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Frequently Asked Questions
All personnel who assist residents with the self-administration of medications must receive the following training pursuant to Health & Safety Code 1569.69, and Title 22:(§87411):
(1) For facilities with 16 or more residents: 8 hours of hands-on shadowing training and 8 hours of other training; or
(2) For facilities with 15 or fewer residents: 2 hours of hands-on shadowing training and 4 hours of other training.
(3) In all facilities, personnel continuing to assist residents with the self-administration of their medication must complete four hours of training every 12 months.
After receiving the appropriate training, staff who assist residents with their medication should be competent in all of the following areas and must pass an examination demonstrating their comprehension of the subject matter, and competency:
a) The role, responsibilities and limitations of staff who assist residents with the self-administration of medication,
b) Terminology specific to medication assistance,
c) Different types of medication orders: prescription, over-the-counter, controlled,
d) Assistance procedures (in and out of the facility),
e) Medication documentation system used within the facility,
f) Proper storage, security, and disposal,
g) Process used for ordering medication, refills, and handling receipt of medications from the pharmacy,
h) Medication side effects, adverse reactions and errors,
Passing a test on medication management is an ambiguous accomplishment, as the test is not standardized within the industry, nor is it administered by a third party (i.e. CCLD or another regulatory/licensing board). Upon completion of the test, no state or national accreditation is issued; a record of completion, however, should be maintained by the facility in their personnel records.
Facilities with 16 or more residents are required to have a pharmacist or nurse review their facility's medication management program and procedures at least twice a year. Documentation of the review is mandated. Facilities with 15 or fewer residents are not required to seek such guidance.
There is not a specific regulation stating that RCFEs must centrally store all resident medications.
According to Title 22 (§87465), "medications shall be centrally stored under the following circumstances:
1) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom the medication is prescribed.
2) The medication requires refrigeration and the resident has no private refrigerator. Such medication may not be stored in the kitchen refrigerator. It must be kept in a safe and locked refrigerator that is not accessible to persons other than employees responsible for the supervision of centrally stored medication.
3) A physician, the administrator, or CCLD determines that because of potential dangers related to the medication itself, or due to the physical arrangements of the facility and the condition or the habits of other persons in the facility the medication must be centrally stored to ensure the safety of residents.
4) If a facility does centrally store its medication, the following requirements shall be actively in place:
a) The medications are kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of centrally stored medication.
b) Each and every container shall be maintained in compliance with state and federal laws, be labeled and carry all of the following information:
The name of the resident for whom it is prescribed.
The name of the prescribing physician (While not required, the physician's phone number is not a bad idea).
The name, strength, and quantity of the drug.
The date filled.
The prescription number and the name of the issuing pharmacy.
The instructions, if any, regarding control and custody of the medication.
The expiration date and number of refills.
c) Each resident's medications shall be stored in its originally-received container. No medications shall be transferred between containers, and no persons other than the dispensing pharmacist shall alter a prescription label."
(Please note that while most bottles issued by a pharmacy currently will have all of the above information printed on the label, CARR is informing you of these details should you encounter issues with storage and labeling of medications.)
To verify that all of these safeguards are in place at the facility you are considering, consumers can inquire about the following:
Their policy and procedures regarding medications/centrally stored medications;
Ask to see their storage units;
Possibly ask to preview a sample of their record keeping; (FYI:They might need to redact confidential information prior to your review)
Ask about the training and experience of those responsible for administering medications.
Review the facility's file for cited deficiencies, or grievances regarding medications (LIC 809s and/or LIC 9099s)
And most importantly, follow-up on all of these items consistently while in residence at a facility. Consider it a good way to avoid the possibility of a medication error.
Morphine is typically prescribed to individuals experiencing chronic or severe pain or those who are terminally ill. In assisted living facilities, residents prescribed morphine are most often times receiving hospice services. The intended use of morphine at the end-of-life is to maintain an appropriate level of comfort for the resident.
Morphine can be administered in many forms. The same rules that apply to administering other medications in the assisted living setting, apply to morphine. Most notable is the requirement that residents must be able to self-administer medications or, if unable, medications must be administered by a skilled medical professional only. For terminally ill residents, self-administration is often times not an option and, as pain can be unpredictable, the absence of an on-site skilled medical professional presents a challenge. (Hospice nurses do visit residents, but are not available at the facility 24/7 to meet unscheduled needs.)
To address this, Title 22 (§ 87633) allows family members or friends (NOT receiving monetary or any other form of compensation for their services) to administer medications (including morphine) to hospice residents who are unable to self-administer, as long as the following criteria are met:
- It is written in the hospice care plan.
- The family members have been trained by the hospice agency in proper administration.
- It is recorded in the plan, that if the family or friend is not available and/or fails to arrive at the appointed time, that a licensed health professional will be made available to attend to the residents needs and administer the medication.
A few other notes on morphine/medications:
Morphine pumps are permissible if:
The facility has received a Hospice Care Waiver
The hospice resident, hospice health care professional, or other appropriately skilled professional is administering the medication
The procedure is specified in the Hospice Care Plan
For medications that need to be pre-drawn into an individual syringe or oral dosing unit, the following shall apply:
- Only a registered nurse may pre-draw the medication for later administration
- The pre-drawn medication in the individual syringe or oral dosing unit must be labeled and properly stored
- Medications may be set up in advance for a period not to exceed 24 hours
When administering lethal medications such as morphine, residents should be closely monitored. More information about hospice care and morphine may be found here.
Notes in italics represent the views and/or experience of CARR regarding this topic and/or regulation.
Title 22 §87618
A facility may accept or retain a resident who requires the use of oxygen GAS if:
(1) the resident is mentally and physically capable of operating the equipment, is able to determine his/her need for oxygen, and is able to administer it him/herself *; OR
(2) intermittent oxygen administration is performed by an appropriately skilled professional.
*The facility is responsible for continuously monitoring the resident's ongoing ability to operate the equipment in accordance with the physician's orders.
Since a licensed professional is not required per regulation to be onsite 24/7 in an RCFE, in some cases the ability of a facility to guarantee intermittent administration and assistance by a skilled professional may be difficult.
The regulations do, however, require that the facility staff have knowledge of, and the ability to operate the oxygen equipment. But they are not allowed to assist the resident, per the regulations; only an appropriate skilled professional is allowed to provide this assistance.
In addition to the administration of oxygen, Title 22 includes the following requirements as they pertain to the oxygen equipment:
(1) The facility shall submit a written report to the local fire jurisdiction notifying them oxygen is in use at the facility.
(2) "No Smoking-Oxygen in Use" signs shall be posted in appropriate areas.
(3) Smoking shall be prohibited where oxygen is in use.
(4) Oxygen tanks that are not portable must be secured in a stand or to a wall.
(5) Plastic tubing from the nasal canula or mask to the oxygen shall be long enough to allow movement by the resident but not constitute a hazard to the resident or others.
(There are special conditions if oxygen tubing exceeds 7 feet in length. Refer to Title 22 or contact CARR if you require detailed information.)
(6) Oxygen from a portable source shall be used by residents when they are outside their rooms.
(7) Equipment shall be operable.
(8) Equipment shall be removed when no longer in use.
(9) Room size should be appropriate to accommodate all equipment.
A facility may accept or retain a resident who requires the use of LIQUID oxygen if:
(1) The licensee obtains prior approval from the licensing agency; AND
(2) If the resident is mentally and physically capable of operating the equipment, is able to determine his/her need for oxygen, and is able to administer it him/herself.
The regulations do not speak to a resident remaining in an RCFE if he requires assistance with liquid oxygen. Even if a licensed skilled professional is available to assist, it is not clear that the regulations allow this type of assistance. If this could be an issue for your resident, contact CCLD for regulatory clarification.
Title 22 §87608.
The following regulations pertain to postural supports:
(1) Supports shall be limited to devices used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of a bed, a chair, etc. Included here are physician-prescribed orthopedic devices (braces or casts) used for support of a weakened body part or correction of body parts.
(2) Supports shall be fastened or tied in a manner that permits quick release by the resident.
(3) A written order from a physician indicating the need for the support shall be maintained in the resident's record, and if necessary CCLD may require additional documentation to verify the order.
(4) If the use of the support changes the ambulatory status of a resident to non-ambulatory, the licensee shall ensure that the appropriate fire clearance has been secured prior to the use of the support.
(5) Under no circumstances shall postural supports include tying, depriving or limiting the used of a resident's hands or feet.
(6) Bed rails that extend from the head half the length of the bed and are used only for assistance with mobility shall be allowed.
(7) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and who have a hospice care plan that specifies the need for full bed rails.
Under Title 22, §87101(p)3), PRN (pro re nata) medication ". . . means any non-prescription or prescription medication which is to be taken 'as needed'." This prescribing protocol ('as needed') contrasts with other prescribing protocols, i.e every 12 hours, or three times a day, with meals.
Nothing in Title 22 authorizes caregivers to directly administer medications; this task is reserved for appropriately skilled professionals. Most facilities do not retain appropriately skilled professionals, since Title 22 does not require it. Therefore, it is imperative consumers clarify with facilities what the facility means when it advertises "Medication Management Services"; does the facility have a nurse on staff to oversee the handling of both prescription and non-prescription drugs?
To directly administer medications (per CARR's recent discussions with CCLD's Sacramento office), is to place the medication in a resident's mouth or, in the case of injections, to fill a syringe and/or inject a resident with medication. Unlicensed (not appropriately skilled professional) caregivers are not allowed to administer medications. They are allowed to prepare medications (i.e. dispense and pour). This preparation is what is meant by "assist with self-administration" in the regulations. Facilities that provide assistance with medications are responsible for accurately logging dosage and maintaining medical records, and for prompt communications with resident's physician.
When considering placement, the consumer should consider the ability of the resident to self-administer medications. Matching the resident's ability to the competency and capabilities of the facility is critical to be avoid medication errors.
Provided here is Title 22's (§ 87455 & § 87465) guidance and requirements for medication assistance.
RCFEs are allowed to accept or retain:
- Persons capable of administering their own medications,
- Persons who because of forgetfulness or physical limitations need only be reminded or to be assisted to take medication usually prescribed for self-administration,
- Persons receiving needed medical care from a visiting nurse.
1) Staff designated by the licensee may assist persons with self-administration as needed. Assistance shall be limited to the following:
- Medications usually prescribed for self-administration which have been authorized by the person's physician.
- Medications during an illness determined by a physician to be temporary or minor.
- Assistance required because of tremor, failing eyesight, and similar conditions.
- Assistance with self-administration does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's rights to refuse medications.
2) Staff shall be permitted to assist if:
- the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or non-prescription PRN ("as needed") medication.
- the resident's physician has stated in writing that the resident is unable to determine his/her own need for PRN medications but can communicate his/her symptoms clearly. Provided there is written direction from the physician, on a prescription blank, specifying all administering information; the medication is given according to the physician's directions; a record of each dose is maintained in the resident's record (including the date and time given, the dosage, and the resident's response).
- the resident is unable to determine his/her own need for PRN medications, and is unable to communicate symptoms clearly. Provided staff contact the resident's physician prior to each dose, describe resident's symptoms, and receive direction to assist the resident in self-administering that dose of medication; the date and time of each contact with the physician, the physicians directions, are documented and maintained in resident's record; the date and time the PRN med was taken, dosage, and resident's response recorded.
3) For every PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank maintained in the residents file and a label on medication (both containing specific symptoms to indicate need, exact dosage, minimum number of hours between dosage and maximum number of doses allowed in 24-hour period).
In conversations between CCLD's Duty Worker, and CARR in May 2011, to administer PRN ("as needed") medications, a physician must be contacted prior to each dosage. Medications administered daily must be given according to the physician's directions which must be reflected on the prescription bottle and in the resident's file (§87465 (c)(2)). Records of daily medications must be maintained as well.
Title 22, Section 87465 (a)(6)(D): "Incidental Medical and Dental Care Services," provides the state's requirements and guidance for crushing medications.
There are only two reasons, under the regulations, when a medication can be crushed: to enhance swallowing, or to disguise the taste. Crushing a medication cannot be done to trick a resident into taking a medication s/he would otherwise refuse.
Prior to any crushing of a resident's medications, the facility administrator must consult with a pharmacist and the physician. The consultation can be done verbally or in writing, but either way, must be documented; documentation becomes part of the resident's permanent medical record. Documentation required includes:
- instructions when and how often the medication will be given.
- the names of the doctor and pharmacist, along with their business names and the date of the conversation
- a written statement that the medication can 'be safely crushed without losing potency,"
- identification of the foods and liquids the crushed medications can be mixed with, and
- instructions for crushing and mixing medication.
- a consent form giving authorization for the medication to be crushed signed by either:
- The resident if s/he isn't conserved. If the resident cannot sign his name, his mark must be witnessed by a person who is not the license nor an employee of the facility.
- The resident's conservator when the conservator has authority to make decisions on this issue.
[Some medications (i.e. slow release, extended release, enteric coated, gels) cannot be crushed, and may be very dangerous for the resident if they are: the resident will receive too much of the dose too quickly. For that reason, a doctor’s order is needed before any medication can be crushed, then dosed, to a resident.
The facility cannot unilaterally decide to crush and dose a medication for your resident. If you are uncertain about why your resident is receiving crushed medications, ask to see the documentation required under Title 22. If the facility doesn't have the documentation, file a complaint with CCL.
Medications, after crushing, can be mixed with a small amount of applesauce, yogurt, pudding or mashed potatoes – the doctor or the pharmacist will give guidance on an appropriate carrier at the time the crushed-medication order is received.
- Crushing medications without a doctor's order could lead to adverse effects on the resident - including death.
- If your resident has swallowing difficulties, notify the resident's doctor at the time the medication is being prescribed, as many medications are available in alternate forms (patches, suppositories, liquids, inhalers). /
Title 22 §87628 & 87629
Diabetes is an on-going medical condition and without proper management can result in serious medical complications. RCFEs are licensed as non-medical facilities and are not required to have on staff a licensed skilled professional. Therefore, the consumer should know what is legally allowed within the RCFE setting regarding diabetes care, and compare that to the current and potential needs of the resident.
Facilities are allowed to accept or retain a resident who has diabetes if:
(1) the resident is able to perform his/her own glucose testing with blood or urine specimens and is able to administer his/her own medication (which includes both oral and injections)
(2) or if the resident has the medication administered by an appropriately skilled professional.
If the resident is able to manage her condition independently, then there is no need to read further. If the resident requires assistance in managing her diabetes and there is a skilled professional (i.e. an RN) on-staff available 24/7 to assist, then you will want to be sure there is good communication between yourself/the resident, the skilled professional and other staff members. If the resident requires assistance in managing her diabetes, and there is not a skilled professional on staff and readily available, then review the remainder of this FAQ to review that placement in such a facility will meet the resident's specific needs.
Regarding injections, unless they are a licensed skilled professional, staff cannot mix medication, fill a syringe, nor can they administer injections.
Facilities are charged with the responsibility of ensuring that sufficient amounts of medicines, testing equipment, syringes, needles and other supplies are maintained and stored in the facility.
Facilities must also ensure that syringes and needles are disposed of properly (per California Code of Regulations, Title 8, §5193 & Title 22 § 87303(f)(2).
Managing diabetes is not simply medication management; proper diet and sufficient physical activity are important as well. Title 22, §87628 states that the facility is responsible for providing modified diets as prescribed by a resident's physician. Discuss with the facility its ability to consistently accommodate dietary needs. Deviations from established/pre-approved menus are known to occur in some facilities. Equally important: double-check that the physical activities scheduled on the facility's activities calendar are sufficient and actually take place.
Contact the LPA assigned to the facility if you have concerns regarding your diabetic resident; in many cases, facility personnel are unclear as to what they are allowed and not allowed, to do.
If you experience unlicensed personnel performing functions reserved for skilled professionals, report the incident to CCLD immediately. LPAs are required to issue a notice of deficiency to the facility immediately, citing Regulations §87629(a) and (b)(1), and §87465 (a)(6), per CCLD's Evaluators Manual.
Title 22 §87465
The regulations read:
"When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility."
CCLD (or the Department) makes Form LIC 622 available to facilities on its website. This form is designated as The Centrally Stored Medication and Destruction Record.
Most larger facilities have 'corporate' policies and procedures in place to record centrally stored medications. Some smaller facilities have them in place as well. However, there is no explicit declaration in the facility's public file as to whether or not they record such information, or if they meet the criteria requiring central storage.
Assuming that precise information regarding a resident's medications is being recorded is not valid. In CARR's experience, we have seen documentation of facilities using shoe boxes as storage units, with post-it notes serving as official documentation for the next shift, or other insufficient techniques. We have also seen incomplete and inconsistent use of LIC 622s. Asking questions and being vigilant with regard to a facilities' centrally stored medication policies and procedures is consumers best way to obtain confidence in how the facility manages medications.