W. Va. Code R. § 64-11-11

Current through Register Vol. XLI, No. 36, September 6, 2024

Section 64-11-11 - Compliance with Legal, Health, and Regulatory Requirements

11.1. Emergency Planning and Response.

11.1.1. The provider shall have written procedures in place for responding to accidents, serious illness, fire, medical emergencies, flood, natural disasters, and other life-threatening situations that:

11.1.1.a. Address the needs of any special population served by the provider;

11.1.1.b. Provide staff-to-consumer ratios for the adequate protection and supervision based on the consumer's assessed needs, treatment plan or treatment strategy, functional level, identified behaviors, and physical limitations.

11.1.1.c. Specify evacuation procedures including an evacuation site, parties to notify, and emergency items to take when evacuating;

11.1.1.d. Describe relocation plans for the behavioral health center or any part thereof, if it becomes necessary; and

11.1.1.e. Specify appropriate responses to medical emergencies.

11.1.2. The provider shall have procedures in place for dealing with consumers or other individuals who threaten violence or harm to themselves or others including staff and other consumers.

11.2. Medication Control and Administration.

11.2.1. Medication shall be prescribed and monitored by a licensed physician, dentist, or physician extender according to their scope of practice and state law. Contracted medical staff functioning on the provider's premises are responsible for complying with provider policies and procedures. The physicians and other staff shall have files containing the materials or information specified in this rule.

11.2.2. The provider shall note changes in a consumer's condition including, but not limited to, adverse reactions as a result of receiving a medication.

11.2.3. The provider shall inform a consumer, and his or her legal representative, about the medication including, but not limited to, the dosage, purpose, possible side effects, effects, of not taking the medication, and about alternate treatments and their effects.

11.2.4. Providers who administer medication using approved medication assistive personnel shall comply with the Department's Legislative Rule, Delegation of Medication Administration and Health Maintenance Tasks to Approved Medication Assistive Personnel, 64CSR60.

11.2.5. When medication is administered by the provider, the organization shall ensure that there is an individual medication administration record for those consumers who receive medications to include:

11.2.5.a. Medications administered;

11.2.5.b. The date medications were administered;

11.2.5.c. The actual time of administration, which shall be within one hour of the prescribed time;

11.2.5.d. The initials and signature of the individual administering the medication;

11.2.5.e. A record of missed medications and the reason; and

11.2.5.f. Any special instruction as directed by prescriber.

11.2.6. Prescription medications administered by the provider shall be properly labeled and packaged and remain in the original packaging until administration, and include:

11.2.6.a. The name of the person served;

11.2.6.b. The route of administration;

11.2.6.c. The dosage and the name of the medication;

11.2.6.d. The name of the prescriber; and

11.2.6.e. The expiration date.

11.2.7. The provider shall have written procedures that govern:

11.2.7.a. The safe disposal of discontinued, out-of-date, or unused medications, syringes, medical waste, or medication; and

11.2.7.b. Provision for locked, supervised storage of medications, including that controlled substances be double locked, with access limited to authorized staff. Authorized staff must have the authority to administer medications.

11.2.8. Medication samples are considered to be the property of the provider. Samples shall be stored in a systematic fashion in a locked area with limited access to unauthorized staff or consumers. The provider shall document distribution of sample medications in the consumer medical record.

11.2.9. If a provider both prescribes and administers medications, only licensed nursing staff shall accept verbal orders for changes in medication regimens. These shall be signed by the prescriber within one week.

11.2.10. A registered nurse or a licensed practical nurse working within his or her scope of practice, shall be responsible for:

11.2.10.a. Generating and reviewing monthly medication administration records (MARs) or reconciling them to MARs provided by a duly authorized and qualified pharmacist or pharmacy;

11.2.10.b. Matching physician's or physician extender's orders or prescriptions to the medication administration records;

11.2.10.c. Assisting interdisciplinary teams to develop educational goals for consumers taking regularly prescribed medications and participating in a supervised self-administration protocol as identified in the consumer's plan for services;

11.2.10.d. Instructing staff in dietary or medication administration issues as necessary; and

11.2.10.e. Responding to emergency calls from staff on medical issues.

11.2.11. Medications shall be self-administered under supervision of trained staff under the following conditions:

11.2.11.a. As part of the consumer's plan of need, he or she is taught to identify his or her medications, recognize possible side effects, describe the purpose of the medication, and indicate the time of day and frequency with which he or she is to take the medications;

11.2.11.b. The consumer is assessed by a registered nurse, physician, physician extender, or licensed or supervised psychologist as being cognitively capable of learning these skills;

11.2.11.c. Medication is kept in a secure location with access limited only to staff with capability of medication administration;

11.2.11.d. Staff is fully trained as to the purpose, most common side effects, and dangers of each medication prescribed for consumers in the facility or home; and

11.2.11.e. Staff is trained in emergency procedures for overdose or adverse reactions.

11.2.12. Delivering and monitoring medications in a consumer's place of residence:

11.2.12.a. If a provider delivers medications to a consumer on a regular basis, the provider must:

11.2.12.a.1. Document delivery date, time, person receiving medication, and name and amount of medication delivered;

11.2.12.a.2. Ensure that if there are children or other incapacitated adults in the home, medications are at least initially stored properly in secured containers;

11.2.12.a.3. Provide medications in properly packaged format as required by W. Va. Code §30-5-1, et seq.; and

11.2.12.a.4. Develop a system of monitoring the consumer's compliance with consumption of medications that is created with the agreement and participation of the consumer. This system may consist of the consumer logging consumption of his or her own medications. The consumer has the right to refuse participation in a monitoring system. However, the provider may then refuse to deliver medications to the consumer's residence and make alternative arrangements for the provision of medications.

11.2.13. Medical and Psychiatric Emergency Services. The provider shall have written policies and procedures for handling medical and psychiatric emergencies to ensure:

11.2.13.a. Communication with the nearest medical emergency services, hospital, and local polices;

11.2.13.b. A 24-hour telephone response system; and

11.2.13.c. An investigation of any incident that results in serious injury or death, a reporting by the provider to the appropriate authorities and the Secretary, and a written report of the investigation.

11.2.14. Emergency Medical and Psychiatric Services in Group Homes and Residential Treatment Facilities.

11.2.14.a. The provider shall respond to a consumer's needs 24 hours a day, seven days a week, including providing appropriate triage for a consumer who poses a danger to himself, herself, or others.

11.2.14.b. The provider shall provide onsite staff with immediate access to relevant information in a consumer's record in case of an emergency.

11.2.14.c. Written policies shall be developed and implemented for the treatment, referral, and follow-up of a consumer who attempts or threatens suicide, homicide, or assault.

W. Va. Code R. § 64-11-11