R03-609 Accountability and Medication Control

A. A licensee shall develop, implement and comply with written policies and procedures for providing medication services to include:

1. A method for ensuring that a client is informed of the risks or benefits of medications prescribed while in treatment,

2. Requirements for storing medication in a locked storage area according to the health, safety, and security requirements of federal, state, and local laws, including:

a. Storage of bulk medication,

b. Medication provided off the premises, if applicable,

c. Medication requiring refrigeration shall be stored in a separate refrigerator from food or other items,

d. Medications for topical use are maintained in a separate unit from internal and injectable medications, and

e. Disinfectants, urine specimens, or toxic materials are stored in a separate unit from medications,

3. Requirements for ensuring that all medication is accounted for, including bulk medication and, if applicable, medication that is provided off the premises,

4. Requirements for disposing of medication including:

a. Expired medications, or

b. Discontinued medications,

5. Procedures to ensure that a client’s current medication is provided to the client or designated representative at the time of discharge,

6. Procedures for preventing, responding to, and reporting:

a. A medication error,

b. An adverse response to a medication, or

c. A medication overdose,

7. Procedures to ensure that medication is provided to a client only as prescribed to include the:

a. Name of the medication,

b. Date and quantity of the medication received by the agency,

c. Name of the individual who ordered the medication,

d. Name of each client for whom the medication is prescribed,

e. Date, time, and dosage of each medication intake or application,

f. Staff signature or initials,

g. Documentation of a client's refusal to take prescribed medication, and

h. Maintenance of a medication log listing (7) (a) through (g),

8. Procedures for documenting each instance of medication intake or application including:

a. A specific route for drug administration,

b. Dosage,

c. Standard abbreviations,

d. The signature or initials of the client receiving the medication, and e. The signature or initials of the staff member administering or observing when medication is taken.

Review policy and procedure manual for elements of R03-609 A 1-8. 2. Tour facility and verify medication is in locked storage area. 7. Review and verify medication bottles and medication logs during facility tour.

 

B. A licensee shall ensure that:

1. Medication is prescribed or adjusted only by a licensed medical professional who is authorized to do so.

2. Medication is administered only by a medical professional or nurse or self-administered by the client. Non-medical program staff may monitor and document the client’s self-administration of medication but may not administer such medication,

3. Verbal orders for medication services are taken by a nurse, unless otherwise provided by law, and

4. Medications are clearly labeled.

Review policy and procedure. 3. Review clients files for doctors orders and verify nursing staff was took the orders, if applicable. 4. Verify medication labels in medication storage room during facility tour.

 

C. A licensee shall ensure that a drug reference guide is available and accessible, with a copyright date that is no more than five years before the current date.

Verify copy date of reference guide.

D. A licensee shall ensure that a list of licensed medical staff that are authorized to administer medications is maintained at the program.

Review and verify medical credentials are in the employee's file.

 

E. A licensee shall develop, implement, and comply with written policies and procedures for the self-administration of prescription medications by a client when:

1. Medication is prescribed by a medical professional, and

2. Documentation in the client’s records verifies:

a. A medication is being taken by the client for whom it is prescribed,

b. The dosage is labeled on the container, and

c. The medication is being taken as directed.

Review policy and procedure manual. Verify medication log.

 

F. A licensee shall:

1. Develop, implement, and comply with written policies and procedures regarding staff members authorized to have access to the locked medication storage,

2. Maintain controlled substances in a locked box within a locked cabinet,

3. Prohibit prescribed medication to be in the possession of any client except the client for which it was prescribed,

4. Ensure that a client who self administers prescribed medication is:

a. Observed by a staff member who has been oriented to program policies and procedures on self administration of medication, and

b. Permitted only when a client’s medication container is labeled, and

5. Provide a locked storage area where prescribed and over the counter medications are maintained according to the requirements of federal, state, and local regulations.

Review policy and procedure manual for elements of R03-609 1-5. 2. Verify controlled substance storage meets this requirement.