I am a fairly new employee for a company that runs group homes. We have a consumer who is his own guardian and currently administers his own medications with oversight by a CRMA who uses a MAR to complete checks, etc. He is requesting a new medication self administration assessment be completed because he does not want to have daily oversight and use of a MAR. I have scoured the state regs and I cannot find definitive information about documentation for self administration. Our agency has not encountered this thus far. The regs only state that those consumers deemed capable of self administration of medications by a nursing assessment
must keep medications in a locked box in their room. No information on who holds the key or documentation to complete. From all that I have read about this consumer, and reviewing his MAR, talking with him, I have a feeling the assessment will show that he is capable of self administration with minimal oversight. I want to be sure to have adequate documentation, at least weekly, that his pill counts are accurate, etc. I am charting unknown waters and could use any advice you have.
For a quick background- this is considered ALF by state regs, the state of Maine. It is a group home of 4 consumers with a CRMA (someone to pass meds). He is his own guardian. Is permitted as much independent time as he wishes. He takes the city bus out and about, has a job, etc. And his medications are low risk, no controlled, mostly routine and are only once daily AM meds.
Also in this agency I am THE nurse. No other nurse to ask. Administration here are not clinical types. They know the state regs, but can't provide much guidance in this area as he is a unique case. Most of our consumers have more severe issues requiring 24 hour supervision and meds administered for them.