6 Colo. Code Regs. § 1011-1-2.9
Current through Register Vol. 47, No. 11, June 10, 2024
Section 6 CCR 1011-1-2.9 - Medication Administration, Storage, Handling, and Disposal2.9.1 Any BHE that administers medications at any physical location and/or under any endorsement, shall develop and implement policies and procedures regarding medication procurement, storage, administration, and disposal. Such policies and procedures may be for the BHE, an endorsement, or a particular physical location, as appropriate, and shall, at a minimum: (A) Require a policy specifying whether each physical location(s) and service(s) serving clients under the Part 3, Outpatient Endorsement provides medication administration.(B) Ensure that medication administration provided as part of an endorsement or service complies with the applicable requirements, as described within this Chapter.(C) Include policies and procedures providing guidance on determining when clients may be discharged with unused portions of their current prescriptions, and ensuring such action is in the best interest of the client. Clients shall not be discharged with unused medications if it is clinically contraindicated.(D) Ensure that personnel authorized to administer medications are on-site at all times when medications are administered.(E) Ensure medications are administered only by licensed or certified personnel allowed to administer medications under their own scopes of practice, or an unlicensed personnel who are qualified medication administration persons (QMAPs) acting within their own scope of practice.(F) Ensure compliance with 6 CCR 1011-1, Chapter 24 when using QMAPs to administer medications.(G) Ensure medication orders include the client's name, date of order, medication name, strength of medication, dosage to administer, route of administration along with timing and/or frequency of administration, any specific considerations, if substitutions are allowed or restricted, and the signature of the practitioner ordering the medication. (1) All medication orders shall be documented in writing by the prescribing practitioner. Verbal orders for medication shall not be valid unless received by licensed personnel who are authorized to receive and transcribe such orders.(H) Ensure that any medications kept at the BHE are maintained, stored, and disposed of in a manner that ensures the safety of all clients and protects against the misappropriation or diversion of such medications, including, at a minimum:(1) Medications shall be stored at the appropriate temperature.(2) Refrigerated medications shall be stored in a refrigerator that does not contain food and that is not accessible to clients.(3) Medications shall be routinely checked for expiration and disposed of according to instructions or when expired, whichever is earlier.(4) Medication shall be stored in the original prescribed/manufacturer containers.(5) All medication shall be stored in a locked cabinet, cart, or storage area when unattended by qualified medication administration persons or other licensed personnel authorized to administer medications, with the additional requirement that controlled substances shall be stored under double lock storage.(6) Medications shall be counted by two individuals who are either qualified medication administration persons or otherwise authorized to administer medications, at least daily, or more frequently, if the BHE is required to meet the standards in Part 4 of these rules.(7) Any discrepancy in counts for controlled substances shall be immediately reported in accordance with BHE policies and procedures required at Part 2.3.4(C)(7).(8) Outdated, discontinued, and/or expired medications shall be stored in a locked storage area until properly disposed of, with the additional requirement that any controlled substance medications designated for destruction and disposal shall be kept in a separate locked container within the locked storage area until they are destroyed.(9) Outdated, discontinued, and/or expired medications shall be destroyed in accordance with governing body policies. Such policies may vary based on type of medication or setting, and shall include, but not be limited to:(a) Medications shall be destroyed in accordance with federal, state, and local regulations within thirty (30) days of determination that such medication is outdated, discontinued, or expired.(b) Medications shall be destroyed in the presence of two (2) individuals, each of whom is either a qualified medication administration person or is otherwise authorized to administer medications.(c) All medications shall be destroyed in a manner that renders the substances totally non-retrievable to prevent diversion of the medication.(d) There shall be documentation that identifies the medications, the date and method of destruction, and the signatures of the witnesses performing the medication destruction.(10) All destroyed medications shall be disposed of in compliance with 6 CCR 1007-2, Part 1, Regulations Pertaining to Solid Waste Disposal Sites and Facilities, Section 13, Medical Waste, and/or 6 CCR 1007-3, Part 262, Standards Applicable to Generators of Hazardous Waste, as applicable.(I) Ensure each client receives proper administration and monitoring of medications in accordance with their service plan.(J) Ensure medication administration is documented in accordance with Part 2.9.2 of this Chapter.(K) Include policies and procedures for documenting, investigating, reporting, and responding to any errors related to medication administration, accounting of controlled substances, or medication diversion.(L) Require audits of the accuracy and completeness of the medication records, controlled substance inventories, medication error reports, and medication disposal records. (1) The audit shall be performed at least quarterly, or more often, as required in the standards of the applicable endorsement, as found in this Chapter.(2) Any irregularities shall be investigated and resolved.(M) Comply with all federal and state laws and regulations relating to procurement, storage, administration, and disposal of medications, including controlled substances. 2.9.2 The BHE shall maintain a medication administration record for each client who receives medication, as part of the client record. The record shall include, at a minimum: (A) The name, strength, dosage, and mode of administration of each medication.(B) The date and time of administration, recorded at the time of administration.(C) The signature or initial of the person administering the medication.(D) Documentation of any medication omissions or refusals.(E) Documentation of monitoring and/or observation of medication self-administration.