Medication Setup 
in Assisted Living and Adult Day Care

PDF Version of DQA 12-007  (PDF, 53 KB)

Medication Setup in Assisted Living and Adult Day Care

Issue

Who may set up medications for residents/tenants/participants to take or for unlicensed assisted living staff or adult day care staff to administer?

Assumptions

Medication setup by personnel other than a physician or pharmacist involves medications that have already been dispensed by a pharmacist or physician and meet prescription-labeling requirements under Wis. Stat. § 450.11(4).

Medication setup means the placing of medications into another container-like a medication planner-for easier administering at a later time. Medication setup does not include preparing and immediate administering of the medication by the person who prepared it.

Best Practice

Each manipulation of a medication creates an opportunity that invites medication errors. Although medication setup is done with the best of intentions, taking the medication out of one container and placing into another creates a situation that increases the number of errors. Less handling of the medication decreases the potential for errors that may occur between the manufacturer/distributor
and the person who receives the medication. Therefore, it is highly recommended that pharmacists dispense the medication initially in the specialized packaging needed like medication planners or medication cards.

However, current assisted living regulations and adult day care standards may allow others to set up medications in different packages than that which was dispensed from pharmacies. The following analysis addresses the regulations or standards that affect medication setup. It is highly recommended that all providers consult with a pharmacist for alternative packaging solutions if medication setup is being considered.

Analysis

Adult Day Care (ADC)

Standard I.F. (3)(c)-Over-the-counter and prescription medications shall remain in the original labeled containers and be stored in a locked, safe place.

• Medication Administration by Adult Day Care Staff

If ADC staff is administering medications, staff need to take medications out of the original package provided by the pharmacy. Labeling is done by the pharmacy as required by pharmacy regulations.

Per this memo, if the ADC has a registered nurse, that nurse may set up and label medications and delegate to ADC staff the responsibility to administer medication to participants. The ADC registered nurse may delegate medication setup and labeling to a licensed practical nurse.

If the adult attending the day care comes from a community-based-residential-facility (CBRF), Residential Care Apartment Complex (RCAC), adult family home (AFH), or another DQA regulated facility, the ADC can accept and use the medications that have been set up in those facilities. Or have the CBRF, RCAC, AFH or nursing home send the original packaged medications provided by the pharmacy.

Another alternative for an ADC is to ask the pharmacy to supply two packages, one for use in the ADC and one for use at the CBRF, RCAC, AFH or the nursing home. If the ADC has a nurse, it is acceptable for the nurse to review the medications to determine their safety. If the nurse feels the medication's integrity is compromised the nurse may decide the medications are unusable and require the medications to come in a package provided by the pharmacy. ADCs that control and administer medications are encouraged to consult with a pharmacist regarding appropriate packaging and storage alternatives.

• Participant Self-Administration

If the participant is responsible for self medication management, the individual service plan (ISP) will so indicate. Participant can set up and label as they wish.

Adult Family Homes (AFH):

Wis. Admin. Code § DHS 88.07(3)(a)-Every prescription medication shall be securely stored, shall remain in its original container as received from the pharmacy and stored as specified by the pharmacist.

• Medication Administration by AFH Staff

If AFH staff is administering medications, they need to take the medications out of the original package provided by the pharmacy. Labeling is done by the pharmacy as required by pharmacy regulations.

• Resident Self-Administration

Per this memo, Wis. Admin. Code § DHS 88.07(3)(a) is waived for residents who per their individual assessment and services are determined to be able to self administer medications. In these cases residents could, on their own, setup medications or have family members assist them. The labeling can be determined by the resident or family, but it is recommended that the facility know what medications are being taken, and in what dosage, so that this information can be given to emergency personnel or others, as may be necessary.

Residential Care Apartment Complex (RCAC):

Under Wis. Admin. Code § DHS 89.23(2)(a)2.c., an RCAC shall have the capacity to provide "nursing services: health monitoring, medication administration and medication management."

Under Wis. Admin. Code § DHS 89.23(4)(a)2., "nursing services and supervision of delegated nursing services shall be provided consistent with the standards contained in the Wisconsin nurse practice act. Medication administration and medication management shall be performed by or, as a delegated task, under the supervision of a nurse or pharmacist."

Setting up medication is listed under "medication management," which is a nursing service.

• Medication Administration by RCAC Staff

If RCAC staff, who are not RNs, are administering medications, that service is listed in the service agreement and falls under nursing services. This requires RN delegation which can only be done by an RN. The RN may delegate the setting up of medication to a licensed practical nurse (LPN). The RN may also delegate this activity to other qualified staff. There are no specific requirements for labeling. However, it is recommended that the facility at least have the resident's name on the package, name of the medication, strength of the medication and instructions for use. The RCAC should maintain the original package they received from the pharmacy until all the medication is gone.

• Tenant Self-Administration

Tenant assessment indicates the tenant is capable and responsible for medication management. The tenant may set up and label medications as they wish.

Community-Based Residential Facilities (CBRF)

Wis. Admin. Code §DHS 83.37(1)(b) "Medications. Prescription medications shall come from a licensed pharmacy or a physician and shall have a label permanently attached to the outside of the container. Over-the-counter medications maintained in the manufacturer's container shall be labeled with the resident's name. Over-the-counter medications not maintained in the manufacturer's container shall be labeled by a pharmacist."

Wis. Admin. Code §DHS 83.37 (2)(c) "Medication administration not supervised by a registered nurse, practitioner or pharmacist. When medication administration is not supervised by a registered nurse, practitioner or pharmacist, the CBRF shall arrange for a pharmacist to package and label a resident's prescription medications in unit dose. Medications available over-the-counter may be excluded from unit dose packaging requirements, unless the physician specifies unit dose."

Wis. Admin. Code §DHS 83.37 (3) "MEDICATION STORAGE. (a) Original containers. The CBRF shall keep medications in the original containers and not transfer medications to another container, unless the CBRF complies with all of the following:
1. Transfer of medications from the original container to another container shall be done by a practitioner, registered nurse, or pharmacist. Transfer of medication to another container may be delegated to other personnel by a practitioner, registered nurse or pharmacist.
2. If a medication is administered by CBRF employees and the medication is transferred from the original container by a registered nurse, or practitioner or other personnel who were delegated the task, the CBRF shall have a legible label on the new container that includes, at a minimum, the resident's name, medication name, dose and instructions for use. The CBRF shall maintain the original pharmacy container until the transferred medication is gone.
(b) Unit dose packaging. For use during unplanned or non? routine events or activities, employees who have completed medication administration training as required in s. DHS 83.20 (2) (d) may transfer unit doses of medications into packages for the resident."

• Medication Administration by CBRF Staff

No RN or practitioner supervision. In this situation, a pharmacist must do all packaging and labeling of a resident's prescription medications in unit dose. Wis. Admin. Code § DHS 83.37(2)(c).

With RN or practitioner supervision. In this situation, medications must be obtained from a pharmacy and the pharmacist must label the medications appropriately according to Wis. Stat. § 450.11(4). The CBRF shall ensure that: the RN, practitioner or pharmacist coordinates, directs and inspects the administration of medications and the medication administration system; and that they participate in the resident's assessment under s. DHS 83.35(1) and development and review of the individual service plan under s. DHS 83.35(3) regarding the resident's medical condition and the goals of the medication regimen. Wis. Admin. Code § DHS 83.37(2)(b).

• Resident Self-administration

In the case where the CBRF is not controlling the medication and residents are taking their own medications, residents may set up medications for themselves or have family members do it. No labeling is required, but the CBRF must have a list of medications the resident is taking, and in what dosage, so that this information can be given to emergency personnel or others, as may be necessary. Wis. Admin. Code § DHS 83.37(2)(a)2.

All Providers

For unplanned or non-routine events staff with appropriate training may place single doses of medications into other packages for the resident or resident's guardian to administer during the event. Planned or routine events are subject to the setup provisions as stated within this memo. It is highly recommended that all providers consult with a pharmacist for alternative packaging solutions for planned or routine events.

The following table is a quick reference for the analysis contained in this memo.

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Last Updated: May 15, 2012