1201. General (I)

A.Medications, including controlled substances, medical supplies, and those items necessary for the
rendering of first aid shall be available and properly managed in accordance with local, State, and Federal
laws and regulations. Such management shall address the securing, storing, and administering of
medications, medical supplies, first aid supplies, and biologicals, their disposal when discontinued or
outdated, and their disposition at discharge, death, or transfer of a resident.

B.Applicable reference materials published within the previous three years shall be available at the
facility in order to provide staff members/volunteers with adequate information concerning medications.

1202. Medication and Treatment Orders (I).

A.Medications and treatments, to include oxygen, shall be administered to residents only upon orders (to
include standing orders) of a physician or other authorized healthcare provider. Medications accompanying
residents at admission may be administered to residents provided the medication is in the original labeled
container and the order is subsequently obtained as a part of the admission physical examination. Should
there be concerns regarding the appropriateness of administering medications due to the condition/state of
the medication, e.g., expired, makeshift or illegible labels, or the condition/state of health of the newly admitted
resident, staff members shall consult with or make arrangements to have the resident examined
by a physician or other authorized healthcare provider, or at the local hospital emergency room prior to
administering any medications.

B.All orders (including verbal orders) shall be received only by staff members authorized by the facility
and shall be signed and dated by a physician or other authorized healthcare provider no later than three (3)
business days after the order is given.

C.Medications and medical supplies ordered for a specific resident shall not be provided/administered to
any other resident.

1203. Administering Medication/Treatments (I).

A.Doses of medication shall be administered by the same staff member who prepared them for
administration. Preparation shall occur no earlier than one hour prior to administering. Preparation of doses
for more than one scheduled administration shall not be permitted. Each physician-ordered treatment or
medication dose administered/supervised shall be properly recorded by initialing on the resident’s
medication administration record (MAR) as the medication is administered or treatment record as treatment
is rendered. Recording medication administration shall include medication name, dosage, mode of
administration, date, time, and the signature of the individual administering or supervising the taking of the
medication. If the ordered dosage is to be given on a varying schedule, e.g., “take two tablets the first day
and one tablet every other day by mouth with the noon meal,” the number of tablets shall also be recorded. The
treatment record shall document the type of treatment, date and time of treatment, and signature of the
individual administering treatment.

B.Facility staff members may administer routine medications, acting in a surrogate family role, provided
these staff members have been trained to perform these tasks in the proper manner by individuals licensed
to administer medications. Facility staff members may administer injections of medications only in
instances where medications are required for diabetes and conditions associated with anaphylactic reactions
under the established medical protocol. A staff licensed nurse may administer influenza and vitamin B-12
injections and perform tuberculin skin tests. Although facility staff members may monitor blood sugar
levels (provided s/he has been appropriately trained and the facility has received a “Certificate of Waiver”
from Clinical Laboratories Improvement Amendments (CLIA)), the provision of sliding scale insulin
injections by facility staff members is prohibited.

C.Self-administering of medications by a resident is permitted only:
1. Upon the specific written orders of the physician or other authorized healthcare provider, obtained
on a semi-annual basis, or
2. The facility shall ascertain by resident demonstration to the staff and document, at least quarterly,
that s/he remains capable of self-administering medications.

D.Facilities may elect not to permit self-administration.

E.When residents who are unable to self-administer medications leave the facility for an extended period
of time, the proper amount of medications, along with dosage, mode, date, and time of administration, shall
be given to a responsible person who will be in charge of the resident during his/her absence from the
facility; these details shall be properly documented in the MAR. In these instances, the amount of
medication needed for the designated period of time may be transferred to a prescription vial or bottle that
is properly labeled.

F. At each shift change, there shall be a documented review of the MAR’s by outgoing staff members
with incoming staff members that shall include verification by outgoing staff members that they have
properly administered medications in accordance with orders by a physician or other authorized healthcare
provider, and have documented the administrations. Errors/omissions indicated on the MAR’s shall be
addressed and corrective action taken at that time.

1204. Pharmacy Services (I).

 

A.Any pharmacy within the facility shall be provided by or under the direction of a pharmacist in
accordance with accepted professional principles and appropriate local, State, and Federal laws and
regulations.

B.Facilities which maintain stocks of legendary drugs and biologicals for dispensing to residents shall obtain
and maintain a valid, current pharmacy permit from the S.C. Board of Pharmacy.

C.Labeling of medications dispensed to residents shall be in compliance with local, state, and Federal
laws and regulations, including expiration date.

1205. Medication Containers (I).

A.Medications for residents shall be obtained from a permitted pharmacy or prescriber on an individual
prescription basis. These medications shall bear a label affixed to the container which reflects at least the
following: Name of the pharmacy, name of the resident, name of the prescribing physician or another authorized

healthcare provider, date and prescription number, directions for use, and the name and dosage unit of the
medication. The label shall be brought into accord with the directions of the physician or other authorized
healthcare provider each time the prescription is refilled. Medication containers having soiled, damaged,
incomplete, illegible, or makeshift labels shall be returned to the pharmacy for re-labeling or disposal.
Residents may obtain their over-the-counter (OTC) medication from a pharmacy other than a pharmacy
contracted with the facility.

B.Medications for each resident shall be kept in the original container(s) including unit dose systems;
there shall be no transferring between containers (except in instances such as in Section 1203.E above), or
opening blister packs to remove medications for destruction or adding new medications for administration,
except under the direction of a pharmacist. In addition, for those facilities that utilize the unit dose system
or multi-dose system, an on-site review of the medication program by a pharmacist shall be conducted on
at least a quarterly basis to ensure the program has been properly implemented and maintained. For changes
in dosage, the new packaging shall be available in the facility no later than the next administration time
subsequent to the order.

C.If a physician or other authorized healthcare provider changes the dosage of a medication, a label,
which does not obscure the original label, shall be attached to the container which indicates the new dosage,
date, and prescriber’s name. In lieu of this procedure, it is acceptable to attach a label to the container that
states, “Directions changed; refer to MAR and physician or other authorized healthcare provider orders for
current administration instructions.” The new directions shall be communicated to the pharmacist upon
receipt of the order.

1206. Medication Storage (I).

A.Medications shall be properly stored and safeguarded to prevent access by unauthorized persons.
Expired or discontinued medications shall not be stored with current medications. Storage areas shall be
locked, and of sufficient size for clean and orderly storage. Storage areas shall not be located near sources
of heat, humidity, or other hazards that may negatively impact medication effectiveness or shelf life.
Medications requiring refrigeration shall be stored in a refrigerator at the temperature established by the
U.S. Pharmacopeia (36-46 degrees F.). Medications requiring refrigeration shall be kept in a secured
refrigerator used exclusively for medications, or in a secured manner in which medications are separated
from other items kept in a refrigerator (e.g. Lock Box). All refrigerators storing medications shall have
accurate thermometers (within plus or minus 2 degrees).

B.Medications shall be stored:
1. Separately from poisonous substances or body fluids;
2. In a manner that provides for separation between topical and oral medications, and which provides
for separation of each individual resident’s medication.

C.A facility shall maintain records of receipt, administration, and disposition of all controlled substances
in sufficient detail to enable an accurate reconciliation including:
1. Separate control sheets on any controlled substances. This record shall contain the following
information: date, time administered, name of resident, dose, the signature of individual administering, name
of physician or other legally authorized healthcare provider ordering the medication; and
2. At each shift change, a documented review of the control sheets by outgoing staff members with
incoming staff members including verification by outgoing staff members indicating they have properly
administered medications in accordance with orders by a physician or other authorized healthcare provider,
and have documented the administrations. Errors/omissions indicated on the control sheets shall be
addressed and corrective action taken at that time.

D.Unless the facility has a permitted pharmacy, legend medications shall not be stored except those
specifically prescribed for individual residents. Nonlegend medications that can be obtained without a
prescription may be retained and labeled as stock in the facility for administration as ordered by a physician
or other authorized healthcare provider.

E.The medications prescribed for a resident shall be protected from use by any other individuals. For
those residents who have been authorized by a physician or other authorized healthcare provider to self-administer
medications, such medications may be kept on the resident’s person, i.e., a pocketbook, pocket,
or any other method that would enable the resident to control the items.

F. No medication shall be left in a resident’s room unless the facility provides an individual
cabinet/compartment which is kept locked in the room of each resident who has been authorized in writing
to self-administer by a physician or other authorized healthcare provider. In lieu of a locked cabinet/
compartment, storage of medications shall be permitted in a resident room which can be locked, provided
the room is licensed for one bed; medications are not accessible by unauthorized persons; the room is kept
locked when the resident is not in the room; the medications are not controlled substances and all other
requirements of this section are met.

G.During nighttime hours in resident rooms, only medications which a physician or other authorized
healthcare provider has ordered in writing for emergency/immediate use, e.g., nitroglycerin or inhalers,
may be kept unlocked in or upon a cabinet or bedside table, and only when the resident to whom that
medication belongs is present in the room.

1207. Disposition of Medications (I).

A.Upon discharge of a resident, the facility shall release unused medications to the resident, family
member, or responsible party, as appropriate, and shall document the release with the signature of the person
receiving the unused medications unless specifically prohibited by the attending physician or other
authorized healthcare provider.

B.Residents’ medications shall be destroyed by the facility administrator or his/her designee when:
1. Medication has deteriorated or exceeded its expiration date;
2. Unused portions remain due to death or discharge of the resident, or discontinuance of the
medication (may also be returned to the dispensing pharmacy). Medication that has been discontinued by
order may be stored for a period not to exceed thirty (30) days provided they are stored separately from
current medications.
C.The destruction of medication shall be witnessed by the administrator or his/her designee, the mode of

destruction indicated, and these steps documented. Destruction records shall be retained by the facility for
a period of two (2) years.

D.The destruction of controlled substances shall be accomplished only by the administrator or his or her
designee and witnessed by the administrator or his or her designee and a staff member trained by individuals
licensed to administer medications.

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