Medication management in assisted living can be one of the most complex and confusing topics for new providers. The level of assistance offered must be based on each individual resident assessment; without a clear understanding of the different levels of assistance, the provider as well as medication staff may find themselves facing citations. Perhaps even more perplexing is the plethora of regulation on this topic found in WAC 388-78A, RCW 69.41, RCW 18.79, WAC 246-945 (which, frustratingly, the medication assistance sections are not yet published on the web), and WAC 246-840 (specifically, for nurse delegation, sections -910 through -970).

This article aims to concisely delineate the different medication service levels based on resident needs and preferences. Note that a resident can be assessed as needing multiple different medication service levels, depending on the type of medication ordered and the resident’s abilities and preferences regarding self-administration.

All residents must be assessed regarding their level of service necessary to ensure prescribed medications are provided as ordered. The four different categories of medication services as outlined in WAC 388-78A-2090 (2)(a)(b)(c) include:
For a resident to fall into this category, the resident knows s/he is receiving medications and is knowledgeable of how and when to take them. The resident does not need to know the name of the medications or the specific reason(s) for the medications but can follow the prescriber’s orders.

Generally in this category, the resident stores the medications independently; if this is the case, WAC 388-78A-2270 comes into play, and the facility is responsible for ensuring the resident’s self-storage of medications prevents other residents from gaining access to them.

There is no expectation for staff to follow up in ensuring the resident took medications, nor must staff document that medications were taken or refused.
This “carve-out” is specifically for assisted living providers only and allows for times when a resident cannot physically get the medication where it needs to go independently but can accurately direct a caregiver to get the medication where it needs to go. This category is limited to oral, topical (such as creams and patches), eye medications, nasal medications, inhaled medications, as well as rectal and vaginal medications. Injectable medications cannot be accurately directed by a resident. This medication category is considered medication assistance and does not require nurse delegation. The WAC on this topic was recently updated and is not yet found on the web; the exact verbiage is highlighted below:
Staff must document medications taken and refused, following standard best practice and facility systems.

This category is where most resident medications are given. The definition of “medication assistance” is best depicted in RCW 69.41.010(15) and reads:

 "Medication assistance" means assistance rendered by a nonpractitioner to an individual residing in a community-based care setting or in-home care setting to facilitate the individual's self-administration of a legend drug or controlled substance. It includes reminding or coaching the individual, handing the medication container to the individual, opening the individual's medication container, using an enabler, or placing the medication in the individual's hand, and such other means of medication assistance as defined by rule adopted by the department. A nonpractitioner may help in the preparation of legend drugs or controlled substances for self-administration where a practitioner has determined and communicated orally or by written direction that such medication preparation assistance is necessary and appropriate. Medication assistance shall not include assistance with intravenous medications or injectable medications, except prefilled insulin syringes.

For a resident to fall into this category, s/he must be knowledgeable that s/he is receiving a medication and can get the medication where it needs to go (do the “final step”). The resident does not need to know the name of the medication or its intended effects.

Staff must document medications taken and refused, following standard best practice and facility systems.
Legally, this is the only medication service level that requires the involvement of a nurse. The term “administer” is defined by the pharmacy board as “the direct application of a legend drug whether by injection, inhalation, ingestion, or any other means, to the body of the patient…by a practitioner….”

There are rare instances when a resident requires medication administration. In one situation, the resident’s cognition does not allow for the understanding that s/he is taking a medication. In another situation, the resident is unable to get the medication where it needs to go with assistance, cueing, or prompting and cannot accurately direct. In some instances, both situations would apply to the resident.

When medication administration is required, a registered or licensed practical nurse must administer the medication(s), or a qualifying caregiver can administer via the nurse delegation process. Staff must document medications taken and refused, following standard best practice and facility systems.

The full resident assessment prompts the facility assessor to determine which medications fall into which medication service level. There are times when a resident could receive medications using some or all the categories at any given time. For example, a resident might keep a rescue inhaler at the bedside and be considered independent with that medication, accurately direct the application and removal of a medicated patch, receive all oral medications via medication assistance, and have a vitamin B12 shot administered once a month by an LPN.

Whenever a resident requires medication administration, this rises to the level of needing intermittent nursing services and a registered nurse must perform this specific part of the resident assessment. Staff must be aware of the service levels each resident is in, so that medications are offered in such a way to promote independence and ensure staff works within individual scope of practice.

If you have questions about assisted living regulations, please contact Vicki McNealley via email, or call her at (800) 562-6170 extension 107.
The Centers for Medicare and Medicaid Services (CMS) has issued QSO-22-19-NH, which includes new and updated surveyor guidance for the following areas:  
  • Phase 2 and 3 Requirements: Clarifications and technical corrections of Phase 2 guidance issued in 2017; and new guidance for Phase 3 requirements, which became effective November 28, 2019.  
  • Arbitration Requirements: Guidance on the new requirements, which became effective September 16, 2019. 
  • Complaint and Facility Reported Incidents (FRIs): CMS revised the guidance in Chapter 5 and related exhibits of the State Operations Manual (SOM) to strengthen the oversight of nursing home complaints and FRIs. CMS also revised its guidance for all Medicare-certified provider/supplier types to improve consistency across the State agencies in their communication to complainants. 
  • Psychosocial Outcome Severity Guide: CMS revised guidance to clarify the reasonable person concept and examples across the different severity levels. 

CMS has released an advance copy of the Appendix PPSOM Chapter 5, and the Psychosocial Outcome Severity Guide, and the agency is publicly posting training on these changes for surveyors and the public at the Quality, Safety, and Education Portal.  

Surveyors will begin using this guidance to identify non-compliance on October 24, 2022. AHCA has advocated to CMS to give facilities time to review and update existing systems and processes where needed when new guidance is released.  

The American Health Care Association (AHCA) will review this new and updated guidance in detail over the coming weeks and will share resources to assist members. The Association is also planning sessions at the upcoming 73rd AHCA/NCAL Convention & Expo to help members with this guidance. Convention registration is now open.  

More information about the revised guidance can be found on the CMS website. if you have questions, please email Elena Madrid or call her at (800) 562-6170, extension 105.
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