Facility policies and procedures must specify how medications will be handled.

01. Medication Distribution System.
Each facility must use medi-sets or blister packs for prescription
medications. The facility may use multi-dose medication distribution systems that are provided for resident’s
receiving medications from the Veterans Administration or Railroad benefits. The medication system must be filled
by a pharmacist and appropriately labeled in accordance with pharmacy standards and physician or authorized
provider instructions. The facility’s licensed nurse may fill medi-sets, blister packs, or other Licensing Agency
approved systems as described in Section 39-3326, Idaho Code.
a. All medications must be kept in a locked area such as a locked box or room;
b. Poisons, toxic chemicals, and cleaning agents must not be stored with medications;
c. Biologicals and other medications requiring cold storage must be maintained at thirty-eight degrees
Fahrenheit to forty-five degrees Fahrenheit (38°F-45°F), and the temperature monitored and documented daily;
d. Assistance with medication must comply with the Board of Nursing requirements;
e. Each prescription medication must be given to the resident directly from the medi-set, blister pack,
or medication container;
f. Each resident must be observed taking the medication; and
g. Each prescribed PRN must be available in the facility.

02. Discontinued and Expired Prescriptions.
Discontinued or outdated medications and treatments
must be removed from the resident’s medication supply and cannot accumulate at the facility for longer than thirty
(30) days. The unused medication must be disposed of in a manner that ensures it cannot be retrieved. The facility
may enter into agreement, a copy of which must be maintained, with a pharmacy or other authorized entity to return
unused, unopened medications for proper disposition. A written record of all drug disposals must be maintained in the
facility and include:
a. A description of the drug, including the amount;
b. Name of the resident for whom the medication is prescribed;
c. The reason for disposal;
d. The method of disposal;
e. The date of disposal; and
f. Signatures of responsible facility personnel and witness.

03. Controlled Substances.
The facility must track all controlled substances entering the facility,
including the amount received, the date, a daily count, reconciliation of the number given or disposed, and the
number remaining.

04. Psychotropic or Behavior Modifying Medication.
a. Psychotropic or behavior modifying medication intervention must not be the first resort to address
behaviors. The facility must attempt non-drug interventions to assist and redirect the resident’s behavior. (3-20-20)T
b. Psychotropic or behavior modifying medications must be prescribed by a physician or authorized
c. The facility must monitor the resident to determine continued need for the medication based on the
resident’s demonstrated behaviors.
d. The facility must monitor the resident for any side effects that could impact the resident’s health
and safety.
e. The use of psychotropic or behavior modifying medications must be reviewed by the physician or
authorized provider at least every six (6) months. The facility must provide behavior updates to the physician or
authorized provider to help facilitate an informed decision on the continued use, and possible reduction, of the
psychotropic or behavior modifying medication.