N.J. Admin. Code § 10:44A-5.2

Current through Register Vol. 56, No. 19, October 7, 2024

Section 10:44A-5.2 - Prescription medication

(a) Individuals receiving medication shall take their own medication to the extent that it is possible, as assessed and determined by the PT, documented in the individual's record, and in accordance with licensee procedure.

(b) If the individual is not responsible for or capable of taking his or her own medication, the licensee or his or her designee shall assist and supervise the administration of the medication as prescribed.

(c) A record shall be maintained of all medication administered by the licensee or the designee.

1. The record shall include the following:

i. The individual's name;

ii. The date;

iii. The name of medication;

iv. The type of medication;

v. The dosage;

vi. The frequency;

vii. The initials and corresponding signatures of staff administering the medication or in the case of electronic records, a means by which the identification of the administering staff is verified;

viii. All known allergies; and

ix. Medication administration codes.

(d) If an individual is capable of taking medication without assistance, no daily medication administration record is required.

1. A current list identifying the name of the medication(s), type of medication(s), dosage, frequency, date prescribed, and the location of the medication(s) shall be filed in the individual's record and updated as changes occur.

(e) Written documentation shall be filed in the individual's record indicating that all prescribed medication was re-evaluated at least annually by the prescribing physician or advanced practice nurse.

(f) Staff shall have access to medication information, either in a reference book or an online resource approved by the licensee, current within three years and written for lay persons, which shall include information on side effects and drug interaction.

(g) Any new medication or change in medication order by the physician or advanced practice nurse, as well as new and discontinued prescriptions, shall be immediately noted on the current medication record by staff consistent with the licensee's procedure.

1. Verbal orders from the physician or advanced practice nurse shall be confirmed, in writing, within 24 hours or by the first business day following receipt of the verbal order.

2. The prescription shall be revised at the earliest opportunity.

(h) A supply of medication and prescribed nutritional supplements, adequate to ensure no interruption in the medication schedule, shall be available to individuals at all times.

(i) The licensee or designee shall supervise the use and storage of prescription medication, ensuring that:

1. A storage area of adequate size for both prescription and over-the-counter medications shall be provided and kept locked for those individuals who are not self-administering their own medication.

2. Each individual who administers his or her own medication shall receive training and monitoring by the licensee regarding the safekeeping of medications for the protection of others, as necessary.

i. Medication shall be kept in an area that provides for the safety of others, if necessary;

3. Staff shall have a key to permit access to all medication at all times and to permit accountability checks and emergency access to medication.

i. Specific controls regarding the maintenance and use of the key to stored medication shall be established by agency procedure;

4. Prescribed medication for each individual shall be separated within the storage areas, as follows:

i. Oral medications, eye drops, and ear drops shall be separated from other medications; and

ii. If necessary, medications that require refrigeration shall be maintained in a manner that provides for the safety of others, for example, by using locked boxes.

5. All medications shall be kept in their original containers from the pharmacy and shall be properly identified with the pharmacist's label.

i. An individual who is self-medicating may choose adaptive equipment that continues to assure the safe storage of medication;

6. No stock supply of prescription medications shall be kept;

7. Medications that are outdated or no longer in use shall be safely disposed of, according to licensee procedure;

8. When medication is prescribed PRN (as needed), the prescription label shall include the following: the individual's name, date, name of medication, dosage, specification of interval between dosages, maximum amount to be given during a 24-hour period, a stop date, when appropriate, and under what conditions the PRN medication shall be administered; and

9. The administration of PRN medication, along with the time of administration, shall be documented on the medication record and shall be communicated to the on-coming shift of residential staff.

N.J. Admin. Code § 10:44A-5.2

Amended by 55 N.J.R. 171(a), effective 2/6/2023