16 Del. Admin. Code § 3225-8.0

Current through Register Vol. 28, No. 3, September 1, 2024

Section 3225-8.0 - Medication Management

8.1 An assisted living facility shall establish and adhere to written medication policies and procedures which shall address:

8.1.1 Obtaining and refilling medication;

8.1.2 Storing and controlling medication;

8.1.3 Disposing of medication; and

8.1.4 Administration of medication, self-administration of medication, assistance with self-administration of medication, and medication management by an adult family member/support person.

8.1.5 Provision for a quarterly pharmacy review conducted by a pharmacist which shall include:

8.1.5.1 Assisting the facility with the development and implementation of medication-related policies and procedures;

8.1.5.2 Physical inspection of the medication storage areas;

8.1.5.3 Review of each resident's medication regimen with written reports noting any identified irregularities or areas of concern.

8.2 Each assisted living facility shall have a drug reference guide, with a copyright date no older than 2 years, available and accessible for use by employees.

8.3 Medication stored by the assisted living facility shall be stored and controlled as follows:

8.3.1 Medication shall be stored in a locked container, cabinet, or area that is only accessible to authorized personnel;

8.3.2 Medication that is not in locked storage shall not be left unattended and shall not be accessible to unauthorized personnel;

8.3.3 Medication shall be stored in the original labeled container;

8.3.4 A bathroom or laundry room shall not be used for medication storage; and

8.3.5 All expired or discontinued medication, including those of deceased residents, shall be disposed of according to the assisted living facility's medication policies and procedures.

8.4 Residents who self-administer medication shall be provided with a lockable container or cabinet. This requirement does not apply to medications which are kept in the immediate control of the individual resident, such as in a pocket or in a purse. Facility policies must require that medications be secured in a locked container or in a locked room.

8.5 A separate medication log must be maintained for each resident documenting administration of medication by staff and staff assistance with self-administration.

8.6 Within 30 days after a resident's admission and concurrent with all UAI-based assessments, the assisted living facility shall arrange for an on-site review by an RN of the resident's medication regime if he or she self-administers medication. The purpose of the on-site review is to assess the resident's cognitive and physical ability to self-administer medication or the need for assistance with or staff administration of medication.

8.7 The assisted living facility shall ensure that the review required by section 8.6 is documented in the resident's records, including any recommendations given by the reviewer.

8.8 Concurrently with all UAI-based assessments, the assisted living facility shall arrange for an on-site medication review by a registered nurse, for residents who need assistance with self-administration or staff administration of medication, to ensure that:

8.8.1 Medications are properly labeled, stored and maintained;

8.8.2 Each resident receives the medications that have been specifically prescribed in the manner that has been ordered;

8.8.3 The desired effect of each medication is achieved, and if not, that the appropriate authorized prescriber is so informed;

8.8.4 Any undesired side effects, adverse drug reactions, and medication errors are identified and reported to the appropriate authorized prescriber; and

8.8.5 Any unresolved discrepancy of controlled substances shall be reported to the Delaware Office of Narcotics and Dangerous Drugs.

8.9 Records shall be kept on file at the facility for those who have completed the AWSAM course which is required by 24Del.C.Ch. 19 for those who assist the residents with self-administration of medication.

8.10 Each assisted living facility shall complete an annual AWSAM report on the form provided by the Board of Nursing. The report must be submitted pursuant to the Delaware Nurse Practice Act, 24Del.C.Ch. 19.

16 Del. Admin. Code § 3225-8.0

13 DE Reg. 1328 (04/01/10)
15 DE Reg. 81 (07/01/11)