The discipline of Ohio Medication Aide (MA-C [Medication Aide-Certified]) was initiated in 2009. Obviously, the creation of the discipline was a concession that nurses in long-term care spend too much time passing medications. If that was true in 2009, it is exceedingly true now; the long-term care nursing discipline is dominated by medication administration, which excludes the remaining scope of practice and to the detriment of resident care. Nevertheless, fourteen years later, for the most part, the long-term care community is divided into two groups: those who have never heard of the MA-C discipline and those who are against it, primarily nurses. In addition, MA-C antagonists are woefully uninformed or misinformed concerning the discipline.
Recently, that was beginning to change. Ohio staff shortages are extreme enough to cause facility administrators to seek solutions. During that search, many have stumbled upon Sherri Gunasekera, a pioneer in advancing the MA-C discipline in Ohio. Finally, strides were being made, primarily due to the years of work by Gunasekera. At a recent nursing convention in Columbus, Ohio, more than 200 facility managers and directors attended a 90-minute seminar by Gunasekera on the MA-C discipline and scope of practice. It should be noted that only two facilities represented at the presentation are presently using MA-Cs, and all the others “still have questions.” Until recently, most discussions about MA-Cs were dismissed out of hand, but it seems that facilities are beginning to understand that Ohio MA-Cs are extensively trained to pass medications, even more so than nurses. In other words, the MA-C discipline was finally poised to solve LTC staffing problems in Ohio, primarily by convincing facilities that MA-Cs can be trusted to pass medications.
You might notice that I am using past-tense terms to describe the present favorable position the MA-C program finds itself in. This is because of new legislation in the state of Ohio. This new legislation will likely result in outcomes that are the antithesis of what is intended. The new legislation will further exacerbate staffing shortages, compromise resident safety, destroy the MA-C program for all practical purposes, and present opportunities for accusations of state-sponsored medical fraud.
We will pause here to look at the new legislation. SB 131 resulted from Governor DeWine’s Common Sense Initiative (CSI), an executive order. The stated goals follow:
- Regulations should facilitate economic growth.
- Regulations should be transparent and responsive.
- Compliance should be easy and inexpensive.
- Regulations should be fair and consistent.
SB 131 involves a plethora of different professions regarding state reciprocity. In most cases, these goals are somewhat achieved, but in the case of MA-C, the goals are inverted with sobering consequences.
According to a post on governor.ohio.gov, dated January 02, 2023, regarding bills signed into law, we have the following information regarding SB 131:
Senate Bill 131, sponsored by Senators Kristina Roegner and Rob McColley, requires an occupational licensing authority to issue a license or government certification to an applicant who holds a license, government certification, or private certification or has satisfactory work experience in another state under certain circumstances; specifies that individuals may not register as credit services organizations; specifies that individuals may not be licensed as manufacturers or wholesalers of fireworks; and maintains State Teacher Retirement System membership for certain school psychologists.
In the case of MA-C, the occupational licensing authority is the Ohio Board of Nursing. The zeal of the board to apply this law to the MA-C certification is a bit surprising; perhaps the reason follows. In response to a letter I sent to the OBN, an attorney for the OBN replied by email and stated that the OBN was mandated to apply SB 131 to the MA-C discipline. In fact, the new rules submitted by OBN that will become part of the SB 131 law if approved by the Joint Committee On Agency Rule Review (JCARR), seem to be an attempt to adapt healthcare rules to the four goals of DeWine’s executive order. That is the first big problem with the bill; it attempts to apply business concerns to healthcare safety issues. In nursing, safety is always the first priority.
However, before we move on, let me give a thumbnail of the process: DeWine signed an executive order. From that, state legislators proposed new laws to meet the executive order goals. The new laws then mandated licensure agencies to accept licenses and certifications from other states according to new rules presented by the agencies. If these new rules are approved by JCARR, they become part of the law.
JCARR oversees rules submitted by occupational agencies to ensure they do not exceed the authority granted by the General Assembly (Ohio legislative body of the House and Senate). This also applies to the Legislative Service Commission review, which reviews laws for legal sufficiency. Lastly, in this case, OBN must also submit a report to the committee overseeing the executive order (CSI) concerning the impact on business, which is one of the initiative’s primary goals. Conspicuously absent from that report is the impact of the new rules on companies that train MA-Cs and certify them to take the state test. The new rules will close those businesses for all practical purposes, but more on that later.
The new law covers numerous healthcare certifications except the nurse aide scope of practice. Why this exclusion? The answer to this question reveals another huge problem. Regarding this huge problem, it is a movie that we have seen before. The lack of qualifications for nurse aides led to a national crisis of abuse and inferior care in long-term care (LTC) facilities. This resulted in OBRA, a federal law, and included the same training and stringent testing mandates for nurse aides in all states. So, neither the Ohio Board of Health nor OBN would have the authority to change rules for a federal law. It is neither here nor there regarding nurse aide reciprocity because the qualifications and standards are universal in the United States.
Thank goodness for that, but don’t miss the second point. Apparently, few have learned from the OBRA lesson on what results in the lowering of healthcare standards. And please recall the first point that the one-size-fits-all “commonsense” initiative approach will compromise healthcare safety in LTC because the initiative focuses on business concerns to the exclusion of safety, which boils down to qualifications. Think about this; the discipline of nurse aide will require more qualifications than those passing medications in LTC.
How is this going to happen because of SB131? The initiative, as reflected by the OBN rules, requires OBN to certify people from other states WITH an Ohio MA-C certification if they are certified by another state, certified by a “private” certification, or have LIKE experience in states that do not offer a medication administration certification. The descending levels require more experience respectively; a state certified medication aide needs one year experience passing meds to apply, certification by a private entity requires two years, and like experience requires three years. These experience requirements also must be within five years from the date of application. In other words, a lull in experience that exceeds 1-4 years would disqualify an applicant depending on which certification by endorsement they are applying for.
So, if an individual lives in a state that does not offer medication certification and has some sort of similar experience for three years (“satisfactory work experience”), they qualify to apply for an Ohio MA-C certification. The OBN nomenclature for this is someone who has worked as a medication aide without private or government certification in a state that does not offer certification. This helps to veil the audacity of the rule in the medical realm. Regarding private certifications, like a certification to pass medications in group homes, many of those types of certifications only require eight hours of training. Also, with private certifications, those passing the medications can only do so in homes or facilities owned by the company that certified them. Shockingly, the new law qualifies them to obtain a MA-C certification and pass medications wherever an Ohio MA-C would be qualified to do so. That is hardly, “consistent,”
The certification “by endorsement” is the same certification issued to Ohio healthcare workers without distinction, regardless of training. When Sherri Gunasekera made this point at a legislative hearing where an OBN representative was testifying, the OBN representative did not deny that it is a singular certification regardless of qualifications. This isn’t the case with nurses or even state-tested nurse aides because of nationwide standards and testing. When a nurse or an STNA applies for a job at a facility, Human Resources assumes a certain level of knowledge and training based on licensure and certification. This will not be the case with a MA-C certification. The MA-C certification could represent a plethora of different training, experience, and knowledge. Basically, it defeats the whole purpose of a certification to begin with. And remember, one of the four goals of the CSI is “fairness.” This is hardly fair to Ohio residents who must take 120 hours of classroom instruction to sit for a state exam and state skills test to be certified as a MA-C in Ohio.
For example, state certifications in Kentucky only require 40 hours of training, which is only 1/3 of what Ohio requires. The other two qualification levels are even lower in the training category. The new rules reduce training requirements and transcend scope of practice by virtue of being from another state. Some argue that out-of-state recipients still must abide by Ohio MA-C rules, but that is not true regarding the basic requirements. Someone with a former private certification from another state can now pass meds in any Ohio LTC facility. Simply because someone is from another state, they will receive a state certification in place of a private certification or no certification at all, but rather based on “satisfactory work experience.” The conjunction in the bill is not “and,” it is, “or” representing a noncertified category.
The following is a scenario that grants perspective. An individual who cared for her mother’s medical needs decides to get a job at an assisted living facility in a state that does not offer government certifications for nurse aides. She then works there for three years. Now, she qualifies to apply for a STNA certification in Ohio. By the criteria of SB 131, she could be granted the same certification without any STNA training or testing, and qualify to work in any LTC skilled facility.
Furthermore, the state issued certification would misrepresent her qualifications based on prior STNA precedent. Normally, it is not lawful for a healthcare professional to misrepresent their qualifications. In other words, if a LPN states that he or she is a RN, that’s medical fraud, unless the state makes the two licenses the same thing, which doesn’t seem like a good idea. However, even if that is the case, patients are being misled based on past understanding of what a RN discipline meant regarding qualifications.
Of course, this can’t happen with nurse aides in Ohio because of OBRA, but let’s take this example a little bit further. Let’s say she helped the nurses pass medications in the aforementioned assisted living facility. She can’t apply for a STNA certification by endorsement but can apply for a MA-C certification by endorsement. Deemed unqualified by Ohio to perform ADLs (activities of daily living), she can pass medications instead. The blatant disregard for resident safety speaks for itself.
And what about another CSI concern regarding impact on business? As discussed earlier, it will render MA-C training in Ohio irrelevant, affecting about 30 companies. When the word gets out to facilities that MA-C certifications represent subjective qualifications, consideration of the discipline will be dead on arrival. Skepticism will turn to rejection with prejudice.
A study conducted by Excellence in Assisted Living-University of North Carolina Collaborative, and posted by the NIH in 2011, found the following:
Medication aides do not commit more errors than LPNs, but other nonnurses who administered a significant number of medications and assisted with self-administration committed more errors…(odds ratio=2.10, 95%). Consequently, all staff who handle medications should be trained to the level of a medication aide.
It should be noted that the Ohio Department of Health requires medication errors to be less than 5%. An influx of unqualified people with unearned MA-C certificates will likely exceed that percentage. Obviously, Ohio LTC residents will be at risk.
Moreover, if they continue to operate, MA-C schools and holders of legitimate MA-C certificates will be promoting false assumptions that all MA-C recipients are equally qualified, albeit unwillingly.
Again, the problem is a state determination that reciprocity yields the same results over different professions. For example, notaries or real estate agents. Private certification or like experience is not an issue with those professions because the licensure requirements are similar nationwide. In no state do you have someone selling real estate or notarizing for a company with in-house certification. Medications are different: people self-medicate, people assist others in remembering their medication, parents administer insulin to their children, etc. In states where nurse aides are allowed to assist residents with medications in assisted living, and have done so for three years, they are now qualified to come to Ohio and pass cardiac glycosides, schedule II narcotics, and cancer medications to Ohio residents in LTC.
All in all, the same certification for different qualifications in healthcare is not only a very bad idea but also a fraud perpetrated on those depending on competent caregivers. No serious person can argue that SB 131 puts safety first when applied to Ohio Medication Aides. Ironically, the application of the CSI to the MA-C discipline not only puts safety dead last but also violates all four goals of the initiative to begin with.
When we consider all of this, it begs the question: “What political motive is really behind all of this?” Only time will tell. Others say, “Always follow the money.” There is that also. But thirdly, you can always count on safety first as pretense being along for the ride. And of course, we all know where this will end up because medication errors are already a leading cause of death in healthcare. It’s the nurse aide movie we have already seen.
Posted by Paul M. Dohse, STNA, MA-C, LPN
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