Medication Aides – What the Laws and Rules Say

This independent study has been developed for nurses to better understand the new laws and rules relative to medication aides.

1.46 contact hours of Category A (Law and Rules) will be awarded for successful completion of this independent study.

The Ohio Nurses Association (OBN-001-91) is accredited as a provider of continuing education in nursing by the AmericanNursesCredentialingCenter’s Commission on Accreditation.

Expires 6/2016.

Directions

1. Please read the below article carefully.

2. Complete the post-test, evaluation form and the registration form.

The post-test will be reviewed. If a score of 70 percent or better is achieved, a certificate will be sent to you. If a score of 70 percent is not achieved, a letter of notification of the final score and a second post-test will be sent to you. We recommend that this independent study be reviewed prior to taking the second post-test. If a score of 70 percent is achieved on the second post-test, a certificate will be issued.

If you have any questions, please feel free to call Zandra Ohri, MA, MS, RN, Director, Continuing Education, zohri@ohnurses.org, 614-448-1027, or Sandy Swearingen, sswearingen@ohnurses.org. 614-448-1030, Ohio Nurses Association at (614) 237-5414.

Objectives:

1.   Describe the training an individual must complete to become a Certified Medication Aide.

2.   Identify three prohibitions relative to medication Administration by a Certified Medication Aide.

Developed by: Janice K. Lanier, RN, JD. Reviewed by Kathleen Morris, MSA, RN, Director, Nursing Practice, Ohio Nurses Association. The authors and planning committee members have declared no conflict of interest.

Disclaimer: Information in this study is intended for educational purposes only. It is not intended to provide legal and/or medical advice or to be a comprehensive compendium of evidence-based practice. For specific implementation information, please contact an appropriate professional, organization, legal source, or facility policy.

Introduction

Beginning in May, 2006 non-nurses were authorized to administer certain medications in nursing homes and assisted living or residential care facilities. Initially, this was a pilot program so only certain facilities were involved. As of March 26, 2009, medication aides could be used statewide. Although nurses may no longer be performing the actual task of handing a medication to a resident; applying a topical medication; or administering eye, ear, or nose drops, they will continue to be responsible for the overall safety of the residents relative to medication administration. For that reason, it is essential for nurses to know the extent of the authority granted to medication aides by Ohio law and the extent of the nurses’ ongoing duties when delegating medication administration to a certified medication aide. This study provides background information regarding the law, reviews principles of delegation and communication essential for safe practice, outlines the Board of Nursing rules that define how medication aides will be trained and regulated, and highlights nursing responsibilities relative to medication aides in a nursing home or residential care facility utilizing certified medication aides.

Historical perspective

For many years the long-term care industry urged the Ohio General Assembly to join the growing number of states that authorize non-nurses to administer medications in nursing homes and assisted living (residential care) facilities (RCFs). Nursing organizations such as the Ohio Nurses Association (ONA) and consumer groups were able to repeatedly defeat the proposal, citing resident safety issues. Then in 2004-2005, despite nursing’s ongoing concerns, the powerful long-term care lobby was able to convince legislative leaders and key individuals in Governor Bob Taft’s administration that “medication aides” were necessary. Because of the shortage of nurses working in long-term care and the expected cuts in Medicaid reimbursement to nursing homes necessitated by state budget constraints, the idea of medication aides became a foregone conclusion to state health policy makers. Nursing’s legislative fight then became focused on ways to best assure resident safety. The result of those efforts are reflected in the safeguards that ultimately became part of the statutory language enacted by the legislature.

On July 1, 2005 Ohio law that specifies who can administer medications was expanded when Gov. Taft signed HB 66 (the 3,000 page state budget bill) giving the Ohio Board of Nursing authority to regulate a new entity–certified medication aides (medication aides or CMAs), and to develop the mechanisms needed to appropriately train would-be CMAs.  Sections 4723.61 through 4723.69 of the Revised Code were added to the Nurse Practice Act, and the Board of Nursing was directed to have regulations in place to implement the statutory mandate no later than February 1, 2006.[1]

In response to nursing’s concerns about the lack of any data to show whether medication aides pose a risk to resident safety, the legislature required the use of medication aides to first be tested in limited pilot programs to be operated for a specified period of time.  The use of medication aides became a statewide reality on March 26, 2009. The Board’s rules governing medication aides can be found in Chapter 4723-27 of the Ohio Administrative Code.  As of 2013, the Board reported it had certified a total of 163 medication aides in Ohio.

Who are medication aides?

Not just anyone can call himself/herself a “medication aide”.  Only individuals certified by the Board of Nursing may use that title and administer medications.  To be eligible for this certification by the Board, an individual must:

  • Be at least 18 years of age;
  • Hold a high school diploma or GED;
  • Be a state tested nurse aide if working in a nursing home or have at least one-year of      direct care experience if working in an RCF; and
  • Complete a criminal records check.

Eligible individuals must also satisfactorily complete the required medication aide training program, pass a board authorized standardized examination, and obtain certification from the Board of Nursing.  Certification as a medication aide must be renewed biennially with the CMA required to complete 15 hours of continuing education each renewal cycle.  The continuing education must include one hour related to Chapter 4723 of the Revised Code and the rules of the Board of Nursing; one hour related to establishing and maintaining professional boundaries; and ten hours related to medication or medication administration.  The remaining three hours may cover any other related topic.[2]

The Board will not issue a medication aide certificate by endorsement. That means if someone has been a medication aide in a state other than Ohio, that individual must still complete the required training program, pass the examination, and meet all other criteria set forth by the Board to be eligible for a medication aide certificate.

If a medication aide allows his/her certificate to go inactive or lapse for more than two years, that person must retake and successfully complete the medication aide training program within six months prior to submitting an application to re-instate the certificate.

Practice Tips

Individuals who qualify to be a CMA by virtue of having one-year of direct care experience in an RCF may not administer medications in a nursing home. Their certification document will include documentation of this restriction.  If these individuals subsequently satisfy the requirements to become a state tested nurse aide, the Board will issue an unrestricted certificate. 

Nurses in administrative roles should check the wallet-sized certificates issued by the Board to determine the extent of the CMA’s authority with respect to medication administration and to verify that the certificate is current and valid.

The Board may take disciplinary action affecting a medication aide’s certificate according to processes used to take action involving licensed nurses and other individuals regulated by the Board. The same infractions that can result in disciplinary action for licensed nurses apply to CMAs as well and are set out in Rule 4723-27-09 of the Administrative Code. Board action involving CMAs will be posted on the Board’s web site (www.nursing.ohio.gov) and publicized in the Board’s quarterly publication, “Momentum.”

What medications may a CMA administer?

The enabling statute is relatively non-specific regarding the medications that may be given by a medication aide.[3]The law states that the CMA may give oral medications, topical medications, medications administered as drops to the eye, ear, or nose; medications given rectally or vaginally, and medications requiring administration on an as-needed basis only if a nursing assessment is completed before the medication is administered. The Board rules go on to define “oral medication” as anything that can be taken by mouth[4], which would therefore include metered dose inhalers. Nose drops are interpreted per Board rule as including nasal sprays (aerosols, nebulizers and inhalers provided no oxygen is included in the administration and no dosage calculation is required), and ointments include preparations that are to be administered to the eyes or ears.[5]Topical medications may be applied to intact skin only.

Practice Tips:

A medication aide is not limited to administering unit dose medications provided there is no dosage calculation or “pill splitting” required.

Medication aides may administer medications prescribed by any authorized prescriber, including an advanced practice registered nurse holding prescriptive authority.

Medications administered by a medication aide must come from a properly labeled container that includes the medication name, the medication dose, the name of the resident to whom the medication is to be given and the expiration date of the medication. An aide may administer a contingency drug, provided it is stored and supplied in accordance with pharmacy board rules AND are supplied by the delegating nurse to the medication aide. In other words, the CMA may not have independent access to contingency medications.

Medication available over-the-counter must include the original manufacturer’s label and must be purchased and prescribed for the resident.

Medication aide authority—Delegation[6]

A medication aide has no independent authority to administer medications. Rather, a CMA’s authority arises solely through delegation by a registered nurse (RN) or licensed practical nurse (LPN) acting at the direction of an RN.  Further, the delegating nurse must hold a current valid license authorizing medication administration that has no medication-related restrictions on it imposed by the Board of Nursing.  Nurses who are participating in one of the Board’s alternative programs (the alternative program for chemical dependency or the practice intervention and improvement program) may delegate medication administration unless the participation agreement entered into with the Board restricts the authority of the nurse to administer medications.

Although the law and rules state that nurses may not withdraw delegation on an arbitrary basis or for any purpose other than those related to resident safety,[7]nurses remain responsible for fulfilling their own duties relative to delegation.  These duties include evaluating both the resident’s needs and the aide’s skills and abilities, communicating the parameters of the delegated responsibility, and supervising the aide’s performance. It is through this evaluation and assessment process that the nurse determines whether there are safety reasons for withholding/withdrawing delegation.  A registered nurse or licensed practical nurse who delegates in accordance with standards for delegation will not be liable in damages for injury, death, or loss to person or property that arises from the actions or omissions of a CMA.[8]

Evaluation

The principles underlying the delegation of medication administration to a certified medication aide are similar to those guiding delegation of any nursing task or activity. That means the nurse must evaluate the resident’s mental and physical stability, the medication to be administered, the time frame during which the medication is to be administered, the route of administration, and the ability of the medication aide to safely administer the medication in light of the above considerations. For example, a CMA is passing medications and one of the residents who is to receive an antibiotic begins to complain of nausea and pruritus.  In addition, the resident, who in the past has been compliant with the medication regimen, is suddenly adamant about not taking the medication. Even though the CMA has been safely administering the drug for several days, it is the nurse’s responsibility to assess the resident’s status and take appropriate steps to assure that the antibiotic is not administered if doing so would jeopardize the resident’s safety. Similarly, if one of the medications the CMA is to administer is an eye drop, the nurse must verify that the aide actually demonstrated competence using that route of administration during the medication aide training program.[9] If the aide has not administered eye drops, a nurse must personally oversee the aide’s performance of that task (and any others not completed according to the checklist) until the nurse is satisfied the aide can safely perform the requisite task.

Communication

The safety of delegation is inherently dependent on the clarity of the communication between the delegating nurse and the delegatee. The nurse who is delegating medication administration must clearly communicate information regarding the residents to whom the aide is to administer medications, the medications to be administered, the time frames during which the medications are to be given, and any special instructions concerning the administration of medications to specific residents. Much of this information can be written on the medication administration record (if applicable) or on other documents typically used for medication administration purposes in a particular facility.

Of equal importance, the nurse must clearly identify how the aide is to respond to the unexpected or to the abnormal, in other words, what to report to the nurse.  The curriculum content required by the Board in the medication aide training program includes four hours on communication and interpersonal skills and four hours on circumstances for reporting to the licensed nurse.  Nonetheless, it is the delegating nurse who must clearly set forth his/her expectations in this regard, taking into consideration the residents actually being cared for on any given day and any other variables that may be involved.

Supervision (Rule 4723-27-03 OAC)

In a nursing home setting a nurse must provide on-site supervision of a CMA. In a residential care facility, supervision may be provided by a nurse who is not on site BUT who is immediately and continuously available through some form of telecommunication.

Delegation of as-needed or PRN medications

Because administration of an as-needed medication inherently requires a nursing assessment, the law and rules treat nursing homes and residential care facilities differently when a resident has an order for a PRN medication. If a nurse is not on-site in an RCF to determine the resident’s need for the medication, the aide may administer only over-the-counter PRN medications.  Further, the off-site nurse must first determine the resident’s need for the medication based on his/her knowledge of the resident’s health status, the resident’s clinical record, the data provided by the aide, and the nurse’s determination of the safety of having the aide administer the medication. This determination must be made each time a resident’s health status appears to warrant administration of a PRN medication.

When a nurse is available on-site, delegation of an as-needed medication is not limited to over-the-counter medications.  However, the nurse must first make certain a nursing assessment performed by a registered nurse is on record.  The nurse must then determine the resident’s need for the medication and evaluate other resident-related safety factors on a case-by-case basis.  In other words, a nurse cannot give blanket approval for a CMA to administer all PRN medications to a particular resident who is repeatedly expressing a specific complaint.  The CMA and nurse must communicate with each other about the resident’s request or demonstrated need for a the medication, and the nurse must determine whether the medication should be administered by the CMA.

What may NEVER be delegated—Prohibitions (Rule 4723-27-02 OAC)

Certain activities may not be performed by a CMA even if a nurse were willing to delegate them.  These general prohibitions include:

  • Medications to be administered to a pediatric resident;[10]
  • Medications administered through a gastrostomy or jejunostomy tube or through an oral or naso gastric tube;
  • Oxygen;
  • Medications containing a schedule II controlled substance.  The aide may not even have access to these drugs;
  • Inhalants, nebulizers, aerosols, or other medications requiring dosage calculations;
  • Medications that are not approved drugs;
  • Medications administered as part of a clinical trial;
  • Injections, including intravenous procedures;
  • Splitting pills for purposes of changing the dose being given;[11]
  • Receiving, transcribing or altering a medication order; and
  • Administering the initial dose of a medication.

Practice Tips:

 Nurses who delegate medication administration to a CMA are expressly responsible for the following:

Completing the assessment of a resident to whom an as-needed medication is to be given and determining the resident’s need for the medication;

Reviewing the medication delivery process to assure there have been no errors stocking or preparing the medication;

Accepting, transcribing, and reviewing medication orders;

Monitoring the resident for side-effects or changing health status;

Reviewing the documentation completed by CMA; and

Supervising the medication aide.

The rules for delegation of medication administration, just like the rules for delegating any other nursing task, do not address how the delegation process is to be documented. If a nurse (or CMA) is suspected of inappropriate delegation, the Board of Nursing will review all relevant records and interview the parties involve to determine whether the principles of delegation have been followed. For example, in the case of an as-needed medication, documentation should reflect that a nurse was contacted and authorized administration of the medication by the CMA. The Medication Administration Record may be reviewed to determine whether it clearly communicated the parameters for administering a particular drug to a particular resident.

Standards of practice for a Certified Medication Aide (12)

Standards of practice for a CMA parallel the expectations established for licensed nurses and others regulated by the Board of Nursing.  That means, in part:

  • Certified medication aides are responsible for documenting accurately, timely, and completely the medications they administer. (Nurses should not document      medications administered by CMAs);
  • The CMA to whom the task of medication administration has been delegated, may not delegate that task to any other person;
  • A CMA may not perform nursing tasks unrelated to medication administration when engaged in administering medications;
  • The CMA must wear his/her applicable title ( Certified Medication Aide or CMA) at all times when administering medications;
  • The CMA must maintain resident confidentiality;
  • The CMA must treat each resident with respect and dignity;
  • The CMA must maintain professional boundaries with each resident; and
  • The CMA must demonstrate competence and accountability in the task of medication administration, including appropriate recognition, referrals, and consulting with the delegating nurse.
  • The CMA must not falsify any resident record or document prepared or utilized in the course of medication administration

Medication aides are expected to take measures to ensure resident safety that include reporting to the nurse in a timely manner the following:

  • The potential need for an as-needed medication based on expressions of discomfort demonstrated by the resident or other indications;
  • Refusal by the resident to comply with medication administration;
  • Any deviation from the delegated procedure;
  • Any unanticipated reaction by the resident to the medication; and
  • Anything about the condition of the resident that should cause concern to the CMA.

Standards also require that CMAs:

  • Verify the identity of the resident to whom the medication is to be given;
  • Witness the resident swallow an oral medication that is to be ingested or otherwise take the medication as prescribed;
  • Immediately document and report medication errors to a nurse; and
  • Utilize the medication delivery process in use in the nursing home or RCF.

If a certified medication aide fails to conform to these standards that would be grounds for disciplinary action by the Board of Nursing.[12]

Practice Tips:

Nurses should take special notice of the limitation that CMAs may not perform tasks unrelated to medication administration while passing medications.  This limitation is included as a resident safety measure to help assure that the MA-C is not distracted during a medication pass. [See Rule 4723-27-02 (L) OAC].

Unlike licensed nurses and others over whom the Board of Nursing has jurisdiction at all times when they are engaged in practice, the Board’s jurisdiction over certified medication aides is limited to when they are performing tasks related to medication administration. That means when the individual is acting solely in his/her state tested nurse aide capacity, the rules of the Board are not applicable. How this will impact the Board of Nursing’s disciplinary activities with respect to MA-Cs remains to be seen. In other states where medication aides are regulated by the Board of Nursing, the Board typically has jurisdiction over all nurse aides.

Training medication aides[13]

One of the keys to a nurse’s comfort level with delegating medication administration to a CMA will be the extent and quality of the training programs in place to prepare medication aides.  While the statute requires a minimum 70 hours of training, the rules require 120 hours[14], 80 of which must be the didactic (classroom) and laboratory component and 40 must include the actual administration of medications in a clinical setting with one-on-one supervision by a licensed nurse. The Board of Nursing must approve the training program before the program can admit any would-be CMAs. Programs can use a model curriculum developed by the Board staff or may use their own curriculum provided it contains the requisite content.  Required topic areas include:

  • Communication and interpersonal skills—4 hours;
  • Resident rights—1 hour
  • Six rights of medication administration—3 hours
  • Drug terminology—4 hours;
  • Fundamentals of specific body systems—20 hours;
  • Basic pharmacology—12 hours;
  • Safe administration of medications—20 hours;
  • Principles of infection control—2 hours;
  • Documentation—2      hours;
  • Circumstances for reporting to a licensed nurse—4 hours;
  • Medication errors—4 hours; and
  • The role of the MA-C—4 hours.

The training programs also must include a mechanism for evaluating whether the candidate possesses the reading, writing, and mathematical skills sufficient to assure safe medication administration.16A registered nurse must be the program administrator and a registered nurse must also teach the didactic and laboratory portions of the program.  During the didactic and laboratory portion, students and instructors must be present in the same location.  In other words, the instruction must be provided in person rather than by means of electronic communication.  The rules do not constrain, however, who can conduct a program.  Training programs may take place in a nursing home or residential care facility or may be conducted by community colleges or vocational schools, provided they meet Board standards and receive approval.

All training programs must provide each student with the clinical skills checklist used during the training program to indicate satisfactory performance of all skills needed for safe medication administration utilizing all of the approved routes.  If a student has not had an opportunity to demonstrate a particular skill, that deficit will be reflected on the checklist. Before the CMA may perform that skill outside of the training program, he/she must be supervised by a licensed nurse to determine that the aide uses the proper techniques. Once that requirement is met, the nurse should update the skills checklist accordingly. For example, although a CMA is authorized to administer medications vaginally, there may not be a resident with a medication administered using that route during the actual training period. If a CMA subsequently is expected to administer a vaginal medication, a nurse must supervise the performance of that task until satisfactory performance is demonstrated and appropriately documented on the checklist.

After completing the training, the CMA candidate must pass a standardized examination administered by a Board-approved independent testing entity. The test will include both written and clinical components. The aide must achieve an 80% score on the written test and 100% on identified critical elements of the clinical test in order to pass the examination.  The test may be taken one additional time if a passing score is not achieved initially. After that, the individual must complete the training program again to be eligible to re-test. The tests will be given in locations throughout Ohio on a schedule established by the testing company.

In an attempt to address timeliness issues, the training program must be structured so that a class of students completes it in no fewer than 20 business days and in no more than 90 days. The examination must be taken no more than 60 days after the student completes his/her classroom and supervised clinical practice components of the program.

The statute provides that a person employed by a nursing home or residential care facility that utilizes medication aides who reports in good faith a medication error at the nursing home or residential care facility is not subject to disciplinary action by the Board of Nursing or any other government entity regulating that person’s professional practice and is not liable in damages to any person or government entity in a civil action for injury, death, or loss to person that allegedly results from reporting the medication error.17  What this language fails to specify is to whom this report must be made.  Interestingly, it could be interpreted that the act of self-reporting precludes disciplinary action by the Board of Nursing; whereas, a report made by a third party would not result in the same immunity for the individual actually committing the error.

Conclusion

The safety of using CMAs depends in large measure on how effectively nurses delegate the task to them.  In the past, when non-nurses have been authorized to administer medications, some nurses would tend to separate themselves from the entire medication administration process.  They often neglected to assess the effects the medications were having on the patient or resident as well as the patient’s ongoing overall health status.  While nurses may believe their practice has been eroded by the creation of medication aides, in reality only the task of actually giving the medication has been relegated to other individuals. The nurse remains responsible for all other aspects of medication administration.  The new law may affect how nurses practice, but it will not alter their overall accountability for resident/patient outcomes.

 

 

 Continue to Post Test>>

 


[1] To comply with this requirement, the Board of Nursing first adopted emergency rules effective for 90 days.  No public testimony was heard prior to the effective date, however.  In order to adopt permanent rules, the Board had to comply with certain requirements, including conducting a public hearing and submitting the rules to the Joint Committee on Agency Rule Review (JCARR) for a determination that all rule-filing processes were followed.  The permanent rules became effective when the temporary rules expired May 1, 2006.  A Medication Aide Advisory Council was established in the law to provide input regarding the rules.  The Council was comprised of representatives from nursing organizations, the trade associations representing the long-term care and assisted living industries, consumer and family groups, long-term care ombudsmen, and state agencies involved in nursing home regulation and reimbursement.

[2] Rule 4723-27-06 of the Administrative Code.

[3] Section 4723.67 of the Revised Code.

[4] Rule 4723-27-01 of the Administrative Code.

[5] Rule 4723-27-02 (B) of the Administrative Code.

[6] The rule that primarily addresses delegation is 4723-27-03 of the Administrative Code. Nurses should also review the rules in Chapter 4723-13 of the Administrative Code for general principles of delegation applicable to any nursing task.

[7] Section 4723.67 (A) of the Revised Code & Rule 4723-27-03 (D) of the Administrative Code.

[8] Section 4723.68 (A) of the Revised Code.

[9] Each CMA is required to have a skills checklist issued by the training program that indicates the skills the aide actually performed during the clinical portion of the training.  Rule 4723-27-08 of the Administrative Code.

[10] A pediatric resident is defined as someone under 18 years of age. Rule 4723-27-01 of the Administrative Code.

[11] This language is taken directly from the statute.  Efforts to add clarity during discussions about these rules were not successful.

[12] Rule 4723-27-09 (B) of the Administrative Code

[13] Training program requirements and standards are found in Rules 4723-27-07 and 4723-27-08 of the Administrative Code.

[14] Language in the law sets the requirement for a minimum number of hours in the training program; therefore, the Board of Nursing, through its rules, is able to require additional training hours without running afoul of the law.

15 This requirement is in statute at Section 4723.66 (B)(2) of the Revised Code. The Board-approved examination will evaluate these factors.

16 This requirement is in statute at Section 4723.66 (B)(2) of the Revised Code. How that requirement is met is left to the discretion of the training programs.

17 Section 4723.69 (B) of the Revised Code.

Posted in Category A Ohio Nursing Law and Rules, Independent Study