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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:


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:

  • In the med cards or bottles, med sheets or during the medication assistance process.
  • Notify the RM team immediately and then notify the nurse on-call, if applicable.
  • Complete Incident Report through website
  • All medication incident reports will be reviewed and investigated.  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.
  • If determined necessary by the Incident Hotline the following will occur:
  • Nurse notified to correct medication error
  • Physician notified
  • Lead/Program Coordinator notified
  • Staff removed from work schedule
  • FCBDD notified, when applicable
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 box/bottles 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. (For JT, designated staff may do this at the direction with oversight from nurse)
  • Only a licensed nurse can add to, delete from or discontinue an order given from a physician. (For JT, designated staff may do this at the direction with oversight from nurse)
  • All narcotics or schedule II drugs that are being given to a individual by staff or a nurse must have a narcotic count sheet.  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.  The assigned nurse for that home will also do a narcotic count at the end of each month when doing the monthly medication sheet changeover.  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. A narcotics key will remain in the medical office at CAC, and the PM has spare keys. Narcotics may only be given as outlined in the delegated nursing program.   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.  If any narcotic count is off, staff must contact Incident hotline and write incident report immediately. Staff will complete the narcotic count in electronic documentation system; any discrepancies will be reported to the incident hotline immediately. 
  • Medications that have been discontinued will be wasted by the nurse with another staff as a witness.
  • Records for wasting of medications must be kept on file for three (3) years.  Records to be stored in the home filed by month.
  • When medication changes occur, for example a decrease or increase for the same medication, the nurse may place a medication change sticker to the pharmacy label.  This will call to the staff’s attention that a change has been made in the individual’ medication and that the label does not reflect the current order.  The staff will give the medication based on the transcription as written on the medication sheet.  When the medication prescription is refilled, the pharmacist will create a new label to reflect the physician’s order.
  • PRN Medications
    • Must have specific instructions as to why, when, how much and how often to take. 
    • Always check time of last dose before giving.  Interval should be as ordered by the physician.
    • Always document reason for giving on the PRN med sheet. This should also include the specific complaint and later document action/reaction to medication, ie; relief noted or feels better.
    • PRN medications may be given from stock bottle as prescribed by physician, 
    • If a PRN medication, for example Tylenol, is prescribed as routine daily medication, a label must be on the bottle/med card specified for a specific individual
Charting the Medication

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

  • 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.
  • For errors in documentation such as: chart on wrong box, ink blots, etc; or errors in taking medications such as wrong individual, wrong dose, wrong time, missed med, gave med previously D/C’d or medication not available, follow steps below:
  • Circle error (initials must be in the circle)
  • List date, time, initials and brief description of error on the back of med sheet.
  • All medications given are to documented by using the staff’s initials.  However, the following codes are acceptable:
    • W =  Workshop
    • H  =  Hospital
    • R  =  Refused
    • V  =  Vacation
    • D/C = Discontinued
    • L  =  Leave of Absence
  • When an individual is on an activity or vacation day(s), the staff will package the required meds using a small clear plastic bag for each individual medication and a LOA sticker.  The staff will document the giving of each medication on the LOA sticker.  When the staff person returns to the home with the individual, he/she will peel the sticker from the LOA plastic bag and place on a temporary medication sheet placed behind the monthly medication sheets.  On the original medication sheet the staff person will document an  L or V which will correspond to the documentation on the temporary medication sheet. 
  • 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 special fill 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) 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, providing paper MAR, and any other details. The MAR on Brittco will reflect out of facility–meds given by natural support.  
Self Medication and/or Assistance Procedure
  • Self med assessments will be obtained from providers as outlined in IPP/ISP.
  • 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 delegated nursing rule.
  • Self medicating individuals must fill their own med 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.
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 or in the individual location medication carts.  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
  • The licensed nurse is responsible for preparing the monthly Medication Sheet for the following month. The following codes are acceptable:
    • W =  Workshop
    • H  =  Hospital
    • R  =  Refused
    • V  =  Vacation
    • D/C = Discontinued
    • L =   Leave of Absence
  • All regular medications should be listed on the “routine” med sheet and all PRN (as needed) medications should be listed on the “PRN” med sheet.
  • Only yellow highlight should be used to indicate when medications are discontinued.
  • 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. 
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 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.
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.

Last Revised: 6/6/22

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