55 Pa. Code § 5320.53 - Medication

(a) The provider shall establish and implement written medication policies and procedures that conform to Pennsylvania law. Medication administration policies and procedures shall address:

(1) How the education of residents regarding their medication will be accomplished.

(2) How residents who need assistance with medication prescribed by a physician for self-administration receive it.

(i) For residents who need assistance, the least assistance necessary should be provided within the context of a planned program toward self-administration of medication.

(ii) Assistance with self-medication including handling the medication containers or taking medication out of its container for the resident is considered medication administration and shall be done by licensed medical staff.

(3) How medications and treatments shall be administered by the licensed medical staff person who prepared the dose for administration.

(4) Documentation of the written orders provided by the attending physician for each resident receiving medication.

(5) Recording of physicians' orders in each resident's clinical record that is reviewed, renewed and signed by the physician every 30 days.

(6) Documentation of the reason a prescribed medication was not given and notice of same to the prescribing physician.

(7) The taking and recording of telephone orders by only licensed medical staff, pharmacists or other individuals authorized by law to accept a physician's telephone orders for medication.

(i) Oral orders are recorded immediately on the resident's record, dated and signed by the person receiving the order.

(ii) Oral orders are countersigned by the prescribing physician within 48 hours.

(8) Training by a physician or other licensed medical staff person that will cover, at minimum, medications used by the residents, their purposes and function, major side effects and recognition of signs that the medication is not being taken or is being misused.

(b) The circumstances under which the provider stores medication for residents shall include the following limitations:

(1) Only medications which are prescribed for self-administration or that will be administered by an individual appropriately licensed to administer medication is stored in the LTSR.

(2) Medications stored in the LTSR are kept in a locked container in a locked room.

(3) Each prescription medication ordered for a resident is kept in the original prescription container labeled by the dispensing pharmacist for the sole use of the resident.

(4) If over-the-counter drugs are maintained in the facility, they will bear the original label and the name of the resident for whom the drug is ordered.

(c) Pharmaceutical services shall include:

(1) A written quarterly review of the drug regimen of each resident by a licensed pharmacist and the findings submitted to the program director and prescribing physicians.

(2) A pharmacist or licensed medical staff annual review of the provider's medication policies and procedures including inspection of the medication storage areas. A written report of the review including inservice training recommendations, if any, is submitted to the program director.

(3) A policy developed or approved by a pharmacist that specifies the disposition of discontinued, unused, outdated or deteriorated medication.

(4) A written procedure for accessing pharmaceutical services on an emergency basis.

Notes

55 Pa. Code § 5320.53

This section cited in 55 Pa. Code § 5320.22 (relating to governing body); and 55 Pa. Code § 5320.53a (relating to clarification of the term "written"-statement of policy).