5123:2-6-06 Qualifications, training, and certification of MR/DD personnel in the administration of prescribed medications, performance of health-related activities, and performance of tube feedings.

(A) MR/DD personnel who meet the following qualifications are eligible to receive training in giving oral or applying topical prescribed medication, performing health-related activities, or administering food or prescribed medication via stable labeled gastrostomy tube or stable labeled jejunostomy tube:

(1) At least age eighteen years;

(2) Earned a high school diploma or a certificate of high school equivalency (GED). MR/DD personnel who, pursuant to rule 4723-21-16 of the Administrative Code, were employed on or before February 1, 2000 and determined eligible to give oral or apply topical prescribed medication without having earned a high school diploma or GED by demonstrating to a nurse instructor sufficient skills in writing, reading, and mathematics to be able to safely give oral or apply topical prescribed medications are not required to have a high school diploma or certificate of high school equivalency(GED).

(B) Prior to permitting MR/DD personnel to take a program of instruction set forth in this rule, the employer of MR/DD personnel shall do the following:

(1) Determine whether the state nurse aide registry created under section 3721.32 of the Revised Code contains a statement included pursuant to division (B)(1) of that section regarding the MR/DD personnel's alleged abuse or neglect of a long-term care facility resident or misappropriation of resident property;

(2) Verify that the MR/DD personnel's name does not appear on the abuser registry created under sections 5123.50 to 5123.54 of the Revised Code as having committed alleged abuse or neglect of an individual or misappropriation of an individual's property; and

(3) Verify compliance with the applicable criminal background check requirements established under sections 5126.28 and 5126.281 of the Revised Code and rules 5123:2-1-05 , 5123:2-1-05.1, and 5123:2-3-06 of the Administrative Code.

(C) MR/DD personnel: Prescribed medication administration and health-related activities training program

(1) A prescribed medication administration and health-related activities training program provided pursuant to this paragraph on or after the effective date of this rule, to allow MR/DD personnel to give oral or apply topical prescribed medication and perform health-related activities shall be at a minimum a fourteen-hour course. The content of a training course or part of a training course that trains MR/DD personnel in the administration of prescribed oral and topical prescribed medications and performance of health-related activities shall include all of the following:

(a) Infection control and universal precautions.

The registered nurse course instructor may waive the infection control and universal precautions instruction material and instruction time of the program of instruction if the MR/DD personnel can document training on that topic within the previous year.

(b) A review of applicable federal and state drug laws and rules.

(c) Information and instruction on the concepts underlying each step for giving oral or applying topical prescribed medications and how to correctly give oral or apply topical prescribed medications according to current standards of safe practice, including correct and safe practices, procedures, and techniques for administering prescribed oral or topical prescribed medication to train the MR/DD personnel to administer the right medication, at the right dose, to the right individual, by the right route, at the right time.

(d) Written step-by-step directions on how to give oral or apply topical prescribed medications.

(e) Instruction in quality measures, including but not limited to, procedures for reporting and documenting all prescribed medication errors that may occur when giving oral or applying topical prescribed medications or errors that may occur when performing health-related activities, procedures in case of emergency, and procedures on when and how to contact the trained MR/DD personnel's employer or designee or the supervising licensed nurse when medication is administered or a nursing task is performed pursuant to nurse delegation.

(f) Information about what MR/DD personnel may be authorized to perform with respect to giving oral or applying topical prescribed medications.

(g) Limitations with respect to as needed prescribed medications or PRN, which state that MR/DD personnel shall not give or apply a prescribed medication ordered by a physician or other licensed health care professional authorized by the Revised Code to prescribe medications when the prescribed medication is to be given as needed, unless the order is written with specific parameters which preclude independent judgment.

(h) Information about what MR/DD personnel are prohibited from giving, which includes but is not limited to the following:

(i) An intramuscular injection;

(ii) An intravenous injection;

(iii) A subcutaneous injection, except an injection of subcutaneous insulin providing the MR/DD personnel are trained in the subcutaneous injection of insulin pursuant to section 5123.42 of the Revised Code and paragraph (E) of this rule and the subcutaneous injection of insulin is delegated to a specific person by a licensed nurse pursuant to section 5123.42 of the Revised Code and this chapter;

(iv) Any prescribed medication administered through a nasogastric tube or any unstable or unlabeled gastrostomy tube or unstable or unlabeled jejunostomy tube; or

(v) Any debriding agent used in the treatment of a skin condition or minor abrasion.

(i) Instruction in the use of commercially packaged epinephrine auto-injector for treatment of anaphylactic allergic reaction as prescribed by a licensed health professional authorized to prescribe drugs.

(j) Instruction in the use of commercially packaged rectal diazepam gel for the treatment of epilepsy as prescribed by a licensed health professional authorized to prescribe drugs.

(k) Instruction in the use of commercially packaged glucagon for the treatment of hypoglycemia as prescribed by a licensed health professional authorized to prescribe drugs. Teaching must be completed and nursing delegation must be in place prior to administration of glucagon.

(l) Instruction in potential drug reactions, including known side effects, interactions, and the proper course of action if a side effect occurs, and sources for prescribed medication information (such as pharmacist, physician, nurse, or poison control).

(m) The requirements for documentation of prescribed medications administered, applied, missed, held or refused to, by or for each individual.

(n) Information regarding the proper storage and care of prescribed medications.

(o) Information and instruction about who may receive and who may transcribe physician orders and prescriptions onto a prescribed medication administration record and a treatment administration record specific to each category pursuant to rule 5123:2-6-03 of the Administrative Code.

(p) Performance of a successful return demonstration for each route of prescribed medication administration MR/DD personnel are being trained in;

(q) Information that health-related activities are performed only pursuant to nurse delegation except for individuals receiving family support services or services from certified supported living providers, if the services are offered or provided pursuant to Chapter 5123. or 5126. of the Revised Code; individuals receiving residential support services from certified home and community-based services providers, if the services are received in a community living arrangement that includes no more than four individuals; or individuals residing in a residential facility with five or fewer beds.

(r) Information and instruction on the concepts underlying each step for performing health-related activities according to current standards of safe practice, including instruction in the correct and safe practices, procedures, and techniques for performing health-related activities.

(s) Instruction in the usual parameters of health-related activities including vital signs, signs of possible wound infection and complications, bodily intake and output, and glucometer readings and instruction in the course of action to be taken when parameters of health-related activities are above or below those taught.

(t) The requirements for documentation of health-related activities done, missed, held or refused to, by or for each individual.

(u) The requirements for documentation and notification of health-related activity errors.

(v) Performance of successful return demonstration for each health-related activity MR/DD personnel are being trained to perform;

(w) Completion of written examination pursuant to paragraph (C)(6)(d) of this rule.

(x) Requirements for individual-specific training including the individual's needs, a summary of the individual's relevant health care information, and implementation of the individual's health care plan as part of the individual service plan. The individual-specific training shall occur after certification and prior to administration of prescribed medication or performance of health-related activities. The employer of MR/DD personnel and the delegating licensed nurse shall ensure that MR/DD personnel receive individual specific training pursuant to paragraphs (C)(5) and (C)(6) of rule 5123:2-6-03 of the Administrative Code.

(2) Except as specified in paragraph (C)(3) of this rule, a prescribed medication administration and health-related activities training program provided pursuant to this paragraph for MR/DD personnel already trained prior to the effective date of this rule to receive nursing delegation to give oral prescribed medication or apply topical prescribed medication shall be at a minimum a three-hour course and include at a minimum the following:

(a) Update of applicable federal and state drug laws and rules.

(b) Review of correct and safe practices, procedures, and techniques for administering prescribed oral or topical prescribed medication to train MR/DD personnel to administer the right prescribed medication, at the right dose, to the right individual, by the right route, at the right time.

(c) Instruction in quality measures including, but not limited to, procedures for reporting and documenting all prescribed medication errors that may occur when giving oral or applying topical prescribed medications or errors that may occur when performing health-related activities, procedures in case of emergency, and procedures on when and how to contact the trained MR/DD personnel's employer or designee, or the supervising licensed nurse when performing a delegable nursing task.

(d) Limitations with respect to as needed or PRN prescribed medications, which state that MR/DD personnel shall not give or apply a prescribed medication ordered by a physician or other licensed health care professional authorized by the Revised Code to prescribe medications when the prescribed medication is to be given as needed, unless the order is written with specific parameters which preclude independent judgment.

(e) Information about what MR/DD personnel are prohibited from giving, which includes but is not limited to the following:

(i) An intramuscular injection;

(ii) An intravenous injection;

(iii) A subcutaneous injection, except an injection of subcutaneous insulin providing the MR/DD personnel is trained in the subcutaneous injection of insulin pursuant to section 5123.42 of the Revised Code and paragraph (E) of this rule and the subcutaneous injection of insulin is delegated to a specific person by a licensed nurse pursuant to section 5123.42 of the Revised Code and this chapter;

(iv) Any prescribed medication administered through a nasogastric tube or any unstable or unlabeled gastrostomy tube or unstable or unlabeled jejunostomy tube; or

(v) Any debriding agent used in the treatment of a skin condition or minor abrasion.

(f) Instruction in the use of commercially packaged epinephrine auto-injector for treatment of anaphylactic allergic reaction as prescribed by a licensed health professional authorized to prescribe drugs.

(g) Instruction in the use of commercially packaged diazepam rectal gel for the treatment of acute repetitive seizures or cluster seizures as prescribed by a licensed health professional authorized to prescribe drugs.

(h) Instruction in the use of commercially packaged glucagon for the treatment of hypoglycemia as prescribed by a licensed health professional authorized to prescribe drugs. Teaching must be completed and nursing delegation must be in place prior to administration of glucagon.

(i) Reminder of proper course of action if a side effect occurs, and sources for prescribed medication information (such as pharmacist, physician, nurse, or poison control).

(j) Update in the requirements for documentation of prescribed medications administered, applied, missed, held or refused to, by or for each individual.

(k) Update in the requirements for documentation and notification of prescribed medication errors.

(l) Update in information regarding the proper storage and care of prescribed medications.

(m) Information and instruction about who may receive and who may transcribe physician orders and prescriptions onto a prescribed medication administration record and a treatment administration record specific to each category pursuant to rule 5123:2-6-03 of the Administrative Code.

(n) Performance of a successful return demonstration for each route of prescribed medication administration MR/DD personnel are being trained in.

(o) Instruction in the correct and safe practices, procedures, and techniques for performing health-related activities.

(p) Instruction in the usual parameters of health-related activities including vital signs, signs of possible wound infection and complications, bodily intake and output, and glucometer readings and instruction in the course of action to be taken when parameters of health-related activities are above or below those taught.

(q) The requirements for documentation of health-related activities done, missed, held or refused to, by or for each individual.

(r) The requirements for documentation and notification of health-related activity errors.

(s) Performance of successful return demonstration for each health-related activity MR/DD personnel are being trained to perform.

(t) Completion of written examination pursuant to paragraph (C)(6)(d) of this rule.

(u) Requirements for individual specific training including the individual's needs, a summary of the individual's relevant health care information, and implementation of the individual's health care plan as part of the individual service plan. The individual specific training shall occur after certification and prior to administration of prescribed medication or performance of health-related activities. The employer of MR/DD personnel and the delegating licensed nurse shall ensure that MR/DD personnel receive individual specific training pursuant to paragraphs (C)(5) and (C)(6) of rule 5123:2-6-03 of the Administrative Code.

(3) MR/DD personnel may forego any instruction material and corresponding instruction time of the training outlined in paragraph (C)(2) of this rule by providing the certified registered nurse instructor with documentation of having received training provided by a registered nurse as part of nursing delegation prior to the effective date of this rule. Documentation must be by the registered nurse who taught the delegation. Such MR/DD personnel must still complete those portions of the prescribed medication and health-related activities training program required in paragraph (C)(2) of this rule that they have not been trained on and meet the certification requirements outlined in paragraphs (C)(6)(b) to (C)(6)(d) of this rule.

(4) The registered nurse coordinator of the prescribed medication administration and health-related activities training program shall ensure that the prescribed medication administration and health-related activities training program shall be planned, developed, and taught in accordance with requirements set forth in this chapter. The registered nurse certified instructor may utilize other licensed health care professionals to assist with conducting the training as long as the other health care professionals have received instruction on the material and are acting within the professional's scope of practice as outlined in the Revised Code. None of the other licensed health care professionals shall teach the class in its entirety, but may serve as a guest instructor at the direction of the registered nurse certified instructor.

(5) A prescribed medication administration and health-related activities training program course not developed by the department must be approved by department prior to use in the prescribed medication administration and health-related activities training program.

(6) Certification

Successful completion of the prescribed medication administration and health-related activities training program is required to receive a certificate of training. To receive certification, MR/DD personnel shall do the following:

(a) Attend the entire program of required training;

(b) Participate in class discussions, activities, and return demonstration of proficiency in administering prescribed medications and performing health-related activities;

(c) Complete and submit to the registered nurse certified instructor the evaluation of the prescribed medication administration and health-related activities training program; and

(d) Complete the final closed book written examination with a score of at least eighty per cent. MR/DD personnel scoring less than eighty per cent on the final written examination shall retake the program of training in its entirety to be eligible to retake the final written examination. The final written examination shall be developed and maintained by the department, and only this final written examination shall be used in this program.

(7) Renewal of certification

(a) To maintain certification in the prescribed medication administration and health-related activities training program, trained MR/DD personnel shall complete at a minimum two hours of continuing education annually that relate to the information taught in the prescribed medication administration and health-related activities training program or that will enhance the role of MR/DD personnel who have completed the prescribed medication administration and health-related activities training program. MR/DD personnel shall provide documentation of such hours to the certified registered nurse trainer. Cardiopulmonary resuscitation (CPR), universal precautions, and first aid training shall not make up any part of these two hours.

(b) If the minimum two hours of continuing education are not completed by the annual anniversary date of certification, the MR/DD personnel's certification shall be temporarily suspended for a maximum period of sixty days, during which time the required continuing education shall be completed, and during which time the MR/DD personnel may not administer prescribed medication or perform health-related activities. If the required continuing education is not completed within this sixty-day-period, the MR/DD personnel's certification will be revoked, and the MR/DD personnel shall be required to retake the course in prescribed medication administration and health-related activities in total to become recertified.

(D) MR/DD personnel: Feeding tube by nursing delegation training program

(1) The training provided pursuant to this paragraph to allow MR/DD personnel to provide prescribed medication administration or feeding via stable labeled gastrostomy tube or stable labeled jejunostomy tube feedings by nursing delegation shall be at a minimum four hours and shall be in addition to the prescribed medication and health-related activities training required in paragraph (C) of this rule. MR/DD personnel shall successfully complete the prescribed medication administration and health-related activities training required in paragraph (C) of this rule prior to participating in training for feeding or prescribed medication administration via stable labeled gastrostomy or stable labeled jejunostomy tube. The content of the training course that trains MR/DD personnel in the administration of food or prescribed medications via stable labeled gastrostomy or stable labeled jejunostomy tubes shall include all of the following:

(a) Correct and safe practices, procedures and techniques for administering food or prescribed medication via a stable labeled gastrostomy tube or a stable labeled jejunostomy tube including possible signs and symptoms of gastrostomy tube or jejunostomy tube malfunction or tube problems, complication or intolerance of food or prescribed medication by the individual, and appropriate response to gastrostomy tube or jejunostomy tube that becomes dislodged.

(b) The requirements for documentation of food and prescribed medications administered, missed, held or refused to, by or for each individual via a stable labeled gastrostomy tube or stable labeled jejunostomy tube.

(c) Requirements for documentation and notification of prescribed medication errors or feeding errors via a stable labeled gastrostomy tube or stable labeled jejunostomy tube.

(d) Information regarding the proper storage, care, and preparation of food and prescribed medications to be given via a stable labeled gastrostomy tube or stable labeled jejunostomy tube.

(e) Information regarding the proper storage and care of tube feeding equipment.

(f) Requirements for nursing delegation of prescribed medication or food administration via a stable labeled gastrostomy tube or a stable labeled jejunostomy tube.

(g) Instruction that only the delegating licensed nurse shall receive prescriptions for food or prescribed medication to be administered by stable labeled gastrostomy tube or stable labeled jejunostomy tube and only the delegating nurse shall transcribe these prescriptions into an individual's prescribed medication administration record or treatment record.

(h) Completion of written examination pursuant to paragraph (D)(5)(d) of this rule.

(i) Requirements for individual-specific training including the individual's needs, a summary of the individual's relevant health care information, and implementation of the individual's health care plan as part of the individual service plan. The delegating licensed nurse shall be responsible for the individual-specific training. The individual-specific training shall occur after certification and prior to administration or feeding via a stable labeled gastrostomy tube or stable labeled jejunostomy tube.

(2) MR/DD personnel who prior to the effective date of this rule were receiving nursing delegation and performing prescribed medication administration or provision of food via stable labeled gastrostomy tube or stable labeled jejunostomy tube may forego the training outlined in paragraph (D)(1) of this rule by performing a return demonstration of these skills to the delegating registered nurse. The delegating registered nurse shall update MR/DD personnel who are being delegated to on sections 5123.41 to 5123.47 of the Revised Code and rules adopted under this chapter.

(3) The registered nurse coordinator of the feeding tube by nursing delegation training program shall ensure that the feeding tube by nursing delegation training program shall be planned, developed and taught in accordance with requirements set forth in this chapter. The registered nurse certified instructor may utilize other licensed health care professionals to assist with conducting the training as long as the other health care professionals have received instruction on the material and are acting within the professional's scope of practice as outlined in the Revised Code. None of the other licensed health care professional shall not teach the class in its entirety, but may serve as a guest instructor at the direction of the registered nurse certified instructor.

(4) A feeding tube by nursing delegation training program course not developed by the department must be approved by the department prior to use in the feeding tube by nursing delegation training program.

(5) Certification

Successful completion of the feeding tube by nursing delegation training program is required to receive a certificate of training. To receive certification, the MR/DD personnel must do the following:

(a) Attend the entire program of required training;

(b) Participate in class discussions, activities, and return demonstration of proficiency in administering prescribed medications and food via stable labeled gastrostomy tube and stable labeled jejunostomy tube;

(c) Complete and submit to the registered nurse certified trainer the evaluation of the feeding tube by nursing delegation training program; and

(d) Complete the final closed book written examination with a score of at least eighty per cent. MR/DD personnel scoring less than eighty per cent on the final written examination shall retake the program of training in its entirety to be eligible to retake the final written examination. The final written examination shall be developed and maintained by the department, and only this final written examination shall be used in this program.

(6) Renewal of certification

(a) To maintain certification in the feeding tube by nursing delegation training program, trained MR/DD personnel shall complete one hour of continuing education annually that is planned or coordinated by a registered nurse certified pursuant to rule 5123:2-6-04 of the Administrative Code and that relates to the information taught in the feeding tube by nursing delegation training program or that will enhance the role of MR/DD personnel who have completed the feeding tube by nursing delegation training program. MR/DD personnel shall provide documentation of such hours to the certified registered nurse trainer. Cardiopulmonary resuscitation (CPR), first aid, and universal precautions training shall not make up any part of this one hour.

(b) If the minimum one hour of continuing education is not completed by the annual anniversary date of certification, the MR/DD personnel's certification shall be temporarily suspended for a maximum period of sixty days, during which time the required continuing education shall be completed, and during which time the MR/DD personnel may not administer prescribed medication or food via stable labeled gastrostomy tube or stable labeled jejunostomy tube, and may not receive nursing delegation to perform administer prescribed medication or food via stable labeled gastrostomy tube or stable labeled jejunostomy tube. If the required continuing education is not completed within this sixty-day-period, the MR/DD personnel's certification shall be revoked, and the MR/DD personnel shall be required to retake the course in feeding tube by nursing delegation in total to become recertified.

(E) MR/DD personnel: Subcutaneous insulin injection by nursing delegation training program

(1) The training provided pursuant to this rule to allow MR/DD personnel to provide subcutaneous insulin injection by nursing delegation shall be at least four hours and in addition to the prescribed medication administration and health-related activities training required in paragraph (C) of this rule. MR/DD personnel shall successfully complete the prescribed medication administration and health-related activities training required in paragraph (C) of this rule prior to participating in training for subcutaneous insulin injection. The content of the training course that trains MR/DD personnel in the administration of insulin by subcutaneous injection shall include all of the following:

(a) Information on the basic pathophysiology of diabetes mellitus.

(b) Correct and safe practices, procedures and techniques for administering subcutaneous insulin injection, possible signs and symptoms of subcutaneous insulin injection complication, and instruction in safe handling and disposal of sharps.

(c) The requirements for documentation of subcutaneous insulin injection administered, missed, held or refused to, by or for each individual

(d) Requirements for documentation and notification of subcutaneous insulin injection or insulin pump errors.

(e) Information regarding the proper storage, care, and preparation of insulin to be given by subcutaneous injection or insulin pump.

(f) Signs and symptoms of hypoglycemia and hyperglycemia and procedure for intervention and notification of nurse, physician, or emergency medical services.

(g) Instruction in the use of commercially packaged glucagon for the treatment of hypoglycemia as prescribed by a licensed health professional authorized to prescribe drugs. Teaching must be completed and nursing delegation must be in place prior to administration of glucagon.

(h) Instruction that only a licensed nurse shall transcribe an insulin prescription into an individual's prescribed medication administration record.

(i) Completion of written examination pursuant to paragraph (E)(4)(d) of this rule.

(j) Requirements for nursing delegation of subcutaneous insulin injection.

(k) Requirements for individual-specific training including the individual's needs, a summary of the individual's relevant health care information, and implementation of the individual's health care plan as part of the individual service plan. The delegating licensed nurse shall be responsible for the individual-specific training. The individual-specific training shall occur after certification and prior to administration of subcutaneous insulin injection.

(2) The registered nurse coordinator of the subcutaneous insulin injection by nursing delegation training program shall ensure that the subcutaneous insulin injection by nursing delegation training program is planned and developed in accordance with requirements set forth in this chapter. The registered nurse certified instructor may utilize other licensed health care professionals to assist with conducting the training as long as the other health care professionals have received instruction on the material and are acting within the professional's scope of practice as outlined in the Revised Code. None of the other licensed health care professionals shall teach the class in its entirety, but may serve as a guest instructor at the direction of the registered nurse certified instructor.

(3) A subcutaneous insulin injection by nursing delegation training program course not developed by the department must be approved by the department prior to use in the subcutaneous insulin injection by nursing delegation training program.

(4) Certification

Successful completion of the subcutaneous insulin injection by nursing delegation training program is required to receive a certificate of training. To receive certification, MR/DD personnel shall do the following:

(a) Attend the entire program of required training;

(b) Participate in class discussions, activities, and return demonstration of proficiency in administering subcutaneous insulin injection;

(c) Complete and submit to the registered nurse certified trainer the evaluation of the subcutaneous insulin injection by nursing delegation training program; and

(d) Complete the final closed book written examination with a score of at least eighty per cent. MR/DD personnel scoring less than eighty per cent on the final written examination shall retake the program of training in its entirety to be eligible to retake the final written examination. The final written examination shall be developed and maintained by the department, and only this final written examination shall be used in this program.

(5) Renewal of certification

(a) To maintain certification in the subcutaneous insulin injection by nursing delegation training program, trained MR/DD personnel shall complete one hour of continuing education annually that is planned or coordinated by a registered nurse certified pursuant to rule 5123:2-6-04 of the Administrative Code and that relates to the information taught in the subcutaneous insulin injection by nursing delegation training program, and that will enhance the role of MR/DD personnel who have completed the subcutaneous insulin injection by nursing delegation training program. MR/DD personnel shall provide documentation of such hours to the certified registered nurse trainer. Cardiopulmonary resuscitation (CPR), first aid, and universal precautions training shall not make up any part of this one hour.

(b) If the minimum one hour of continuing education is not completed by the annual anniversary date of certification, the MR/DD personnel's certification shall be temporarily suspended for a maximum period of sixty days, during which time the required continuing education shall be completed, and during which time the MR/DD personnel may not administer subcutaneous insulin injection, and may not receive nursing delegation to perform subcutaneous insulin injection. If the required continuing education is not completed within this sixty-day-period, the MR/DD personnel's certification shall be revoked, and the MR/DD personnel shall be required to retake the course in subcutaneous insulin injection by nursing delegation in total to become recertified.

(F) The standards established by the Ohio board of nursing under Chapter 4723-13 of the Administrative Code shall apply when an unlicensed person is performing delegable nursing tasks that are not defined as health-related activities.

R.C. 119.032 review dates: 07/05/2012 and 07/05/2015
Promulgated Under: 119.03
Statutory Authority: 5123.04 , 5123.42 , 5123.43 , 5123.45 , 5123.46
Rule Amplifies: 5123.04 , 5123.41 to 5123.47
Prior Effective Dates: 09/30/1993 (Emer.), 12/29/1993, 05/16/1994 (Emer.), 08/06/1994, 06/30/1995, 02/14/2000, 10/22/2003 (Emer.), 01/08/2004