September 25 | Is It Medication Assistance, Or Medication Administration?

The nuanced differences between medication assistance (called “self-administration with assistance” by the pharmacy board) and medication administration require looking at different Washington Administrative Codes (WACs) – one from the Washington State Board of Nursing (WAC 246-840), one from the Washington State Board of Pharmacy (WAC 246-945), and of course one from the Department of Social and Health Services (WAC 388-78A).

With three different regulatory chapters to consider, in three different state agencies, it’s no wonder citations are rampant in the areas of medication services for assisted living facilities. This article aims to clear up these differences by referencing regulations and real-world applicability.

MEDICATION ASSISTANCE

First, let’s start with medication assistance. The definition of this service can be found in WAC 388-78A-2020: “Medication assistance” means assistance with self-administration of medication rendered by a nonpractitioner to a resident of an assisted living facility in accordance with chapter 246-945 WAC.

This definition itself is not particularly helpful, until WAC 246-945 is read thoroughly. WAC 246-945-714 calls out exactly what is included in the task of medication assistance. First, this WAC states that a resident may receive medication assistance from nonpractitioners (meaning, caregivers). Then it goes on to list what might be included in medication assistance:

• Reminding or coaching the individual to take their medication;
• Handing the individual their medication container;
• Opening the individual’s medication container;
• Using an enabler, except if a nonpractitioner uses the individual’s hand as an enabler, the nonpractitioner may only steady or guide an individual’s hand while the individual administers a medication to themselves and may not engage in “hand-over-hand” administration;
• Placing the individual’s medication in their hand;
• Setting up a diabetic device for self-administration;
• Handing injectable medication to an individual for self-administration;
• The transfer of an individual’s medication from one container to another container for the purpose of preparing an individual dose; or
• Medication alteration (for example crushing a pill, splitting a tablet in half, or opening the contents of a capsule and mixing in pudding). An individual must be aware that their medication has been altered. [Of note: a practitioner must approve of the alteration and that approval must be documented in the resident’s record. By way of pharmacy definitions, a “practitioner” includes an MD, APRN, PA-C, dentist, RN, or LPN.]

This section of WAC also clarifies that, “a nonpractitioner shall not provide medication assistance to individuals that involves intravenous medications or injectable medications, except setting up diabetic devices for self-administration or handing injectable medications to an individual for self-administration.”

In the typical assisted living, much of what care staff do with medications likely falls under the category of medication assistance. For instance, medications are likely stored in a medication cart, and near the time of delivery, the trained caregiver removes the medication from its original container and places it in an enabler, such as a medication cup or an oral syringe, for instance. The caregiver then delivers the medication to the resident, hands it to him or her, encourages or cues the resident to take the medication, and watches the resident take the medication. All these features represent medication assistance.

The act of assisting a resident to take their medication is considered an activity of daily living in Washington state (see WAC 388-106-0010) and therefore requires no nursing oversight or involvement in the task. The skill of medication assistance does, however, require the caregiver to know what they are doing and their limitations to assisting with medications. The expectation that the facility provides sufficient trained staff is captured in WAC 388-78A-2450 (1)(a).

MEDICATION ASSISTANCE: THE ASSISTED LIVING CAVEAT

Washington’s assisted living facilities enjoy an extension of the definition of “medication assistance” that other home- and community-based care settings do not. Per WAC 246-945-716, a resident can fall under the “medication assistance” umbrella if he or she cannot physically get the medication where it needs to go but can accurately direct the caregiver to get the medication there. In a different part of the same WAC, there is some clarity added that this caveat does not pertain to injectable medications.

This relatively small section of WAC offers a huge opportunity to residents and staff: provided a resident cannot physically perform actual administration himself due to a physical condition, he can direct the caregiver to do it for him. A great example: a resident who has limited mobility has an order for medicated cream to be applied to his foot. He cannot reach the area himself, so he tells the caregiver where to apply it and essentially supervises this task.

In cases of “accurately directing,” it is important that the facility include this caveat in the resident’s assessment and negotiated service agreement, and the caregiving staff are trained on this nuance.

MEDICATION ADMINISTRATION

This term is defined, also in WAC 388-78A-2020: “Medication administration” means the direct application of a prescribed medication whether by injection, inhalation, ingestion, or other means, to the resident’s body by an individual legally authorized to do so.

Of highlight here are two terms: direct application and an individual legally authorized to administer medications.

The term “direct application” means the resident is not applying the medication themselves, but rather another person must do this task. Whether a resident requires direct application depends on their abilities (both physical and cognitive) and preferences.

“An individual legally authorized” to administer medications includes health care practitioners (RNs, LPNs, MDs, APRNs, etc) as well as nursing assistants or home care aides via RN delegation. In assisted living, the most common individuals to administer medications are delegated caregivers and licensed nurses. There are some medications that a caregiver cannot legally administer via delegation, including injectable medications other than insulin; in these cases, a licensed nurse would need to administer. Of course, should family assistance with medications be allowed by the facility, residents’ families can also serve in this capacity.

CONCERNS AND OPPORTUNITIES

Residents’ abilities and preferences may mean they receive medication assistance for some medications, and medication administration for others. The assessment and negotiated service agreement must be clear on which medications (or types of medications) require which level of service; this ensures the resident receives the level of service needed and staff do not work outside their scope of practice.

All caregiving staff assisting with medications must be trained to do so. While there is no standardized training requirement, WHCA does offer a medication assistance training program for member facilities. Likewise, caregivers who will be administering medications via delegation must successfully complete the nine-hour Core Nurse Delegation training and, if administering insulin, the three-hour Focus on Diabetes Delegation course. WHCA has combined all three of these classes – Medication Assistance, Core Delegation, and Focus on Diabetes Delegation – into one course (MedTechU) available only to members.  In addition, we have created free access videos to RNs wishing to learn more about how to delegate in assisted living; others working in assisted living can also access these free videos and forms to learn more about the delegation program.

Next month’s article will cover medication errors.

For questions about medication management or other assisted living topics, email Vicki McNealley at the WHCA office.