Current through Register Vol. 56, No. 18, September 16, 2024
(a) When an individual cannot administer his
or her own medication due to intellectual or behavioral disabilities, as
determined by the IDT and recorded in the service plan, the licensee or his or
her alternate, who has successfully completed medication training, shall give
it to the individual to take exactly as prescribed, and assure that the
medication is taken.
1. The licensee, and
when necessary, the trained alternate, shall maintain a medication
administration record of all medications taken where assistance is required.
The licensee, and when necessary, the alternate, shall complete the medication
administration record as he or she was trained to do by the placing agency. The
medication record shall include:
i. The
signature of any persons administering medication followed by his or her
initials;
ii. The brand name and,
if applicable, generic name of the medication;
iii. The dosage;
iv. The date and time of
administration;
v. A record of each
dosage at the time it is administered, identified by the initials of the person
administering the medication;
vi.
Documentation of the proper code for instances when a medication is not
administered; and
vii. A list of
all known allergies.
2.
Errors in medication documentation or administration shall be recorded on the
medication record at the time of their occurrence.
3. Medications may be changed or discontinued
only upon written documentation from the physician or nurse practitioner, which
shall be maintained in the individual's file.
(b) Individuals who have the potential to be
self-medicating shall be assessed by the IDT and the results of this assessment
shall be recorded in the service plan and reviewed annually by the IDT.
1. Only those individuals who have been
determined by the IDT to be self-medicating, and who have documentation of such
in their service plan, which shall include a current Self-Medication
Assessment, shall administer their own medications.
2. Upon determination by the IDT as
documented in the service plan that an individual is capable of
self-medication, no daily medication administration record is required;
however, the licensee shall maintain in the individual's record all copies of
prescriptions/physician's orders for currently prescribed medications, as well
as all documentation from the physician for any changes and/or discontinuations
of medications.
3. The licensee
shall be familiar with all medications being taken by the individual who
self-medicates, their side effects, and where they are stored.
4. Medications administered by injection may
be self-administered if there is documentation of the individual's successful
training by licensed medical personnel. This determination shall be approved by
the IDT and included in the service plan.
5. Only a licensee who has documentation of
successful completion of training from licensed medical personnel may
administer medication by injection.
(c) Medications shall only be administered to
or used by the person for whom they are prescribed.
(d) The licensee shall ensure that an
adequate supply of medication is maintained for the individual at all
times.
(e) The licensee shall
dispose of expired and discontinued medications in such a manner so that they
cannot be ingested or used by anyone in or out of the home.
(f) The licensee shall supervise the storage
and accessibility of all medication, assuring access only by authorized
persons.
1. Medication shall be stored
separately from all food, household cleaners, insecticides, poisons,
etc.
2. All medications shall be
kept in their original containers and shall be properly identified.
i. Medications obtained from a pharmacist
shall include a pharmacy label with the individual's name, medication name,
frequency of dosing, and dosage amount, in accordance with the physician's
prescription.
ii. Medications
available over-the-counter shall include the manufacturer's label identifying
the content and strength of the medication, exactly matching the physician's
order.
3. Pill planners
shall not be utilized.
4. The
licensee may not repackage medications from one container to another container
for administration by another person. Medications that are to be administered
by another person shall be maintained in the original container that has been
obtained directly from the pharmacy.
(g) The licensee shall be familiar with all
medications being administered to the individual, their purpose, and side
effects.
(h) Medication errors and
drug reactions shall be reported at the time of the occurrence to the
individual's physician or nurse practitioner and case manager and documented in
the individual's file.
