Medication services compliance | AZ

Medication services compliance

Perhaps one of the most important elements of a resident’s care is the proper distribution of their medication. Think about it- these people are entrusting us with their life. The medication that often keeps them functioning and at times even alive rests in our care. That is why the state of Arizona Bureau of Residential Facilities Licensing takes the following regulation so seriously. Check it out and see how you can keep your facility compliant with BRFL:

R9-10-816. Medication Services

1. A manager shall ensure that:
2. Policies and procedures for medication services include:
3. Procedures for preventing, responding to, and reporting a medication error;
4. Procedures for responding to and reporting an unexpected reaction to a medication;
5. Procedures to ensure that a resident’s medication regimen and method of administration is reviewed by a medical practitioner to ensure the medication regimen meets the resident’s needs;
6. Procedures for:
7. Documenting, as applicable, medication administration and assistance in the self-administration of medication; and
8. Monitoring a resident who self-administers medication;
9. Procedures for assisting a resident in procuring medication; and f. If applicable, procedures for providing medication administration or assistance in the self-administration of medication off the premises; and
10. If a verbal order for a resident’s medication is received from a medical practitioner by the assisted living facility:
11. The manager or a caregiver takes the verbal order from the medical practitioner,
12. The verbal order is documented in the resident’s medical record, and
13. A written order verifying the verbal order is obtained from the medical practitioner within 14 calendar days after receiving the verbal order.
14. If an assisted living facility provides medication administration, a manager shall ensure that:
15. Medication is stored by the assisted living facility;
16. Policies and procedures for medication administration:
17. Are reviewed and approved by a medical practitioner, registered nurse, or pharmacist;
18. Include a process for documenting an individual, authorized, according to the definition of “administer” in A.R.S. § 32-1901, by a medical practitioner to administer medication under the direction of the medical practitioner;
19. Ensure that medication is administered to a resident only as prescribed; and
20. Cover the documentation of a resident’s refusal to take prescribed medication in the resident’s medical record; and
21. A medication administered to a resident:
22. Is administered by an individual under direction of a medical practitioner,
23. Is administered in compliance with a medication order, and
24. Is documented in the resident’s medical record.
25. If an assisted living facility provides assistance in the self-administration of medication, a manager shall ensure that:
26. A resident’s medication is stored by the assisted living facility;
27. The following assistance is provided to a resident:
28. A reminder when it is time to take the medication;
29. Opening the medication container or medication organizer for the resident;
30. Observing the resident while the resident removes the medication from the container or medication organizer;
31. Except when a resident uses a medication organizer, verifying that the medication is taken as ordered by the resident’s medical practitioner by confirming that:
32. The resident taking the medication is the individual stated on the medication container label,
33. The resident is taking the dosage of the medication stated on the medication container label or according to an order from a medical practitioner dated later than the date on the medication container label, and

iii. The resident is taking the medication at the time stated on the medication container label or according to an order from a medical practitioner dated later than the date on the medication container label;

1. For a resident using a medication organizer, verifying that the resident is taking the medication in the medication organizer according to the schedule specified on the medical practitioner’s order; or
2. Observing the resident while the resident takes the medication;
3. Policies and procedures for assistance in the self-administration of medication are reviewed and approved by a medical practitioner or nurse; and
4. Assistance in the self-administration of medication provided to a resident:
5. Is in compliance with an order, and
6. Is documented in the resident’s medical record.
7. A manager shall ensure that:
8. A current drug reference guide is available for use by personnel members, and
9. A current toxicology reference guide is available for use by personnel members.
10. A manager shall ensure that a resident’s medication organizer is only filled by:
11. The resident;
12. The resident’s representative;
13. A family member of the resident;
14. A personnel member of a home health agency or hospice service agency; or
15. The manager or a caregiver who has been designated and is under the direction of a medical practitioner, according to subsection (B)(2)(b).
16. When medication is stored by an assisted living facility, a manager shall ensure that:
17. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;
18. Medication is stored according to the instructions on the medication container; and
19. Policies and procedures are established, documented, and implemented for:
20. Receiving, storing, inventorying, tracking, dispensing, and discarding medication including expired medication;
21. Discarding or returning prepackaged and sample medication to the manufacturer if the manufacturer requests the discard or return of the medication;
22. A medication recall and notification of residents who received recalled medication; and d. Storing, inventorying, and dispensing controlled substances.
23. A manager shall ensure that a caregiver immediately reports a medication error or a resident’s unexpected reaction to a medication to the medical practitioner who ordered the medication or, if the medical practitioner who ordered the medication is not available, another medical practitioner.
24. If medication is stored by a resident in the resident’s bedroom or residential unit, a manager shall ensure that:
25. The medication is stored according to the resident’s service plan; or
26. If the medication is not being stored according to the resident’s service plan, the resident’s service plan is updated to include how the medication is being stored by the resident

Top Takeaways:

• Policies and procedures for medication services include:

1. Procedures for preventing, responding to, and reporting a medication error;
2. Procedures for responding to and reporting an unexpected reaction to a medication;
3. Procedures to ensure that a resident’s medication regimen and method of administration is reviewed by a medical practitioner to ensure the medication regimen meets the resident’s needs;
4. Procedures for:
5. Documenting, as applicable, medication administration and assistance in the self-administration of medication; and
6. Monitoring a resident who self-administers medication;

Having effective policies and procedure for medication services is necessary to stay in compliance with BRFL regulations. If you do not have p&ps readily available for review you will be tagged. Ensure you cover all the areas listed above to avoid being cited as deficient.

• A written order verifying the verbal order is obtained from the medical practitioner within 14 calendar days after receiving the verbal order.

You will often run into a situation where a residents physician gives you or your staff a verbal order to make changes to a resident’s medication regiment. This is one of the most effective ways for facilities to get immediate results for a resident. Just be sure you follow up to receive a written order within 14 days to stay compliant. If you do not have written orders in the residents’ medical charts you will be at risk for a citation.

• A manager shall ensure that a caregiver immediately reports a medication error or a resident’s unexpected reaction to a medication to the medical practitioner who ordered the medication or, if the medical practitioner who ordered the medication is not available, another medical practitioner.

Even the most capable and diligent medication aides will eventually make a med error for one reason or another. When this happens, you must take the necessary steps listed above to ensure you avoid further issues.

Pro Tip:

It is necessary for your entire clinical team to be well versed in the regulations that is applicable to their position. The Nursing Director or their designee should hold frequent refresher trainings and have processes put into place for all matters related to medication administration, storage, procurement as well as the destruction of expired or discharged medication.