Advisory  Guidance on medication storage and administration for recreational camps

Date:	04/19/2018
Referenced Sources:	105 CMR 430.00

This document summarizes the requirements for the storage and administration of medications at recreational camps for children in Massachusetts (see 105 CMR 430.159 and 105 CMR 430.160), including the roles of the health care consultant and health care supervisor.

Each recreational camp is required to:

• Have a health care policy and written procedures for medication administration;¹
• Obtain written permission from the parent/guardian for administration of any medications by staff and for campers to self-administer certain medications;
• Provide for secure storage of refrigerated and unrefrigerated medication;
• Engage at least one Health Care Consultant and at least one Health Care Supervisor to fulfill duties described below 

This guidance is designed to provide further detail on these requirements.

Requirements and duties of the health care consultant

Every camp must have a health care consultant who is a licensed physician, or nurse practitioner, or a physician’s assistant with documented pediatric training.

Consistent with the requirements of the 105 CMR 430.159 and 105 CMR 430.160, the camp must engage a health care consultant to:

1. Assist in developing the camp’s health care policy, including medication storage and handling of health emergencies;
2. Develop and oversee a written policy for administering medications, including written medication administration orders to be followed by the health care supervisor and a list of any prescription or over-the-counter medications that will be administered at camp.
3. Be available for consultation at all times or provide appropriate professional coverage. The camp must be informed that there will be substitute coverage;
4. Provide and document the required DPH-approved training to health care supervisors on administering medications, the signs and symptoms of hypo or hyperglycemia, and appropriate diabetes management plans; and
5. Provide and document the required DPH-approved training and test of competency to all camp employees designated to administer epinephrine auto-injectors.

Requirements and duties of the health care supervisor

Every camp must have at least one health care supervisor. The health care supervisor should be a licensed physician or practical nurse, a registered nurse, a certified nurse practitioner or a licensed physician’s assistant; but at a minimum, must be at least 18 years of age, specially trained in first aid (at least current American Red Cross Standard First Aid certification or its equivalent) and CPR, and must have successfully completed all trainings provided by the health care consultant.

• EXCEPTION: In camps specifically for children with mild or severe disabilities, medical specialty camps or residential camps where the number of staff and campers totals 150 or greater, the health care supervisor must be a licensed physician or practical nurse, a registered nurse, a certified nurse practitioner or a licensed physician’s assistant.

Consistent with the requirements in 105 CMR 430.159 and 105 CMR 430.160, the camp must employ at least one health care supervisor to:

1. Be present at the camp at all times and be available to render emergency first aid;
2. Be responsible for the day to day operation of the camp’s health program, including medication administration in accordance with the orders of the health care consultant and with permission of the parent/guardian; and
3. Support blood monitoring activities and self-injection of insulin of diabetic children, if the health care supervisor has relevant training and with permission of the parent/guardian.

Requirements of the written medication administration policy

The medication administration policy must include, but is not limited to, the following:

1. A list of individuals at the camp authorized by scope of practice to administer medications and/or properly trained or instructed health care supervisors that may administer oral or topical medications;
2. A list of all medications that will be administered at the camp; 
3. Requirement that parent/guardian permission be obtained for any administration of medication;
4. Requirement that medication must be taken from an original container and administered directly to the camper, and a procedure to ensure positive identification of each camper who is to receive medication; and
5. Procedure addressing the circumstances in which a camper or other employee may administer epinephrine injections based upon the following requirements:
   1. A camper prescribed an epinephrine auto-injector for a known allergy or pre-existing medical condition may self-administer and carry an epinephrine auto-injector with him or her at all times for the purposes of self-administration if:
      1. The camper is capable of self-administration; and
      2. Both the health care consultant and camper’s parent/guardian have given written approval
   2. A camper prescribed an epinephrine auto-injector for a known allergy or pre-existing medical condition may receive an epinephrine auto-injection from someone who may give injections within their scope of practice, or from a camp employee if:
      1. Both the health care consultant and camper’s parent/guardian have given written approval; and
      2. The employee has completed a training developed by the camp’s health care consultant in accordance with the requirements in 105 CMR 430.160.
6. Procedure addressing the circumstances in which a camper may self-administer insulin injections based upon the following requirements:
   1. A diabetic camper that requires his or her blood sugar be monitored, or requires insulin injections may self-monitor and/or self-inject himself or herself if:
      1. The camper is capable of self-monitoring or injecting; and
      2. Both the health care consultant and camper’s parent/guardian have given written approval.
   2. Self-injection must take place in the presence of the health care consultant or health care supervisor who may support the camper’s process of self-administration.
7. The circumstances under which the health care consultant and/or parent/guardian must be notified. These must include mechanisms for timely notification of a parent/guardian when medication was not administered in accordance with the prescription (e.g., medication not available; missed dose; dose refused) and a procedure to ensure these circumstances are identified when they occur.

Requirements for storage, disposal and delivery of medication

• Storage: All medications must be stored in a secure manner or under the direct control of the health care consultant, health care supervisor, or camper authorized to self-administer.
  • The health care policy must include the designated secure locations where refrigerated and unrefrigerated medication will be stored and the procedures for ensuring proper storage conditions for medications, including the use of thermometers to monitor the temperature of refrigerated medications.
  • Prescribed medication must always be kept in an original pharmacy container. Repackaging of medication and intermediary or substitute containers is NOT allowed.² Camp personnel cannot transfer medications from one bottle to another.
  • Medication can be taken from the camp on a trip, but may not be repackaged. To ensure repackaging does not occur:
    • The original prescription container can be taken from the camp base as long as the medication remains in a locked case, in the possession of the licensed health care professional or the supervisor until return to the home base of the camp.
    • The camp operator may require that parents/guardians supply the camp with two (2) original prescription containers for each type of prescription medication necessary for their child. Each container would have an allotment of medication that would allow one container of medication to remain at the camp base and the second bottle to travel securely as described in the bullet above.

• Disposal: When no longer needed, medications must be returned to a parent or guardian whenever possible.  If the medication cannot be returned, it must be properly disposed of in accordance with state and federal laws and be documented in writing in a medication disposal log.
  • The camp must dispose of any hypodermic needles and syringes in accordance with 105 CMR 480.000: Minimum Requirements for the Management of Medical or Biological Waste (State Sanitary Code VIII).
     
• Delivery:
  • The health care supervisor, health care consultant or a licensed health care professional may accept delivery of prescription medications from a parent/guardian or may pick up prescription medications from a licensed retail pharmacy upon the written authorization of the parent/guardian.
  • A camp may not arrange for or accept delivery of prescription medications directly from a pharmacy, except in the case in which only licensed health care professionals receive, manage and administer medications to campers.
  • If prescription medications are to be delivered to such a camp by a licensed pharmacy:
    • only a licensed health care professional may accept delivery from the licensed pharmacy; and
    • the camp must obtain written authorization for such delivery from the parent/guardian.

Regardless of the mode of delivery, medications must be delivered and maintained at all times in the original container as dispensed by the licensed pharmacy. All packaging and labeling should be in accordance with the most recent guidelines of the U.S. Pharmacopeia (USP).

¹ Please note that the Americans with Disabilities Act (ADA) requires that all children be given equal access to recreational camps. Therefore, a recreational camp that refuses admission of a camper based on a camper’s need to take medication, has a no medications policy, or refuses to accommodate a disabled camper requiring medication administration, may be in violation of the ADA. For more information regarding ADA compliance, please visit the U.S. Department of Justice website at www.usdoj.gov.

² If medication is dispensed by a pharmacy in customized packaging (e.g., different medications packaged together for one patient in a sealed unit for administration together), all relevant staff should be appropriately trained in the management and utilization of such packaging. The camp should verify with the pharmacy that such customized packaging meets DPH/Board of Registration in Pharmacy requirements for packaging and labeling.