Current through 2024-38, September 18, 2024
7.1
Use of
safe and acceptable procedures. The administrator shall ensure that all
persons administering medications and treatments (except residents who
self-administer) use safe and acceptable methods and procedures for ordering,
receiving, storing, administering, documentation, packaging, discontinuing,
returning for credit and/or destroying of medications and biologicals. All
employees must practice proper hand washing and aseptic techniques. A
hand-washing sink shall be available for staff administering medications.
[Classes I/II/III]
7.1.1
Residents shall receive only the medications ordered by his/her duly authorized
licensed practitioner in the correct dose, at the correct time, and by the
correct route of administration consistent with pharmaceutical standards.
[Classes I/II/III]
7.1.2 No injectable medications may be
administered by an unlicensed person, with the exception of bee sting kits and
insulin.
7.1.3 Before using a bee
sting kit, unlicensed persons must be trained by a registered professional
nurse in regard to safe and proper use. Documentation of training shall be
included in the employee record.
7.1.4 Unlicensed assistive personnel must be
trained by a registered professional nurse in regard to the management of
persons with diabetes. The registered professional nurse must provide
in-service training and documentation to include:
[Class III]
7.1.4.1 Dietary requirements;
7.1.4.2 Anti-Diabetic Oral Medications -
inclusive of adverse reactions and interventions, hyper and hypo glycemic
reactions;
7.1.4.3 Insulin mixing
including insulin action;
7.1.4.4
Insulin storage;
7.1.4.5 Injection
techniques and site rotation;
7.1.4.6 Treatment and prevention of insulin
reaction including signs/symptoms;
7.1.4.7 Foot care;
7.1.4.8 Lab testing, urine testing and blood
glucose monitoring; and
7.1.4.9
Standard Precautions.
Documentation of training shall be included in the employee
record.
Review of this training shall be on an annual basis.
7.1.5 Urine testing
shall not be done around medication or areas where food is stored or prepared.
Proper Standard Precautions relative to body fluids shall be implemented.
Toilets shall be used for the disposal of urine and test sample waste. Toxic
urine testing chemicals (tablets, solutions) shall be stored in a locked area
totally apart from oral medications.
7.1.6 For those residents whom the facility
is responsible for assistance with medication administration, no medications,
including those brought into the facility by the resident, family or friends,
shall be administered or discontinued without a written order signed by a duly
authorized licensed practitioner or other person licensed to prescribe
medications. [Class III]
7.1.7 Orders for medications and treatments
shall be in writing, signed and dated by a duly authorized licensed
practitioner and shall be in effect for the time specified by the duly
authorized licensed practitioner, but in no case to exceed twelve (12) months,
unless there is a written reorder. Orders for psychotropic medications shall be
reissued every three (3) months, unless otherwise indicated by the duly
authorized licensed practitioner. Standing orders for individual residents are
acceptable when signed and dated by the duly authorized licensed practitioner.
7.1.7.1 Upon admission to another facility,
all existing orders are no longer in effect. Upon return to the facility, all
orders must be reviewed and approved by the resident's duly authorized licensed
practitioner within 72 hours. During that time frame, orders that are signed
and dated by the discharging duly authorized licensed practitioner are the
current acceptable orders. Prior to admission to another facility all
medications must be removed from service and placed in a locked area in
accordance with Section 7.7.
7.2
Administration of
medications.
7.2.1
Self-administration. Upon admission, each individual's ability to
self-administer medications will be determined by an assessment of his/her
ability or need for assistance, unless the resident/legal representative elects
(in writing) to have the facility administer his/her medications. A final
decision will be reached between the resident, his/her legal representative,
his/her duly authorized licensed practitioner and a facility
representative.
7.2.2
Medications administered by facility. For those medications and/or
associated treatments for which the facility is responsible, the following
apply:
7.2.2.1 Telephone orders shall be
accepted only by a registered or licensed nurse or pharmacist. Written dated
orders for telephone orders must be signed by the duly authorized licensed
practitioner within five (5) working days.[Class
III]
7.2.2.2 Facsimile
orders are acceptable legal orders as long as they are in compliance with the
Commission on Pharmacy regulations.
7.2.3
Unlicensed Health Care Assistive
Personnel. Unlicensed assistive personnel administering medications
and/or treatments must successfully complete training approved by the
Department. There shall be evidence available in the facility that such
training has been successfully completed. Whenever the standards or guidelines
of the medication administration course are substantially revised, unlicensed
personnel must be re-certified within one (1) year of the revision, by a method
approved by the Department. An additional exception will be made on a
case-by-case basis for persons who only administer dietary supplements and/or
minor medicated treatments, shampoos, lotions and creams that could be obtained
over the counter without a physician's order. Any person who is certified as a
CNA-M may administer medications and/or treatments.
A person qualified to administer medications must be on
site at the facility whenever a resident(s) have medications prescribed "as
needed" (PRN) if this medication is not self-administered.
All unlicensed assistive personnel administering
medications and/or treatments must complete a Department-approved eight (8)
hour refresher course biennially for re-certification within two (2) years of
the original certification. [Class III]
7.2.4
PRN Medications.
7.2.4.1
PRN Psychotropic medications.
Psychotropic medications ordered "as needed" by the duly authorized
licensed practitioner, shall not be administered unless the duly authorized
licensed practitioner has provided detailed behavior-specific written
instructions, including symptoms that might require use of medication, exact
dosage, exact time frames between dosages and the maximum dosage to be given in
a twenty-four (24) hour period. Facility staff shall notify the duly authorized
licensed practitioner within twenty-four (24) hours when such a medication has
been administered, unless otherwise instructed in writing by the duly
authorized licensed practitioner.
7.2.4.2 A person qualified to administer
medications must be on site at the assisted living program, residential care
facility or private non-medical institution whenever a resident(s) have
medications prescribed "as needed" (PRN) if this medication is not
self-administered.
In no event, however, shall antipsychotic-type psychotropic
medications be prescribed on a PRN basis only, having no routinely scheduled
and administered doses.
7.3
Medication storage.
7.3.1 Residents who self-administer
medications and who handle their own medical regime may keep medications in
their own room. To ensure the safety of the other residents, the facility will
provide a locked area/container, if necessary. [Class
III]
7.3.2 Medications
administered by the assisted living program, residential care facility or
private non-medical institution shall be kept in their original containers in a
locked storage cabinet. The cabinet shall or private non-medical institution be
equipped with separate cubicles, plainly labeled, or with other physical
separation for the storage of each resident's medications. It shall be locked
when not in use and the key carried by the person on duty in charge of
medication administration. [Class III]
7.3.3 Medications/treatments administered by
the assisted living program, residential care facility or private non-medical
institution for external use only shall be kept separate from any medications
to be taken internally. [Class III]
7.3.4 Medications administered by the
assisted living program, residential care facility or private non-medical
institution which require refrigeration, shall be kept safely stored and
separate from food by placement in a special tray or container, except
vaccines, which must be stored in a separate refrigeration unit that is not
used to store food. Refrigeration shall be forty-one (41) degrees Fahrenheit or
below. A thermometer shall be used to ensure proper refrigeration.
[Class III]
7.4
Temporary absences. When a
temporary absence from the facility is expected to be greater than seventy-two
(72) hours, medications leaving the facility (except those for resident's who
self-administer) must be in a form packaged and labeled by a pharmacist. For
medications leaving the facility for seventy-two (72) hours or less, the
medication shall be packaged in such a way as to facilitate self-administration
or administration by a responsible party of the correct medication at the
appropriate time. Properly certified or licensed staff will use acceptable
methods and procedures for preparing medications for leaving the facility.
Staff will follow the same policies used in the facility for administering
medications. The name of the resident and the name and strength of each drug,
as well as the directions from the original prescription package, should be
conveyed to the resident or their responsible party along with all cautionary
information in writing, either directly on an envelope containing the
appropriate dose or on a separate instruction sheet. If the medication is sent
in original container, pills must be counted and documented upon leaving and
returning to the facility. [Class III]
7.5
Medication labeling. Each
prescription dispensed by a pharmacy shall be clearly labeled in compliance
with requirements of the Commission on Pharmacy and shall include at least the
following:
7.5.1 Prescription
number;
7.5.2 Resident's full
name;
7.5.3 Name, strength and
dosage of the drug;
7.5.4
Directions for use;
7.5.5 Name of
prescribing duly authorized licensed practitioner;
7.5.6 Name and address of issuing
pharmacy;
7.5.7 Date of issue of
latest refill;
7.5.8 Expiration
date; and
7.5.9 Appropriate
accessory and cautionary instructions.
7.6
Improperly labeled
medications. For medications administered by the assisted living
program, residential care facility or private non-medical institution, all
pharmaceutical containers having soiled, damaged, incomplete, incorrect,
illegible or makeshift labels shall be returned to the original dispensing
pharmacy for relabeling within two (2) working days or shall be disposed of in
accordance with the requirements contained in Section 7.9. [Class
III]
7.7
Expired
and discontinued medications. For all medications administered by the
assisted living program, residential care facility or private non-medical
institution medications shall be removed from use and properly destroyed after
the expiration date and when discontinued, according to procedures contained in
Section 7.9. They shall be taken out of service and locked separately from
other medications until reordered or destroyed.
[III]
7.8
Medication owned by residents. Prescribed medicines are the property of
the resident and shall not be given to or taken by other residents or any other
person.
7.9
Destroying medications. For medications administered by the assisted
living program, residential care facility or private non-medical institution,
all discontinued medications, expired medications or medications prescribed for
a deceased resident, except controlled substances and individual doses, shall
be destroyed by the administrator or the administrator's designee and witnessed
by one (1) competent person who is not a resident. The destruction shall be
conducted so that no person can use, administer, sell or give away the
medication. Individual unit doses may be returned to the pharmacist and a
credit or rebate made to the person(s) who originally paid for the medication.
Amounts destroyed or returned shall be recorded on the resident's record, with
the signature of the administrator or the administrator's designee and
witness(es). Destruction or return to the pharmacy shall take place within
sixty (60) calendar days of expiration or discontinuation of a medication or
following the death of the resident.
7.10
Schedule II controlled
substances. All Schedule II controlled substances administered by the
residential care facility listed in the Comprehensive Drug Abuse Act of 1970,
Public Law 91-513, Section 202 and as amended pursuant to Section 202 are
subject to the following standards. [Class II]
7.10.1 For all Schedule II controlled
substances, there shall be an individual record in which shall be recorded the
name of the resident, prescription number, the date, drug name, dosage,
frequency and method of administration, the signature of the person
administering it and verification of the balance on hand. [Class
II]
7.10.2 There shall be
a recorded and signed count of all Schedule II controlled substances at least
once a day, if such substances have been used in the facility that day.
[Class II]
7.10.3
All Schedule II controlled substances on hand shall be counted at least weekly
and records kept of the inventory in a bound book with numbered pages, from
which no pages shall be removed. [Class II]
7.10.4 All Schedule II controlled substances
shall be stored under double lock in a separate locked box or cabinet within
the medication cabinet or in an approved double-locked cabinet attached to the
wall. [Class II]
7.10.5 All excess and undesired Schedule II
controlled substances in the possession of a licensed facility that are no
longer required for a resident, shall be disposed of in the following manner.
The Administrator or a licensed or registered nurse shall list all such unused
substances and keep the same in a securely locked area apart from all other
drugs. Disposal shall be in the form of incineration or flushing into the
sewage system only in the presence of an authorized representative of the
Department, a licensed pharmacist, a member of the Commission on Pharmacy or an
authorized representative of the Drug Enforcement Agency. At least one (1) of
the persons must be a person who did not dispense the drug or who was the last
person to inventory the drug. Documentation of such destruction shall be made
on the resident's record and in the inventory record required in Section
7.10.3, signed by the individual authorized to dispose of the drug.
[Class II]
7.11
Bulk supplies. Facilities
may stock in bulk supply those items regularly available without prescription
at a pharmacy.
7.12
Medication/treatment administration records (MAR) for medications administered
by the assisted living program, residential care facility or private
non-medical institution.
7.12.1
Individual medication/treatment administration records shall be maintained for
each resident and shall include all treatments and medications ordered by the
duly authorized licensed practitioner. The name of the medication, dosage,
route and time to be given shall be recorded in the medication/treatment
administration record. Documentation of treatments ordered and time to be done
shall be maintained in the same manner. These rules apply only to treatments
ordered by licensed health care professionals. [Class
III]
7.12.2 Whenever a
medication or treatment is started, given, refused or discontinued, including
those ordered to be administered as needed (PRN), the medication or treatment
shall be documented on the medication/treatment administration record. It shall
be initialed by the administering individual, with the full signature of the
individual written on the first page of each month's MAR . A medication or
treatment shall not be discontinued without evidence of a stop order signed and
dated by the duly authorized licensed practitioner. [Class
III]
7.12.3 Medication
errors and reactions shall be recorded in an incident report in the resident's
record. Medication errors include errors of omission, as well as errors of
commission. Errors in documentation or charting are errors of omission.
[Class II]
7.12.4
Administration of medications ordered as needed (PRN) shall be documented and
shall include date, time given, medication and dosage, route, reason given,
results or response and initials or signature of administering individual.
Treatments ordered PRN shall be documented in the same manner.
7.13
Medication
containers. Graduated medicine containers, for the accurate measurement
of liquid medications, shall be used. If not disposable, medicine containers
shall be returned to the facility's dishwashing unit for sanitization after
each use. Only sterile disposable syringes and needles shall be used for
insulin injection. Disposable medicine containers shall not be reused.
[Class III]
7.14
Breathing apparatus. When the facility assists a resident with a
hand-held bronchodilator, metered dose nebulizers, intermittent positive
pressure breathing machine or oxygen machine, there shall be documentation of
the following:
7.14.1 The names of staff who
are qualified or trained to use the equipment and/or to mix medications, the
nature of their training, the date and who provided it;
7.14.2 The name of the distributing agency
and the frequency and specific directions for cleaning the equipment;
and
7.14.3 The resident's record
shall contain a copy of the duly authorized licensed practitioner's order,
possible side effects to be monitored, specific instructions as to when the
duly authorized licensed practitioner must be notified regarding side effects
and instructions to the resident on the use of the breathing
apparatus.
7.15 Whenever
a Registered Nurse teaches or provides in-service training to unlicensed
personnel on medical issues, treatments and/or use of medical equipment not
specifically outlined in these regulations, there must be documentation in the
employee file.
7.16 Whenever
employees are provided in service training or taught procedures, the use of
equipment or anything else which impacts resident care, there must be
documentation in the employee file. This in service training could be taught by
other professionals including a Physician, Registered Nurse, Practitioner,
Dietician, Physical Therapist, Occupation Therapist, Speech Therapist, product
company representative, or other experts in their field.
