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HEALTH RELATED POLICIES & PROCEDURES SELF-ADMINISTRATION OF MEDICATIONS Re: CFR 483.460, SB1857 Self-Administration of Medication Principle and Introduction: Each consumer will be encouraged to participate in the Self-Administration of Medication process, to his/her highest level of independence. Self Administration of medication is defined: Individual knows how to safely take each medication (what, why, dose, route and time of each medication). The individual is competent to safely self-administer medications independently or independently with ancillary aid provided to the individual in the individuals self-administered medication treatment or regimen, such as reminding and individual to take a medication at the prescribed time, opening and closing a container, pouring a predetermined quantity of liquid to be ingested, returning a medication to the proper storing area, and assisting in reordering medications from a pharmacy. ***Note*** Unlicensed staff who is supervising an individuals self-administration of medication training program is considered to be administering medication (defined by DADS and BON). Procedures: 1. Each consumer will be evaluated, using the Self-Medication Assessment tool, to determine his/her ability to administer own medication (s). Self-Administration of Medication (SAM) assessment must be completed by a Licensed Nurse, at the following time (s). Residential Setting at time of admission to the residence and at least annually, thereafter; Natural Home Setting prior to initial respite visit (if self-administration of medications is planned/requested), and as recommended by the IDT. The assessment will address cognitive skills. At a minimum, the consumer must know the following information about his/her medication in order to be considered independent in self administration of medication Medication what it is Purpose why it is taken Dose How many pills to take Route Time If a consumer is a minor and the Interdisciplinary Team determines the consumer competent to Self Administer medication, consent will be signed by the parent/guardian/LAR. The consumer must possess/exhibit the following skills to be eligible for participation in selfadministration of medication: Cooperate in the self-administration process Self - Medication training options used in the program: Independent Self Administration of medication with or without supervision. Administration of medication with training in self-administration of medication by unlicensed staff, under SB1857 oral, topical and metered dose inhalers.

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6. Delegation of administration of medication with training in self-administration by an RN to unlicensed staff. A licensed nurse must supervise the self-administration of medication training.

The RN will determine which Self-Medication option is appropriate for the consumer and make recommendations to the IDT. Following assessment, the attending physician will be informed of the consumers appropriateness for participation in Self-Administration of Medications and will give orders stipulating whether or not the consumer may self-administer his/her own medications. The physicians order will indicate whether the individual may take his/her own medications with or without supervision. The supervision provided during the self-administration process, will be provided by unlicensed staff, unless the physician specifically orders the supervision to be provided by licensed nurse If the physician orders that the individual may self-administer his/her own medications, the Interdisciplinary Team (IDT) will determine training needs, and these will be incorporated into the individuals IPP. The Licensed nurse will be responsible for insuring appropriate implementation of training based on written curriculum. Specific training will address identified needs/deficits, and may be addressed through other disciplines (i.e. physical limitations, non-compliance, etc.). Self-administration of medication training will generally be sequential in nature and address the specific needs of the individual. Minimally, self administration of medication training will address the following areas: a. identifying medication b. purpose of medication c. dose of medication d. route of medication e. time of medication to be taken Other training may be included as appropriate for the individual: a. learning information about the medication b. Maintaining medications in a secure location c. Recognizing and reporting side effects d. Dangers of taking illicit drugs e. Use of non-prescriptions drugs and f. Obtaining refills of medication or newly-prescribed medication For those consumers who require medication administration and training to administer own medications, there will be: a. locked storage area (cabinet or closet) where all medications will be maintained and the keys maintained by staff; b. a basket/container for each consumer to store internal medications; and c. a basket/container for each consumer to store external medications d. A locked box in the refrigerator, if needed, for medications that must be refrigerated e. An adequate supply of items needed in administering medications (i.e. syringes, etc.) When a consumer has mastered the skill and no longer requires training, he/she will continue to administer his/her medication with minimal oversight provided as needed: a. medications will be stored I a locked storage box, separate from other consumer medications b. consumer will have access to his/her medication boxes

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c. staff will also have access to the medication boxes to insure compliance with the medications regimen

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Generally, medication will be self-administered within 1 hour of the scheduled time indicated on the Medication Administration Record (MAR). a. Changes in consumers schedules, routine and unplanned activities may prevent medication administration within this timeframe. b. When this occurs, staff will notify the nurse for instructions on when medication should be taken. c. The nurse will notify the physician, as needed, to inform the physician that the medication was not taken within the time frame and receive instructions / guidance. d. Medications that are taken outside the One-hour time frame will be considered a medication error only when it can cause the consumer discomfort or jeopardize the consumers health and /or safety. All medications must be administered with training or self-administered in accordance with the physician orders. Staff must ensure the 6 Rights of medication administration are followed: a. Right Person b. Right Medication c. Right dosage and form d. Right route e. Right time f. Right documentation Unlicensed staff will initial the MAR for each dose of medication administered, whether there is selfmedication training or not. The consumer will not initial the MAR unless: a. He/she is independent in medication administration as defined above; or b. He/she have a specific training objective If for any reason, medications are administered by a licensed nurse, the nurse will initial the MAR, indicating the actual administration of medication. On a regular basis, the nurse, should evaluate the ability of the staff that are administering medication and providing training to consumers in the self administration medication process. If an error occurs during this observation, staff should be provided with immediate in-service training.

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Policy: Self-Administration of medication Revised 1/25/12