Who May Give Injections in a California Assisted Living or Board and Care Home?

Assisted living communities and board and care homes, licensed in California as residential care facilities for the elderly (RCFEs), are non-medical homes. Title 22, section 87612, lists injections among the restricted health services: a home may care for a resident who needs them, on the terms of section 87629. The other restricted conditions are set out in health conditions assisted living can accept.

Section 87629 is short. A home may accept or keep a resident who requires intramuscular, subcutaneous or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional. If the resident requires assistance, the home is responsible for seeing that a professional administers them.

The rule turns on the route, not the drug. An injection into a muscle, under the skin or into the skin is treated the same way whether it is insulin, a vitamin or a blood thinner. The section does not make an exception for prefilled pens or auto-injectors, and it does not mention medication given into a vein at all, so ask the home and the doctor about anything outside those three routes.

Health and Safety Code section 1569.39 defines the term: an individual who has training and is licensed to perform the necessary medical procedures prescribed by a physician. Its examples include a registered nurse and a licensed vocational nurse. The statute says these professionals may be employed by a home health agency, by the resident or by the facility, and must be currently licensed in California.

The same statute says a professional may not be required when the resident is providing self care and the resident's service plan documents that the resident is capable of it. So the home needs something in writing about your parent's ability, and Title 22 requires the physician's documentation to cover the resident's ability to perform the procedure.

Title 22, section 87465, draws the line in one sentence: facility staff, except those authorized by law, shall not administer injections, but staff designated by the home may assist persons with self-administration as needed. The table shows how the tasks divide. Our guide to medication management in assisted living explains assisting versus administering for pills, drops and other medications.

The regulations do not spell out every step that counts as assisting with a self-administered injection. The safest reading for a family is the plain one: if your parent cannot physically give the injection, a licensed professional has to. Ask each home to describe exactly what its caregivers do.

Section 87629 ties injections to the home's infection control rules. Section 87470 says all staff assigned to assist residents with the self-administration of injectable medication shall observe these procedures:

• Medications given by injection are drawn up in a clean area.
• A syringe and needle are used only once, for one injection on one resident, and then properly disposed of.
• The top of a medication vial is always cleaned with an alcohol swab before the needle goes in.

Insulin is the case families ask about most. Diabetes has its own section of Title 22, number 87628, which adds rules on glucose testing and diet. See diabetes and insulin in assisted living.

Vitamin B12 is at the other end. MedlinePlus, the National Library of Medicine's health site, says treatment for some people with B12 deficiency may include a shot of vitamin B12, often once a month. Title 22 allows a home to accept people who receive medical care outside the home or from a visiting nurse, so a monthly shot may be given at the doctor's office or by a nurse who comes in.

Injected blood thinners sit in between. MedlinePlus describes heparin as a blood thinning medicine that has to be given as a shot, and says a nurse or other health professional teaches the person how to prepare and give it. If the doctor prescribes an injected blood thinner, ask how long it is expected to continue and whether your parent can learn to give it, because that decides who has to be present for each dose.

Two rules can change the paperwork. Under section 87616 a home may send the Department of Social Services a written exception request for a resident with a restricted condition; the home applies and the department decides. And a home with a hospice care waiver needs no separate exception for a terminally ill resident whose hospice care plan addresses the injections. Section 87633 still says facility staff may not perform a procedure that by law only a licensed professional may perform, so caregivers do not start giving injections because a resident is on hospice.

Four steps usually settle it:

1. 1

   Ask the doctor what your parent can do

   Ask whether your parent can self-inject reliably, and ask for that to be written into the physician's report the home needs.

2. 2

   Ask the home who gives injections

   Some communities employ nurses. Many small homes use an outside agency. A home is never required to accept a particular person, so answers differ from one licensed home to the next.

3. 3

   Get the nursing arrangement in writing

   When a home health agency is used, Title 22 requires a written agreement between the home and the agency covering the services, their frequency and duration. See therapy and home health in an RCFE.

4. 4

   Find out who pays

   Medicare's home health benefit lists injections among the part-time or intermittent skilled nursing services it covers for people who qualify, which includes being homebound. Ask the agency and the doctor whether your parent qualifies. If not, the visits may be a private cost.

Hamssa Benrekia is a senior living placement specialist in Torrance with a background in hospice, palliative care and home health. When a parent needs regular injections, she can help a family in the South Bay and Harbor area look for a licensed assisted living community or board and care home that has a workable way to provide them, and she goes on the tours with you. To talk it through, contact Hamssa, or start with the California Assisted Living Placement Guide.