5.04 – Medication Administration

ICF- Park West

At Park West, only Licensed nursing staff will administer all medications for all individuals while present at the facility, or delegate as permitted.

During vacations and/or outings off-site, DSPs at Park West who have been certified to provide Medication Administration may administer medications as per OAC 5123 and the policy starting  in section B of this section.

Johnstown ICF and Waiver Residential and ADS Settings:

Purpose

Open Door does not have any role in the prescribing of individual medications. 

However, Open Door offers assistance to individuals to maintain and improve their health and medical status in collaboration with their medical doctor.  Assistance with medication is a very important part of this effort toward a positive health status.  Because each individual’s medical regime is specifically prescribed for them, Open Door tailors the supports according to those specific needs in the medical care plan and the person-centered plan.    

In accordance with the Medication Administration Rules (OAC 5123), the following procedures have been designed to ensure adherence to each individual’s prescribed medication requirements.

Employee Requirements

• High School Diploma, GED equivalency or proof of higher education (OBN 4723-21-16-A)
• BCI check (OBN 4723-21-16-C)
• Nurse Aide Registry Check  (OBN 4723-21-16-C)
• Abuse Registry Check  (OAC 56123:2-17-03)
• Current employees hired prior to 2/1/00 are exempt from the educational requirements.  (OBN 4723-21-16-A)

Staff Initial Training

• Complete a DODD approved medication administration course that consists of the number of hours the  registered nurse determines are necessary to ensure sufficient training for unlicensed workers to give oral and apply topical medications.  (ODMR 5123:2-1-07E & OBN 4723-21-12 B)
• Perform a satisfactory return demonstration medication pass in the location with the supervision of a licensed nurse. (Completed skills checklist will be kept in personnel file)

Staff On-going Training

• Staff must perform a successful medication return demonstration with the Supervision of a nurse yearly. (ODMR 5123:2-1-07-E4 & OBN 4723-21-27-D2)
• The licensed nurse may withdraw the delegation to pass medications if the situation calls for withdrawal.  (OBN 4723-21-01-G)
• Staff will have access to a licensed nurse at all times.  (OBN 4723-21-27 E4)

Reporting medication discrepancies or errors:

• Any errors or discrepancies noted on the med cards or bottles, med sheets/orders,or during the medication assistance process, must be immediately reported to the Incident Hotline and the nurse on-call, if applicable.
• Complete Incident Report through website outlining details of any med discrepancy or issue.
• All medication incident reports will be reviewed and investigated through root cause analysis. 
• Medication mistakes may result in retraining, review, corrective action, the withdrawal of delegated nursing tasks from the unlicensed worker, or  termination as part of the progressive disciplinary process.
• Medication Errors will be documented in the Medication Administration Information System database.
• If determined necessary by the Incident Hotline the following will occur: Nurse notified to correct medication error, Physician notified, Lead/Program Coordinator notified, county board notified

Medication Administration

The role of the Nurse/DSP with medications is assistance. Encourage the individual to participate in taking their own medication to their full capability.  Some individual’s may require total assistance.  Those procedures will be separately outlined in the medications book for each individual. 

Follow these steps for administration:

• Environment should be free from distractions.
• Focus all attention on the task.
• Do not assist with medications while cooking, assisting with personal hygiene, etc. or while talking on the phone
• Never assume anything
• Always check the medications 3 times
• Wash and dry hands well.  Have individual wash and dry hands.
• Give medications to one individual at a time.
• Obtain med bottles/cards and take to table or other safe, dry area.
• Verify name on med card/bottle with individual’s name and current photograph
• Verify day & time on med card/bottle with medication sheet.
• Check meds three times, when picking up, pouring out, and putting back.
• Check any qualifying statements such as “Must be taken with a full glass of water.” Or  “Must be taken with food.”
• If anything doesn’t seem right—STOP!  Recheck and/or call to clarify. 
• Be careful not to spill and do not touch with hands as moisture can cause to disintegrate.
• Watch individuals to insure that they have swallowed the medications.  Have individual speak to you or open their mouth to check.
• Always listen to individual complaints/statements regarding how med makes them feel, if med looks different, etc. 
• Stop and check for side effects and recheck for accuracy.
• If assisting with liquid medication measure at eye level, do not confuse tsp and tbsp.  Shake if suspension and be aware that most can not be diluted.
• Medications that need to be crushed or dissolved must have a physicians order. ENSURE THAT IF INSTRUCTIONS SAY DO NOT CRUSH THAT THEY ARE NOT CRUSHED!
• Remember that there is a one (1) hour window before and after the medications are due that they can be administered.
• Medications need renewal orders every year or as appropriate.
• Only a licensed nurse and or agency designee can accept and transcribe a doctor’s order.
• Only a licensed nurse and or agency designee can add to, delete from or discontinue an order given from a physician.

Narcotics and Controlled Substances

• All narcotics or schedule II drugs that are being given to a individual by staff or a nurse must have a narcotic count sheet. 
• AT THE ICF AND DAY SERVICE LOCATIONS, The narcotic count sheet must be completed by two (2) staff at the end of each shift for all narcotics or scheduled II drugs whether given by nurse or staff.  Incoming/Outgoing Staff will complete the Narcotic Count, if any controlled substances are available in home.  This includes a physical count of the narcotic indicating a true number reflecting the physical count upon arrival to shift.  If another staff is present, the count should be witnessed. 
• IN SUPPORTED LIVING SITES, there may not be two staff to count by nature of the schedule/service, therefore, if only one staff is present, that staff will physically count the medication and sign the count sheet with the number on hand. Narcotics may only be given as outlined in the delegated nursing program FOR WAIVER SITES.
• If any narcotic count is off or any discrepancy noted, staff must immediately contact Incident hotline and write incident report.
• The assigned QA will check narcotic count sheets during home visits.  Additionally, the contract nurse or facility nurse will also check narcotic sheets when visiting homes.
• Narcotics are to be counted will be kept locked in a lock box.  One person on duty will have a key.  At the end of that person’s shift, the key will be passed after a narcotic medication count has been done with the relieving staff or placed in designated secure location if no relieving staff. A narcotics key will remain in the medical office at ICF, CAC, and the Program Manager will lock up the spare key.

Medication disposal of expired, discontinued, or unused medications:

• The home staff/lead will separate any medications that are expired, discontinued, unused, or needing disposal.
• During home visits, the QA will be responsible to check all medications and remove any expired, discontinued, unused, or needing disposal and take them back to the office and immediately ensure that any unopened card/bottles are provided to Medication Services Coordinator to follow pharmacy protocol to return medication including logging on pharmacy form, placing in designated bag and ensuring that the courier driver returns to pharmacy. Any medication card or bottle that has been opened, must be disposed of by nurse (Medical Services Manager); disposal will be documented and witnessed by another personnel utilizing approved techniques for disposal.
• Records for wasting of medications must be kept on file for three (3) years.  Records to be stored in the office.

PRN Medications

• PRN medication orders must have specific instructions including the reason they are giving, when it is to be given, how much is to be taken, and how often to take.
• Topical PRN medications must also list specifically the area to which it is to applied.
• Staff must always check time of last dose before giving a PRN Medication.  Interval should be as ordered by the physician.
• Staff must always notify the CAST station when giving PRN medication. The CAST station will verify in the notes section of the MAR listing the time administered and then review within one hour the effectiveness of the PRN medication. The CAST personnel will document time reassessed, the effectiveness of the PRN, and any follow-up on the notes section of MAR. Staff initials will appear on the MAR as administering with a circle on MAR. When clicking on the electronic copy of the MAR, the effectiveness note will appear including a second set of initials identifying the CAST station personnel who took the call with all required notations.

Charting the Medication and Interruption Codes on MAR

At the ICF locations, all documentation is done electronically for medication administration. Nursing staff and delegated staff will receive individual training for medication administration and medical documentation. Open Door has emergency medication documentation logs and physician’s orders for completing med passes in the event of power failure or unavailability of electronic means.

• Charting may be done electronically utilizing the medication standards listed above with individual staff logins.
• All staff should be aware of each individual’s medication plan.  Some individuals may be independent in all or part of the task, some individuals require to be monitored while others require more direct supervision such as insuring that they have swallowed.  Staff initials on the Medication Sheet indicate that each individual’s service plan has been followed with regard to medications.
• All medications given are to documented by using the staff’s initials through electronic submission. A record of the staff initials and signatures are maintained in the electronic platform.
• When any medication is put on hold, the physician must write the order or a nurse can accept a verbal order directly from the physician. Once order is received, the incident hotline and nurse should be notified. The MAR will be transcribed to reflect an interruption code by the personnel initialing the MAR and placing a circle and placing in the notes that the medication was put on hold and providing information including the reason.
• When a medication is refused, the staff will document the MAR electronically and call nurse and the incident hotline immediately to see if they can assist with encouraging individual to take medication. The CAST station must be called to verify the refusal and place the circle on the MAR listing in the notes that medication was refused and any additional information.
• When an individual is on an activity or vacation day(s), the staff will package the required meds using a small clear plastic bag containing information from the medication label for each individual medication.  When staff are present for the activity/vacation, staff will be responsible to document the giving of each medication. 
• When an individual is without staff (going to family visit alone or vacation with natural supports), the staff in home will either have med card packaged from Pharmacy for a card that only has meds for the time period out of home OR- staff will pack the medications necessary. The family or natural support should sign off that they understand that they are responsible for the medication. Staff should give copy of MAR (paper format from pharmacy or electronic print out) and have family/natural support return medications and MAR when they return. Staff should document on the electronic MAR, out of facility and in notes be specific about giving meds to responsible person during time out of home, med orders, and any other details. The MAR will reflect out of facility–meds were packaged and given by natural support.  If individual returns and any medication discrepancy is noted during the visit away, staff will immediately call the Incident Hotline and nurse-on call. An incident report must be filed.
• When a medication order is discontinued (must be in writing by physician), the incident hotline and nurse must be notified. The IH or nurse is responsible to discontinue the medication on the electronic MAR. The MAR will show D/C in the MAR box to indicate that it is discontinued- the personnel must note their initials.
• If staff administered medication but cannot document due to malfunction or not being able to access the electronic MAR or other extenuating circumstances, staff will call the incident hotline and CAST station. The CAST station must clearly put in notes the time that med was administered, the reason it could not be administered, and staff calling, note must indicate med was given within the required time frame.

Self Medication and/or Assistance Procedure

• Self med assessments will be administered as outlined in OISP at least every three years. They will be updated adn reviewed yearly. The results of the self-med assessment will indicate those who are able to self-medicate
• Self medicating individuals do not fall under the delegated nursing rule; however all staff will still be trained in medication administration.
• Medication pill boxes may be used by individuals who are self medicating.
• Staff will provide assistance with medications as outlined in the rule.
• Self medicating individuals med minders/pill boxes can only be filled by a nurse, the individual self-filling, or an assigned family member per their OISP.  Staff may not fill the pill box.
• Staff will provide assistance by reminding the individual to take their meds, setting the med bottles down from storage area or opening bottles or pill boxes for them as outlined in the plan.

Delivery and Storage of Medications

• The pharmacy typically delivers routine medications to Corporate Office and to the ICF sites monthly.  Each med must be checked off with delivery sheet and medication list upon delivery. 
• The medications will be stored in locked medication room separated by individual.  For waiver sites, meds will be at Corporate office until the Lead staff picks up medication.   The Lead staff must sign for all medications and keep in sealed containers during transportation to the location.  Once arriving to location, medications must again be checked for accuracy with medication administration records.
• For ICF, all medications will be stored in either locked medication storage room at Park West by apartment or in the individual location medication carts at off-site ICFs.  ALL MEDICATION CARTS MUST STAY LOCKED unless they are being used and nurse/staff has them in their line of site.
• Any discrepancies with medications must immediately be called into pharmacy and incident hotline.   Nurses should report any discrepancies to nursing supervisor.

In the Locations:

• Store all meds in a cool, dry, dark, safe and secure area.
• Separate internal medications from external medications; i.e., Oral meds from creams or ear drops.
• Medications that require refrigeration will be kept in a locked box.  Staff and individual may each have a key.
• Medications may be stored by frequency of use. I.e., meds given four times a day may be in front of meds given at bedtime.
• It is the responsibility of each staff person to maintain an appropriate storage area for all medications.
• Individual’s medications should be stored separately. 
• ICF LOCATIONS-all med carts must be kept locked at all times when not in use or in nurse’s/staff’s site.

Monthly Medications Documentation Sheet and Monitoring

• The licensed nurse and/or agency designee is responsible for maintaining the electronic medication orders to match Physician orders in the Medication Administration Record.
  • All regular medications should be listed on the “routine” med sheet
  • All PRN (as needed) medications should be listed with specific instructions for staff that describe under what circumstances and conditions the PRN should be administered and how much/how often.
• ELECTRONIC DOCUMENTATION OF MAR: for electronic sites, nurse will monitor electronic medication list and documentation to ensure all match Physician orders and be responsible for overseeing medication lists for staff documentation. 
• Random house visits will be completed by QA staff. QA staff will complete medication audit when completing visits including observation of medication pass (if applicable to that time) and use the med pass observation form to note any issues for follow-up. This is routed to team and supervisors for follow-up.

Maintaining the Prescriptions

• Delegated staff will report to Program Director/Nurse for reordering of medications.
• Prescriptions should be called in to the designated pharmacy according to what is documented in the individual’s plan.  In some instances, the individual may be able to perform this task.  Always be aware of the medication plan outlined in the ISP.
• Refills should be obtained 2-3 days prior to the completion of the current medication/card bottle of medication.
• A call should be made to the physician when the last refill is obtained for a medication.  Usually another visit to the physician or a blood level is required in order to obtain another prescription of the medication.  Timing is imperative so that there is no delay in receiving the required medications.
• Over the counter (OTC) medications should be obtained by receiving an order from the physician.
• All changes in medications must be in writing by the physician on the Medical Appointment Report, physician order sheet and the physician’s prescription pad.  Prescriptions must be emailed to the SCL office when changes are made by telephone.
• The physician’s prescription must be faxed or emailed to the workshop when medications are taken during the workday.  Medications will be taken to the workshop by the Nurse, Lead or Program Specialist on a monthly basis (30 day supply) in a medication bottle with a pharmacy label and instructions.
• Nurses, Leads and Program Specialists will plan in advance for scheduled time off and vacations to insure that all medications are available during the time off. 
• Verify the name on the prescription, the dose and the number of refills with the doctor’s order BEFORE leaving the pharmacy to check for errors.
• The computer generated print out provided by the pharmacy listing the information about a specific drug should be placed in the individual’s medication book behind the medication sheets.
• If home health or other contract is responsible for medication or treatment orders, the staff will notify incident hotline if they do not show up within 30 minutes of the scheduled medication time.  Incident Hotline will notify home health or make other arrangements to ensure that medication is administered via nurse or other trained/certified staff.

Medication Identification and Side Effect information

SCL Provides tablets for each location/home. The tablets have access to Drugs.com which provides all required medication information including identification of the medication and all side effect information. As a back-up staff can also use the company-provided cell device in each home.

Staff Training Procedures

• All staff will complete a medication course within the first thirty (30) days of employment.
• All staff must perform a successful med pass demonstration, in the home, within thirty (30) days from last day of medication class.
• Staff may not pass medications until a successful med pass demonstration has been performed in the home with a licensed nurse.
• The licensed nurse may determine the need for additional training in medication information.
• The licensed nurse may review and revise procedures to ensure the quality of services to the individuals.

Staffing/scheduling requirements for Medication Administration or HRA:

• FOR SCL homes, ALL staff receive Cert I Medication Administration and HRA training during orientation period. They may not be left alone during medication times until all requirements for MAC AND HRA specific to the home needs are completed per the regulation.
• ALL staff receive individual specific training during their orientation period prior to administering any medication.
• The assigned QA for each location will check on medication administration and HRA needs when doing home visits. Any issues will be reported to incident hotline for team follow-up.
• If staff are in home, and the trained personnel responsible for medication administration or HRAs is absent or is not available, all staff must immediately notify the scheduling on-call phone.
• The scheduler on-call is responsible to ensure that trained personnel for that medication or HRA task are sent to home to ensure that the medication is administered by trained personnel.
• The CAST Station and Incident Hotline personnel will also maintain Medication Administration Certification.

Health-Related Activities (HRAs)

In any setting, all other prescribed health-related activities must be taught AND delegated by a nurse according to Ohio Board of Nursing OAC (Ohio Administrative Code) 4723-13. These activities require individual specific training, as well. The 13 HRAs Include:

• Taking vital signs
• Application of clean dressings that do not require health assessment
• Basic measurement of bodily intake and output
• Oral suctioning
• Use of glucometers
• External urinary catheter care
• Emptying and replacing ostomy bags
• Pulse oximetry reading
• Use of continuous positive airway pressure machines, including biphasic positive airway machines (CPAP & BiPAP)
• Application of percussion vests
• Use of cough assist devices and insufflators
• Application of prescribed compression hosiery
• Collection of specimens by noninvasive means

Prohibition on Health Related Activities and Administration of Medication

• If a DSP is unsafely performing HRAs or passing medications, the employer will take corrective action by not allowing further medication administration to occur, a notation is made in MAIS, and corrective action is taken.
• If corrective action is taken and DSP can resume activities, another notation is made in MAIS
• Denial, suspension, or revocation of certification can occur when there is a significant issue

DSPs are NOT permitted to:

• Administer intramuscular and intravenous injections
• Provide subcutaneous injections, except in specific instances with proper training (i.e.: Insulin)
• Administer medication through a nasogastric tube, unstable or unlabeled gastrostomy or jejunectomy tube
• Use debriding agent for treatment of skin conditions or minor abrasions

Last Revised: 2/25/2026