Effectively executing the med pass process

The medication pass in an assisted living facility is perhaps the most complex and daunting task your team will be asked to perform. There are many important factors involved with properly distributing medications as well as the added pressure of this being one of the top areas that the DOSS survey team will target so you need to be confident you are executing this efficiently. When the DOSS survey team audits your med pass procedures, they will be looking for the techniques described in the following regulation:

22VAC40-73-680. Administration of medications and related provisions.

  1. Staff who are licensed, registered, or acting as medication aides on a provisional basis as specified in 22VAC40-73-670 shall administer drugs to those residents who are dependent on medication administration as documented on the UAI.
  2. Medications shall be removed from the pharmacy container, or the container shall be opened, by a staff person licensed, registered, or acting as a medication aide on a provisional basis as specified in 22VAC40-73-670 and administered to the resident by the same staff person. Medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
  3. Medications shall be administered not earlier than one hour before and not later than one hour after the facility’s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
  4. Medications shall be administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
  5. Medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. The documentation shall be maintained in the resident’s record.
  6. Sample medications shall remain in the original packaging, labeled by a physician or other prescriber or pharmacist with the resident’s name, the name of the medication, the strength, dosage, and route and frequency of administration until administered.
  7. Over-the-counter medication shall remain in the original container, labeled with the resident’s name, or in a pharmacy-issued container, until administered.
  8. At the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-thecounter medications and dietary supplements.
  9. The MAR shall include:
  10. Name of the resident;
  11. Date prescribed;
  12. Drug product name;
  13. Strength of the drug;
  14. Dosage;
  15. Diagnosis, condition, or specific indications for administering the drug or supplement;
  16. Route (e.g., by mouth);
  17. How often medication is to be taken;
  18. Date and time given and initials of direct care staff administering the medication;
  19. Dates the medication is discontinued or changed;
  20. Any medication errors or omissions;
  21. Description of significant adverse effects suffered by the resident;
  22. For “as needed” (PRN) medications:
  23. Symptoms for which medication was given;
  24. Exact dosage given; and c. Effectiveness; and
  25. The name, signature, and initials of all staff administering medications. A master list may be used in lieu of this documentation on individual MARs.
  26. In the event of an adverse drug reaction or a medication error, the following applies:
  27. Action shall be taken as directed by a physician, pharmacist, or a poison control center;
  28. The resident’s physician of record and family member or other responsible person shall be notified as soon as possible; and
  29. Medication administration staff shall document actions taken in the resident’s record.
  30. The use of PRN medications is prohibited, unless one or more of the following conditions exist:
  31. The resident is capable of determining when the medication is needed;
  32. Licensed health care professionals administer the PRN medication; or
  33. Medication aides administer the PRN medication when the facility has obtained from the resident’s physician or other prescriber a detailed medication order. The order shall include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist.
  34. In order for drugs in a hospice comfort kit to be administered, the requirements specified in subsection K of this section must be met, and each medication in the kit must have a prescription label attached by the pharmacy.
  35. Medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility.
  36. Stat-drug boxes may only be used when the following conditions are met:
  37. There is an order from the prescriber for any drug removed from the stat-drug box; and
  38. The drug is removed from the stat-drug box and administered by a nurse, pharmacist, or prescriber licensed to administer medications. Registered medication aides are not permitted to either remove or administer medications from the statdrug box.

Top Takeaways:

  • Medications shall be removed from the pharmacy container, or the container shall be opened, by a staff person licensed, registered, or acting as a medication aide on a provisional basis as specified in 22VAC40-73-670 and administered to the resident by the same staff person. Medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.

NO PRE-POURING. Facilities are tagged so often due to pre pouring or pre popping blister packs for residents’ medications. You must wait until you are with the resident to take their medication out of the pack.

  • At the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-the counter medications and dietary supplements.

A well-documented MAR is integral to the med pass process. If your med aides or nurses are not documenting what medication is given to the resident there will be a med error which could lead to a tag by DOSS if they see it as a trending issue.

  • In the event of an adverse drug reaction or a medication error, the following applies:
  1. Action shall be taken as directed by a physician, pharmacist, or a poison control center;
  2. The resident’s physician of record and family member or other responsible person shall be notified as soon as possible; and
  3. Medication administration staff shall document actions taken in the resident’s record.

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.

 

FEATURED COMMUNITY PARTNERS

If your organization has a collaborative relationship with the assisted living facilities and would like to be included on our website, ALF BOSS is happy to help you.