinion from the Wisconsin Board of Nursing whether it is within the scope of practice of an LPN to administer methadone in a narcotic treatment service for opiate addiction. Secondly, if it is within the scope of practice of the LPN to administer methadone in a narcotic treatment service for opiate addiction, what level of supervision is required?

The Wisconsin Board of Nursing response is detailed in a "white paper" dated September 25, 2007. The entire article may be reviewed at: http://drl.wi.gov/profession_list.asp?locid=0

The Board confirms the LPN scope of practice may involve "basic" and "complex" patient care situations. The Board concluded that basic care involves situations where the patient's medical condition is stable and the dosing level is not frequently changing. The Board also concluded that: "In basic patient care situations, the LPN administers the medication dose, witnesses the consumption of the dose, and observes and records the administration. 

In basic patient care situations, the administration of methadone shall be performed by the LPN under the general supervision of a physician or registered nurse. General supervision means to regularly coordinate, direct and inspect the practice of another; it does not require that the supervising health care provider be available on-site at all times."

The Board states that "In other situations when the patient is not stable, such as during the induction phase of a narcotic maintenance treatment program, or when the patient is non-compliant with treatment or has other co-morbidities, the administration of methadone may constitute a complex patient situation that requires the performance of delegated medical or nursing acts beyond basic nursing care. 

The LPN who administers methadone in a complex patient situation shall be under the direct supervision of a physician or registered nurse. Direct supervision requires immediate availability to continually coordinate, direct and inspect at first hand the practice of another. Direct supervision has been generally defined as on-site presence, access or communication within a relatively short time period."

DHS Conclusions

DHS concurs with the paper summary published by the Wisconsin Board of Nursing and provides the following direction regarding the administration of methadone in Certified Narcotic Treatment Services. Each certified service must ensure that qualified medical or nursing staff members of the treatment team are on staff and available to provide direct supervision as identified in the Wisconsin Board of Nursing "white paper". 

In cases where a patient is not stable, providers electing to utilize the LPN in these certified programs must have a developed and implemented written policy for utilizing the LPN and qualified supervision in the delivery of narcotic treatment services for opiate addiction. The Department will confirm the existence of established policies and procedures during on-site reviews. Procedures should include evidence that all staffs are instructed on their role(s) in case of crisis for any client(s).

If you have questions about this interpretative memo, please contact your Behavioral Health Certification Specialist or the State Methadone Authority. Contact phone numbers are attached.

 

cc:  Susan Gadacz, Bureau of Prevention, Treatment and Recovery
      Mark Hale, Chief, Behavioral Health Certification Section
      Deborah Powers, Bureau of Prevention, Treatment and Recovery

 

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