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 West Virginia Office of Healthcare Facility Licensure & Certification takes the following regulation so seriously. Check it out and see how you can keep your facility compliant with OHFLAC:
6.4. Medications and Treatments.
6.4.1. The licensee shall ensure that resident care is provided by appropriately licensed health care professionals, and that medications and treatments given to residents are administered as required by applicable federal and state law, including W. Va. Code §§16-5O-1, et seq. and Department of Health and Human Resources rule, “Medication Administration and Performance of Health Maintenance Tasks by Approved Medication Assistive Personnel,” W. Va. Code R. §§64-60-1, et seq. (Class I)
6.4.2. A prescription or written or verbal order from a professional authorized by state law to prescribe medications is required for obtaining, altering, discontinuing, and administering or self-administering prescription and over-the-counter medications, treatments, and therapies. The licensee shall keep copies of the prescriptions or written orders in the resident’s record. (Class I)
6.4.3. A licensed health care professional shall determine whether or not a resident is capable of self-administration of medications in accordance with subsection 2.35. of this rule and shall document it in the resident’s medical record prior to the resident self-administering medications, and also on a significant change of the resident’s condition. (Class II)
6.4.4. The prescribing health care professional who gives a verbal order shall review and sign the order within 30 working days of the original order date. (Class II)
6.4.5. The attending physician, prescribing health care professional, or a consulting pharmacist shall review the medication regimen of each resident as needed, and at least annually. The resident’s record shall contain documentation of this review. (Class II)
6.4.6. The licensee shall keep a record of all medications given to each resident indicating each dose administered. The record shall include the resident’s name; the name of the medication; the dosage to be administered and route of administration; the time or intervals at which the medication is to be administered; the date the medication is to begin and end; the printed name, initials, and signature of the individuals who administered the medication; and any special instructions for handling or administering the medication, including instructions for maintaining aseptic conditions and appropriate storage. (Class I)
6.4.7. The licensee shall keep medications in a locked room, cabinet, or other storage receptacle, accessible only to the staff responsible for medications. If a resident is capable of self-administration of medication, the licensee shall provide him or her resources to store medications in a manner to be inaccessible to other residents. (Class I)
6.4.8. The licensee shall store all medications in their original containers, legally dispensed, and labeled in accordance with the rules of the West Virginia Board of Pharmacy, for the resident for whom it has been prescribed, including the name and strength of medication, manufacturer name, lot number, and expiration date. Only a licensed pharmacist shall re-label medications. If the prescribing health care provider changes medication directions, the licensee shall have a written, signed, and dated order for the change in the resident’s record. (Class I)
6.4.9. If refrigeration of medication is required, the licensee shall provide: a refrigerator in a locked room, a locked refrigerator, or a locked box within the refrigerator for storage. A thermometer is required in a refrigerator storing medications. The licensee shall store refrigerated medications within the recommended temperature range on the medication package. (Class II)
6.4.10. If Schedule II drugs of the Uniform Controlled Substances Act W. Va. Code §§60 A -1-101, et seq. are administered, a copy of the written prescription signed by the physician shall be in the resident’s record and a proof of use record shall be maintained. Schedule II drugs shall be stored in a manner so that they are securely protected by two locks. The key to the separately locked Schedule II drugs shall not be the same key that is used to gain access to the non-scheduled drugs. (Class I)
6.4.11. The licensee shall not return unused, discontinued, or outdated drugs listed in Schedules II, III, IV or V of the Federal Comprehensive Drug Abuse Prevention and Control Act of 1970, 21 U.S.C. § 801, et seq., to the pharmacy, but shall destroy them in the presence of a pharmacist and a registered nurse; and keep a record for at least two years that contains the resident’s name that was on the prescription, the name and strength of the drug, the prescription number, the amount destroyed, the date of destruction, and the signatures of the witnesses. (Class III)
6.4.12. The licensee shall have a policy regarding unused over-the-counter and non-scheduled drugs of a resident no longer at the facility.
6.4.13. When a resident requires oxygen, the licensee shall ensure there is a portable source available for out-of-room activities and in the event of power failure.
6.4.14. The licensee shall provide all resident care and services in accordance with current standards of practice using appropriate infection control techniques. (Class I)
Top Takeaways:
- 4.2. A prescription or written or verbal order from a professional authorized by state law to prescribe medications is required for obtaining, altering, discontinuing, and administering or self-administering prescription and over-the-counter medications, treatments, and therapies. The licensee shall keep copies of the prescriptions or written orders in the resident’s record. (Class I)
Any medication that is being given to residents in the facility must be issued by a prescribing physician. If any medication is administered to residents without an order by a physician. If OHFLAC audits your medication administration records and recognizes a medication without an order you will be cited as deficient.
- 4.5. The attending physician, prescribing health care professional, or a consulting pharmacist shall review the medication regimen of each resident as needed, and at least annually. The resident’s record shall contain documentation of this review. (Class II)
Having a process in place for reviewing the medication residents in your facility are being prescribed has been shown to reduce drug related problems by cutting down on inappropriate medication, inappropriate dosages and adverse drug to drug reactions. By effectively reviewing a residents medication regiment you may be able to reduce hospitalizations and mortality by identifying issues before they arise.