How Medications Are Handled in California Assisted Living

Assisted living communities and board and care homes, licensed in California as residential care facilities for the elderly (RCFEs), are non-medical. Title 22, section 87465, says the home must assist residents with self-administered medications as needed. It does not make caregivers into nurses.

Health and Safety Code section 1569.69, which sets the training for staff who help with medications, ends with a plain statement: nothing in it authorizes unlicensed personnel to directly administer medications. Title 22 adds that facility staff, except those authorized by law, may not administer injections.

The regulation also says what assistance is not. It does not include forcing a resident to take a medication, hiding or camouflaging medication in food or drink without the resident's knowledge and consent, or otherwise interfering with the resident's right to refuse.

The regulations do not spell out each step of a medication pass. In everyday terms, families usually see staff keep the medications, bring the labeled dose at the right time and record it. Ask each home to walk you through its routine.

The table brings together the rules in Title 22. Injections and diabetes are on the state's list of restricted health conditions, which our guide to health conditions assisted living can accept explains.

A resident who is capable of it may keep and take their own medications. Title 22 requires central storage in three situations: the medicine needs refrigeration and the resident has no private refrigerator; a physician decides the medication would be hazardous if the resident kept it; or a physician, the administrator or the licensing agency decides it is a safety hazard to others in the home. The medical assessment completed before move-in, often called the physician's report, is supposed to say whether medications should be centrally stored.

For centrally stored medications, the rules are specific:

• They are kept in a safe, locked place that only the employees responsible for them can reach.
• Each resident's medication stays in the container it came in. Medications may not be moved between containers.
• Labels must meet state and federal law.
• The home keeps a record for each resident for at least one year, with the prescriber, drug name, strength, quantity, date filled, prescription number and pharmacy.
• A record of doses is kept when the prescribing physician or the licensing agency asks for one.

When a resident leaves, prescription medications that are not taken along, returned to the pharmacy or handled under hospice procedures are destroyed by the administrator and one other adult who is not a resident. Both sign a record that is kept for at least three years.

PRN means a medication taken as needed, such as a pain reliever. For every PRN medication the home helps with, Title 22 requires a signed, dated written order from a physician and a label on the medication. Both must state the specific symptoms that call for it, the exact dosage, the minimum number of hours between doses and the maximum number of doses in 24 hours.

What staff may do then depends on the resident's ability to recognize and report the need.

The third situation often applies to a person living with advanced dementia. It is worth asking a home how it reaches a doctor at night and on weekends.

1. 1

   The resident can decide and say when it is needed

   If the physician has stated this in writing, staff may assist the resident with a prescription or nonprescription PRN medication.

2. 2

   The resident cannot decide but can describe symptoms clearly

   For a nonprescription PRN medication, designated staff may assist when there is written direction from the physician, the medication is given as directed, and each dose is recorded with the date, time, dosage and the resident's response.

3. 3

   The resident cannot decide and cannot describe symptoms

   Staff must contact the resident's physician before each dose, describe the symptoms and receive direction. Each contact and each dose is documented in the resident's record.

Under Health and Safety Code section 1569.69, an employee who assists with self-administration must complete medication training and pass an exam. The hours depend on the size of the home.

The training covers the limits of the role, including tasks reserved for licensed medical professionals, along with storage, documentation, side effects, errors and the risks of antipsychotic medications for residents with dementia. Licensed medical professionals are exempt. Homes licensed for 16 or more must also keep proof that a consultant pharmacist or nurse has reviewed their medication program at least twice a year. General caregiver training is separate and is covered in assisted living staffing requirements.

• Homes licensed for 16 or more: 24 hours of initial training, with 16 hours of hands-on shadowing before assisting with medications and 8 hours of other instruction in the first four weeks.
• Homes licensed for 15 or fewer: 10 hours of initial training, with 6 hours of hands-on shadowing before assisting and 4 hours of other instruction in the first two weeks.
• Every year after: 8 hours of in-service training on medication topics.

Bring a current medication list to the first conversation. The home's care assessment will ask for it, and so will the paperwork described in move-in requirements. Then ask:

• Who assists with medications on each shift, and what training have they had?
• Is there a nurse on staff? If not, who gives injections?
• Which pharmacy do you use, and can we keep our own?
• How do you record each dose, and may the family see the record?
• What do you do when a resident refuses a medication?
• How do you handle PRN medications for someone who cannot say what they feel?
• Do you charge a separate fee for medication assistance?

Questions about whether a medication is right for your parent belong with the doctor or pharmacist, not the home. If someone is in immediate danger, call 911. Concerns about how a licensed home handles medications can be reported to California's Community Care Licensing Division, which takes complaints by phone, email and online.

Hamssa Benrekia is a senior living placement specialist in Torrance with a background in hospice, palliative care and home health, and she holds an RCFE Administrator Certificate. When a parent has insulin, many daily medications or frequent PRN doses, she can help a family in the South Bay and Harbor area look for a licensed community or board and care home that says it can manage them, and she goes on tours with you. To talk it through, contact Hamssa. The California Assisted Living Placement Guide covers the other steps.