Code of Colorado Regulations
1000 - Department of Public Health and Environment
1011 - Health Facilities and Emergency Medical Services Division (1011, 1015 Series)
6 CCR 1011-1 Chapter 07 - ASSISTED LIVING RESIDENCES
Part 14 - MEDICATION AND MEDICATION ADMINISTRATION
Current through Register Vol. 48, No. 6, March 25, 2025
General Requirements:
14.1 An assisted living residence shall not allow an employee or volunteer to administer or assist with administering medication to a resident unless such individual is a practitioner, nurse, qualified medication administration person (QMAP), or certified nurse medication aide (CNA-Med) acting within his or her scope of practice.
14.2 For purposes of this Part 14, a practitioner is "authorized" if state law allows the practitioner to prescribe treatment, medication, or medical devices.
14.3 An assisted living residence shall not allow a QMAP or a CNA-Med to assist a resident with medication administration unless the resident is able to consent and participate in the consumption of the medication.
14.4 If a CNA-Med is used to administer or assist with administering medication to a resident, the assisted living residence shall ensure that the CNA-Med complies with the medication administration procedures listed in this Part 14, except that a CNA-Med may perform additional tasks associated with medication administration as authorized by his or her certification.
14.5 An assisted living residence that utilizes qualified medication administration persons shall ensure the qualified medication administration persons meet the definition at Part 2.52, and comply with the requirements of 6 CCR 1011-1, Chapter 24, Medication Administration Regulations, in addition to the requirements set forth in this Part 14.
14.6 The assisted living residence shall comply with all federal and state laws and regulations relating to procurement, storage, administration, and disposal of controlled substances.
14.7 The assisted living residence shall ensure that each resident receives proper administration and/or monitoring of medications.
14.8 The assisted living residence shall be responsible for ensuring compliance with all safety requirements regarding oxygen use, handling, and storage as set forth in Parts 22.29 through 22.34 of this chapter.
14.9 No medication shall be administered by a qualified medication administration person on a pro re nata (PRN) or "as needed" basis except:
14.10 Unless otherwise allowed by statute, the assisted living residence shall not permit a qualified medication administration person to perform any of the following tasks:
14.11 Only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents.
Training, Competency and Supervision
14.12 The assisted living residence shall ensure that all qualified medication administration persons are trained in and adhere to the following medication administration procedures:
14.13 The assisted living residence shall designate a QMAP supervisor who is a nurse, practitioner, or meets the definition of a qualified medication administration person at Part 2.52.
Resident Rights
14.14 All personal medication is the property of the resident and no resident shall be required to surrender the right to possess or self-administer any personal medication unless an authorized practitioner has determined that the resident lacks the decisional capacity to possess or self-administer such medication safely.
14.15 The assisted living residence shall ensure each resident's right to privacy and dignity with respect to medication monitoring and administration.
14.16 Each resident shall have the right to refuse medications.
Orders
14.17 The assisted living residence shall ensure that each authorized practitioner's order for medication includes the correct name of the resident, date of the order, medication name, strength of medication, dosage to administer, route of administration along with timing and/or frequency of administration, any specific considerations, if substitutions are allowed or restricted, and the signature of the practitioner.
14.18 All medication orders shall be documented in writing by the authorized prescribing practitioner. Verbal orders for medication shall not be valid unless received by a licensed staff member who is authorized to receive and transcribe such orders.
14.19 Any orders received from medical staff on behalf of an authorized practitioner must be countersigned by said practitioner as soon as possible.
14.20 The assisted living residence shall contact the authorized practitioner for clarification of any orders which are incomplete or unclear and obtain new orders in writing.
14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.
14.22 The assisted living residence shall coordinate care and medication administration with external providers.
Medication Reminder Boxes
14.23 For medication reminder boxes that the assisted living residence is responsible for, the assisted living residence shall ensure that the box contains:
14.24 Medication reminder boxes shall be stored in a manner that ensures access for the designated resident and prevents access from unauthorized persons.
Medication Preparation and Handling
14.25 The assisted living residence shall maintain medication storage and preparation areas which are clean and free of clutter.
14.26 All reusable medical devices shall be cleaned according to the manufacturer instructions and appropriately stored.
14.27 No stock medications shall be stored or administered by qualified medication administration persons.
14.28 The assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications.
Record Keeping
14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner.
14.30 The assisted living residence shall maintain a record on a separate sheet for each resident receiving a controlled substance which contains the name of the controlled substance, strength and dosage, date and time administered, resident name, name of authorized practitioner, and the quantity of the controlled substance remaining.
14.31 The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence's Quality Management Program assessment and review.
Reporting
14.32 The assisted living residence shall have policies and procedures for documenting, investigating, reporting, and responding to any errors related to accurate accounting of controlled substances and/or medication administration.
14.33 The assisted living residence shall ensure that the resident's authorized practitioner and resident's legal representative are promptly notified of:
Self-Administration
14.34 The assisted living residence shall compile a list of all resident medications, along with any known allergies, and verify the accuracy and completeness of the list with the resident and authorized practitioner at the time of admission.
14.35 The assisted living residence shall review this list with the resident and authorized practitioner at least once a year and maintain documentation of such review.
14.36 The assisted living residence shall report non-compliance, misuse, or inappropriate use of known medications by a resident who is self-administering to that resident's authorized practitioner.
Medication Storage
14.37 All medications shall be stored in the original prescribed/manufacturer containers with the exception of medications placed in medication reminder boxes pursuant to Part 14.23.
14.38 All medications shall be stored in a locked cabinet, cart, or storage area when unattended by qualified medication administration persons or other licensed staff.
14.39 Controlled substances shall be kept in double lock storage.
14.40 All refrigerated medications shall be stored in a refrigerator that does not contain food and that is not accessible to residents.
14.41 Outdated, discontinued, and/or expired medications that are not returned to the resident or legal representative shall be stored in a locked storage area until properly disposed of.
14.42 The assisted living residence shall conduct, on a monthly basis, a joint two person audit of medications designated for disposal.
Medication Destruction and Disposal
14.43 Medication shall be returned to the resident or resident's legal representative, upon discharge or death, except that return of medication to the resident may be withheld if specified in the care plan of a resident of a facility which is licensed to provide services specifically for the mentally ill, or if a practitioner has determined that the resident lacks the decisional capacity to possess or administer such medication safely.
14.44 The assisted living residence shall have policies and procedures regarding the destruction and disposal of outdated, unused, discontinued, and/or expired medications which are not returned to the resident or legal representative. At a minimum, the policies and procedures shall include the following requirements: