Section 116.60  Medication Self-Administration

a)         As part of the normalization process, in order for each individual to attain the highest possible level of independent functioning, all individuals shall be permitted to participate in their total health care program [20 ILCS 1705/15.4(d)].  Every program shall include, but not be limited to, individual training in promoting wellness, prevention of disease, and medication self-administration procedures.

1)         Every program shall adopt written policies and procedures for assisting individuals in obtaining preventative health and medication self-administration skills in consultation with the registered professional nurse [20 ILCS 1705/15.4(d)].

2)         Individuals shall be evaluated to determine their self-administration of medication capabilities by a Nurse-Trainer through the use of DHS required, standardized screening and assessment instruments.

3)         When the results of the screening and assessment indicate an individual not to be independently capable to self-administer his or her own medications, programs shall be developed in consultation with the Community Support Team (CST) or Interdisciplinary Team (IDT) to provide individuals with medication self-administration training as identified in each individual's treatment/service plan [20 ILCS 1705/15.4(d)].

b)         Each individual shall be presumed to be competent to self-administer medications if he or she has been determined to be:

1)         capable by a registered professional nurse or advanced practice nurse;

2)         approved to self-administer medication by the individual's CST or IDT; and

3)         authorized by a written order of a physician.

c)         Training of individuals to self-administer medication shall minimally include instruction, for each medication prescribed, in the following areas:

1)         identification of a medication by any of the following methods:

A)        name;

B)        purpose;

C)        size;

D)        shape;

E)        color; or

F)         other distinguishing feature;

2)         dosage or quantity to be taken;

3)         route of administration;

4)         frequency or times of administration;

5)         purpose of medication, special instructions, common side-effects and potential consequences of not taking the medication or of not taking the medication properly; and

6)         when to seek medical assistance.

d)         When requested to do so by an individual, authorized direct care staff may assist an individual in the self-administration of medications by taking the medication from the locked area where it is stored and handing it to the individual.  If the individual is physically unable to open the container, a staff member may open the container for the individual.  Agency staff may also assist physically impaired individuals, such as those who have arthritis, cerebral palsy or Parkinson's disease, in the removal of the medication from the container and in consuming or applying the medication.

e)         Each individual shall remain under observation by authorized direct care staff and be assisted by the staff to correct or prevent medication errors and to safeguard against adverse drug reactions.  Observation frequency shall be determined by the Nurse-Trainer and the individual's Community Support or Interdisciplinary Team to maintain an individual's safety when independently self-administering his or her medication.  All observation and assistance shall be noted in the individual's file.

f)         Individuals specifically determined to be competent, by a physician who has issued a written order, to self-administer their own medications may maintain possession of the key or combination of the lock to their own medication storage area.  A duplicate key or a copy of the combination shall be kept in a secure location for emergency use by licensed personnel or authorized direct care staff, should the individual lose or misplace the key or forget the combination.

g)         A medication administration record need not be kept for those individuals for whom the attending physician has given permission to have access to their own medications and to be fully responsible for taking their own medications.  However, each agency shall develop and implement a quality assurance procedure to ensure that self-administered medications are taken in accordance with prescribed orders.  Documentation must include medication name, dosage and frequency, and the identity of the prescribing physician or other person licensed to prescribe medications in Illinois.

(Source:  Amended at 41 Ill. Reg. 6534, effective May 26, 2017)