Halfway House Health Services Manual


Chapter: Medication Administration
Title: On-Campus Self-Administration of Medication with Supervision

ACA Standard(s): 3-JCRF-4C-08

Effective Date: 11/21/12


  1. Standard.

    Supervised self-administration of medication by youth is permitted when agreed upon by the youth and approved by the youth’s multi-disciplinary team (MDT) in accordance with the procedures described in this standard.

  2. Applicability.

    This standard applies to youth who are prescribed medication for treatment of a physical or mental health condition.

  3. General Provisions.

    1. To be authorized to self-administer medication, a youth must:

      1. complete the halfway house orientation phase;
      2. be approved by the MDT to self-administer medication; and
      3. if the youth is under 18 years of age, have received parent/guardian consent.

    2. The superintendent is responsible for ensuring that youth privacy is maintained during supervised self-administration of medication.

    3. All youth authorized to self-administer medication will receive instruction from a health care professional.

  4. Procedures.

    1. Discuss the appropriateness of self-administration of medication.  If determined to be appropriate, discuss the recommendation with the youth.
      Person Responsible: MDT

    2. For youth under 18 years of age, obtain parent/guardian consent on the Parental Consent for Supervised On-Campus Self-Administration of Medication form, HLS-307.  File the original form in the youth’s master file, and place a copy in the daily health records binder.
      Person Responsible: Superintendent or designee / Human Services Specialist (HSS)

    3. Notify the health services administrator (HSA) or designee that the youth has been approved to self-administer medication with supervision and requires medication training.
      Person Responsible: HSS

    4. Provide medication instruction to the youth in person or via digital medical services (DMS) that includes the following:
      Person Responsible: HSA/Nurse/Clinical Case Manager

      1. expectations regarding self-administration of medication (youth initiation, provision of privacy, responsible handling of medication and consequences for cheeking or misuse of medication, right to refuse by signing a Refusal Form);

      2. medication name;

      3. medication dose and route;

      4. purpose of the medication;

      5. medication schedule (time and frequency);

      6. anticipated actions and potential side effects; and

      7. how to ask for help or report concerns.

    5. Document the instruction in the electronic medical record (EMR).
      Person Responsible: Nurse/Clinical Case Manager

    6. Obtain the youth’s signature on the Youth Acknowledgement of Instructions for Self-Administration of Medication form, HLS-305
      Person Responsible: Nurse

    7. File the original form in the youth’s master file and place a copy in the daily health record binder.
      Person Responsible:  HSS/Juvenile Correctional Officer (JCO)

    8. Scan the completed HLS-305 and HLS-307 into the EMR.
      Person Responsible: Nurse.

    9. Call youth one at a time to self-administer medication.  The area should be quiet and ensure youth privacy.  If a youth has not arrived at the designated area within 15 minutes after the prescribed medication time, locate the youth and remind him/her.
      Person Responsible:  HSS/JCO

    10. Verbally review the medication self-administration procedure with the youth.  Instruct the youth to use hand sanitizer. 
      Person Responsible:  HSS/JCO

    11. Ask the youth to state the medication name, dose/number of pills, and purpose.  Verify in the Pharmacy Replacement System (PRS) that the medication is correct. Encourage the youth to read the prescription label on the blister pack and provide verbal assistance as needed. (Repeat this process for each medication just prior to self-administration).  Verbally commend youth who provide correct information.  If the youth is unable or unwilling to provide the correct information or staff determines the process cannot be implemented safely, offer to administer the medication to the youth in accordance with HHS.31.05
      Person Responsible: HSS/JCO

    12. Provide the youth a soufflé cup for the pill(s) and a cup of water.  With close supervision, hand the youth the multi-dose blister pack of medication that corresponds with the medication information provided by the youth.
      Person Responsible: HSS/JCO

    13. Observe the youth removing the correct number of pills from the blister pack and placing the pill(s) directly into the soufflé cup.  Repeat this process for each pill prescribed.
      Person Responsible: HSS/JCO

    14. Observe the youth swallow the medication.  Check the youth’s mouth at the end of the process to make sure the medication was swallowed.
      Person Responsible:  HSS/JCO

    15. Document medication administration in the PRS by using the “Custom Entry” tab to document the actual time medication was administered.  Record controlled substances on the Individual Youth Narcotic Record, HLS-730.
      Person Responsible: HSS/JCO

    16. Repeat steps (7)-(15) each time medications are given. Make sure that PRS is used to document each dose.
      Person Responsible: HSS/JCO

    17. REFUSAL:

      1. If a youth refuses a medication, ensure the youth completes a Refusal Form, HLS-520. The form is filed in the daily health records binder and the refusal is reported to the superintendent and the nurse in accordance with HHS.70.10.
        Person Responsible: HSS/JCO

      2. If a youth refuses one dose of a medication for a life-threatening condition (e.g., diabetes, seizure disorder, etc.), notify the nurse and superintendent immediately.
        Person Responsible: HSS/JCO

      3. If a youth refuses a psychotropic medication three times consecutively:

        1. notify the youth’s TJJD case manager, superintendent, and nurse and document notification on the Treatment & Intervention Record, HLS-505;
          Person Responsible: HSS/JCO

        2. meet with the youth within three business days to discuss reasons for the medication refusal, document the discussion on a Chronological Record: Medication Non-Compliance, CCF-520med, and place the form in the daily health records binder and the youth’s masterfile; and
          Person Responsible: Youth’s TJJD case manager

        3. scan the CCF-520med into the EMR during routine nursing visits and contact the prescribing provider for direction.
          Person Responsible: Nurse


      1. If a youth is observed to be cheeking, hoarding, or otherwise misusing a prescribed medication, document the incident on the youth’s Treatment & Intervention Record, HLS-505 and notify the youth’s TJJD case manager, nurse, and superintendent. 
        Person Responsible: HSS/JCO

      2. Contact the prescribing provider for direction. 
        Person Responsible: Nurse

      3. Meet with the youth within three business days to discuss reasons for the medication non-compliance, document the discussion on a Chronological Record: Medication Non-Compliance, CCF-520med, and place the form in the daily health records binder and the youth’s masterfile.
        Person Responsible: TJJD case manager

      4. Scan the CCF-520med into the EMR during routine nursing visits.
        Person Responsible: Nurse

    19. Review PRS for accuracy and refusals during routine visits.
      Person Responsible: Nurse

    20. Encourage youth to address medication-related issues in their Making It Happen Plan. 
      Person Responsible: TJJD Case Manager

    21. Review, discuss, and make recommendations regarding the youth’s continued participation in medication self-administration not later than 30 days after beginning the process.  
      Person Responsible: MDT

HHS Table of Contents