Policies for Self-Administration of Medication in OASAS Programs

LSB 2022-01: Policies for Self-Administration of Medication in OASAS Programs

Date Issued: April 27, 2022


· OASAS Programs Certified Pursuant to Parts 817, 819 and 820 in accordance with this LSB

· Local Governmental Units (LGUs)



This Local Services Bulletin (LSB) serves to support the development of a Medication Policy and Procedure to ensure that medications are used safely by patients and safely and appropriately stored by programs. Such program’s policies and procedures should reflect their philosophy and actual practices and should not be a verbatim recitation of the regulations or this LSB; rather it should be the program’s way of implementing and complying with these rules.



OASAS-certified programs have a responsibility to ensure that patients have access to their prescribed medications, including but not limited to over-the-counter (OTC) medications and that the medications are stored safely for use by the intended patients. The elements in this bulletin are critical to ensure that patients can receive their medications as directed and to reduce the risks of diversion and misuse of medication.



New York State law limits the ability of individuals who are not licensed medical professionals such as doctors, nurses, nurse practitioners, and physician assistants to administer medications to patients, based on the principle that the administration of medications involves the correct identification of the medication, the accurate implementation of instructions from an authorized prescriber and the process of identifying when a patient’s response to the medication requires consultation with the prescriber.



While mindful of the limitations on medication administration, OASAS-certified programs may allow patients to self-administer medications with staff oversight in Part 819 Intensive Residential and Community Residential and Part 820 Stabilization, Rehabilitation and Reintegration programs in a congregate setting. Patients may be permitted to self-administer without staff supervision in Part 819 Supportive Living and Part 820 Reintegration programs in a scattered site setting consistent with this LSB.



What is oversight of self-administration?

Oversight of a patient’s self-administration requires that trained staff, as defined in this bulletin, approach self-directed patients in a consistent manner when overseeing them self-administer their medications. Oversight does NOT include preparing a dose of medication (e.g., pouring a liquid), handing a specific dose of medication to a patient or providing guidance on the manner of administration of a medication.


Who may self-administer with oversight?

To self-administer medication, patients must be over the age of sixteen (16) years old and able to state the following:

· The name(s) of the medication(s) that they take;

· The time(s) at which they are to take their medication(s);

· The prescribed dose(s) (i.e., number of pills and dosage amount) of their medication(s);

· Whether they are experiencing any side effects from their medication(s);

· Whether, as provided, the medication is a different shape, size, color, or texture than usual. If a medication looks different than previously, the patient should question the staff member, and this should be evaluated.


Who may NOT self-administer?

· Patients who cannot articulate the information described above regarding their medication(s);

· Patients under the age of sixteen (16) years old.1 NOTE: Only licensed nurses or physicians may administer medication to children under sixteen (16) years old. Any facility that allows children to live with their parent while in treatment must address in policy and procedure how children’s medication administration will be overseen.

Who can oversee patient self-administration of medication?

Under the supervision of a Registered Nurse (RN), appropriately trained program staff who are not licensed medical professionals may oversee patient self-administration of medication(s) in certified programs.

Appropriately trained program staff are staff trained by a RN who has documented Train the Trainer Training for the Oversight of Patient Self Administration of Medication Part I and Part II. Part I of this training is the OASAS developed online training specific to the requirements of this LSB. Part II of this training provides the information RNs must use to train non nursing staff who will provide the oversight of patient self-administration of medication. Part II of the training will also include a training manual and sample forms.


For purposes of this LSB, appropriately trained program staff include staff who have:

· A High School diploma, General Equivalency Degree (GED) or Test Assessing Secondary Completion (TASC); and

· One year of experience working in a human services program in a caregiving role; and

· Documented proof of completion of the internal training at the program site, administered by the provider’s RN, with a qualifying score.


Where will patients self-administer their medications?

· A separate locked area where staff can see patients self-administer their medications must be designated in the facility.

Important Considerations for Self-Administration with Oversight

Programs providing services where patients self-administer their medication with staff oversight must develop and implement policies and procedures in consultation with the program’s trained Registered Nurse.


When overseeing patient medication self-administration, staff should confirm the following:

· THE RIGHT PATIENT - The medication is given to the patient for whom it is prescribed;

· THE RIGHT TIME - The medication is given to the patient at the time when it is supposed to be taken, based on the schedule on the medication administration record;

· THE RIGHT MEDICATION - The patient is taking the medication that has been prescribed for them;

· THE RIGHT DOSE - The patient takes the prescribed dose of the medication;

· THE RIGHT ROUTE - The patient administers the medication in the correct way (orally, topically, by injection, etc.);

· THE RIGHT DOCUMENTATION - The medication is properly labeled and the patient’s use of it is documented in the medication administration record.

· THE RIGHT REASON - The patient is taking the medication for the prescribed purpose.

· The RIGHT RESPONSE - The medication has the desired effect.

Medication Administration Record (MAR)

· Providers must maintain an up-to-date individual record of all prescription and OTC medications used by patients, to include:

o the name of the medication;

o dose;

o frequency of administration (including “as needed” or “Pro Re Neta (PRN)”);

o instructions for use;

o prescribing professional; and

o a list of known patient allergies.

· Any deviation from the prescribed dose and/or frequency of administration should be noted in the MAR.

· Providers should assure that patients have access to their medication whenever it is needed including in the event of an emergency.

· Providers must develop a policy that designates the staff responsible for documentation by signing the MAR upon medication administration by either program staff or the patient.

· If a patient refuses a medication, program staff should document such refusal in the MAR and the treatment team should be informed.

· A policy should be developed to manage charting mistakes in the MAR. Under no circumstance should the MAR be changed in the event of a mistake. Corrective action should be addressed as part of such policy.

· The MAR must be reviewed weekly, and incidents of incorrect medication counts must be addressed with incident review procedures.

· Competency reviews (covered in Part II of the RN training) must be completed periodically by the program’s RN. This includes the observation of the program staff oversight of patient self-administration.

o The RN may suspend or remove the ability for program staff to oversee patient self-administration for any staff that fail to meet the standards developed and documented in the program’s policy and procedures.

Required Quality Assurance Activities

· Providers must conduct ongoing quality assurance monitoring for all activities including, but not limited to medication self-administration, storage, patient referrals and emergencies. Ongoing quality assurance monitoring includes documenting staff accountability and follow up by the provider where deficiencies are found.

The provider's policy also must address:

A. Medication Disposal Logs and Procedures

· Disposal of medication including documentation of all medication disposal, documentation of the method of disposal, and the identity of the person disposing of medication and the witness to such disposal.

· How medication will be stored pending disposal including appropriate staff access to the medication. Medication designated for disposal should not be used for any other purpose.

· Providers are strongly encouraged to the extent possible to dispose of all medications in an environmentally sound method which includes, but is not limited to, community take-back events and drop-off collection boxes at authorized hospitals/clinics and law enforcement agencies.

· NOTE: Controlled substances only can be disposed of in accordance with NYS Department of Health (NYS DOH) regulations. See 10 NYCRR Part 80.51 for requirements and record keeping relating to the disposal of controlled substances.

· Service types which do not qualify for NYS DOH Bureau of Narcotic Enforcement (BNE) Class 3A Licenses must dispose of any controlled substances left behind by the patient with the local police department.

B. Medication Storage

· Patients’ medication, dietary supplements, and medical equipment should be safely stored and inventoried by the program.

· Patients who are sixteen (16) years old or older may keep lotions, ointments, inhalers and EpiPens on their person as their use is determined by individual need. All other medications, including OTC medications, must be stored in the separate, locked area.

o Patients under the age of sixteen (16) years old may be permitted to keep and carry these medications where a prescriber has determined the patient has been instructed and has demonstrated to the prescriber that the patient can self- administer the medication(s)safely and effectively.

· All providers that store and oversee controlled substances medication administration or self- administration who are licensed by the NYSDOH as a Class 3A Institutional Dispenser Limited must comply with NYS Department of Health Bureau of Narcotic Enforcement regulations.

· Facilities not qualifying for Class 3A Institutional Dispenser Limited Licenses must establish a procedure whereby patients have access to prescribed controlled substances. These facilities must have policies and procedures for secure storage, staff and patient training for management and accountability and disposal if necessary.

· Controlled substances must be stored consistent with state and federal requirements and programs should have procedures in place to limit access to one assigned staff member per shift. The staff member who can access controlled substances must be a staff member who has been trained in medication self-administration oversight.

· Inventory of controlled substances must be done at each shift change with outgoing and incoming staff assigned to oversee the controlled substances for the shift.

C. Passes, Including Overnight Leave

Providers must have a policy and procedure in place which provides a process for the provision of medications to patients on day and overnight passes and must ensure the documentation of medication taken out of the program by the patient in the MAR.

D. Staff/Patient Training and Orientation

· Programs should offer education, directly or through referral, to all patients and staff about the importance of medication adherence, possible medication-medication interactions, and the importance of taking medication as recommended/directed by the medical provider.

· Programs should review with new patients, as part of their orientation to the program, the policies and procedures regarding:

o Accessing medications prescribed for them by their provider whenever it is needed, including during an emergency.

o Seeing medical or psychiatric providers for routine and urgent conditions

o Self-administering their medications as is clinically indicated and if recommended by the prescribing professional.

· Programs should explain to the patient that the patient’s responsibilities include:

o Abiding by the program’s medication storage policy to reduce the possibility of diversion and/or misuse;

o Complying with the medication regimen as identified by the prescribing professional;

o Abiding by the program’s medication self-administration policy for those patients for whom self-administration is clinically indicated and recommended by the prescribing professional;

o Reporting any concerns about or side effects from any medications to provider’s staff/ prescribing professional.

Self-Administration Without Staff Oversight

In OASAS Certified Part 819 Supportive Living and Part 820 Reintegration in a scattered site setting, providers may choose to allow patients to self-administer their own medication without direct staff oversight. Providers who wish to allow self-administration without oversight must have a process for:

o Determining which patients are competent to self-administer medication;

o Storing medications securely to allow for patients’ access only;

o Having staff periodically monitor patients self-administering their medications to ensure that patients are self-administering their medications appropriately; and

o Disposing medications safely .


1See Medication Storage section for a limited exception.



If you require further clarification of the issues detailed in this Bulletin, please contact [email protected]