Indiana Department Annual Inservice Form PDF Details

The Indiana Department of Health, as part of its oversight and commitment to ensuring the provision of quality care in long-term healthcare settings, mandates that Qualified Medication Aides (QMAs) undergo annual in-service training. This requirement, established to maintain the competency of QMAs in medication administration, is meticulously outlined in the State Form 51654. This form, also known as the Qualified Medication Aide Record of Annual In-Service Training, is a critical document, approved by the State Board of Accounts in 2009, that helps streamline the recertification process for these aides. To comply, QMAs must not only complete a minimum of six hours of in-service education related to medication administration each year but must also ensure that their certification remains current, as dictated by the Indiana Administrative Code. This education may cover a variety of procedures, including medication administration via G-tube/J-tube, hemoccult testing, and finger stick blood glucose testing, among others, depending on the facility's policies. The form is a testament to the state's rigorous standards for medication aides, requiring clear documentation of the in-service training undertaken and the submission of a nominal fee for the processing of recertification. This protocol not only ensures the adequacy of medication administration skills among QMAs but also plays a crucial role in upholding the health and safety of patients in long-term care facilities across Indiana.

QuestionAnswer
Form NameIndiana Department Annual Inservice Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesQMA, CNA, qma study guide indiana, inservice

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QUALIFIED MEDICATION AIDE RECORD OF ANNUAL IN-SERVICE TRAINING

State Form 51654 (R / 11-09)

Approved by State Board of Accounts, 2009

INDIANA STATE DEPARTMENT OF HEALTH - DIVISION OF LONG TERM CARE

INSTRUCTIONS: 1. Please print or type clearly.

2.No abbreviations.

3.This form and fee must be submitted to ISDH by March 31.

4.The QMA is responsible for completing the in-service education requirements, maintaining documentation of in- service education, and submitting, or ensuring the submission of, the qualified medication aide record of annual in- service education form and appropriate fee. Annual in-service education MUST relate to medication and/or medication administration. If a QMA performs medication administration via a G-tube/J-tube, hemoccult testing, finger stick blood glucose testing, annual in-service must be done yearly.

QMA Name: _______________________________________QMA Certification #:______________________

LastFirstM.I

Home Address: ___________________________________________________________________________

(street address (include Post Office box number, if applicable) City State ZIP code

Phone: __ ___/_________________ CNA Expiration Date*: __________________(CNA status MUST be current)

Payment (check one)*: _____Fee included OR _______Date paid online

Date

Topic

Location (facility name)

Length

(in ¼ hour

segments, i.e., 0.25, 0.50, 0.75, 1.0 hour)

Signature of Instructor*

 

Approved

 

Not

 

 

 

Approved

 

 

 

 

 

Office Use Only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office Use Only TOTAL APPROVED HOURS:

 

REVIEWED BY:

Date:

 

 

 

 

 

 

I submit the above information as proof of having met the six (6) hour per year in-service requirement and hereby apply for re-certification.

QMA Signature*: ___________________________________________

Date:___________________

*Mandatory information, form will be returned if * items are not completed.

For office use only:

Entered by:_______________________________

Date:_______________-____________________

Receipt #

IMPORTANT NOTICE

CERTIFICATION/RECERTIFICATION/REINSTATEMENT and IN-SERVICE EDUCATION REQUIREMENTS FOR

QUALIFIED MEDICATION AIDE (QMA)

Effective January 1, 2005, the QMA certification process and in-service education requirement is mandatory every year. This is in accordance with Indiana Administrative Code 412 IAC 2-1-10. Under this rule all QMAs must meet the following three (3) requirements:

1.Be certified by the Indiana State Department of Health every year;

2.Obtain a minimum of six (6) hours per year of in-service education in the area of medication administration; and

3.Submit appropriate fee to Indiana State Department of Health with recertification request.

RECERTIFICATION:

At least 30 days prior to the expiration of the certificate, the individual must:

1.obtain a minimum of six (6) hours per year of annual in-service education;

2.submit to the Indiana State Department of Health a qualified medication aide record of annual in-service education on the form approved by the ISDH; and

3.submit to the ISDH the appropriate fee.

The QMA is responsible for completing the in-service education requirements, maintaining documentation of in-service education, and submitting, or ensuring the submission of, the qualified medication aide record of annual in-service education form and appropriate fee.

REINSTATEMENT:

If the recertification fees and/or in-service education form is received by the ISDH ninety-one (91) or more days after expiration of the QMA certification, the individual is removed from the QMA registry and must be reinstated. For reinstatement as a QMA following removal from the QMA registry, the individual must:

1.complete an ISDH approved QMA course;

2.submit to the testing entity an application approved by the ISDH;

3.pass the written competency test in three (3) or fewer attempts with a passing score of 80%.

IN-SERVICE EDUCATION REQUIREMENTS:

Annual in-service education shall include medication administration. If facility policy allows the QMA to perform such functions in the facility, annual in-service education shall also include:

1.medication administration via G-tube/J-tube;

2.hemoccult testing;

3.finger stick blood glucose testing (specific to the glucose meter used).

QMA certificates are effective upon issue and expire on March 31 of the next year. The annual in-service education requirement period begins each year on March 1 and concludes on the last day of February of the next year. In the case of an initial certificate, the annual in-service education requirement period begins on the QMA certification effective date and concludes on the last day of February of the next year. The in-service education requirement period therefore ends one (1) month prior to the expiration of the certification.

Qualified Medication Aide Record of Annual In-service Training form and fee ($10.00 check or money order payable to Indiana State Dept. of Health) should be submitted to ISDH. The form and fee must be sent to:

Indiana State Department of Health

Cashier’s Office

PO Box 7236

Indianapolis, IN 46207-7236

Failure to submit certification in a timely manner may result in additional fees or removal from the QMA registry. (Removal from the registry will require completion of a QMA course and passing of the QMA competency test for re- instatement).

If you have additional questions, please contact Gina Berkshire at gberkshire@isdh.in.gov or 317/233-7497

or Nancy Gilbert at ngilbert@isdh.in.gov or 317/233-7616.

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