Current through Bulletin 2024-06, March 15, 2024
(1)
(a) The licensee shall provide routine and
emergency medications and biologicals.
(b) The licensee may obtain medications and
biologicals from community or contract pharmacists, or the licensee may
maintain a licensed pharmacy.
(c)
The licensee shall ensure pharmacy services are under the direction and
responsibility of a qualified, licensed pharmacist who may be employed full
time by the facility or may be retained by contract.
(d) The pharmacist shall develop pharmacy
service policies and procedures in conjunction with the administrator that
address:
(i) medication orders;
(ii) labeling;
(iii) storage;
(iv) emergency medication supply;
(v) administration of medications;
(vi) pharmacy supplies; and
(vii) automatic-stop orders.
(2)
(a) The pharmacist, with input from the
interdisciplinary team, shall review the medication regimen of each client at
least quarterly.
(b) The pharmacist
shall report any irregularities or errors in a client's medication regimen to
the prescribing physician and interdisciplinary team.
(c) The pharmacist shall develop and review a
record of each client's medication regimen.
(3) The licensee shall maintain an individual
medication administration record for each client.
(4) The pharmacist shall participate in the
development, implementation, and review of each client's individual program
plan, either in person or through a written report to the interdisciplinary
team.
(5) The licensee shall ensure
the facility has an organized system for medication administration that
identifies each medication up to the point of administration and ensure that
medications and treatments:
(a) are
administered in compliance with the physician's orders;
(b) are administered without error;
and
(c) are administered by
licensed medical or licensed nursing personnel.
(6)
(a) The
licensee shall teach clients how to administer their own medications if the
interdisciplinary team determines that self-administration of medications is an
appropriate objective.
(b) The
licensee shall inform the client's physician of the interdisciplinary team's
recommendation that self-administration of medications is an objective for the
client.
(c) The licensee may not
allow a client to self-administer medications until they demonstrate the
competency to do so.
(7)
The licensee shall immediately record each telephone order for medications
including the date and time of the order and the receiver's signature and title
and ensure the person who prescribed the order countersigns and dates the order
within 15 days of writing the order.
(8)
(a) The
licensee shall maintain records of the receipt and disposition of controlled
medications.
(b) The licensee shall
maintain records of schedule III and IV drugs in such a manner that the receipt
and disposition are readily traced.
(c) The licensee shall, on a sample basis,
periodically reconcile the receipt and disposition of controlled drugs in
schedules II through I V, drugs subject to the Comprehensive Drug Abuse
Prevention and Control Act of 1970 as implemented by 42 CFR Part 308.
(9) The licensee shall:
(a) store medications under proper conditions
of sanitation, temperature, light, humidity and security;
(b) secure controlled substances in a manner
consistent with applicable pharmacy laws;
(c) separate and secure the storage of
non-medication items such as poisonous and caustic materials;
(d) clearly label medication
containers;
(e) only allow a person
authorized by facility policy top access to medications;
(f) store medication intended for internal
use separately from medication intended for external use;
(g) maintain medications stored at room
temperature between 59 and 80 degrees Fahrenheit and maintain refrigerated
medications between 36 and 46 degrees Fahrenheit;
(h) store medications, and similar items that
require refrigeration, securely and segregated from food items; and
(i) store medications in the original
pharmacy container and not transfer the medications to other
containers;
(j) ensure medications
taken out of the facility for home visits, workshops, school or other
activities are packaged and labeled by a person authorized to package
medications in accordance with law; and
(k) ensure clients who have been trained to
self-administer medications in accordance with Subsection
R432-152-19(6)
have access to keys to their individual medication supply.
(10) The licensee shall ensure labeling of
medications and biologicals:
(a) is based on
currently accepted professional principles and practices; and
(b) includes the appropriate accessory and
cautionary instructions, as well as the expiration date, if
applicable.
(11) The
licensee shall remove outdated medications and medication containers with worn,
illegible or missing labels from use.
(12) The licensee shall immediately remove
medications and biologicals packaged in containers designated for a particular
client from the client's current medication supply if the medication is
discontinued by the physician.
(13)
The licensee may send medications with the client upon discharge if ordered by
the discharging physician, as long as the medications are released in
compliance with Utah pharmacy law and rules and a record of the medications
sent with the client is documented in the client's health record.
(14)
(a)
Within one month of a medication being discontinued, the licensee shall destroy
the individual client medications supplied by prescription or those that remain
in the facility after discharge or death of the client as follows:
(b) the licensee shall destroy medications in
the presence of the staff pharmacist or consulting pharmacist and an appointed
licensed nurse employed by the facility;
(c) if one or both of the individuals listed
in Subsection R432-152-19(14)(a)
are not available within the month, a licensed nurse and an individual
appointed by the administrator may serve as witnesses;
(d) the licensee shall rotate appointments
periodically among responsible staff members; and
(e) the licensee shall document and retain
the following in the client record for three years:
(i) the name of the client;
(ii) the name and strength of the
medication;
(iii) the prescription
number;
(iv) the amount
destroyed;
(v) the method of
destruction;
(vi) the date of
destruction; and
(vii) the
signatures of the witnesses.
(15) Unless otherwise prohibited by federal
or state law, the licensee may return individual client medications to the
issuing pharmacy in sealed containers, if unopened, as long as:
(a) no controlled medications are
returned;
(b) medications are
identified by lot or control number; and
(c) the signatures of the receiving
pharmacist and a licensed nurse employed by the licensee are recorded and
retained for at least three years in a separate log that lists:
(i) the name of the client;
(ii) the name, strength and prescription
number, if applicable;
(iii) the
amount of the medication returned; and
(iv) the date of return.
(16)
(a) The licensee shall maintain an emergency
medication supply appropriate to the needs of the clients served.
(b) The pharmacist, in coordination with the
administrator, shall develop an emergency medication supply policy that
ensures:
(i) there is a list of each specific
medication and dosage to be included in the emergency medication
supply;
(ii) a requirement that
containers are sealed to prevent unauthorized use;
(iii) the contents of the emergency
medication supply are listed on the outside of the container and the use of
contents is documented by nursing staff;
(iv) the emergency medication supply is
accessible to nursing staff;
(v)
the pharmacist inventories the emergency medication supply monthly;
and
(vi) staff replace used or
outdated items within 72 hours.
(17) The licensee shall ensure the pharmacy
provides medications and biologicals as follows:
(a) medications ordered for administration as
soon as possible shall be available and administered within two hours of a
physician's order;
(b) antibiotics
are available and administered within four hours of a physician's
order;
(c) new medication orders
are initiated within 24 hours of the order or as indicated by the
physician;
(d) prescription
medications shall be refilled in a timely manner;
(e) orders for controlled substances are sent
to the pharmacy within 48 hours of the order; and
(f) an order sent to the pharmacy may be a
written prescription by the prescriber, a direct copy of the original order, or
an electronic reproduction.
