UNITEDRx POLICY AND PROCEDURE MANUAL
135
heid UNITEDRX POLICY AND PROCEDURE MANUAL Ami Patel, PharmD Director of Pharmacies
Transcript of UNITEDRx POLICY AND PROCEDURE MANUAL
heid
UNITEDRX POLICY AND PROCEDURE
MANUAL
Ami Patel, PharmD Director of Pharmacies
1 May 2019
TABLE OF CONTENTS (Pages 1-3)
SECTION 1.0 GENERAL OVERVIEW 4
SECTION 1.1 FACILITY APPROVAL OF POLICIES AND PROCEDURES 5 SECTION 1.2 MANUAL OBJECTIVES 6 SECTION 1.3 MISSION STATEMENT 7 SECTION 1.4 VERIFICATION OF LICENSURE 8 SECTION 1.5 PHARMACY SERVICES 9 SECTION 1.6 PHARMACY HOURS AND DELIVERY 10 SECTION 1.7 ADDRESS AND PHONE NUMBERS 11 SECTION 1.8 RESIDENT RIGHT TO SELECT PHARMACY PROVIDER 12-13 SECTION 1.9 FACILITY RIGHTS/RESPONSIBILITIES RELATED TO PHARMACY SERVICES 14 SECTION 1.10 NONCONTRACTED PHARMACY FACILITY AGREEMENT 15-16 SECTION 1.11 COMPLAINT/CONCERN RESOLUTION 17 SECTION 1.12 EMERGENCY PREPAREDNESS 18 SECTION 1.13 FACILITY LIMITED VISITOR NOTIFICATION 19 SECTION 1.14 NEW RESIDENT INFORMATION LETTER 20-22
SECTION 2.0 MEDICATION ORDERS 23
SECTION 2.1 RESIDENT INFORMATION (ADMISSION/CHANGE OF STATUS) 24 SECTION 2.2 GENERIC SUBSTITUTION 25 SECTION 2.3 PHYSICIAN’S ORDERS 26 SECTION 2.4 STANDING ORDERS 27 SECTION 2.5 STOP ORDERS 28 SECTION 2.6 ORDERING MEDICATIONS 29 SECTION 2.6A ORDERING MEDICATIONS ELECTRONICALLY 30-31 SECTION 2.7 STAT ORDERS 32 SECTION 2.8 CLOZAPINE 33 SECTION 2.9 CONTROLLED SUBSTANCE ORDERS 34 SECTION 2.10 ORDER CLARIFICATION 35-36 SECTION 2.11 FLOOR STOCK MEDICATIONS 37 SECTION 2.12 REFILL TOO SOON 38 SECTION 2.13 NONCOVERED MEDICATIONS 39 SECTION 2.14 DELIVERY MANIFEST 40 SECTION 2.15 OUT OF STOCK MEDICATION 41 SECTION 2.16 EMERGENCY DISPENSING KIT-NONCONTROLLED SUBSTANCES 42-43 SECTION 2.17 EMERGENCY DISPENSING KIT-CONTROLLED SUBSTANCES 44-45 APPENDIX A CUBEX DISPENSING UNIT – CONTROLLED SUBSTANCES 135 SECTION 2.18 FORMULARY INTERCHANGE PROGRAM 46 SECTION 2.19 INTRAVENOUS (IV) PUMPS 47
2 May 2019
SECTION 3.0 MEDICATION STORAGE 48
SECTION 3.1 MEDICATION STORAGE IN THE FACILITY 49-50 SECTION 3.2 BEDSIDE STORAGE OF MEDICATIONS 51-52 SECTION 3.3 CONTROLLED SUBSTANCES 53-54 SECTION 3.4 IRRIGATION SOLUTIONS 55 SECTION 3.5 REFRIGERATED PRODUCTS 56
SECTION 4.0 LABELING 57
SECTION 4.1 PRESCRIPTION LABELS 58-59 SECTION 4.2 DIRECTION/LABEL CHANGE 60
SECTION 5.0 MEDICATION ADMINISTRATION 61
SECTION 5.1 DRUG ADMINISTRATION-GENERAL GUIDELINES 62-67 SECTION 5.2 MEDICATION ADMINISTRATION 68-69 SECTION 5.3 SELF-ADMINISTRATION OF MEDICATIONS BY RESIDENTS 70-71 SECTION 5.4 CONTROLLED SUBSTANCE MEDICATIONS 72-73 SECTION 5.5 ENTERAL TUBE MEDICATION ADMINISTRATION 74-75 SECTION 5.6 NOSE DROP ADMINISTRATION 76 SECTION 5.7 EAR DROP ADMINISTRATION 77 SECTION 5.8 EYE DROP ADMINISTRATION 78 SECTION 5.9 EYE OINTMENT ADMINISTRATION 79 SECTION 5.10 HEPARIN SUBCUTANEOUS INJECTION ADMINISTRATION 80 SECTION 5.11 INSULIN VIAL INJECTION ADMINISTRATION 81 SECTION 5.12 INSULIN PEN INJECTION ADMINISTRATION 82 SECTION 5.13 INTRAMUSCULAR MEDICATION ADMINISTRATION 83-84 SECTION 5.14 INHALATION (ORAL AND NASAL) ADMINISTRATION 85-86 SECTION 5.15 RECTAL SUPPOSITORY ADMINISTRATION 87 SECTION 5.16 SUBCUTANEOUS MEDICATION ADMINISTRATION 88 SECTION 5.17 SUBLINGUAL MEDICATION ADMINISTRATION 89 SECTION 5.18 TRANSDERMAL PATCH APPLICATION 90 SECTION 5.19 TUBERCULOSIS TESTING (MANTOUX TEST) 91 SECTION 5.20 VAGINAL MEDICATION ADMINISTRATION 92 SECTION 5.21 VIALS AND AMPULES 93
3 May 2019
SECTION 6.0 DRUG DISPOSAL 94
SECTION 6.1 BED HOLD MEDICATIONS 95 SECTION 6.2 CONTROLLED SUBSTANCE DISPOSITION 96-97 SECTION 6.3 DISCONTINUED MEDICATION 98 SECTION 6.4 SYRINGE AND NEEDLE DISPOSAL 99
SECTION 7.0 QUALITY ASSURANCE/CONSULTANT SERVICES 100
SECTION 7.1 COMMITTEE PARTICIPATION 101 SECTION 7.2 QUALITY ASSURANCE PARTICIPATION 102 SECTION 7.3 QUALITY ASSURANCE MONITORING 103 SECTION 7.4 DRUG INTERACTIONS/ALLERGIES 104 SECTION 7.5 DRUG REFERENCE INFORMATION 105 SECTION 7.6 FACILITY EDUCATION 106 SECTION 7.7 MEDICATION ERROR REPORTING 107 SECTION 7.8 NARCOTIC DIVERSION POLICY 108 SECTION 7.9 CONSULTANT PHARMACY SERVICES PROVIDER AGREEMENT 109-111 SECTION 7.10 MEDICATION REGIMEN REVIEW 112 SECTION 7.11 DISTRIBUTION OF MEDICATION REGIMEN REVIEW REPORT 113 SECTION 7.12 SHORT TERM STAY/CHANGE OF CONDITION MEDICATION REVIEW 114 SECTION 7.13 NURSE CONSULTANT SERVICES 115 SECTION 7.14 DRUG PRODUCT RECALLS 116 SECTION 7.15 INFLUENZA VACCINATION PROGRAM 117
SECTION 8.0 MEDICAL RECORDS 118
SECTION 8.1 MEDICAL RECORDS 119-121
SECTION 9.0 BILLING 122
SECTION 9.1 MEDICATION RETURN POLICY 123 SECTION 9.2 FORMS THAT MUST BE RETURNED TO THE PHARMACY 124-129 SECTION 9.3 INSURANCE COVERAGE 130 SECTION 9.4 TERMS OF PAYMENT 131 SECTION 9.5 BILLING INFORMATION 132-133
APPENDIX 135
4 May 2019
SECTION 1.0 GENERAL OVERVIEW 4
SECTION 1.1 FACILITY APPROVAL OF POLICIES AND PROCEDURES 5 SECTION 1.2 MANUAL OBJECTIVES 6 SECTION 1.3 MISSION STATEMENT 7 SECTION 1.4 VERIFICATION OF LICENSURE 8 SECTION 1.5 PHARMACY SERVICES 9 SECTION 1.6 PHARMACY HOURS AND DELIVERY 10 SECTION 1.7 ADDRESS AND PHONE NUMBERS 11 SECTION 1.8 RESIDENT RIGHT TO SELECT PHARMACY PROVIDER 12-13 SECTION 1.9 FACILITY RIGHTS/RESPONSIBILITIES RELATED TO PHARMACY SERVICES 14 SECTION 1.10 NONCONTRACTED PHARMACY FACILITY AGREEMENT 15-16 SECTION 1.11 COMPLAINT/CONCERN RESOLUTION 17 SECTION 1.12 EMERGENCY PREPAREDNESS 18 SECTION 1.13 FACILITY LIMITED VISITOR NOTIFICATION 19 SECTION 1.14 NEW RESIDENT INFORMATION LETTER 20-22
5 May 2019
1.1: FACILITY APPROVAL OF POLICES AND PROCEDURES
The UnitedRx Policy and Procedures Manual shall be reviewed and updated at least annually, or more often as needed. Please note this is a general policy and procedure manual; specific policies, procedures, and/or State regulations can be obtained by your consultant.
A paperless copy of the most current and up to date manual will be kept on a UnitedRx USB. A paperless copy can also be requested from your consultant pharmacist.
All staff involved in the administration of medications will receive training regarding the contents of this policy and procedures manual.
Administrator/Date
Director of Nursing/Date
Medical Director/Date
Consultant Pharmacist/Date
6 May 2019
1.2: MANUAL OBJECTIVES UnitedRx Pharmacy Policy and Procedures Manual objectives:
• To standardize procedures for the safe procurement, storage, distribution, and control of medications in the facility.
• To set standards as a means of evaluating the quality of medication related services.
• To provide general information that will direct the use of appropriate forms. Where possible, forms created for customers use by UnitedRx Pharmacy will have directions for use on the form.
• To serve as a guide for the orientation of new employees.
This manual will be periodically updated by UnitedRx Pharmacy. The revision date will appear on the bottom of each page. Any revision necessitated by a change in federal or state regulations will be provided.
7 May 2019
1.3: MISSION STATEMENT Build the Midwest’s leading pharmacy services organization dedicated to enhancing the quality and cost effectiveness of the care for the elderly thereby creating value for UnitedRx’s customers, stakeholders; employees, and shareholders. UnitedRx Pharmacy is a customer driven, value orientated, healthcare company specializing in providing cost-effective pharmaceutical services to institutions with unique populations. We listen to our customers and communicate with them honestly. We respect and service our residents as though they were members of our own family, for indeed, they may be. We foster a work atmosphere that places high value on personal integrity, creativity, and innovation: while stressing the importance of teamwork. We develop programs to anticipate and exceed our customer’s expectations. We believe our employees are the company’s most valuable resource.
8 May 2019
1.4: VERIFICATION OF LICENSURE Policy: UnitedRx ensures that each Consultant Pharmacist and all our pharmacy locations are appropriately licensed by the state in which services are being provided, and that such license is renewed according to state laws. Procedures: 1. UnitedRx will ensure that each Consultant Pharmacist is appropriately licensed by verifying such
licensure, and maintaining a record of the licensure status of each pharmacist employee. The Director of Pharmacy maintains the pharmacy license and it is renewed according to state laws.
2. Prior to employment of a Consultant Pharmacist, UnitedRx representatives will verify his/her
pharmacist’s license. 3. A copy of the original license will be maintained in the pharmacy and a copy will be sent to the facility
upon initiation of consultant services. The consultant pharmacist in accordance with state laws will renew the license every two years.
4. The pharmacy license will be sent with the Consultant Pharmacist license every two years to the
Administrator of the facility. The copy of the license from the previous 2 years should not be discarded until the new copies arrive.
9 May 2019
1.5: PHARMACY SERVICES An agreement is executed between authorized representatives of the facility and UnitedRx Pharmacy. A copy of the agreement will be kept in the facility by the responsible party. UnitedRx Pharmacy is responsible for rendering the required services in accordance with local, state, and federal laws and regulations, facility policies and procedures, and community standards of practice. UnitedRx Pharmacy agrees to perform the following pharmaceutical services, in addition to others that may be stipulated in the agreement: • Assisting the facility, as necessary, in determining the appropriate equipment and packaging to meet
the medications needs of residents and the facility. • Accurately dispensing prescriptions based on authorized prescriber orders. • Providing medications packaged in accordance with the facility’s needs and equipment requirements. • Supplying only USP and NF approved medications, biologicals, and supplies, other than
extemporaneously compounded medications or investigational new drugs. • Labeling all medications dispensed in accordance with all applicable laws. • Providing routine and timely pharmacy service 7 days per week and emergency pharmacy service 24
hours per day, seven days per week. • Maintaining a medication profile on each resident that includes all medications allergies, diet, and any
other pertinent information. • Screening each new medication order for:
o An appropriate indication or diagnosis; o Drug -drug, drug-food, drug-disease interactions, and contraindications; o Duplication of therapy with other drugs in the same therapeutic class o Appropriate drug dose, dosing interval, and route of administration, based on resident and other
pertinent information. • Providing medication information and consultation to the facility’s nursing staff. • Providing, maintaining, and replenishing in a timely manner, emergency medications supplies in a
sealed and properly labeled container. • Be responsible for all third party billing, including but not limited to Medicaid, private pay, and
insurance. • Provides the facility with a copy of its certificate of liability, control substance license, tax revenue
certificate, pharmacist-in-charge license, and consultant pharmacist license.
10 May 2019
1.6: PHARMACY HOURS AND DELIVERY UnitedRx is open 24 hours/365 days a year. New orders and refill requests may be faxed or sent electronically at any time. Facility specific fax cut-off times are arranged between the facility and pharmacy upon start up and adjusted as needed. New orders communicated to the UnitedRx Pharmacy after the cut-off time will automatically go into the next regular delivery for the facility. Routine deliveries are made to the facility in accordance with the established time frames for each facility. The medication therapy should be initiated promptly if the new order is a medication contained in the facility convenience box or emergency box supply. If the resident is clinically unstable or the resident is in need of medication as a STAT order, the medication should be started from the emergency dispensing kit if applicable, and/or an emergency delivery must be requested. An emergency delivery can be requested by sending the order to the UnitedRx Pharmacy, Contact the pharmacy by phone to alert them that you sent a STAT order.
Facilities will be notified of holiday pharmacy hours and holiday delivery times on an individual basis prior to the holiday. Please see most current cut-off time and hours of operation sheet for the most accurate information.
11 May 2019
1.7: ADDRESS AND TELEPHONE NUMBERS Main Pharmacy: 708-449-7600 150 Fencl Lane, Hillside, IL 60162 Carbondale Pharmacy: 877-896-7090 1120 W. Main Street, Carbondale, IL 62901 Shelbyville Pharmacy: 317-606-4700 1408-A Miller Avenue, Shelbyville, IN 46176 Tennessee Pharmacy 615-502-4040 553 East Bledsoe Street, Gallatin, TN 37066 Main Fax Number for ALL Pharmacies: 855-422-0782 All questions or concerns should be promptly directed to the appropriate department or department manager. Please obtain most current phone directory and extension sheet from the pharmacy.
12 May 2019
1.8: RESIDENT RIGHT TO SELECT PHARMACY PROVIDER The philosophy of UnitedRx is to allow and provide as much choice in treatment options for the resident/caregiver as is allowable by law, regulation, customary practice and ethical considerations. Care and planning is utilized to assure this choice is based on informed and educated consent. In addition, each resident/caregiver will be afforded attention and courtesy as a member of the community, as a client, as a family member and with human dignity. This right is intended for the person and property of the resident/caregiver. Each resident serviced by UnitedRx Pharmacy has the right to:
• Receive RESIDENT RIGHTS AND RESPONSIBILITIES RELATED TO PHARMACY SERVICES information.
• Each resident and their responsible party upon admission will be informed that the facility contracts with UnitedRx Pharmacy to provide pharmaceutical services.
• Choose the pharmacy provider of their choice. • Refuse pharmacy service. • Have personal information handled in a confidential manner with clinical and financial records
maintained so they are secure, not altered or damaged, or used without authorization. • Have complete and accurate accounting of pharmacy service charges. • Review and question all pharmacy charges. • Voice concerns and complaints and except equal and effective resolution without coercion,
discrimination, reprisal, or unreasonable interruption of care and services. • Express concerns either verbally or in writing. • Receive courteous and respectful responses to all inquiries. • Receive delivery of medications and supplies in agreed time frame. • Have medications secured, stored, and administered in a safe manner.
Each resident and/or responsible party has the responsibility to:
• Provide complete health information concerning illnesses, hospitalizations, medications, allergies, and other pertinent information to pharmacy provider as requested.
• Provide accurate payment information. • Provide payment within agreed upon terms
Facility admission staff will explain that the contractual arrangement includes providing daily delivery, consulting services, specialty packaging, and emergency delivery services to residents for physician ordered medications and pharmaceuticals. Residents and their responsible parties will be informed that they may select any pharmacy provider that provides required services including but not limited to the following:
• Twenty- four hour emergency service. • Labeling of all medications according to state and federal laws. • Compatible packaging to the facilities’ distribution system. • Monitoring of all new orders to assure there are no contraindications (e.g., medication allergy,
medication interactions, etc.)
13 May 2019
• Medications regimen reviews by a licensed pharmacist. UnitedRx Pharmacy can conduct medication regiment reviews for residents not utilizing the dispensing service of UnitedRx. The consultant pharmacist will report to the facility those resident lacking a current medication regimen review. This service could be provided in accordance with a predetermined monthly fee, according to the terms of the pharmacy contract. General facility consultation provided by the consultant pharmacist will be provided without regard to the supplier of medication. Residents who do not use UnitedRx Pharmacy dispensing services on a routine basis, but utilize UnitedRx Pharmacy emergency services to provide them with medications not available through their pharmacy, will be charged a delivery fee. Residents who wish to utilize the contingency and emergency medications provided to the facility by UnitedRx Pharmacy must provide UnitedRx Pharmacy with written authorization including billing information and authorization.
14 May 2019
1.9: FACILITY RIGHTS/RESPONSIBILITIES RELATED TO PHARMACY SERVICES EACH FACILITY SERVICED BY UnitedRx HAS THE RIGHT TO:
• Receive this FACILITY RIGHTS AND RESPONSIBILITIES RELATED TO PHARMACY SERVICES information.
• Receive information about the pharmacy services available and the financial considerations. • Have facility information handled in a confidential manner with financial records maintained so
they are secure, not altered or damaged, or used without authorization. • Have complete and accurate accounting of pharmacy services charges. • Review and question pharmacy charges. • Voice concerns and complaints and expect equal and effective resolution without coercion,
discrimination, reprisal, or unreasonable interruption of care and services. • Express concerns either verbally or in writing. • Receive courteous and respectful responses to all inquiries. • Receive delivery of medications and supplies in the agreed time frame.
EACH FACILITY HAS THE RESPONSIBILITY TO:
• Provide a copy of the RESIDENT RIGHTS AND RESPONSIBILITIES RELATED TO PHARMACY SERVICES to each resident upon admission to the facility.
• Provide complete resident specific health information concerning illnesses, hospitalization, medications, allergies and other pertinent information to the pharmacy provider as requested.
• Provide accurate payment information. • Provide payment within agreed upon terms • Receive, secure, store, and administer if applicable all pharmaceutical product in accordance with
approved policies and procedures.
15 May 2019
1.10: NONCONTRACTED PHARMACY FACILITY AGREEMENT The following procedures must be approved by the noncontracted pharmacy provider prior to the provision of pharmaceuticals to residents. • The noncontracted pharmacy must provide written notification to the facility of acceptance of these
policies and procedures prior to the provision of pharmaceutical care. • The noncontracted pharmacy provides only approved medications, biologicals, and supplies and
renders all services in accordance with all applicable requirements of federal, state, or local laws, rules and regulations, and standard of practice.
• All medications are dispensed by the noncontracted pharmacy in containers that meet legal requirement
for stability and that are compatible with the medications packaging system in use at the facility.
• Each medication provided by the noncontracted pharmacy is labeled in accordance with facility requirements, as shown below and with state and federal requirements. Any medication improperly labeled is rejected and returned to the issuing pharmacy. Labeling requirements are as follows: o Labels are permanently affixed to the outside of the prescription container. All prescription
medications have labels that show: the innovator brand or non-innovator brand name of the medication the strength of the medication including strength per ml for liquid medications the quantity dispensed the medication’s expiration date the resident’s name specific directions for use prescriber’s name date dispensed name, address, and telephone number of dispensing pharmacy initials of the dispensing pharmacist prescription number DEA number of the dispensing pharmacy Precautionary labels indication special storage requirements or procedures Total number of containers if more than one per prescription.
• Nonprescription medications without a prescription label are in the manufacture’s original container
and labeled with the resident’s name. • If an error is made on a label by the noncontracted pharmacy or the direction for use change, the
pharmacy is to provide a corrected label on the container the next time the medication is dispensed. Under no circumstances are unattached labels requested or accepted from the pharmacy. Only the pharmacist may place a label on the medication container. The nurse receiving the order change or detecting the label error places a signal label on the container to indicate that the directions for medication administration on the label are incorrect.
16 May 2019
• When medication is ordered for use at the bedside, the medication label contains, in addition to the instruction for use, a notation this is to be stored at the bedside.
• When sublingual nitroglycerin is ordered, the noncontract pharmacy dispenses it in an original
manufacturer’s container containing no more than 100 days.
• Controlled Substances: o Emergency orders for Schedule II controlled medications are filled by the noncontract pharmacy
in accordance with the law. If the noncontract pharmacy declines to promptly supply an emergency Schedule II medication for any reason, the facility shall be notified as to the reason. UnitedRx may then be requested to fill an emergency request that complies with the facility policy and procedures. The facility will assist UnitedRx by furnishing the necessary information for billing for this service.
o Controlled medications listed in Schedule II, III, IV, and V are provided by the noncontracted pharmacy in easily countable quantities and in containers designed for easy counting of contents.
o Schedule II medications that cannot be refilled and that can be dispensed only upon the receipt of an original written prescription are recorded when a seven-day supply remains. The noncontracted pharmacy then has the responsibility to obtain a valid prescription from the physician; however, the facility assists in the acquisition of the prescription if possible. If unable to obtain the prescription and provide the medication prior to the depletion of the current supply, the noncontracted pharmacy will notify the facility immediately. UnitedRx may then be requested to obtain and fill the prescription.
• New medications are received from the noncontracted pharmacy on a prompt and timely basis. Prompt
and timely availability is interpreted as follows: o Medications ordered from the noncontract pharmacy during its regularly scheduled business hours
on an emergency or ‘stat’ basis are available for administration 4 hours after the order is prescribed. o All other new medication orders are received and available for administration on the day they are
ordered by the physician or before the time the first dose would ordinarily be administered, when possible.
o A licensed nurse receives all medications delivered to the facility from the noncontract pharmacy. o Under no circumstances are medications, whether prescription or nonprescription, bought directly
to the resident.
• The noncontracted pharmacy bills the resident or responsible party directly for all medications and supplies provided. The facility is not responsible for collection of payment.
• The noncontracted pharmacy provides the facility with a delivery and on-call schedule and notifies the
facility immediately of any changes in the schedule.
17 May 2019
1.11: COMPLAINT/CONCERN RESOLUTION Policy: All customer concerns will be addressed in a timely manner; complete with a report of resolution being given to the inquirer. Procedure: 1. UnitedRx customer service is available to all individuals served. All customers are encouraged to notify
or contact UnitedRx Pharmacy either in writing, or verbally by contacting the Chief Operating Officer, Director of Pharmacy, and/or General Manager at 708-449-7600.
2. All UnitedRx Pharmacy personnel are trained to address customer concerns. There are specific
personnel available to take calls during normal office hours. 3. The voice mail message system allows capture of customers concerns at other times by calling the
department manager. 4. A representative will work with the individual voicing the concerns until resolution is achieved. The
goal is to resolve concerns as soon as possible. 5. The resolution will be reported to the person voicing the concern either in writing or verbally over the
phone.
18 May 2019
1.12: EMERGENCY PREPAREDNESS
Policy: During prolonged interruption of pharmacy services, UnitedRx Pharmacy will implement a Disaster/Emergency Plan. Procedure: 1. UnitedRx Pharmacy will be responsible to provide continuous, uninterrupted pharmaceutical care to
our customers in the event prolonged interruption of services by implementing a contingency plan to assure access to required supplies and medications and availability of required services to our clients.
2. In the event that UnitedRx Pharmacy is not accessible due to a natural disaster, we will contact you
with an alternate site. 3. When a natural disaster exists in the area, for example a tornado, heavy snow, ice storms, etc. that
causes a failure of normal telephone line the following steps will be followed: 4. UnitedRx will contact the facility using cell phones. 5. UnitedRx will provide instructions at that time which are appropriate for the emergency at hand. 6. If the interruption is greater than three (3) hours, we will contact you with an alternate site. 7. If there has been an interruption in service of greater than 3 hours and no contact has been established
with the pharmacy, attempt to contact the police, or the state police to request that they attempt to contact UnitedRx Pharmacy.
8. When a client experiences a natural disaster or an emergency where the residents have to be moved to
an alternate setting to provide care, the facility will notify UnitedRx Pharmacy. After residents are transported to a secure location, transport the medication administration records and the medications to the alternate facility. Contact UnitedRx Pharmacy and provide current location of residents.
9. UnitedRx will provide appropriate clinical information to assure continuity of pharmaceutical care and
services.
19 May 2019
1.13: FACILITY LIMITED VISTOR NOTIFICATION Policy: The facility will notify UnitedRx Pharmacy of any outbreaks of infection or communicable diseases affecting the facility which limit outside visitors or service persons to assure that alternate arrangements for continuation of essential services can be made. Procedure: 1. The facility will contact the pharmacy, indicating which UnitedRx employees should not provide visits
during the visitor limitation time frame. 2. If the visitor limitation impacts the consultant pharmacists, QA technicians, QA nurses, IV nurses,
customer service managers, or other support services, the information will be forwarded to each affected employee who will contact the facility to rearrange scheduled visits.
3. If the visitor limitation impacts the delivery service, arrangements will be made between the facility
and UnitedRx Pharmacy to set up a mechanism for delivery.
20 May 2019
1.14: NEW RESIDENT INFORMATION LETTER Policy: Newly admitted residents are entitled to information regarding their rights in regard to pharmacy services. Procedure: 1. UnitedRx will provide a package of “New Resident Information” to the Facility for distribution to
newly admitted residents. 2. A copy of the New Resident Information Letter is located on the following pages.
21 May 2019
22 May 2019
THERE IS A DIFFERENCE Why is it important that a nursing facility work with a professional pharmacy like UnitedRx? The State Department of Public Health and the Federal government issue licenses to all long term care facilities. Regulations require that nursing facilities establish a contract with a pharmacy for comprehensive services. Selecting a pharmacy to provide the medication and other pharmacy needs of the long-term resident is an important part of quality patient care. The administrator, director of nursing, and staff at the facility considered many important factors before choosing UnitedRx. Our company provides the most expertise in long-term care pharmacy, innovation, technology, customer service, flexibility in services provided, and a staff of dedicated experienced employees. At UnitedRx we take pride in the high quality service and the products that we provide. UnitedRx provides:
• Specialized services required by state and federal laws. • A large product selection with delivery of medication and supplies 24 hours a day, 365 days a year. • A comprehensive emergency medication system, developed especially for each facility, enabling
the facility to start new orders immediately • A unit dose and unit of use medication system that reduces the potential for medication errors and
reduces the time required for the nursing staff to administer medications. • Highly technical services, when appropriate, including IV therapy, nutritional assessment, pain
management therapy, Total Parenteral Nutrition, and pharmacokinetic dosing. • The assistance of an I.V. team led by an I.V. nurse specialist, to assist the nursing staff when needed. • System that cross-checks each patient’s list of drugs to detect any potentially dangerous drug-to-
drug or drug-to-food interactions. • System checks for drug allergies when such allergies are entered into the patient history. • Pre-printed, computerized records for medication administration, treatments, and physician orders.
This service saves considerable nursing time each month, allowing for more time to be spent caring for residents.
• Medication storage and drug administration carts, treatment carts, and I.V. carts for use by the nursing staff.
• Consultant Pharmacist services, which perform monthly, on-site reviews of the medication records of each resident to assure that the proper drugs are being administered at the proper time and in the proper manner and that each drug has a matching diagnosis.
• Pharmacists are available 24 hours a day, seven days a week to handle emergency needs. The needs of the nursing home resident require much greater attention than the needs of persons who are able to medicate themselves. UnitedRx provides these services not available from a retail pharmacy, making a comparison between the two impractical. UnitedRx provides the services that protect the safety and well-being of you or your loved-one. These services also help nursing facilities stay in compliance with state and federal regulations. At UnitedRx we understand that medical economics of this time are especially trying. Arranging for long-term care for yourself or your loved one can be a complex, and sometimes overwhelming task. Allow us to ease your burden by putting our years of experience and expertise as a provider of pharmacy services to work for you.
23 May 2019
SECTION 2.0 MEDICATION ORDERS 23
SECTION 2.1 RESIDENT INFORMATION (ADMISSION/CHANGE OF STATUS) 24 SECTION 2.2 GENERIC SUBSTITUTION 25 SECTION 2.3 PHYSICIAN’S ORDERS 26 SECTION 2.4 STANDING ORDERS 27 SECTION 2.5 STOP ORDERS 28 SECTION 2.6 ORDERING MEDICATIONS 29 SECTION 2.6A ORDERING MEDICATIONS ELECTRONICALLY 30 SECTION 2.7 STAT ORDERS 31-32 SECTION 2.8 CLOZAPINE 33 SECTION 2.9 CONTROLLED SUBSTANCE ORDERS 34 SECTION 2.10 ORDER CLARIFICATION 35-36 SECTION 2.11 FLOOR STOCK MEDICATIONS 37 SECTION 2.12 REFILL TOO SOON 38 SECTION 2.13 NONCOVERED MEDICATIONS 39 SECTION 2.14 DELIVERY MANIFEST 40 SECTION 2.15 OUT OF STOCK MEDICATION 41 SECTION 2.16 EMERGENCY DISPENSING KIT-NONCONTROLLED SUBSTANCES 42-43 SECTION 2.17 EMERGENCY DISPENSING KIT-CONTROLLED SUBSTANCES 44-45 SECTION 2.18 FORMULARY INTERCHANGE PROGRAM 46 SECTION 2.19 INTRAVENOUS (IV) PUMPS 47
24 May 2019
2.1: RESIDENT INFORMATION (ADMISSION/CHANGE OF STATUS)
Policy:
To ensure that current and accurate information is available to the pharmacy permitting the dispensing of drugs in accordance with Federal and State laws, the facility will provide complete and accurate information to the pharmacy relative to admission/re-admission and change in status prior to the pharmacy dispensing medications.
Procedure:
1. Prior to or at the time of an anticipated admission, the facility will forward to UnitedRx a complete patient profile of billing and clinical information. Information to include complete name, age, gender, social security number, , copies of insurance cards (both sides), names, addresses, and phone number of responsible parties, first and last name of the attending physician, and listing of allergies and diagnoses
2. UnitedRx must receive this information before prescriptions can be dispensed.
3. After admission, any change in resident information will be communicated to UnitedRx with the daily census. This information should be faxed/emailed every business day.
25 May 2019
2.2: GENERIC SUBSTITUTION
Policy:
In accordance with the provision of state law and the physician’s therapeutic objectives, the cost of medications to residents is reduced by using generic medications. Generic means the empirical name of those products having the same chemical ingredients in the same dosage form as the name brand medication.
Procedure:
1. UnitedRx dispenses generic drug products whenever possible and when required according to Medicaid, or other third-party payer programs that dictate generic products in place of brand name products. The Physician Order Sheet contains a statement regarding generic substitution policy for the physician to view at the time of signing the order sheet.
2. Physicians may indicate refusal of generic substitutes when ordering medications. In the case of a
Medicaid resident, the physician complies with the required paperwork to document the necessity of a brand name product, as required by OBRA ’90 to the Title XIX of the Social Security Act, as follows:
Prescriptions:
The physicians must clarify in his or her own handwriting that a specific brand is ‘medically necessary’ for a particular recipient. The handwritten phrase ‘brand necessary’ or ‘brand medically necessary’ must appear on the face of the prescription. The prescriber must also document in the resident records the reason why the drug is medically necessary.
Nursing home orders:
In addition to the above, the prescriber certification must be made on each other written or that drug for that resident. The certification is good only for the length of time that the order is valid. Updated written certifications are required for each new prescription order written. A blanket order for ‘brand medically necessary’ is not acceptable.
3. UnitedRx uses sound professional judgment and prudent buying methods when selecting generic multiple source drug product substitutes for brand products.
4. In accordance with the state law, UnitedRx will select only generic medications, when clinically and lawfully appropriate.
5. In accordance with state law, UnitedRx labels generic drug products as detailed in the Drug Labels
section. 6. When an over-the-counter medication is ordered and a generic version is also available, the generic
version will be supplied.
7. When Insulin orders are received and the source type (Pork, Beef, and Human) is not specified, the pharmacy will dispense the Human type.
26 May 2019
2.3: PHYSICIAN’S ORDERS Policy:
Drugs will be administered only upon a clean, complete and signed order of a person lawfully authorized to prescribe. Verbal orders will be received only by licensed nurses or pharmacists and confirmed in writing by the physician. Electronic orders transmitted via NCPDP Script 10.6 will be accepted.
Procedure:
Elements of the Medication Order: 1. Medication orders specify the following:
a. Name of medication b. Strength of medication, c. Dosage. d. Time or frequency of administration. e. Route of administration, if other than oral. f. Quantity or duration (length) of therapy. If not specified by prescriber on a new order, the duration
is limited by automatic stop order policy. g. Diagnosis or indication for h. Medication Allergy.
1. Any dose or order that appears inappropriate considering the resident’s age, condition, or diagnosis is
verified with the attending physician.
2. PRN (as needed) orders also specify the condition for which they are being administered, e.g., “as needed for pain,” “as needed for sleep”
Documentation of the Medication Order: 1. The physician’s new orders may be received on the Admission Physician’s Order form, by telephone
or handwritten on the Physician Order Sheet. All drug orders received via transfer sheet must be verified by the attending physician and transcribed onto the Physician Order Sheet.
2. Each medication order is documented in the resident’s medical record with the date and signature of the person receiving the order. The order is recorded on the physician order sheet or the telephone order sheet if it is a verbal order, and the Medication Administration Record (MAR) or Treatment Administrative Record (TAR).
3. The following steps are initiated to complete documentation:
a. Clarify the order b. Enter the orders on the medication order and fax the medication order to the provider pharmacy. c. Transcribed newly prescribed medications on the MAR or TAR. If a new order changes the dosage
of a previously prescribed medication, discontinue precious entry by writing “DC’s” and the date.
4. After completion, document each medication order noted on the physician’s order form with date, time, and signature. Example “Noted 1:15 p.m., 3/28/16. M. Jones, R.N.”
27 May 2019
2.4: STANDING ORDERS
Policy:
Certain self-limited conditions that occur frequently are often amenable to treatment with nonprescription medications, using nursing judgment. To facilitate prompt treatment of such conditions, and to avoid unnecessary telephone calls to those prescribers, who approve, standing orders are utilized.
Procedure:
1. On admission, facility Standing Orders will be individualized to meet unique needs of the resident, signed and dated by the Attending Physician.
2. If the Attending Physician does not desire Standing Orders to be utilized, this notation will be made on
the clinical record. 3. A copy of the individualized, signed and dated Standing Orders will be placed in the resident’s clinical
record. 4. Permission to use Standing Orders will be renewed by the physician during each required visit. Only
licensed nurses may utilize Standing Orders Professional judgment is used in the initiation and administration of Standing Orders.
5. Documentation of the situation requiring the use of the Standing Order must be placed in the Nursing
Notes section of the resident’s medical record prior to initiation of the order. 6. It is recommended that facility Standing Orders will be developed according to the following
guidelines: a. They will not include prescription drugs. b. They will not include ‘range’ orders c. They will indicate their limited use by including the number of doses or specific time limit. d. They will include some system to facilitate individualization. e. When more than one medications indicated for the same purpose, a hierarchy for use will be
indicated. f. They will be reviewed and signed/dated by the attending physician per facility protocol. g. They will not include orders for physical restraints. h. They will not include orders for decubitus care. i. They will not include orders which require the nursing staff to make medical judgments.
7. If the resident has experienced a changed in condition, the physician will be contacted regardless of the
presence of Standing Orders.
28 May 2019
2.5: STOP ORDERS
Policy:
Specific classes of medications will require stop dates prior to being dispenses by the pharmacy.
Procedure:
1. The following classes of medications will require stop dates, indicated by number of days, unless the prescriber specifies a different number of doses and duration of therapy to be given. • Antibiotics • Anticoagulants • Cold and Cough Preparations • Antidiarrheals and Antiemetics (scheduled only) • Narcotics ordered for acute pain (scheduled only) • Steroid drugs ordered for acute conditions (scheduled only) • Hypnotics (scheduled only) • Topical Anti-Infectives
2. All medication orders will be discontinued unless reviewed and renewed by the Attending Physician
no later than the last day of the maximum time limit mandated in the physician visitation schedule per facility policy.
3. The responsible nurse will phone the physician at least 48 hours before the stop order date to confirm
discontinuation of the drug or to renew the order.
4. The appropriate documentation will be completed by the nurse on Medication Administration Record to indicate when a drug has been discontinued. When entering medications covered by the Stop Order Policy on the MAR, the automatic stop date is recorded in the appropriate area on the MAR. The blocks of time before the mediation is given are X’ed out, and the locks of time after the medication is given are ‘lined’ out and ‘D/C’ written in, once the last dose is given.
29 May 2019
2.6: ORDERING MEDICATIONS
Policy:
Medications and related products are ordered from UnitedRx on a timely basis.
Procedure:
New medication order requests can be faxed to the pharmacy’s main fax number, sent via electronic health records, EHR system, electronically prescribed by the prescriber, and/or called in by the appropriate personnel according to State laws and regulations. Refill requests can be faxed to the pharmacy’s main fax number, sent via EHR system, reordered via FrameworkLink, and/or left on the pharmacy refill voicemail. Refill requests should be sent in 72 hours prior to the last dose. Please refer to specific EHR policies for your facility regarding compounds, narcotics, directions, and character limit.
30 May 2019
2.6A: ORDERING MEDICATIONS (ELECTRONIC)
Policy:
Medications and related products are ordered from United Rx on a timely basis.
Procedure:
1. New medication orders (excluding controlled substances) that are less than 140 characters are accomplished through the electronic medical record system. The entry is electronically transmitted and includes:
• Date ordered • Name of medication, strength of medication, dosage, time or frequency of administration,
route of administration, quantity or duration, and diagnosis or indications for use. New medication orders (excluding controlled substances) that are 140 characters or greater must be faxed to the pharmacy and must include:
• Date ordered • Name of medication, strength of medication, dosage, time or frequency of administration,
route of administration, quantity or duration, and diagnosis or indications for use. Controlled Substances are filled from the pharmacy after the pharmacy has received a valid prescription from the prescriber. The prescription must include:
• Date ordered • Birthdate of resident • Name of medication, strength of medication, dosage, time or frequency of administration,
route of administration, quantity or duration, and diagnosis or indications for use.
2. Refill orders are initiated within the electronic medical record system as follows: • Reorder medication three days in advance of need to assure an adequate supply is on hand. • Medications can be reordered from an individual resident’s orders screen or from the
electronic medication administration record.
3. Medication order changes should be entered into the electronic medical record as a new or updated order. The previous order should be discontinued. If the current medication supply will be used to fulfill the medication order “Inventory on Hand” should be selected as the new order is entered. The following steps should occur: • A direction change sticker (supplied by pharmacy) should be placed over the label with
instructions to pass the medication according to directions on the MAR. • Use up the medication supply with the direction change sticker applied to the label. The
pharmacy cannot supply a new label until the order is in need of a refill. • When re-ordering a prescription whose directions have changed, the normal procedure for
refills can be followed if all of the above steps have been followed.
4. New medications needed prior to regular delivery • Check your convenience and emergency box (Med-Dispense Unit). If the medication is
available, use that supply for the first dose. If applicable, follow Controlled Substance Emergency Dispensing Kit (EDK) Usage Protocol.
31 May 2019
• If you are in doubt as to the arrival time of your order, place a phone call to the pharmacy and ask if you are beyond the cut-off time for the next delivery. i.e.: always call for verbal help if in doubt
• If not available in the convenience or emergency box (Med-Dispense Unit) and the medication must be administered before the next delivery fax a “STAT” request to the pharmacy.
5. Medications that are temporarily unavailable from the pharmacy
• United Rx will first check back up pharmacies for the medication availability. • If a particular medication is not available from the pharmacy, the licensed nurse should call
the patient’s physician to let him/her know that the ordered medication is not available. The physician can then decide whether to hold the medication until it is available or change the medication to one that is readily available in the convenience box (Med-Dispense Unit). The original medication that was ordered will be sent as soon as it becomes available.
6. Medications that require dispensing from specialty pharmacy • United Rx will notify nursing facility regarding any third-party restrictions including but not
limited to requirement of receiving medication from a specialty pharmacy. It will be the duty of the facility to obtain the medication from the specialty pharmacy.
• United Rx will inform the facility, to the best of our ability, which pharmacy will be specialty pharmacy to obtain the medication.
7. “STAT” orders
• Always use the Convenience or Emergency box supply (Med-Dispense Unit) before requesting a stat.
• Write “STAT” in large block letter in the upper right and corner of the order sheet, contact the pharmacy by phone to alert them that you are faxing a STAT order.
8. New and Readmissions • Medication orders for new admissions will be entered into the Electronic Health Care Record • The facility will notify the pharmacy that medications will be needed stat.
9. Medication orders must contain:
• Resident’s complete First and Last name and Birthdate of resident • Prescription number if a refill • Complete order if a new medication order or direction changes to a previous order • First and last name of the prescribing physician if a new order
32 May 2019
2.7: “STAT” ORDERS
Policy:
Emergency pharmaceutical services will be available at all times. An emergency need for medication will be met by using the facility’s approved contingency supply or by sending an emergency order to UnitedRx Pharmacy.
Procedure:
1. When an emergency or “STAT” order is received, the nurse will determine if the medication is in the emergency dispensing kit by referring to the list of contents posted on the it.
2. If the medication is not available, an emergency delivery can be requested by faxing a “STAT” order
to the pharmacy. Please contact the pharmacy by telephone any time a STAT order is faxed. 3. The pharmacy will deliver the emergency or “STAT” medications as soon as possible, usually within
2 to 4 hours. 4. Staff may not borrow medications from other residents to cover emergency needs.
33 May 2019
2.8: CLOZAPINE
Policy:
Clozapine will only be dispensed to residents enrolled in the Clozapine REMS program, per FDA regulations.
Procedure:
1. UnitedRx is required to obtain a pre-dispense authorization (PDA) from the Clozapine REMS Program before clozapine can be dispensed a. What this means for you (the facility) b. Labs must be faxed to the pharmacy within 7 days of dispensing the medication and/or uploaded
by the physician or an agent of the physician to the Clozapine REMS website. c. If the prescriber is not enrolled, if the prescriber did not enroll the patient, or if the lab is
unavailable, UnitedRx will NOT be able to dispense the medication d. No three-day emergency supplies will be sent
2. For more information, for prescribers and patients
• Visit: www.clozapinerems.com • Call: 844-267-8678
34 May 2019
2.9: CONTROLLED SUBSTANCE ORDERS
Policy:
Controlled substance medications will be dispensed by the pharmacy if ALL State and/or Federal requirements are met.
Procedure:
1. A controlled substance prescription will only be accepted and dispensed if the pharmacy receives a valid prescription, which includes ALL of the following (plus specific State-specific laws/requirements): a. Full name of the resident/patient b. Full address of the resident/patient (can be the facility address) c. Drug name AND strength d. Dosage form (i.e., tablet, capsule, liquid, etc.) e. Quantity prescribed f. Directions for use g. Number of refills, if authorized h. Printed name of practitioner i. Full address of practitioner j. DEA registration number of practitioner k. Date as of, and signed on, the day when issued l. Signature of prescribing practitioner
2. A valid controlled substance prescription can be received by the pharmacy by the following ways:
a. A physician may prescribe electronically b. A physician may fax a valid prescription to the pharmacy him/herself c. A physician may call a valid prescription to a pharmacist him/herself d. An authorized agent may convey to a pharmacist by telephone oral prescriptions for controlled
substances in Schedule III, IV, and V in those instances where the physician has expressly directed the agent to do so (all required elements of the prescription must be given by the physician to the authorized agent) i. The prescribing practitioner must personally communicate all Schedule II emergency oral
prescriptions to the pharmacist e. An authorized agent may transmit by fax to the pharmacy a valid prescription for a controlled
substance that the physician has signed
3. Once the valid prescription is received from the physician the medication will be delivered in the next delivery.
4. If a valid prescription is not received by the pharmacy the medication will not be delivered to the facility.
35 May 2019
2.10: ORDER CLARIFICATION
Policy:
When there is a question due to lack of information, illegible orders, unavailability of products / ingredients, or similar issues, UnitedRx Pharmacy will contact the facility by fax, Mediprocity, or phone for clarification prior to filling orders.
Procedure:
1. When it is impossible to fill an order due to ambiguity of the order, the pharmacy will contact the facility by method of communication discussed upon start up servicing the facility to clarify the order in question.
The list below is an agreed upon clarification standard for the pharmacy and facility. Regardless of the list, a licensed pharmacist may opt to call the nurse and/or physician for a clarification for Coumadin®/warfarin orders written without a specific frequency will be entered and dispensed as daily unless otherwise specified
• Betadine® will be sent as solution unless otherwise specified • If a dosage form is not specified and the medication comes as cream, cream will be sent
Bactroban® will be sent as ointment unless otherwise specified • Metoprolol will be sent as tartrate unless written as Toprol® or specified as succinate • If an order for iron 325mg tablets is written, ferrous sulfate 325mg will be entered and
dispensed unless otherwise specified • Metformin will be entered and dispensed as immediate release, unless specified as ER
(extended release) • Docusate Sodium 100mg will be dispensed as capsule unless otherwise specified as liquid,
syrup, or tablet • ProAir® will be entered and dispensed for Albuterol HFA, Proventil® HFA, and/or
Ventolin® HFA unless otherwise specified or not covered by third party • Gastrostomy Tube (G-Tube) patients will receive liquid formulation of any medications
available in liquid form Multivitamin liquid will be entered with the following directions unless otherwise specified: Give 5mL by mouth (or via g-tube) daily. Multivitamin with minerals liquid will be entered with the following directions unless otherwise specified: Give 15mL by mouth (or via g-tube) daily.
• Calcium/Vitamin D 500mg will be entered and dispensed as 500mg/200mg unless otherwise specified
• Calcium/Vitamin D 600mg will be entered and dispensed 600mg/400mg unless otherwise specified
• Duplicate therapy on admissions: If a patient is on 2 medications from the same class (i.e. simvastatin and Crestor®), a pharmacist will use his or her clinical judgment and send one while we wait for clarification from the physician
• Milk of Magnesia orders written as PRN without a specific frequency will be entered and dispensed as daily as needed
• Aspirin 81mg will be sent as chewable unless otherwise specified
36 May 2019
• Bisacodyl suppository orders written as PRN without a specific frequency will be entered and dispensed as daily as needed
• Mylanta® orders written as PRN without a specific frequency and/or dosage will be entered and dispensed as 30mL every six hours as needed
• Fleet® enema orders written as PRN without a specific frequency will be entered and dispensed as daily as needed
• Pepto Bismol® orders written as PRN without a specific frequency and/or dosage will be entered and dispensed as 30mL every four to six hours as needed
• Multivitamin and/or multivitamin with mineral orders written without a specific frequency will be entered and dispensed as daily unless otherwise specified
• Tums® orders written without a strength will be entered and dispensed as 500mg • Eye drop orders written without a specific number of drops will be entered and dispensed as
one (1) drop • Treatment orders written as PRN without a specific frequency will be entered and dispensed as
daily as needed
37 May 2019
2.11: FLOOR STOCK MEDICATIONS
Policy:
The facility, if allowed by the State, maintains a supply of commonly used non-legend medications considered as floor stock medications.
Procedure:
1. The approved floor stock of non-legend medications will be formulated by the consultant pharmacist, Director of Nursing, and Medical Director.
2. The nursing facility informs UnitedRx Pharmacy of designated nursing personnel that may order floor stock.
3. Floor stock medications are labeled as ‘floor stock” and kept in the original manufacturer’s container
with expiration date and lot number clearly exposed.
38 May 2019
2.12: REFILL TOO SOON
Policy:
Orders that are requested sooner than expected, based on mathematical calculation since the last fill, will not be sent unless explanations are clinically sound and/or approved by the responsible party.
Procedure:
1. If a medication is reordered too soon, based on a mathematical calculation made by the computer during order entry, the order will be will be suspended and the facility will be notified based on communication protocol established with the facility. a. Once approved to send by the facility, the medication will be sent on the next available delivery.
2. Changes in directions which cause increased usage will cause refill-too-soon. All changes in direction must be communicated to the pharmacy as soon as possible to eliminate the possibility of an inappropriate refill-too-soon notices.
39 May 2019
2.13: NONCOVERED MEDICATIONS
Policy:
Medications that are not covered by a third party will not be sent unless explanations are clinically sound and/or approved by the responsible party.
Procedure:
1. If a medication is not covered the order will be will be suspended and the facility will be notified based on communication protocol established with the facility. Once approved to send by the facility, the medication will be sent on the next available delivery.
40 May 2019
2.14: DELIVERY MANIFEST
Policy
The contents of the facility’s delivery will be reviewed by facility staff. This review will be documented on a delivery manifest form. UnitedRx Pharmacy will provide a delivery manifest for each delivery made to the facility.
Procedure:
1. UnitedRx Pharmacy driver will be delivering totes and/or bags and picking up totes and/or bags previously delivered.
2. Controlled Substances will be delivered in a separate bag and listed on a separate manifest from noncontrolled medications. All controlled substance medications will be delivered with a controlled drug receipt/record/disposition form.
3. UnitedRx Pharmacy driver will require the signature of the authorized facility representative receiving
the bags/tote(s) on a copy of manifest and/or hand held device. 4. Each bag/tote will be opened by an authorized facility representative who will check off all items
received against the delivery manifest. 5. The authorized facility representative will retain the signed copy of the delivery manifest, upon the
return of the driver.
6. The contents will be taken to their intended storage area. 7. The pharmacy must be notified upon delivery of any discrepancies.
41 May 2019
2.15: OUT OF STOCK MEDICATION
Policy:
UnitedRx will maintain an inventory of medications available to meet resident’s needs.
Procedure:
In the event the facility orders a medication that the pharmacy does not currently stock:
1. Alternative suppliers will be contacted to check availability and expected date and time of delivery to UnitedRx.
2. UnitedRx will contact the e facility to inform that the medication order is currently not in stock, along with an expected date from the supplier if stock will not be obtained by the following day.
3. The facility and the pharmacy will determine medical necessity. An agreement will be reached as to
the time of delivery of the ordered medication that meets the resident’s need. a. The facility should call the patient’s physician to let him/her know that the ordered medication is
not available. The physician can then decide whether to hold the medication until it is available or change the medication to one that is readily available in emergency dispensing kit. The original medication that was ordered will be sent as soon as it becomes available.
4. If the resident requires the medication sooner than UnitedRx is able to obtain it, other area pharmacy
sources will be contacted to supply the item. 5. If it is determined that medications can be started when UnitedRx is able to receive the product, the
facility will receive the medication on the following delivery once UnitedRx received the medication. 6. The facility does not have to reorder an item that has been determined to be back ordered. It will
automatically be filled by pharmacy when stock becomes available.
42 May 2019
2.16: EMERGENCY DISPENSING KIT-NONCONTROLLED SUBSTANCES
Policy:
An emergency supply of medications typically used for starter doses (STAT doses or to initiate a course of therapy without delay) is maintained in the facility in limited quantities by UnitedRx in a portable, sealed container and/or automated dispensing system.
Procedure:
1. The content of the emergency dispensing kits shall be determined by the management team for the pharmacy and facility.
2. The emergency dispensing kits shall be controlled by the pharmacy and shall be kept in a locked medication room or cabinet in the mobile medication cart.
3. The contents of the emergency dispensing kits are listed on the outside of the box. Lists will also be posted at each nursing station.
4. If applicable, a UnitedRx certified technician will restock all used medications from the automated
dispensing system as needed.
Procedure for using the emergency dispensing kits:
When a licensed nurse receives an order for a STAT dose of a medication or a therapy course that needs to start without delay the nurse will:
1. Check the emergency dispensing kit to determine if the needed item is in the kit.
2. Check the allergy and medication profile to determine the safety of use of the drug for that resident. Call the pharmacy and speak to a pharmacist for any questions/concerns.
3. If the medication is safe to give to the resident and the item needed is in the kit, break the seal on the kit and remove the prescribed medication. a. Blue Tie = Unused/New kit b. Red Tie = Item(s) have been used
4. Fill out the “Proof of Use Form” in its entirety. The form may be found in the kit and/or the log book if applicable to the facility. a. Fax form to pharmacy b. Make copy of usage form for facility (if needed) c. Put original usage form back in the kit medication was taken form (Starting January 1, 2016, if a
usage slip is not returned for each item missing from the kit upon returning to the pharmacy, the facility will be billed for each missing item)
d. Lock kit with a red tie
43 May 2019
5. If the order for the medication that was used has a stop date, please notate on the POS how many doses were used from the kit or the quantity the pharmacy should send to avoid unused medication in the Bingo Card.
6. Reorder kit by faxing refill sticker to the pharmacy or calling the pharmacy. a. If the facility is on a cycle exchange, the kit will be automatically delivered on next exchange
date.
7. When the driver arrives with a new kit (blue tie): a. Sign the manifest and give back to the driver b. Give opened (red tie) kit to the driver to bring back to the pharmacy
44 May 2019
2.17: EMERGENCY DISPENSING KIT-CONTROLLED SUBSTANCES
SEE APENDIX A FOR CUBEX DISPENSING
Policy:
An emergency supply of medications typically used for starter doses (STAT doses or to initiate a course of therapy without delay) is maintained in the facility in limited quantities by the provider pharmacy in a portable, sealed container and/or automated dispensing system.
Procedures:
1. The content of the emergency dispensing kits shall be determined by the management team for the pharmacy and facility.
2. The emergency dispensing kits shall be controlled by the pharmacy and shall be kept in a locked medication room or cabinet in the mobile medication cart.
3. The contents of the emergency dispensing kits are listed on the outside of the box. Lists will also be posted at each nursing station.
4. If applicable, a UnitedRx certified technician will restock all used medications from the automated
dispensing system as needed.
Procedure for using the emergency dispensing kits:
When a licensed nurse receives an order for a STAT dose of a medication or a therapy course that needs to start without delay the nurse will:
1. Check the emergency dispensing kit to determine if the needed item is in the kit.
2. Check the allergy and medication profile to determine the safety of use of the drug for that resident. Call the pharmacy and speak to a pharmacist for any questions/concerns.
3. If the medication is safe to give the following chart will be followed:
45 May 2019
4. Fill out the “Proof of Use Form” in its entirety. The form may be found in the kit and/or the log book if applicable to the facility. a. Fax form to pharmacy b. Make copy of usage form for facility (if needed) c. Put original usage form back in the kit medication was taken form (Starting January 1, 2016, if a
usage slip is not returned for each item missing from the kit upon returning to the pharmacy, the facility will be billed for each missing item)
d. Lock kit
5. If the order for the medication that was used has a stop date, please notate on the POS how many doses were used from the kit or the quantity the pharmacy should send to avoid unused medication..
6. Reorder kit by faxing refill sticker to the pharmacy or calling the pharmacy.
a. If the facility is on a cycle exchange, the kit will be automatically delivered on next exchange date.
7. When the driver arrives with a new kit (blue tie):
a. Sign the manifest and give back to the driver b. Give opened kit to the driver to bring back to the pharmacy
46 May 2019
2.18: FORMULARY INTERCHANGE PROGRAM
Policy:
The Formulary Interchange Program will allow the pharmacy to automatically switch one prescribed medication for a therapeutically equivalent medication that is more cost effective.
Procedure:
1. Prior to implementation of the Therapeutic Interchange Program, the physicians will review the list of medications being interchanged and sign the formulary.
2. Pharmacy will send out an auto substitution notice (bright orange paper) attached to the medications that has been changed.
3. The nurses receiving this medication should discontinue the original order on the POS or eMAR system.
4. The nurse should then add the new order as per the auto substitution notice. The notice will include: a. Medication name b. Dose c. Route d. Frequency
5. The auto substitution notice should be signed and dated by the nurse changing the orders and the notice
should be place in the resident’s medical record.
47 May 2019
2.19: INTRAVENOUS (IV) PUMPS
Policy:
All pumps will be sent from and returned to UnitedRx in proper working order. All pumps will be ordered, received, and returned using the ordering systems and the forms utilized for medications and other supplies. All pumps remain the property of UnitedRx.
Procedure:
1. All pumps sent to facilities will be in proper working order and will be documented as such.
2. Upon day of discontinuation of the pump use, the facility will return the pump with the tote on the same
night. The facility will be charged daily until the pump is returned. If a pump is not returned within 14 days after use is stopped, the facility may be charged a missing pump charge.
3. The facility staff will prepare all pumps for return according to the hazardous material handling procedure attached to the pump.
4. All pumps returned to UnitedRx will be free of damage and will be documented on the medication return form.
5. If a pump is returned with damage sustained at the facility caused by misuse, use of improper procedure
or dropping, the facility may be billed for repair or replacement of the pump. 6. It will be the responsibility of the facility to make sure the delivery personnel pick up the pump that
needs to be returned.
48 May 2019
SECTION 3.0 MEDICATION STORAGE 48
SECTION 3.1 MEDICATION STORAGE IN THE FACILITY 49-50 SECTION 3.2 BEDSIDE STORAGE OF MEDICATIONS 51-52 SECTION 3.3 CONTROLLED SUBSTANCES 53-54 SECTION 3.4 IRRIGATION SOLUTIONS 55 SECTION 3.5 REFRIGERATED PRODUCTS 56
49 May 2019
3.1: MEDICATION STORAGE IN THE FACILITY Policy: Medications and biologicals are stored safety, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedure: 1. UnitedRx dispenses medications in containers that meet legal requirements for stability. 2. Medications are not to be transferred medications in containers in which they were received. 3. Medication rooms, carts, and medication supplies are locked or attended by person with authorized
access: a. Licensed Nurses b. Consultant Pharmacist c. Pharmacist Technician d. Individual lawfully authorized to administer drugs e. Consultant Nurses
4. Drugs for internal use are kept separate from externally used medications. 5. Eye drops, ointments, drops, and inhalers to be kept separate from other medications. 6. Medications labeled for individual residents are stored separately from floor stock medications. 7. External medications including ointments for skin irritations and medication for application to wounds
should be kept in a treatment cart, or in a separate drawer in the medication cart which is labeled as such.
8. Potentially harmful substances (e.g., urine test reagent tablets, household poisons, cleaning supplies,
disinfectants) are stored in a locked area separately from medications. 9. All drugs classified as Schedule II of the Controlled Substances Act will be stored under double locks.
Schedule II-V medications must be maintained in separately locked, permanently affixed compartments and cannot be stored with other nonscheduled medications.
a. Exception: Controlled medications may be stored with noncontrolled medications as part of a single unit package distribution system, if the supply of medications is minimal.
10. Drugs requiring storage at room temperature will be stored at a temperature of not less than 59 degrees
Fahrenheit or more than 86 degrees Fahrenheit. 11. Medications requiring “refrigeration” or temperatures between 36 degrees Fahrenheit and 46 degrees
Fahrenheit are kept in a refrigerator. Medications requiring storage ‘in a cool place’ are refrigerated unless otherwise directed on the label.
50 May 2019
12. A thermometer must be kept in the refrigerator containing medications to allow proper temperature monitoring.
13. Refrigerated medications are to be stored separate from fruit juices, applesauce, and other foods used
in administrating medications. Other foods (e.g. employee lunches, activity department refreshments) should be not be stored in this refrigerator.
14. Outdated, contaminated, or deteriorated drugs and those in containers, which are cracked, soiled or
without secure closures will be immediately withdrawn from stock by the facility. They will be disposed of according to drug disposal procedures, and reordered from the pharmacy if a current order exists.
15. Medication storage areas are kept clean, well lit, and free of clutter. 16. Light sensitive and temperature sensitive drugs will be properly packaged at the pharmacy and will be
properly stored at the facility. 17. Residents who have been trained in self-administration will have access only to their individual drug
supply. 18. Facility staff will assure that the multi-dose vial is stored following manufacturer’s suggested storage
conditions (as indicated by UnitedRx) and that aseptic technique is used by staff accessing the drug product. The nursing staff will inspect the solution prior to each use for unusual cloudiness, precipitation, or foreign bodies. The rubber stopper is inspected for deterioration.
19. Medication and treatment carts are a property of the pharmacy; the facility is required to keep the carts
clean and damage free. If there are any issues with locks, wheels, or the cart itself, please contact your consultant pharmacist and/or the Logistics Manager of UnitedRx.
51 May 2019
3.2: BEDSIDE STORAGE OF MEDICATIONS Policy: Bedside medication storage is permitted for residents who are able to self-administer medications upon the written order of the prescriber and when it is deemed appropriate in the judgment of the facility’s interdisciplinary resident assessment team. Procedure: 1. The physician must specify in writing on the resident’s chart that the resident may ‘Self-Medicate’.
2. A written order for the bedside storage of medication is placed in the resident’s medical record. 3. Bedside storage of medication(s) is indicated on the resident medication administration record (MAR)
for the appropriate medication(s). 4. Emergency medications may be stored in a drawer and cabinet at the resident’s bedside where they are
readily available for emergency use or are kept in the resident’s immediate possession when out of the room. In the event such storage poses a hazard to other residents who may wander into the resident’s room, bedside storage should be discontinued.
5. For resident’s who self-administer all medications, the following conditions are met for bedside storage
to occur: a. Lockable drawers or cabinets are required to prevent access by other residents. A combination lock
is recommended. The combination number is recorded on the MAR. b. The medications provided to the resident for bedside storage are kept in the containers dispensed
by UnitedRx. c. The bedside medication record is reviewed on each nursing shift, and the administration
information is transferred to the MAR kept at the nursing station. Notation of each dose self-administered is made by placing a check mark in the appropriate space and noting in the nursing comments the initials of the nurse who obtained the information from the resident. Only one nurse signature per shift is required to document the resident’s report of self-administration.
6. The resident is instructed about the proper use of bedside medications. Documentation of this
instruction is part of the nurse’s progress note. The nursing staff is complete a periodic review of these instruction with each resident when there is a change in prescription, dose, time schedule or change in resident’s condition.
7. At least once during each shift, the nursing staff checks for resident’s use of the emergency medications.
Resident instruction should include using call light and then taking emergency medications. 8. The nurse records the use of bedside emergency medications in the PRN section of the MAR. Nursing
documentation of each self-administered dose is made by placing a check mark in the appropriate space, on the back of the MAR, and in the nursing progress notes. The following information is recorded: a. Nurse’s initials b. The symptoms reported by the resident for use of the medication c. The resident’s reaction to medication, i.e. relief of symptoms, side effected noted.
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d. One signature per shift is required by the nurse documenting the resident’s report of self-administration.
9. Any unauthorized use of bedside medications by the resident, family and/or responsible caregiver is
reported to the charge nurse by the staff nurse and aides. These medications must be removed from bedside storage and returned to the family or responsible caregiver.
10. Medications stored at the bedside are reordered in the same manner as other medications. The nursing staff is responsible for proper rotation of bedside medication and removal of expired items.
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3.3: CONTROLLED SUBSTANCES Policy: Medications classified by the FDA as controlled substances have high abuse potential and may be subject to special handling, storage, and record keeping. Procedure: 1. Only authorized nursing personnel and pharmacy personnel have access to medication. The Director of
Nursing is responsible for the control of these medications.
2. All controlled substances will be dispensed in tamper resistant containers designed for easy counting of contents.
3. All controlled substances orders will be delivered to a licensed nurse. It is the nurse’s responsibility to
promptly: a. Verify drug strength and number received. b. Sign the manifest sheet verifying receipt of medication and quantity of medication. c. Place medication in appropriate storage area as designated by the facility. Schedule II-V controlled
substance medications (and any other medications that the facility requires a more stringent control) will be kept in a locked area in the medication cart designated for that purpose, separate from other medication. The medication nurse on a duty maintains possession of the key to controlled medications. The access key to this area is separate from the key giving access to the rest of the medication cart.
4. While a controlled substance is in use the nursing staff will maintain the following medication records:
a. Record each dose at the time of administration on the following: 1. MAR
a. Date b. Time c. Initial of nurse administering dose d. If a PRN order, document effectiveness
2. Controlled Substances Count Sheet a. Date b. Time c. Signature (which includes minimum of first initial, last name and title) of nurse who
administered dose d. Number of doses remaining
3. Other documentation as mandated by facility policy.
b. All schedule II controlled substances (and other schedules if facility policy so dictates) will be counted each shift or whenever there is an exchange of keys between off-going and on-coming licensed nurses. The two nurses will: 1. Inspect both the drug package and the corresponding count sheet to verify the accuracy of the
amount remaining. 2. Both nurses will count the number of packages of controlled substances that are being
reconciled during the shift/shift count and document on the Shift Controlled Substance Count Sheet.
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3. Both nurses will count the Controlled Substances count sheets and verify the accuracy of the number of remaining count sheets.
4. Both nurses will sign the Shift/Shift Controlled Substance Count Sheet acknowledging that the actual count of controlled substances and count sheet matches the quantity documented.
5. Discrepancies: • Any discrepancy in the count of controlled substances shall be reported in writing to the
responsible supervisor and a signed entry shall be recorded on the page where the discrepancy is found.
• The supervisor shall institute an investigation to determine the reason for the discrepancy. The record shall then be updated.
• The consultant pharmacist shall be notified if any discrepancy in the count is detected for any controlled substances regardless of the classification. The pharmacist shall make regular checks of the handling, storage, and recording of controlled substances.
CONTROLLED SUBSTANCES PROOF OF USE (EXAMPLE) Amt. Rec.________________ Date Rec.______________________ Nurse Signature_________________________________________ _____________________________________________________ Every dose must be accounted for on this form. If dose is contaminated, lost, broken, or refused enter the information under comments. _________________________________________________________ IMPORTANT: THE NURSE WHO SIGNS THIS RECORD MUST ALSO SIGN THE SEPARATE MEDICATION ADMINISTRATION RECORD FOR EACH DOSE GIVEN. DATE TIME QTY USED QTY REM.
NURSE SIGNATURE COMMENTS
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3.4: IRRIGATION SOLUTIONS Policy: Irrigation solutions are used in accordance with label directions for storage, use, and disposal. Aseptic technique is used in the handling and application of irrigation solutions. Procedure: 1. Irrigation solutions are labeled with the date, time, and initials of the person breaking the product seal.
2. Solutions prepared by UnitedRx, if unopened, are kept until the expiration date indicated. Solutions
without an expiration date indicated are not accepted. 3. Sterile solutions should not be reused once opened. Discard sterile solutions after use. 4. Solutions used for non-sterile procedures will be used for a period of time not to exceed that stated in
facility policy. (This time period should not exceed 2 weeks.) 5. Unused solutions should be poured down the sewer. It is not necessary to record disposal of unused
irrigation solutions.
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3.5: REFRIDGERATED PRODUCTS Policy: Medications required by the FDA to be stored in a refrigerator may be subject to special handling, storage, and record keeping. Procedure: 1. Medications that require to be refrigerated will be delivered from the pharmacy to the facility in a foil
pack and/or ice pack.
2. Upon delivery, the nurse will be responsible for storing the medication in the appropriate facility/medication refrigerator.
3. The registered nurse and/or Director of Nursing will be responsible for following all drug specific
guidelines.
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SECTION 4.0 LABELING 57
SECTION 4.1 PRESCRIPTION LABELS 58-59 SECTION 4.2 DIRECTION/LABEL CHANGE 60
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4.1: PRESCRIPTION LABELS
Policy:
Medications are labeled in accordance with State and Federal laws as well as facility requirements.
Procedure:
1. Each prescription medication label includes: a. Resident’s first and last name b. Drug name c. Strength of medication dispensed d. Directions for use, including route of administration. Please refer to Medication Administration
Record (MAR) for any and all lengthy directions that cannot be completely transcribed onto the direction portion of the pharmacy label.
e. Injectable medications will include strength per milliliter (mL) and the amount to be given in mL equivalent on label.
f. Liquid medications will include strength per mL and the amount to be given in mL equivalent on label.
g. Physician’s name h. Date medication dispensed i. Quantity being dispensed j. Expiration date of prescription k. Name, address, and telephone number of provider pharmacy l. Prescription number m. Accessory labels indication storage requirements and special procedures. Example: ‘Shake well”;
“Take on empty stomach, 1 hour before or 2 hours after meals.” n. Initials of dispensing pharmacist o. Lot number of medication dispensed is on the punch card, unit dose package, or on the
manufacture’s label. Lot number will not be directly on the prescription label.
2. Improperly labeled medications should be rejected and returned to UnitedRx upon delivery.
3. UnitedRx will permanently affix labels to the outside of prescription containers.
4. Nonprescription medications stored at bedside for self-administration may be kept in the manufacturer’s original container and identified with the resident’s name. Facility personnel may write the resident’s name on the container or label as long as the required information is not covered.
5. Nonprescription medications that are administered to a resident by nursing personnel, other than those
taken from floor stock, are dispensed by UnitedRx with a label meeting all requirements of a prescription label.
a. Indiana law for nonprescription medication labeling require the following: Resident name, Physician name, Expiration date, Name of drug and Strength.
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6. Medication labels are not altered, modified, or marked in any way by nursing personnel. Contents are not transferred from one container to another. Under no circumstances are unattached labels requested or accepted from the pharmacy. Only the pharmacist may place a label on the medication container.
7. If the physician’s directions for use change or the pharmacy types an error on the label and it is
impractical to return the medication to the pharmacy for relabeling, the nurse follows the procedures for LABEL CHANGE.
8. If direction for use changes, UnitedRx is informed via a physician’s order prior to the next refill of the
prescription so the new container will show a corrected label. 9. Medication containers having soiled, damaged, incomplete, illegible, or makeshift labels are returned
to UnitedRx for relabeling or destroyed in accordance with medication destruction policy. 10. Medications dispensed by physicians must conform to all of the above labeling requirements. 11. If the pharmacy has labeled a medication incorrectly, a medication incident report is completed (See
sample medication error report form). 12. Floor stock medication are labeled as “floor stock” and kept in the original manufacture’s container.
The expiration date and lot number is present on the original container.
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4.2: DIRECTION/LABEL CHANGE
Policy:
A registered pharmacist is authorized to make a label change on a medication. The pharmacy will not dispense new labels which are not attached to a product.
Procedure:
1. When an existing medication order is changed, the nurse will note the physician’s order and update the medication record or treatment record according to facility policy and procedure.
2. The nurse will affix the ‘Direction Change, Refer to Medication Sheet’ sticker to the label on the medication.
3. At this time, the medication change should be sent to the pharmacy on an order sheet and noted as
“Profile only”. The pharmacy will update the resident’s profile in the computer but will not send any medications. Existing stock should be used until 3-day supply remains.
4. When the medication needs to be refilled, the peel-off label will be removed and placed on a pharmacy
reorder sheet according to medication ordering procedures. If the pharmacy has not already been notified of the change in directions, the new directions should be written on the comment line below the label on the reorder sheet along with the date of change in directions.
5. It is the facility nursing staff’s responsibility to inform the pharmacy of these changes. It is imperative that the POS, the MAR, and prescription label are consistent and uniform.
6. Refer to the Physician Order Sheet (POS) and/or Medical Administration Record (MAR) for most current and complete directions prior to administration of medication.
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SECTION 5.0 MEDICATION ADMINISTRATION 61
SECTION 5.1 DRUG ADMINISTRATION-GENERAL GUIDELINES 62-67 SECTION 5.2 MEDICATION ADMINISTRATION 68-69 SECTION 5.3 SELF-ADMINISTRATION OF MEDICATIONS BY RESIDENTS 70-71 SECTION 5.4 CONTROLLED SUBSTANCE MEDICATIONS 72-73 SECTION 5.5 ENTERAL TUBE MEDICATION ADMINISTRATION 74-75 SECTION 5.6 NOSE DROP ADMINISTRATION 76 SECTION 5.7 EAR DROP ADMINISTRATION 77 SECTION 5.8 EYE DROP ADMINISTRATION 78 SECTION 5.9 EYE OINTMENT ADMINISTRATION 79 SECTION 5.10 HEPARIN SUBCUTANEOUS INJECTION ADMINISTRATION 80 SECTION 5.11 INSULIN VIAL INJECTION ADMINISTRATION 81 SECTION 5.12 INSULIN PEN INJECTION ADMINISTRATION 82 SECTION 5.13 INTRAMUSCULAR MEDICATION ADMINISTRATION 83-84 SECTION 5.14 INHALATION (ORAL AND NASAL) ADMINISTRATION 85-86 SECTION 5.15 RECTAL SUPPOSITORY ADMINISTRATION 87 SECTION 5.16 SUBCUTANEOUS MEDICATION ADMINISTRATION 88 SECTION 5.17 SUBLINGUAL MEDICATION ADMINISTRATION 89 SECTION 5.18 TRANSDERMAL PATCH APPLICATION 90 SECTION 5.19 TUBERCULOSIS TESTING (MANTOUX TEST) 91 SECTION 5.20 VAGINAL MEDICATION ADMINISTRATION 92 SECTION 5.21 VIALS AND AMPULES 93
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5.1: DRUG ADMINISTRATION--GENERAL GUIDELINES Policy: Medications are administrated as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after sufficient information regarding the resident’s condition and expected outcomes of medication therapy is known. The licensed nurse is aware of an indication for the resident receiving medication, usual dose, parameters and routes, contraindications, allergies, precautions, and side effects. Procedure: 1. Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or
other personnel authorized by state laws and regulations.
2. Medications are administered in accordance with written orders of the attending physician. If an unusual dose is ordered, considering the resident’s age and condition, or a medication order seems to be unrelated to the resident’s current diagnosis or condition; the physician is contacted for clarification prior to the administration of the medication. The pharmacist is also available for consultation for drug therapy concerns or questions. This interaction with the physician is documented in the nursing notes and elsewhere in the medical records as appropriate.
3. Residents are allowed to self-administer medications when specifically authorized by the attending
physician and in accordance with facility procedures for self-administration of medications 4. Medications that require preparation by the nurse are administered at the time they are prepared.
Medications are not pre-poured unless the nurse is using a med card specifying the resident’s name, the medication, dose and frequency.
5. All current medications and dosage schedules, except topicals used for treatments are listed on the
resident’s medication administration record. a. Topical medication used in treatments are listed on the treatment administration record.
6. Residents are identified before medication is administered:
a. Check identification band b. Check photograph attached to medical record, header card, or facility approved location c. Call resident by name d. If necessary, verify resident information with other facility personnel.
7. Only the licensed or legally authorized personnel who prepare medication may administer it. This
individual records the administration on the resident’s MAR at the time the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ascertain that all necessary doses were administered and all administered doses were documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications
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8. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administrated precisely as ordered. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility.
9. The resident’s MAR is initialed by the person administering a medication, in the space provided under
the date, and on the line for that specific medication dose administration. Initials on each MAR are verified with a full signature in the space provided on the MAR or on a master signature sheet.
10. When PRN medications are administered, the following documentation is provided:
a. Date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection or application site.
b. Complaints or symptoms for which medication was given. c. Results achieved from giving the dose and the time results were noted. d. Signature or initial of person recording administration and signature or initials of person recording
effects, if different from person administering. 11. If a dose of regularly scheduled medication is withheld, refused, or given at other time than the
scheduled time (e.g., resident not in facility at scheduled dose time, initial dose of antibiotic), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive doses of a medication are withheld or refused, the physician is notified.
12. Medications supplied for one resident are never administered to another resident. 13. For residents not in their rooms or otherwise unavailable to receive medications on the pass, the MAR
is ‘flagged’ per facility protocol. After completing the medication pass, the nurse returns to the missed resident to administer the medication.
14. During routine administration of medications, the medication cart is kept in the doorway of the
resident’s room, with open drawers facing inward and all other sides closed. No medications are kept on the top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.
15. An adequate supply of disposable containers (e.g., soufflé cups) is maintained on the medication cart
for the administration of medications. Disposable containers are never reused. 16. Prior to administration, the medication and dosage schedule on the resident’s MAR is compared with
the medication label. If the drug container is marked with a sticker indicating a recent change in directions or if there is any other reason to question the dosage or direction, the physician’s orders are checked for the correct dosage schedule.
17. All medications will be given PO (by oral route) unless otherwise stated. 18. When medication administration is dependent upon vital sign measures, this monitoring should be
performed before the administration of the prescribed medication. The vitals are recorded per facility policy.
19. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has
difficulty swallowing or is tube fed.
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a. Long-acting or enteric coated dosage forms generally should not be crushed and require a physician specific order to do so.
b. Each medication preparation area includes a device that is specifically used for crushing medications.
c. Medications may be crushed in two soufflé cups to prevent contact between the medication and the crushing device.
d. For residents able to swallow, tablets may be ground coarsely and mixed with the appropriate vehicle (e.g., applesauce) so that the resident receives the entire dose ordered.
e. If the resident is tube-fed, medications are crushed finely to prevent clogging tubes or pump. f. The need for crushing medications is indicated on the resident’s MAR so that all personnel
administering medications are aware of this need and the consultant pharmacist/nurse can advise about safety and alternatives, if appropriate, during MRR/MAR reviews.
20. Where possible, and clinically appropriate, the pharmacy will break tablets and package into the regular packaging system.
21. If tablets must be broken for administration at the nursing facility hands are washed with soap and water or alcohol gel prior to and after handling tablets, and the following guidelines are adhered to: a. A tablet-splitter is used to avoid contact with the tablets. b. If the tablet is scored, every attempt is made to break along score lines. c. Unused tablet portions are disposed of per facility procedure (see drug destruction.) If using only
one-half of the tablet from a unit-dose package, the remainder is used within 24 hours or disposed of.
d. The administration of partial tablets is clearly identified on the resident’s MAR and auxiliary labeling on the product.
e. Since unscored tablets may not be accurately broken, their use is discouraged. Check with a pharmacist for recommendation of a suitable alternative (e.g., liquid, a half strength tablet.)
22. When administering potent medication in liquid form or those requiring precise measurements, such as
digoxin, devices provided by the manufacture, a needle-less syringe, or devices obtained from the pharmacy are used to assure accurate measurement of dose.
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TEN ‘RIGHTS’ FOR ADMINISTRATION OF MEDICATIONS
1. The right resident: before preparing the medication, identify each resident according to your facility’s policies and procedures. For example, identify by photo or ID bracelet.
2. The right drug: verify each drug against the medication record (MAR) before administering. Verify in at least three ways, such as by the drug’s size, shape, color, or label.
3. The right dose and dosage form: verify against the MAR 4. The right time: administer drugs as instructed on the MAR and within the time frame established by
your facility. 5. The right route: verify against the MAR
6. The right documentation: verify if medication is appropriate for this resident
7. The right resident education: nurses should know the reason the medication is being administered and the possible side effects associated with the medications.
8. The right to refuse: resident has the right to refuse medications. Nursing must document the refusal.
9. The right assessment: certain medications require monitoring prior to or after administration.
10. The right evaluation: verify medication allergies and interactions between different medications.
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TIPS FOR SAFE MEDICATION ADMINISTRATION
1. Maintain security of provided medications. a. Cart must always be visible to nurse administering medications. b. Cart may remain unlocked only when in direct line of sight. c. Never leave a medication in a resident’s room without orders to do so. d. Once removed from the package or container, unused doses should be destroyed by flushing in
toilet or washing down drain. e. Return locked medication cart to the medication room after use.
2. Follow good infection control practices.
a. Cleanse hands before beginning each medication pass. Cleanse hands when contact is made with a medication. Cleanse hands whenever they are contaminated. You may use antiseptic foam or gel such as “Spetisol” or “All Care.”
b. Never touch any of the medication with fingers. c. Wipe ring and sides of liquids with tissue or towelette and replace cap after pouring. d. Clean tablet crushed or mortar and pestle immediately after use. e. Never pour excess liquid back into original container.
3. Accurately dispense medications to residents.
a. Allow one (1) hour before to one (1) after schedule time of medication to administer medication (i.e.: Noon medication be giving prior to 11:00 a.m. or after 1:00 p.m.)
b. If you know the resident, address him/her by name. If you do not k now the resident, check ID band, photograph, or check with other staff members to identify resident.
c. Always note any allergies prior to administering any medications to residents. d. Do not administer medication that is not from the pharmacy, unless it is appropriately labeled. e. Be alert to directions. Apply ‘direction change’ stickers to medication labels if the label is incorrect. f. Punch medications directly into cup and never into your hand. With stock bottles (i.e.: Tylenol,
Aspirin), shake tabs into lids, then empty into cup. g. Use liquid form of medication when applicable, instead of crushing (i.e.: Dilantin, K-tabs) h. Obtain MD order to change pill to liquid or liquid to pill form. i. If a medication is a liquid, utilize an appropriate measuring device, shake well if needed prior to
pouring and pour liquid away from label and pour at eye level. Check liquid by placing it on the med cart and looking again.
j. Gently roll insulin in your hands. Never shake insulin. When necessary, obtain MD order to crush medications
i. Consult the ‘Crush List’ reference before crushing medications if indicated. ii. Always inform the resident that there is medication in applesauce, juice or food.
iii. Follow physician orders as needed when administering medications. iv. Never administer medications from memory or directly from patient supply.
4. Follow good clinical practices for administration of medications:
a. Obtain and record any vital signs as necessary prior to medication administration. b. Sign out medications as soon as they are given. ALWAYS use your medication book. c. Document if the medication is refused and the reason. d. For medication that requires blood pressure (BP) parameters, these parameters are charted per
facility policy. e. Behavior documentation and non-pharmacological intervention documentation is required before
administration of a PRN psychotropic medication. f. If a resident is in bed, head of bed should be elevated to > 45 degrees prior to administration of oral
medication and for at least two minutes after.
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g. Administer medication and remain with resident while medication is swallowed. h. Know the use and side effects of each medication that is administered to each resident by consulting
provided drug references. i. Observe the resident for medication side effects and inform the physician if any occur. j. When a Medicare resident is discharged or a medication has been discontinued or changed, return
the medication to the pharmacy (unless it is a controlled substance.) If the resident is a public aide recipient or if their meds are paid by insurance, the meds should be given to the resident or responsible party when they are discharged.
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5.2: MEDICATION ADMINISTRATION
Purpose: To administer all medications safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis. Equipment Required: 1. Medication Cart with Medications 2. Medication Book containing Medication Administration Record 3. Medication Cups 4. Drinking Cups 5. Tablet Crusher/Tablet Splitter 6. Pitcher of Water 7. Controlled Substances Records 8. Hand washing Solutions Before the Medication Pass 1. Gather all necessary supplies 2. Cleanse your hands before beginning and before contact with each resident 3. Make sure you have enough disposable containers and spoons. Never reuse a disposable item. 4. Turn medication cups and liquid cups open and down 5. Arrange spoons so you can grab the handles 6. When opening straws, avoid touching either end of the straw 7. Cover and date fluids, applesauce, or other soft foods used to administer medication.
Procedure: 1. Wash hands before beginning, whenever you contaminate your hands, and if contact is made with the
medication.
2. Bring medication cart to an area adjacent to resident room.
3. Review the resident’s Medication Administration Record (MAR). Read each order entirely.
4. Remove medication from drawer.
5. If there is any discrepancy between the MAR and the label, check physician orders before administering medication.
6. If the label is wrong, it is the responsibility of the nurse to apply a ‘direction change’ sticker to the medication label.
7. If the medication is discontinued or outdated, remove medication from proper disposal.
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8. Pour each dose of medication using an appropriate measuring device.
9. Check appearance of medication for irregularity. If irregularity is present, check with UnitedRx and/or supervisor before administering.
10. Read and follow any special instructions written on labels.
11. Crush medications only after checking with the ‘Crush List’ reference. Medications cannot be crushed and administered together via enteral route. Medications should not be crushed and administered together via oral route unless resident has been evaluated for preference and functional ability.
12. Refer to medication reference text for administration of any medication when added to any substance, i.e., applesauce. juice, milk, etc.
13. Identify resident before administering medication.
14. Explain to resident the type of medication to be administered.
15. Obtain and record any vital signs as necessary prior to medication administration.
16. Give the resident the medication.
17. Remain with the resident to ensure that the medication is swallowed.
18. Return to medication cart and document medication administration with initials in appropriate spaces on Medication Administration Record (MAR).
19. Circle initials on MAR if medication is not administered as ordered and record reason in the PRN/Omission Medication section of the MAR.
20. When administering a PRN medication record the date, time, medication given, route, dose, nurse’s initials, reason and effectiveness of the PRN on the back of the MAR or in the nurse’s notes as specified in your house policy.
21. Any situation that requires monitoring requires an accompanying note.
22. When giving an injection, site rotation is charted in the appropriate space on the MAR.
23. If medication is ordered but not present, call the pharmacy or supervisor to obtain the medication. Return locked medication cart to the medication room after use.
24. Place needles and syringes in the sharps container. NEEDLES AND SYRINGES MAY NEVER BE RECAPPED.
25. Empty trash receptacle on the medication car in the appropriate container in the medication room and clean off the cart.
26. Observe the resident for medication side effects and inform the physician if any occur. Document in Nursing Notes. (Complete medication side effect information is located in the provided drug reference on the medication cart and on your side effect sheets provided by the pharmacy.)
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5.3: SELF-ADMINISTRATION OF MEDICATIONS BY RESIDENTS Policy: Self-administration medications will be encouraged if it is desired by the resident, safe for the resident and other residents of the facility, ordered by the attending physician, and approved by the Interdisciplinary Team. Procedure: 1. Each resident is offered the opportunity to self-administer his or her medications during the routine
assessment by the facility interdisciplinary team.
2. If the resident indicates no desire to self-administrate medications, this is documented on the appropriate form in accordance with facility policy and procedures. This form becomes part of the resident’s medical record and the resident is deemed to have deferred this right to the facility. If the resident desires to self-administer medications, an assessment is conducted by an interdisciplinary team. This assessment includes the resident’s cognitive, physical, and visual ability to carry out this responsibility.
3. An interdisciplinary team determines the resident’s ability to self-administer medications by means of
a skill assessment as follows: a. UnitedRx will provide specially prepared medication packages containing a medication substitute
(e.g., colored candy.) These packages contain a complete label with administration instructions for the resident’s medications that are exactly the same as those used in the facility. Alternatively, the facility may utilize the resident’s existing medication packages, having the resident complete all steps except for the actual removal of the medication from the package.
b. The resident is instructed in the use of the package, purpose of the medication, reading of the label, scheduling of medication doses, and side effects.
c. The resident is then requested to read and label on each package and indicate at what time the medication should be taken and any other special instructions for use.
d. The resident is asked to demonstrate the removal of the medication from the package and, in the case of nonsolid dosage forms, e.g., inhaler, to verbalize the steps above involved in administration.
e. If bedside storage is to be used, the resident is asked to complete a bedside record indicating the administration of the medication.
4. If the resident demonstrates the ability to safely self-administer medications, a further assessment of
the safety of bedside medication storage is conducted. a. The storage does not present a risk to confused residents who wander into the rooms of, or room
with, residents who self-administer. b. The storage method prevents access by other residents. c. The medications provided to the resident for bedside storage are kept in the containers dispensed
by UnitedRx. d. The facility nurse is responsible to account for every dose of medication the resident has taken.
5. A physician order is obtained to self-administer medications if the above storage and skill assessment
has been approved for the resident by the interdisciplinary team. The order is recorded on the MAR.
6. Once the order has been obtained, the procedure is explained to the resident.
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7. Medications and treatments are delivered by the pharmacy and placed in the resident’s storage area.
The nursing staff is responsible for proper rotation and reordering of bedside medications. Bedside medications are reordered in the same manner as other medications.
8. Application of external lotions must be monitored and recorded on the MAR and/or treatment record. 9. Noncompliant residents are informed by the nurse or nurse supervisor that they may not self-administer
medications or treatments. 10. Document noncompliant/compliant monthly in the nursing notes. 11. Update the residents care plan quarterly or as indicated by the change in medication scheduling, dose
or a change in resident’s condition with a reassessment of the resident’s knowledge and ability to self-administer medications.
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5.4: CONTROLLED SUBSTANCE MEDICATIONS Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations. Procedure: 1. Only authorized nursing personnel and pharmacy personnel have access to controlled substances. The
Director of Nursing is responsible or the control of these medications once at the facility.
2. Schedule II, III, IV, and V drugs will be provided by the pharmacy in containers designed for easy counting of contents.
3. When possible, orders for injectable controlled drugs will be provided in single dose containers. 4. Schedule II-V drugs and any other drugs that the facility deems necessary will be kept in a double
locked area separate from other drugs. The access key to this area is separate from the key giving access to the rest of the medication cart.
5. A controlled medication delivery manifest will accompany all Schedule II, III, IV, or V medication
deliveries. The following information will be present. a. Name of resident b. Room number of resident c. Prescription number d. Name, strength (if designated) and dosage form of medication e. Date delivery sent from pharmacy f. Quantity dispensed
6. Controlled substances will be dispensed by the pharmacy along with an Individual Charting Record.
This record will be maintained by the nursing staff at the time of each administration of the medication as follows: a. Place charting record in narcotic box or binder b. Record each dose at the time of administration c. Confirm the amount of controlled drug remaining is correct prior to assembling required dose for
administration i. Date
ii. Time iii. Dosage iv. Signature of nurse who administered dose v. Number of doses remaining.
d. When the prescription has been exhausted, the Individual Charting Record becomes a permanent part of the medical record.
e. When the prescription is no longer an active order and there are remaining doses of medication, the Individual Charting Record and the remaining medications is retained in the facility in a securely locked area with the restricted access. The remaining quantity will remain in this area until destroyed by two licensed personnel.
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f. A controlled medication may never be returned to the pharmacy for destruction.
7. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed in the presence of two licensed nurses and the disposal documented on the accountability record on the line representing that dose. The disposal of unused partial tablets and unused portions of single dose ampules must be destroyed and recorded in the presence of two licensed personnel.
8. When a Fentanyl transdermal patch is removed from the resident, the patch should be folded in half
and flushed down the sink or toilet due to substantial medication remaining in the patch. Facility nurse should follow facility’s controlled substance destruction policy.
9. At each shift change, a physical inventory of specific medications, those selected by the facility, is conducted by two licensed nurses and is documented on an audit record.
10. Current controlled medication accountability records and audit records are kept in the MAR or other
specific binder. When completed, audit and accountability records are submitted to the director of nursing and kept on file according to facility policy for health records retention.
11. Any discrepancy in controlled substance medication counts is reported to the Director of Nursing
immediately. The Director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. Irreconcilable discrepancies are documented by the Director of Nursing and reported to the Consultant Pharmacist and Administrator. The Administrator, Pharmacist, and the Director of Nursing will make a determination concerning of any actions that may need to be taken.
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5.5: ENTERAL TUBE MEDICATION ADMINISTRATION
Policy:
The facility assures the safe and effective administration of enteral formulas, route and methods of administration, and the decision to administer medications via enteral tubes are based on nursing assessment of the resident’s condition and approval by the physician. The facility dietician and consultant pharmacist may provide consultation for this assessment.
Procedure:
1. The selection of the enteral formula, equipment, route of administration and rate of flow is determined by the physician based on the nursing assessment of the resident’s condition. The nursing assessment may require pharmacist and dietician involvement for resident care planning.
2. Interactions between medications and feeding formulas, and interactions of multiple medications are considered before administering medications though the enteral tube.
3. In-service training on bacteriological safety, administration and monitoring of enteral solutions and
medications via the enteral tube is provided by the facility to the nursing personnel. 4. The manufacture’s written recommendations regarding suggested time period for hanging of the
product are consulted when determining the schedule for enteral feeding administration. 5. Caloric content per milliliter is verified before administration to assure that the correct dosage is given
to achieve caloric objectives. 6. When the new medication orders are received from the prescriber, the intended route of administration
is also obtained. UnitedRx is informed that the resident is receiving medications though the enteral tube. Medications for enteral administration are obtained in liquid form whenever possible. The pharmacy is consulted to determine the best method for preparing dosage forms for enteral tube administration when liquid formulations are not available.
7. Prior to crushing tablets for administration through the enteral tube, the Crushing Guidelines and list
are consulted. Guidelines for administering oral medications though an enteral feeding tube: a. Use liquid form of medication whenever possible. b. Check with pharmacy if in doubt about availability of medication in liquid form or whether tablets
are crushable. i. If a tablet must be crushed, be sure it is crushed finely and dispersed well in warm water.
ii. Use 30-60 ml syringe with approximately 30 ml of warm water to rinse feeding tube before administration of medications then 5-10ml after each medication and then 30ml after all medications have been administered.
iii. Give medication at appropriate time in relation to feeding: Some medications should be given with food, while some should be given on an empty stomach and tube feeding withheld for a prescribed time interval before and after medication is given. Call UnitedRx when there may be a question.
iv. For proper action, some medications must be delivered to the stomach. If the tube is in the duodenum or jejunum, you may determine it necessary to call UnitedRx pharmacy before administering the medication.
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c. Do not mix medication with enteral feeding formulas. d. Do not crush enteric-coated or timed-release tablets or capsules. e. Do not mix medications together.
8. The provider pharmacy or consultant pharmacist is consulted when changing to a different formulation or when initiating enteral therapy for necessary dose scheduling adjustments of the medications or feeding schedule adjustments. a. If on continuous feeding, it may be necessary to change to intermittent feeding to avoid an
interaction between enteral solution and some medications. b. If on intermittent feeding, it may be necessary to delay feeding up to two hours to avoid a
medication interaction (e.g., phenytoin) with enteral solution.
9. Medications that are GI irritants (e.g., potassium chloride solution) are diluted as recommended for oral administration, since there is a high potential for gastric irritation when medications are administered directly into the stomach though enteral tubes.
MEDICATION WITH ENTERAL FEEDING GUIDELINES
Common Medications Required Incompatible with Tube Feeding
Aluminum Hydroxide (Amphojel) Magaldrate (Riopan) Aluminum-Magnesium Hydroxide Double Omperazole (Prilosec) Strength (Mylanta II, etc.) Orphenadine (Norflex) Benzonatate (Tessalon) Pentoxifylline (Trental) Chlorpromezine Concentrate (Thorazine) Piroxicam (Feldene) Cimetidine Liquid (Tagamet) Thioridazine (Mellaril) Diltiazem (Cardizem SR) Zinc Sulfate Lithium Carbonate (Cibalith Syr)
ACTION: Contact pharmacist for alternative therapy or administration suggestions.
Medications Which Interact with Enteral Feedings
Digoxine (Lanoxin) Theophylline Phenytoin (Dilantin) Tetracycline Neo-Calgucon Warfarin*
*The Vitamin K content of tube feedings vary and may alter patient response to warfarin. Monitor protime more frequently for required dosage adjustments.
ACTION: Separate administration of these drugs from tube feeding by stopping 30 minutes before and 2 hours after administration.
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5.6: NOSE DROP ADMINISTRATION Purpose: To provide safe and accurate administration of medications into the nasal cavity. Procedure: 1. Follow general medication administration policy and procedures.
2. Proper hand washing before and after medication administration.
3. Position resident properly.
a. If up in chair, instruct resident to hold head back. Nurse stands behind resident’s head. b. If in bed, place pillow under shoulders to allow head to drop back so forehead will be lower than
chin.
4. Instill prescribed number of drops into nostril(s), directing flow toward floor and nasal cavity.
5. Avoid touching nasal cavity to prevent damage to tissue. Insert dropper tip not more than ¼ inches.
6. Use aseptic technique to prevent contamination of dropper.
7. Instruct resident to maintain position for about 2 minutes.
8. This will allow sufficient contact of medication with nasal tissue and flow of medication into sinuses.
9. Raise the resident to a sitting position to allow medication to flow into lower part of nose. Wipe any excess or drainage immediately.
10. Assist resident into a comfortable position
11. Replace bottle cap.
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5.7: EAR DROP ADMINISTRATION Purpose: To administer medication into the auditory canal safely and appropriately to soften cerumen, remove debris; reduce inflammation and other therapeutic purposes as prescribed. Procedure: 1. Follow general medication administration policy and procedures
2. Wash hands before and after administration. 3. If medication was refrigerated, allow it to warm to room temperature. 4. Position resident on the unaffected side, either lying down or sitting up. The affected ear is in the
upward position. 5. Wipe any discharge from external canal with tissues. 6. Straighten external canal by pulling the auricle up and back. 7. Instill amount of medications as ordered using dropper. Hold the medicine dropper almost horizontal.
a. Support resident’s head if necessary b. Use aseptic technique to prevent contamination.
8. Ask resident to remain on the unaffected side for 5 - 10 minutes after instillation.
9. Cleanse reusable items and discard disposable items, wash hands.
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5.8: EYE DROP ADMINISTRATION Purpose: The appropriate and safe administration of liquid ophthalmic medication (eye drops) as a local anesthesia to facilitate eye examination, for therapeutic treatment, or for help in the production of tears. Procedure: 1. Follow general medication administration policy and procedures. 2. Proper hand washing before and after administration of medication. 3. If bottle has separate dropper, draw required amount of solution into dropper, holding dropper upright.
If self-contained unit, invert bottle. a. Do not use eye drops that have changed color b. SHAKE WELL eye drops that are in suspension form AND are so directed by the manufacturer c. Never rinse the dropper
4. Position resident by tilting head back and slightly to the side.
5. Remove secretions around the eye with a gauze pad of tissue by wiping from inner to outer canthus. Discard after each use.
6. Draw lower lid down by pressing cheekbone with thumb. a. Use gauze pad if not wearing gloves.
7. Place hand against resident’s forehead to steady and instill one drop inside lower eyelid close to outer
corner of eye (conjunctival sac.) Instruct resident to look up. a. Do not instill medication directly on the cornea. b. Do not let dropper touch eye or eyelashes.
8. Apply pressure on the lacrimal duct for 1—2 seconds.
9. Ask resident to close eyes for a moment to evenly distribute medication.
a. Instruct resident not to squeeze eyes shut. This may force medication out of the eye.
10. Wipe off excess medication from the eye with gauze pads or tissue by wiping from inner to outer canthus. Discard wipe material after each use.
11. To instill drops in both eyes, use a new gauze pads or tissue from each eye.
12. Recap bottle, returning dropper to bottle if appropriate. a. Use aseptic technique when handling dropper
13. When more than one drop of the same or different ophthalmic solution must be administered at the
same pass time, allow a five minute period between drops unless otherwise specified by product information. (Some ophthalmic solution require ten minutes between administrations.)
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5.9: EYE OINTMENT ADMINISTRATION
Purpose:
Eye ointments are applied appropriately and safely for prescribed therapeutic plan, infections, irritations, or to remove crusts.
Procedure:
1. Follow general medication administration policy and procedures. 2. Proper hand washing before and after administration. 3. If necessary wipe off top of tube applicator with sterile gauze using aseptic technique. 4. Position resident by tilting head back and slightly to the side. 5. To remove secretions around the eye, have resident close the eye and wipe with a gauze or tissue from
inner to outer canthus. Discard wipe after each use. 6. Retract lower lid with index or middle finger and ask the resident to look up.
a. Use gauze pad to pull down lower eyelid if not wearing gloves.
7. Apply a thin line of ointment along the conjunctival surface of the retracted lower lid. Apply ointment from the inner to outer canthus. a. Do not allow tip of tube to touch eyelashes, eyelids, or eyeball. b. Do not place ointment directly over the cornea.
8. Ask resident to close lids and roll eyes to distribute the medication.
a. Eyelids should not be squeezed closed.
9. If necessary, wipe off tip of tube with sterile gauze and recap. 10. When two or more different eye ointments must be administered at the same pass time, allow a 5-
minute period between administrations (unless manufacture instructions require a longer period.) Each drug must have sufficient time to spread over eye surface and be absorbed and to prevent washout or dilution.
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5.10: HEPARIN SUBCUTANEOUS INJECTION ADMINISTRATION
Purpose:
Heparin is administered appropriately and safely as an anticoagulant, without traumatizing the skin and fat at the site of injection.
Sites:
Lower abdomen, below umbilicus
Procedure:
1. Follow general medication administration policy and procedures 2. Observe resident closely for bleeding and bruising. 3. Proper hand washing before and after administration. 4. Apply gloves. 5. Use a tuberculin syringe with a 27G needle. 6. Draw up the medication as ordered. 7. Select injection site. Do not inject within 2 inches of umbilicus or other scars. 8. Sites of injection are rotated and recorded. 9. Clean site with alcohol and allow it to dry. 10. Tap air bubbles and move them to the end of syringe away from needle. 11. Gently raise a fold of skin. 12. Inject needle at a 45-90-degree angle (90 degrees most common). 13. Inject heparin slowly. 14. Place alcohol sponge over injection site and quickly withdraw needle. 15. Do not rub injection site. 16. Record in Medication Administration (MAR). Chart site. 17. Discard needle and syringe in the sharps container.
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5.11: INSULIN VIAL INJECTION ADMINISTRATION Purpose: The appropriate and safe administration of insulin will aid in the management of Diabetes Mellitus by the control of blood sugar levels. Procedure: 1. Follow general medication administration policy and procedures.
2. Allow insulin to warm to room temperature if it had been stored in the refrigerator.
3. Proper hand washing before and after administration of insulin.
4. Apply gloves.
5. Rotate vial of insulin gently between hands to mix.
a. Do not shake vial.
6. Determine the correct amount of insulin to be withdrawn. Prepare injection. a. If the prescriber has ordered two types of insulin to be given, draw up the regular or clean insulin
first, then the NPH or any of the cloudy insulin’s. Do not mix Lantus Insulin with any other Insulin.
7. Cleanse injection site with alcohol wipe.
8. Expel air from syringe.
9. Insert needle quickly at 50-degree angle
10. Pull plunger back slightly.
11. Inject insulin slowly.
12. Remove the needle and apply firm pressure over site.
13. Discard needle and syringe in sharps container.
14. Document administration and site on the Medication Administration Record.
15. Monitor blood glucose as ordered and document the results per facility policy.
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5.12: INSULIN PEN INJECTION ADMINISTRATION Purpose: The appropriate and safe administration of insulin will aid in the management of Diabetes Mellitus by the control of blood sugar levels. Procedure: 1. Follow general medication administration policy and procedures.
2. Allow insulin to warm to room temperature if it has been stored in the refrigerator.
3. Proper hand washing before and after administration of insulin.
4. Apply gloves.
5. Check label to verify correct insulin product and patient.
6. Remove pen cap and wipe rubber stopper with alcohol swab.
7. Always use a new needle for each injection. Remove protective tab from needle and screw it into the pen device.
8. To prime: turn the dose selector to 2 units. Hold pen with the needle pointing up and tap the cartridge gently to move air bubbles to the top. Press the button all the way in. A drop of insulin should appear at the tip of the needle.
9. Selecting the dose: turn the dose selector to the number of units needed to inject. The device will not allow you to select a dose greater than the number of units left in the pen.
10. Wipe the injection site with an alcohol swab and allow the area to dry. Insert the needle into the skin.
11. Press the button all the way until the dose selector is back to zero. Keep the needle in the skin for 10 seconds.
12. After injection, remove the needle (do not recap). Place used needle and empty insulin pens in sharps container as per facility protocol.
13. Replace the cap on the pen and store at room temperature without a needle attached. Follow
manufacturer instructions for expiration dating. 14. Document administration and site on the Medication Administration Record.
15. Monitor blood glucose as ordered and document the results per facility policy.
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5.13: INTRAMUSCULAR MEDICATION ADMINISTRATION Purpose: To safely and accurately administer a medication into the intramuscular tissue. Intramuscular injections are used to administer a medication when a resident cannot take medication orally, when the medication is not prepared in oral form, when a more immediate effect is desired, or to administer a medication into the muscle when it is irritating to the subcutaneous tissue. Sites: 1. Ventragluteal (front of hip area) 2. Deltoid (arms) 3. Dorsogluteal (back buttock) 4. Rectus fermoris (medial upper leg) 5. For Z-tract administration, the gluteus maximus is used for iron dectran and when ordered by a physician. Procedure: 1. Follow general medication administration policy and procedures
2. Proper hand washing before and after administration.
3. Apply gloves.
4. Check expiration date of medication.
5. Cleanse the administration site with an antiseptic wipe.
6. Clean the vial according to your facility’s policies and procedures.
7. Choose the right needle length, according to the resident’s physical stature
8. Draw up the medication into syringe according to the product’s instruction and double check for accurate measurement. If indicated in your facility’s policies and procedures, leave a small air bubble in the syringe, not to exceed 0.02 ml.
9. Do not recap needle.
10. Spread the skin at the injection site with one hand.
11. With the other hand, hold on the syringe like a dart and insert the needle into the muscle, bevel up, at a 45 to 90 degree angle to the skin, depending on the amount of body fat. Release the skin.
12. Withdraw the plunger slightly. If blood appears, remove the syringe, change the needle, and start over. If no blood appears, slowly inject the medication. After withdrawing the needle, wipe the site with an antiseptic wipe.
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13. Dispose of needle and syringe in a sharps container according to your facility’s policies and procedures.
14. Document the injection and the site on the Medication Administration Record.
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5.14: INHALATION (ORAL AND NASAL) ADMINISTRATION Purpose: Oral and nasal inhalation medication will be administered according to physician’s orders using safe and sanitary practices. Procedures: ORAL INHALATION 1. Cleanse hands before and after medication administration
2. Check the product directions, and shake inhaler well before each use if manufacture directions allow.
3. Apply gloves
4. Remove cap from mouthpiece and make sure the canister is firmly in place.
5. Hold the inhaler, or have the resident hold it, to the open mouth.
6. Ask resident to: a. Exhale completely b. Breathe in deeply and slowly through his/her mouth while fully depressing the top of the canister
with index finger c. Hold his/her breath as long as it is comfortable before exhaling.
7. When resident begins to breathe out, remove finger from canister and mouthpiece from resident’s
mouth.
8. If more than one inhalation is ordered, wait one minute, and then repeat steps 2 through 7 above for each inhalation ordered.
9. If specified by the manufacture, rinse patient’s mouth with water after last inhalation.
10. Rinse (and dry) the applicator according to manufacture directors, and return it to the cart.
11. Record in medication administration record.
12. Order replacement before solution in canister is completely gone.
NASAL INHALATION 1. Cleanse hands before and after medication administration.
2. Apply gloves
3. Have resident gently blow nose to clear the nostrils.
4. Shake inhaler well if manufacture directions allow, and remove cap from nozzle.
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5. Hold the inhaler in upright position between second and index fingers, with thumb on bottom of canister.
6. With resident’s head tilted back, carefully insert nozzle into one nostril and close the other nostril with one finger.
7. While resident gently inhales through open nostril, press medication canister up with thumb.
8. Instruct resident to hold breath, and then breathe out through the mouth.
9. Remove finger from canister and nozzle from resident’s nostril.
10. If more than one inhalation is ordered, and if manufacturer instructions specify a waiting period, follow manufacture instructions and repeat steps 2-8 above in each nostril for the number of inhalations ordered.
11. Clean inhaler as directed in package.
12. Clean hands.
13. Record in medication administration record.
14. Order replacement before solution in canister is completely gone.
NEBULIZING SOLUTION 1. Wash your hands: Use soap and water. Apply gloves.
2. Prepare the machine: Place the machine on a hard surface. Check to see if the air filter is clean. If it is dirty, rinse it using cold water and let it air dry.
3. Plug in the machine.
4. Prepare the medicine: If your medicine is premixed, open it and place it in the nebulizer medicine container. If you have to mix medicines, place the right amounts into the container using a dropper or syringe. Add saline if needed: You may need to add saline (saltwater) to your medicine container.
5. Connect the container: Connect the medicine container to the machine.
6. Attach the mask or mouthpiece to the container: Adults and older children: Place the mouthpiece in your mouth. Breathe in and out slowly through your mouth until all the medicine is gone.
7. Start the treatment: Turn on the machine. Keep the medicine container in an upright position. You may need to tap the sides of the container toward the end of the treatment. This will help the last of the medicine become mist. The whole treatment may take 8 to 10 minutes. The treatment is over when all the medicine is gone or there is no more mist coming out. The machine may also make a sputtering noise when treatment is done.
8. Jet Nebulizer should be used for a singe resident. After administration, the nebulizers should be cleaned
and stored as per facility policy (e.g., rinsed with sterile water and air-dried between treatments).
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5.15: RECTAL SUPPOSITORY ADMINISTRATION Purpose: Rectal suppositories are given appropriately and safely for their local effect on the lining of the rectum and for their systemic effect after being absorbed. Procedure: 1. Follow general medication administration policy and procedures.
2. Proper hand washing before and after medication administration.
3. Assist resident in turning to the left lateral position.
4. Put on gloves
5. Remove wrapper from suppository.
6. Lubricate suppository and gloved finger with warm water. a. Do not use another lubricant unless specifically indicated.
7. Separate buttocks.
8. Insert suppository gently into rectum beyond sphincter about 3 inches. a. Ask the resident to take a deep breath, to relax the anal sphincter.
9. Apply pressure with tissue over anus briefly until desire to expel suppository has passed.
10. Instruct resident to retain suppository for 10-15 minutes if possible.
11. Place tissue and glove in paper towel. Discard in appropriate receptacle.
12. If suppository was for bowel evacuation, ambulate resident to the bedpan, commode, or toilet. Make the resident comfortable.
13. If suppository is given for elevated temperature, check temperature one hour after administration of medication.
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5.16: SUBCUTANEOUS MEDICATION ADMINISTRATION
Purpose:
Medications are administered via subcutaneous injection appropriately and safely as ordered by a physician when a rapid and systemic effect is desired and also to administer medications that cannot be given orally.
Procedure:
1. Follow general medication administration policy and procedures
2. Proper hand washing before and after administration of medication.
3. Apply gloves
4. Draw up medication using a 23 G (gauge) needle or smaller.
5. Select site of injection and clean with alcohol prep.
6. Grasp and pinch a cushion of flesh.
7. Hold needle with bevel side up and insert at a 45-degree angle
8. Insert needle quickly.
9. Pull back on plunger to see if needle is in a blood vessel. If so, withdraw needle, secure new equipment and medication and repeat procedure.
10. Inject medication slowly.
11. Remove needle quickly
12. Massage area well with alcohol prep, unless contraindicated.
13. Document the injection on the Medication Administration Record (MAR) along with site used.
14. Discard syringe and needle in sharps container.
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5.17: SUBLINGUAL MEDICATION ADMINISTRATION Purpose: To administer sublingual medications under the resident’s tongue safely and accurately. Procedure: 1. Follow general medication administration policy and procedures.
2. Place proper number of sublingual tablets/capsules into medication cup.
3. Place medication under resident’s tongue (allow resident to do this if capable), and instruct resident to leave medication there until dissolved.
4. Proper hand washing.
5. Return to medication cart and document medication administration with initials in appropriate spaces on Medication Administration Record (MAR).
Note: Sublingual medication is generally not properly absorbed if swallowed. If resident is unable to comply with instruction, contact physician for alternative dosage form.
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5.18: TRANSDERMAL PATCH APPLICIATION Purpose: To administer medication through the skin for continuous absorption while the patch is in place, through proper placement of the patch and care of the application sites. Procedure:
1. Follow general medication administration policy and procedures
2. Cleanse hands before and after administration.
3. After removing the old patch, clean site with soap and water to remove traces of old medication, and pat dry.
4. Alternate sites of patch application
5. Record location in the Medication Administration Record.
6. Remove plastic cover from the medication site of the patch.
7. Avoid any contact with medicated surface.
8. Apply new patch to a clean, dry site.
9. Secure patch with adhesive tape if necessary but do not occlude patch with tape.
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5.19: TUBERCULOSIS TESTING (MANTOUX TEST)
Policy:
The administration of TB tests for residents and employees will be based upon physician’s orders.
Procedure:
1. TB testing solution is only available in multi-dose vials and is to be maintained as facility house supply.
2. Due to the fact that solution must be refrigerated, facility must appropriately label and store it in the medication refrigerator.
3. After a physician’s order is secured, acquire the dose necessary from the vial located in the medication
refrigerator. If you are opening a new vial, it must be initialed and dated, as it is only good for 30 days after opening the vial.
4. After washing hands and gloving, administer the TB test by intra-dermal injection according to the
procedure for intra-dermal injection in the facility policy and procedure manual. 5. Return the vial to its container and place back in the refrigerator. 6. When you need to reorder, pull the reorder portion of the label, place on the appropriate reorder sheet,
(your facility may have a specific house stock reorder form) and fax to the pharmacy. 7. Remember that all House Stock TB testing solution is billed to the facility rather than a resident. You
may need to obtain authorization before reordering.
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5.20: VAGINAL MEDICATION ADMINISTRATION
Purpose:
To administer vaginal medication safely and accurately for therapeutic effect.
Procedure:
1. Follow general medication administration policy and procedures.
2. Wash hands before and after medication administration.
3. Ask resident to void their bladder before positioning for medication administration.
4. Place tablet/suppository in applicator or draw cream/gel into applicator.
5. Have resident lie on back with knees flexed and legs spread apart, or in the Sims position.
6. Wearing gloves, examine perineum.
7. Clean perineal area with soap and water
8. With one hand, spread about the labia.
9. Place applicator into vagina and advance the plunger to instill gel or cream or to release tablet or
suppository. Lubricate tablet, suppository or applicator prior to administration, if required.
10. If without applicator, insert lubricated tablets or suppository approximately 3—4 inches into vaginal
area.
11. Wipe lubricant from vaginal area with tissue.
12. Advise resident to remain in bed with hips elevated if possible for five minutes, then lying down for
about 20 minutes.
13. Wrap tissue and glove in paper towel.
14. Place wrapped and or soiled articles in designated receptacle.
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5.21: VIALS AND AMPULES Policy: All vials and ampoules of injectable medications are used in accordance with the manufacture’s recommendation. Procedure: 1. Vials and ampoules sent in a bag or original container with the label on the outside are to be kept in
that box or container.
2. When drawing medication from an ampoule, a filter needle will be used to remove any glass particles that might have showered into the medication solution when the ampoule was broken open. Once the medication is drawn up, the filter needle will be changed to assure that all glass particles captured by the filter will be discarded.
3. Ampoules and single-use vials are discarded immediately after using according to facility policy. 4. The solution in multi-dose vials is inspected prior to each use for unusual cloudiness, precipitation, or
foreign bodies. The rubber stopper is inspected for deterioration. 5. If a multi-dose vial shows visible evidence of precipitation or contamination prior to the manufacture’s
expiration date, its use is discontinued immediately, and it is returned to the pharmacy. 6. Expiration of multi-dose vials
a. If a multi-dose vial has been opened or accessed, the vial should be dated and discarded within 28 days unless manufacturer specifies a different (shorter or longer) date.
b. If a multi-dose vials has not been opened or accessed, it should be discarded according to the manufacturer’s expiration date.
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SECTION 6.0 DRUG DISPOSAL 94
SECTION 6.1 BED HOLD MEDICATIONS 95 SECTION 6.2 CONTROLLED SUBSTANCE DISPOSITION 96-97 SECTION 6.3 DISCONTINUED MEDICATION 98 SECTION 6.4 SYRINGE AND NEEDLE DISPOSAL 99
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6.1: BED HOLD MEDICATIONS / OUT-ON-PASS Policy: The medications remaining after a resident is transferred to a hospital shall be retained for possible re-use upon the resident’s return. Procedure: 1. UnitedRx will be notified of hospitalization through the use of the daily census form. 2. Upon transfer to a hospital, the medications for the hospitalized resident will be removed from the
active medication area and held for possible re-use by the same resident upon his/her return to the nursing facility.
3. The facility shall, whenever possible, secure all of the medications being held for all hospitalized
residents in one specific, secured area. 4. For the purpose of security, Bed-Hold medications shall be treated in the same fashion as the active
medication supply. 5. For the purpose of security, Bed-Hold controlled substances shall be treated in the same fashion as the
action medication supply. 6. The Bed-Hold medications shall be reviewed on a regular basis to remove, return, or properly dispose
of those medications which will not be usable because of resident’s death, drug recall, expired medications, or similar situations.
7. Upon the return of the hospitalized resident, all medications required for that resident shall be compared
with the medications remaining from the previous period to determine if the bed-hold medication can be re-utilized.
8. Medications that can be re-utilized shall be written as PROFILE ONLY orders on the pharmacy order
form or on the re-admission physician order form. 9. Medications that cannot be re-utilized shall be returned to the pharmacy for credit or destruction (except
for controlled substances), or shall be destroyed in the facility according to the facility policy. 10. Medications that are destroyed at the facility will not be credited by the pharmacy. Specific to a resident out on pass When a resident is leaving the facility out on pass, medications may need to be sent with the resident to avoid missing doses. For facilities that utilize strip packaging, the medication packets should be separated and given to the resident. For facilities that utilize bingo cards, medications should be popped out of the bingo cards and placed in white envelopes, which are provided by the pharmacy. On each envelope, medication name and directions for use should be written by the nurse so resident or resident caregiver can administer the medications appropriately.
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6.2: CONTROLLED SUBSTANCES DISPOSITION
Policy:
It is the policy of this facility to comply with federal and state requirements for controlled substances.
Procedure:
1. Controlled substances that are no longer needed in the facility must be disposed of in the facility. They cannot be returned to the pharmacy.
2. When a dose Schedule II substance is discontinued or when a resident receiving a Schedule II substance
expires, a licensed nurse will record the number of doses that remain and the date of the Resident’s “Controlled Substance Record” (count sheet). If the facility uses a count sheet for Schedule III thru V substances, the same procedure will be followed.
3. The medications and accompanying count sheets will be kept in the medication cart until they are
surrendered to the Director of Nursing (DON) or his/her designee for destruction. Shift-to-shift counts will be done, and endorsed on the appropriate record, for all controlled substances awaiting destruction for which there are count sheets.
4. The DON, or designee, will then record the name of the drug, dosage form, quantity and resident’s
name or the Inventory of Control Drugs form all Schedule II controlled substances. Schedule III thru V controlled substances do not require documentation of the resident’s name on the Inventory of Control Drugs Form. They can be listed as ‘multiple.’
5. The DON will keep the medication and numbered count sheets in a secure, double-locked area. The
DON, or designee, and one additional licensed person will destroy medication utilizing the appropriate form for recording the destruction according to accepted standards of practice for disposal and in accordance will sign the disposal record, including their title. The date of destruction should also be documented.
6. After drug destruction, the count sheets will be forwarded to medical records for filing with each
resident’s clinical record. 7. The DON will retain a copy of the disposal record for filing locally.
97 May 2019
INVENTORY OF CONTROL DRUGS
From: _____________________________________________________Date:________________ Facility Name ______________________________________________________________________________ Address City/State Zip The following control drugs were destroyed at the above facility:
NAME OF DRUG STRENGTH/DOSAGE FORM QUANTITY RESIDENT NAME
Inventoried/Destroyed by 2 licensed medical personnel Method: ________________________________________ Signature_________________________________ Title_________________ Date___________ Signature_________________________________ Title_________________ Date___________
98 May 2019
RX 448 (8/02)
6.3: DISCONTINUED MEDICATIONS Policy: All non-scheduled medication discontinued by the physician will be returned to the UnitedRx for credit if completely unused or will be destroyed in accordance with local, state, and federal regulations. Procedure: 1. An order form will be completed and faxed to the pharmacy to indicate that a medication has been
discontinued.
2. An entry showing the date of discontinuation and initials or signature of the licensed nurse taking the order will be placed on the medication administration record.
3. Authorized staff will remove the medication from the medication cart or from any other storage area
where it is located. 4. Medication may be returned for credit if the medication was (must meet all the criteria):
a. Dispensed to the resident while residing in the facility b. Properly stored and securely maintained c. Returned unopened in the manufacture’s original multiple dose container with an unbroken/tamper
resistant seal or in the unit dose packages or punch card d. Dispensed by UnitedRx e. Not a controlled substance
5. The pharmacy will issue credit for the returns that are deemed to be re-salable by a professional
pharmacist.
6. A restocking fee will be assessed to items return to inventory. 7. The original filling fee will be retained by the pharmacy and not issued as a return credit.
99 May 2019
6.4: SYRINGE AND NEEDLE DISPOSAL
Policy: Used syringes and needles are disposed of safely in conformance with applicable laws and safety regulations. Procedure: 1. To avoid risk of needle-sticks, needles are not recapped after use.
2. Immediately after use, syringes and needles are placed into sharp containers. Do not deliberately bend
or break a needle or syringe.
3. When sharps containers are ¾ full, seal the container.
4. Always maintain a reserve supple of sharps containers.
5. Keep the sealed container in a locked medication room until it can be disposed of properly.
6. Dispose of the container in the same manner as other infectious waste.
100 May 2019
SECTION 7.0 QUALITY ASSURANCE/CONSULTANT SERVICES 100
SECTION 7.1 COMMITTEE PARTICIPATION 101 SECTION 7.2 QUALITY ASSURANCE PARTICIPATION 102 SECTION 7.3 QUALITY ASSURANCE MONITORING 103 SECTION 7.4 DRUG INTERACTIONS/ALLERGIES 104 SECTION 7.5 DRUG REFERENCE INFORMATION 105 SECTION 7.6 FACILITY EDUCATION 106 SECTION 7.7 MEDICATION ERROR REPORTING 107 SECTION 7.8 NARCOTIC DIVERSION POLICY 108 SECTION 7.9 CONSULTANT PHARMACY SERVICES PROVIDER AGREEMENT 109-111 SECTION 7.10 MEDICATION REGIMEN REVIEW 112 SECTION 7.11 DISTRIBUTION OF MEDICATION REGIMEN REVIEW REPORT 113 SECTION 7.12 SHORT TERM STAY/CHANGE OF CONDITION MEDICATION REVIEW 114 SECTION 7.13 NURSE CONSULTANT SERVICES 115 SECTION 7.14 DRUG PRODUCT RECALLS 116 SECTION 7.15 INFLUENZA VACCINATION PROGRAM 117
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7.1: COMMITTEE PARTICIPATION
Policy:
In an effort to enhance continuity of resident care and improve clinical outcomes, the consultant pharmacist will participate as needed in facility committees. Please see contract for pricing.
Procedures:
1. The Consultant Pharmacist will participate as requested in the following committees, including, but not limited to: a. Interdisciplinary Team b. Any specially designated committee with the purpose of reviewing psychotropic
medications/behavior modifications c. Facility Safety Committee d. Infection Control Committee e. Quality Assurance/Improvement Committee f. Pharmaceutical Advisory Committee g. Resident Care Plans on an as needed basis
2. The facility must make arrangements with the consultant pharmacist for participation in required committee meeting at least one (1) month in advance for proper scheduling.
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7.2: QUALITY ASSURANCE PARTICIPATION
Policy:
The UnitedRx Consultant Pharmacist is a member of the facility’s quality assurance committee. As a member of this committee, the consultant pharmacist advises the facility and medical director on the maintenance of medication selection, storage, and administration quality standards. The consultant pharmacist presents drug use evaluations, medication regimen reviews, disease state management programs, quality assurance, educational literature and/or continuous quality improvement studies for this purpose.
Procedure:
1. The consultant pharmacist meets with designated facility personnel to discuss the needs of the facility for quality improvement monitoring. These needs may be identified by facility personnel or though the observations of the consultant pharmacist from previous facility visits, medication regimen review, and medication pass review or other qualitative measurements of staff performance.
2. The consultant pharmacist utilizes this information to establish a disease state management program
and/or quality improvement program that will be initiated. These programs and/or quality improvement studies will be evaluated on a yearly basis.
3. The consultant pharmacist will participate in an interdisciplinary process for monitoring psychotropic
therapy prescribed for each resident. This process includes an evaluation of the use, misuse, or overuse in residents. A report is presented on a quarterly basis (minimally) regarding psychotropic use in the facility. This assessment will include a report of the use of psychotropic medications in the facility compared to national and state averages. The interdisciplinary process will include physician, nurse, and other disciplines involved in the resident’s care.
4. The consultant pharmacist may present to the facility a compliance review of the facility’s drug related
practices including but not limited to: a. Ordering and dispensing b. Timely delivery c. Receipt, storage, control, and distribution d. Labeling e. Preparation, administration, and record keeping f. Disposal, reconciliation, and accountability of all drugs and biologicals g. Review of medication errors and adverse drug reactions h. Status of recommendations regarding monthly medication regimen review reporting.
5. Review of staff noncompliance with stated pharmacy-related policies and procedures.
6. An action plan for improvement strategies of any identified compliance issues.
7. Review of contents of the emergency box and convenience box. The consultant pharmacist reports
additions/deletions to the operational pharmacist for updating. 8. The report is attached and retained with the facility’s meeting minutes according to the documentation
retention policy of the facility.
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7.3: QUALITY ASSURANCE MONITORING
Policy:
The Consultant Nurse or designated pharmacy personnel will assure responsibility for performance of a quarterly inspection of drug storage areas and drug practices. A report indicating facility compliance status will be provided to the Administrator or Director of Nursing.
Procedure:
1. The Consultant Nurse or designated pharmacy personnel will assume responsibility for the performance of inspections to evaluate: a. Personnel conform to medication administration standards—minimally the UnitedRx Consultant
Nurse will perform a yearly medication pass review. b. Proper storage, control and documentation of drugs and biologicals. c. Maintenance of drug storage and administration areas d. Proper temperature, heat, and light controls e. Proper disposal of expired and discontinued medication to UnitedRx f. Proper disposal of expired and discontinued controlled medications g. Proper documentation, storage and accountability of controlled medications
2. The Consultant Nurse or designated pharmacy personnel will discuss the findings of this inspection with the Director of Nursing or designated facility alternate.
3. The Consultant Nurse or designated pharmacy personnel will submit a report indicating findings of this inspection visit to the Director of Nursing at the conclusion of the visit. A copy of this repot will also be maintained at the pharmacy.
4. It is the facility’s responsibility to take actions based on recommendation made in this report.
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7.4: DRUG INTERACTIONS/ALLERGIES
Policy:
To prevent acute drug interactions or allergic reactions, UnitedRx will provide drug interaction and allergy reporting prior to dispensing medications.
Procedures:
1. The facility must provide the pharmacy with the allergy information of all new admissions. The pharmacy must also be made aware of any changes or updates in resident allergy information.
2. Pharmacists review new physician’s orders for significant drug-drug, food, disease interactions and drug-allergy complications. The facility nurse is contacted by the pharmacist for discussion of the interaction and/or allergy prior to dispensing the medication.
3. If necessary, the pharmacist and/or facility nurse will discuss the interaction/allergy with the resident’s physician prior to dispensing the medication.
4. The facility will receive documentation of the interaction/allergy information attached to the order at the time of medication delivery. A copy of this information is maintained at the pharmacy with the medication order.
5. The Consultant Pharmacist will review all medications on the resident’s profile at the time of the drug regimen review for drug-drug, -disease, and –food interactions. The facility and operational pharmacy will be updated with any findings from this drug regimen review via the drug regimen review report.
6. The facility nurse will check the resident’s allergy information before administering a dose of medication from the Emergency or Convenience box. The facility nurse will contact the Pharmacist with questions.
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7.5: DRUG REFERENCE INFORMATION
Policy:
Personnel responsible for medication administration will have access to reference materials that include current information on drug effects, cautions, available strengths, dosage forms, recommended dose, and nomenclature.
Procedure:
1. UnitedRx will provide a source of drug information which will include: current information on drug effects, cautions, available strengths, dosage forms, recommended doses, and nomenclature.
2. Drug reference materials will be replaced annually.
3. When information about a drug is not available, the nurse will request information by calling a UnitedRx pharmacist.
4. The nurse will always consult reference materials or contact the pharmacy before administering an unfamiliar medication.
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7.6: FACILITY EDUCATION
Policy:
The Consultant Pharmacist or Nurse provides education about medication use to the facility staff when requested by the facility.
Procedure:
1. The consultant pharmacist collaborates with facility designated management on education needs regarding medication management.
2. The consultant pharmacist provides education and information to the facility staff on a variety of medication-management issues based on the identified needs of the facility, Education is provided both formally and informally using various tools and methods.
3. The pharmacy provides education to long term care facility staff about the use of psychotropic medications. Minimally, this education includes, information related to the: a. Appropriate diagnosis for the use of a psychotropic medication b. Potential for drug-drug and drug-food interactions c. Adverse reactions to psychotropic medications d. Trial reductions to the lowest effective dose of the medication e. Monitoring medication effectiveness
4. Records of in-servicing provided by UnitedRx Consultant Staff will be maintained by facility staff according to facility policy. A copy will also be maintained in the pharmacy.
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7.7 MEDICATION ERROR REPORTING
Policy:
The facility will notify Director of Pharmacy, Pharmacy Manager or Consultant Pharmacist if medication error has occurred.
Procedure:
1. The facility will notify the appropriate personnel at the pharmacy when a medication error has occurred via phone call or email.
2. The following information should be reported to the pharmacy a. Resident name b. Medication c. If the resident received the medication and for what duration
3. If medication error was dispensed by the pharmacy, the pharmacy will investigate the error.
4. The facility will receive a medication error report from the pharmacy detailing the occurrence after investigation is complete.
5. Facility policy of medication error reporting should also be followed.
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7.8 Narcotic Diversion Policy
Policy: It is the policy of this facility to comply with federal and state requirements for controlled substances. Procedure: 1. The facility must have a system to account for the receipt, usage, disposition and reconciliation of all
controlled medications. 2. If the facility has discrepancies in their count or suspect diversion of controlled medications, an
investigation should be started. 3. The Director of Nursing, the administrator and consultant pharmacist should be informed immediately. 4. The pharmacy will investigate the medication orders in question and provide the facility with reorder
dates, quantities sent to the facility and signed manifests. 5. The facility should then try to reconcile the information to determine if loss or theft has occurred. 6. If loss or theft has occurred, the facility will follow their narcotic diversion policy. If the facility does
not have a policy, these are recommendations to institute after narcotic diversion is suspected: a) Notification of local law enforcement b) Drug testing of all personnel with access to the missing controlled medications c) Re-educating of the nursing staff regarding storage and shift to shift counts d) Auditing of controlled substance count sheets by nursing supervisor or Director of Nursing
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7.9: CONSULTANT PHARMACY SERVICES PROVIDER AGREEMENT Policy: Regular Consultant Pharmacist services are provided to residents for nursing facilities that have a written agreement for such services. Services: 1. The facility maintains a written agreement with the Consultant Pharmacist signed by the administrator
and UnitedRx.
2. The Consultant Pharmacist agrees to render the required services in accordance with local, state, and federal laws, regulations, and guidelines facility; policies and procedures; and community standards of practice.
3. The Consultant Pharmacist, or adjunctive licensed pharmacy personnel under the control of the
Consultant Pharmacist, provides consultant pharmacist services, including but not limited to the following: a. Checking the emergency medication supply to ascertain that it is properly sealed and stored and
that the contents are not outdated. (This is a shared responsibility of the consultant pharmacist and adjunct licensed pharmacy personnel.)
b. Checking the medication storage facilities and the medication carts for proper storage of medications, cleanliness and removal of expired medications. (This is a shared responsibility of the consultant pharmacist, adjunct licensed pharmacy personnel, and/or facility staff.)
c. Submitting a written report and recommendations for each review of medication storage. This is a shared responsibility of the consultant pharmacist and adjunct licensed pharmacy personnel.
d. Reviewing the medication regimen of each resident at least monthly, utilizing federally-mandated standards of care in addition to UnitedRx applicable standards, and documenting the review and finding in the resident’s medical record.
e. Participating in the preparation of the resident care plan for each new resident or current resident with a change in status by reviewing the following information in collaboration with the operational pharmacist. The following examples of information may be reviewed to determine any potential problems related to the medication therapy of the resident, including the presence of a diagnosis to support the medications prescribed:
f. Completing orders, including diagnoses, resident information, including, height, weight, age, and gender (if appropriate for pharmaceutical care decisions), a copy of the resident’s recent history and physical, and; a description of the significant change in the resident’s status if this is the reason for the assessment.
4. The operational pharmacist reviews the physician order at the time of receipt and compares the order with the patient profile and additional information as described above for: a. appropriate drug for indication (diagnosis), b. therapeutic duplication, c. appropriate dosage, d. potential drug- drug, drug- food, drug- disease interactions, e. contraindications, appropriate dosing schedule, f. dosage form and route, allergies and sensitivities.
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5. Communicating to the responsible physician potential or actual problems detected relating to medication therapy.
6. Consulting with attending physicians and nurses to ensure compliance with the Geriatric Pharmaceutical Care Guidelines.
7. Reviewing sample of medication administration records (MARs) and physicians orders to assure proper
documentation of the medication orders and administration of medications to residents. (Adjunct licensed pharmacy personnel, nursing facility personnel, and consultant pharmacy staffs share this function.)
8. Submitting a written report of findings and recommendations resulting from the review of medications
regimen and nursing documentation records to the attending physician and direction of nursing. 9. Assessing the performance of the nursing staff in medication administration through the process of
medication pass observation, as requested by nursing and administration, and as necessary. (A consultant nurse employed by the pharmacy performs this function at the facility.)
10. Assisting in the accounting, destruction, and reconciliation of unused noncontrolled substances as
required by the state and federal law. Review the records for receipt and disposition of controlled drugs and the maintenance of such records in sufficient detail so as to allow an accurate reconciliation. (This is a shared responsibility of the consultant pharmacist, licensed pharmacy personnel, and licensed facility personnel.)
11. Assisting the administrator and Pharmaceutical Services Committee in setting standard and developing,
implementing, and the monitoring policies and procedures for the safe and effective distribution, control, and use of medications and related equipment and services in the facility. (This is a shared responsibility of the consultant pharmacist and nurse.)
12. In conjunction with the facility’s Quality Assessment and Assurance Committee, establishing quality
assurance activities to be undertaken regarding medication prescribing, administration, and storage in the facility; compiling required data; and providing analysis and feedback to the medical and nursing staffs of the facility. For each quality assurance study, preparing a written report summarizing appropriate medication therapy statistics for the facility.
13. Serving on facility committees as required or requested, including but not limited to Quality
Assessment and Assurance Committee, Pharmaceutical Services Committee, and Infection Control Committee.
14. Conducting in-service education programs for the nursing staff on medication-related topics as follows:
a. Provide reference materials and resources b. Continually review and updated federal, state, and local laws pertaining to the nursing home as part
of in-service education. c. Use a variety of teaching techniques to keep educational programs informative and entertaining
(i.e.: visual aids, A/V presentations, Quizzes (pre- and post-), Group discussions, Written handouts, Return Demonstrations, Q & A, Evaluations)
d. Maintain a record of each in-service training program provided, listing subject matter and attendees.
15. Participating in other facility activities as requested by Administrator or Director of Nursing and as agreeable to both parties.
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16. Assisting in developing the facility policies and procedures for routine and emergency/disaster drug controls.
17. The Consultant Pharmacist maintains current licensure and provides proof of it to the facility each renewal period.
18. All pharmacy consultant personnel (pharmacist, nurse, adjunct licensed personnel) maintain a record
of time spent in the facility and documents activities performed and services provided on behalf of the residents and the facility.
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7.10: MEDICATION REGIMEN REVIEW Policy: The consultant pharmacist will provide pharmaceutical care consultation including a Medication Regimen Review on a monthly basis for each resident residing in a certified area of a long-term care facility. For residents residing in long-term care facilities licensed for the developmentally disabled, pharmaceutical care consultation including regimen review will be conducted as required by federal/state laws. Procedure: 1. The consultant pharmacist will review the medication regimen of each resident in sufficient detail
to determine if any apparent irregularities exist. Federally mandated standards of care as well as other applicable standards serve as the basis for the review.
2. The review of the medication regimen will include all medications currently ordered, including
medications that are ordered on an ‘”as needed” basis. The review can incorporate information concerning the resident’s condition, monitoring for side effects of antipsychotic medications, consideration of dose reductions of antipsychotic medications, review for potential unnecessary medication usage, and information contained in medication administration records, the physician’s progress, nurses’ notes, and laboratory test results. The consultant pharmacist will report any apparent irregularities in writing to the attending physician, the director of nursing and the medical director.
3. If the consultant pharmacist identifies a concern or irregularity in the resident’s medication regimen that requires urgent action, the consultant pharmacist will immediately notify the Director of Nursing of the potential for negative outcome.
4. In addition to the written communication to the attending physician, the director of nursing and
medical director on a consultant pharmacist progress report form, a medication regimen review log will be maintained in the resident’s clinical record. The log will include: whether any apparent irregularities were found, Pharmacist’s signature and the date the review was performed.
5. The facility is responsible for ensuring that all clinical records are available for review. 6. The consultant pharmacist is available to consult with the prescribing physicians or the nursing
staff regarding recommendations resulting from medication regimen reviews. It is the responsibility of the facility to assure that each recommendation results in a written response by either the physician or nurse, as appropriate.
7. The log should be kept as a part of the resident’s active clinical record to reflect at least twelve (12)
months of reviews.
8. For facilities that utilize an electronic medication record system (eMAR), the consultant pharmacist’s review will be located in the eMAR system. The consultant pharmacist will document in the progress notes section if any recommendations are made and the note will be electronically signed.
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7.11: DISTRIBUTION OF MEDICATION REGIMEN REVIEW REPORT Policy: The consultant pharmacist will report any recommendations of apparent irregularities resulting from the medication regimen review of each resident to the attending physician, the director of nursing and medical director on a medication regimen review report form or in electronic record keeping system. Each recommendation must be acted upon. Procedure: 1. The report form will be used by the consultant pharmacist to communicate findings of the monthly
pharmaceutical care consultation. 2. The consultant pharmacist will retain the information. 3. The report will be forwarded to the director of nursing. 4. The attending physician and/or medical director will document their review and response to the
recommendations made by the consultant pharmacist directly on the medication regimen review report form or in the resident’s medical record. If physician disagrees with recommendation or no change is being made, the physician must document rationale in the resident’s medical record.
5. The director of nursing will follow up with any nursing actions needed relative to the physician’s
response. 6. Physician response to recommendations resulting in changes in medication therapy for individual
resident will be forwarded to the Director of Nursing or facility nurses. The order will be transcribed to the POS or documented in electronic record keeping system and the nurse will order the medication from the pharmacy.
7. Copies of the recommendations should be retained by the facility for a period of 1 year.
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7.12: SHORT TERM STAY/CHANGE OF CONDITION MEDICATION REVIEW Policy: A licensed pharmacist will provide pharmaceutical care consultation, including a Medication Regimen Review, for a resident residing in a long term care facility for less than 30 days and/or a change of condition occurs. A $10.00 (ten) fee per consultation/review will be charged. Procedure: 1. The facility will fill out and fax “Medication Review Facsimile Cover Sheet” and Physician Orders
and/or Medication Administration Records, along with diagnosis, allergies, and all other pertinent information.
2. A licensed pharmacist will review the medication regimen of each resident in sufficient detail to
determine if any apparent irregularities exist. Federally mandated standards of care as well as other applicable standards serve as the basis for the review.
3. The medication regimen review will include all medications currently ordered, including medications
that are ordered on an ‘”as needed” basis. The review can incorporate information concerning the resident’s condition, monitoring for side effects of antipsychotic medications, consideration of dose reductions of antipsychotic medications, review for potential unnecessary medication usage, and information contained in medication administration records, the physician’s progress, nurses’ notes, and laboratory test results. The licensed pharmacist will report any apparent irregularities in writing to the person requesting the review within 24 business hours to the fax number supplied on the facsimile cover sheet.
4. The facility is responsible for ensuring that all clinical records are available for review. 5. The licensed pharmacist is available to consult with the prescribing physicians or the nursing staff
regarding recommendations resulting from medication regimen reviews. It is the responsibility of the facility to assure that each recommendation results in a written response by either the physician or nurse, as appropriate.
6. The Medication Regimen Review should be kept as a part of the resident’s active clinical record to
reflect at least twelve (12) months of reviews.
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7.13: NURSE CONSULTANT SERVICES Policy: A consultant nurse will provide nursing services as per contracted agreement with each facility. Procedure: 1. The nurse consultant will provide annual survey preparations, which include medication pass and
medication storage audits. The facility will make the Lead Consultant aware of when survey window is open and nursing medication pass audits will be scheduled. Any other requests for medication pass audits outside survey window can be scheduled (a fee will be charged as per contract agreements)
2. The nurse consultant can also be contracted for monthly medication reconciliation as requested by the
facility. The nurse consultant will compare a resident’s medication orders from the previous month to ensure all active medication/treatment orders are correctly carried forward on the current Physician Order Sheet.
3. The nurse consultant prior to exiting the building will provide a report stating irregularities to the Director of Nursing.
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7.14: DRUG PRODUCT RECALLS Policy: UnitedRx maintains a record of all medications dispensed to the facility. In the event of a recall by the manufacturer and/or the Food and Drug Administration (FDA), the facility is notified by UnitedRx. Procedure: 1. UnitedRx maintains a record of all medications dispensed.
2. Upon receipt of a recall notice, UnitedRx will send a written notification to the facility. Specific
instructions will be listed. Please call your consultant if you have any questions.
3. The facility is responsible for locating and returning the affected product to the pharmacy. Please send back to attention of Director of Pharmacy. The pharmacy is responsible for the disposition of the affected product as directed by the manufacturer or FDA.
4. UnitedRx will replace the recalled drug with a new supply, if available. In the event a replacement
supply is unavailable, UnitedRx will provide alternatives to be discussed with the prescriber.
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7.15: INFLUENZA VACCINATION PROGRAM
Policy:
If state regulations allow, UnitedRx can provide Influenza Vaccine administration to residents as requested by the facility.
Procedure:
1. Facility should assess the residents in need of vaccination against Influenza and screen those residents for contraindications to the vaccine.
2. Facility will coordinate with pharmacy the dates when Influenza vaccines should be administered to the residents.
3. Facility will obtain consents and provide Vaccine Information Statements to all residents prior to administration date.
4. The list of residents obtaining the Influenza vaccine should be sent to pharmacy with physician signature at the bottom of the list.
5. Pharmacy Nurse Consultant will ensure consent was obtained prior to administration of the vaccine.
6. Documentation of administration should be placed in the resident’s records.
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SECTION 8.0 MEDICAL RECORDS 118
SECTION 8.1 MEDICAL RECORDS 119-121
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8.1: MEDICAL RECORDS Policy: UnitedRx will provide computer generated Medical Records that are accurate and frequently updated for all clients that need them. Procedures: 1. The pharmacy will provide computerized Physician Order Sheets (POS), Medication Administration
Records (MAR), and Treatment Administration Sheets (TAR) monthly for all residents to ensure accuracy of drug administration and legibility of documented activity.
2. The pharmacy medical records department will update the computer records monthly based on a copy of the POS document that will be forwarded to the pharmacy at a scheduled time.
PHYSICIAN ORDER SHEETS 1. The Physician Order Sheets (POS) is composed of three parts. The top white sheet is the permanent
chart copy and the identical yellow copy is the pharmacy copy. A third copy (pink) may be provided if requested by the facility.
2. The facility will be notified in writing at the beginning of each month of the date and time that the yellow POS copy (pharmacy copy) is to be submitted for computer updating. A follow-up reminder will be sent to the facility via delivery personnel one or two days prior to the date of pick up. It is the responsibility of the facility to remove all current yellow POS’ from the chart. They must be ready for the pharmacy pick up on the appointed day. A delay in printing and delivery of charts will occur if not ready on appointed day.
3. The left side of the POS is the resident’s drug profile and includes pass times. In addition to the drug
profile, it may also contain orders for blood pressures, weights, enteral feedings, and dietary supplements depending upon individual facility requests. Anything printed on the left side of the POS is reproduced on the Medication Administration Record (MAR)
4. The computer prints the list of medications (left side) in alphabetical order according to frequency of dose, with the scheduled medications first, followed by PRN medications also in alphabetical order. If a drug is ordered both on scheduled administration and when needed (PRN), the drug and directions will be in two boxes; one box for each direction of administration i.e.: such a drug will be printed with the listing of scheduled prescriptions and with the list of PRN prescriptions.
5. Literal orders will be on the right side of the POS with specific headings such as ‘Diet’, ‘Dietary’,
‘Treatments’, ‘Rehabilitation’, ‘Ancillary’, ‘Laboratory’ and ‘Level of Care’. The order in which these categories print, are individually decided by the facility according to specifics needs and requests.
6. All orders appearing under the heading ‘Treatments’ will also print on a separate TAR (unless otherwise requested).
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7. Across the bottom of the POS is the pertinent admission information. The resident’s name, admission number, primary physician, room number, bed and nursing unit, date of birth, diagnosis and allergies. The current month and year of the POS also appear in the area.
8. The (MAR is a reproduction of the left side if the POS. The medication pass times are printed according
to each facility’s policy. The word ‘pulse’ is printed in the pass time area for digoxin orders, ‘site’ is printed on all injections, transdermal patches, blood glucose monitoring strips, and sliding scale insulins. These words are printed as reminders to take the pulse and to rotate the site of the patches, and injections.
9. As an alternative to the separate POS & MAR the physicians orders are available on a three part
combination form composed of a two part POS (White and Yellow) and an attached MAR. 10. Documentation of treatments is done on a separately printed TAR. All orders appearing on the right
side of the POS will be reproduced on the treatment sheet for documentation. If a resident does not have any treatment orders, a Treatment Sheet will not be produced.
ADMISSION/RE-ADMISSION FORMS 1. A three-part form composed of a two-part POS (white and yellow) and an attached MAR is available
for customization to facility specification.
2. The left side of the form is blank; the right side contains standing orders to be loaded on all residents as well as a fill-in sheet containing those orders commonly written in the facility needing only a check or ‘X’ to indicate which are relevant to a resident. This form simplifies the admission process by decreasing the time necessary to write admission orders.
3. Resident’s medications (including treatments) are written on the left side of the admission POS and in
doing so they also appear on the attached copy of the MAR. 4. When the admission POS is complete;
a. Remove the attached MAR and place it in the medication book. b. Place both copies (white and yellow) of the POS in the chart. c. Continue using the handwritten admission POS during the month d. Remove the yellow copy on the pharmacy request schedule and the pharmacy driver will pick up
and take to the pharmacy for updating the computer. e. A new set of medical records will be delivered for use in the next month.
EDITING/UPDATING OF NEW PHYSICIAN ORDER SHEETS 1. It is the responsibility of the nursing staff to ensure the accuracy of the computer printed medical
records.
2. After the yellow POS copies are received in the pharmacy and prior to the initiation date for new medication sheets, the completed set of new records (printed POS, MAR and TAR) will be returned to the facility.
3. The person(s) designated to check the forms will verify the accuracy and completeness of each form. Particular attention should be paid to orders that were initiated when the yellow copies were in the
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pharmacy. Such orders may not appear on the new forms and should be added manually. Particular attention should be paid to the following: a. Medication – for dosage, times and complete directions. PRN orders must have frequency and
reason for administration. b. Nursing orders – for completeness and accuracy. This is an excellent time to read through all the
orders and make certain of the appropriateness and relevance. c. Accuracy of patient name, room number and bed. d. Physician Name e. Allergies f. Diagnosis
4. The new printed sheets are checked against the former month’s sheets, written orders and telephone
orders. The following information may be utilized as a guide for the checking process: a. Information missing from the printed POS must be added. b. Orders after the sheets are printed must be written. c. Discontinued (DC’d) orders should be deleted as follows:
i. When a medication on the left side is to be DC’d draw a diagonal line through the box, write ‘DC’, the date and your initials.
ii. When an order on the right side on the POS is to be DC’d draw a single line though the order and write ‘DC’, the date and your initials at the end of the line or section. Note: When medications or treatments are DC’d from the POS, they must also be DC’d from the MAR and the Treatment Sheet.
iii. If a duplicate medication appears on the POS. Cross through the medication with a diagonal line and write duplicate.
iv. If more than one POS and MAR is used, a “page” and page “number” will appear at the top right corner of the record.
v. The nurse that is editing and updating the record must initial and date on the line provided in the lower right hand corner of each sheet to validate this nursing review.
vi. After the forms have been verified, changes made, and current orders transcribed, the new POS is placed in the resident’s chart. (This form can be used even if prior to the first of the month. It is considered a 30-day document, usable from date of print to date of replacement.) Draw diagonal lines through any unused space in the previous month’s POS to prevent any further orders from being written on this sheet. The MAR and Treatment Sheet cannot be used until the first of the month and should be placed in a designated holding area. If you are using POS with attached MAR, put the form in the chart intact, transcribing new med changes to the left. The MAR should be removed from the chart at the end of the month after again verifying accuracy.
vii. If you receive a “new” POS and/or MAR for a discharged or expired resident, return the forms to the medical records department with the appropriate notation and date resident was discharged or expired.
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SECTION 9.0 BILLING 122
SECTION 9.1 MEDICATION RETURN POLICY 123 SECTION 9.2 FORMS THAT MUST BE RETURNED TO THE PHARMACY 124-129 SECTION 9.3 INSURANCE COVERAGE 130 SECTION 9.4 TERMS OF PAYMENT 131 SECTION 9.5 BILLING INFORMATION 132-133
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9.1: MEDICATION RETURN POLICY
Due to the nature of our business, UnitedRx has the unique opportunity to accept the return of certain unused medications for credit. This is a service that retail pharmacies cannot offer their customers. If a resident’s medications are discontinued, returned to the pharmacy within the established timeframe, meet the return guidelines published in the USP (United States Pharmacopeia), and meet the return guidelines in the UnitedRx policy, a credit for the cost of the product will be issued to your or the resident. UnitedRx may charge a restocking fee.
Certain medications cannot be returned due to strict packaging and storage guidelines, and to ensure the safety and quality of our products, UnitedRx has identified certain medications as non-returnable. Please review the list below for these items:
• Any controlled/scheduled medications (Scheduled CII-CV) (Regulations prohibit the return of these items)
• Unit dose package or punch card with broken seal • Half-Tabs (1/2 tablets) • Expired medication • Inhalers • Liquids • Eye Drops / Ear Drops • External medications (creams, ointments, topical solutions. etc.) • Bulk items • Items not provided by UnitedRx • Compounded prescription orders, IV mixtures • Refrigerated items • Special order items
Also our policy indicates a time frame in which returnable medications must be received by the pharmacy. This time period is 30 days from the time the medication was dispensed. Items received after this period (31 days and beyond) will not be issued credit.
Unfortunately, UnitedRx is not able to provide the drug return service if your patients have insurance coverage. Due to the limitations of insurance processor’s system, we are unable to transmit credit transactions to insurance companies.
When a resident is discharged from the facility, all medications billed to the resident’s insurance should be sent home with the resident. Facility should inform resident/resident caregiver that the medications are not packaged in child-resistant packaging.
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9.2: FORMS THAT MUST BE RETURNED TO THE PHARMACY
Agreement for pharmaceutical service (Required)
This form is required to obtain accurate billing information and ensure that accurate statements are generated. The front page of the form has demographic data that provides UnitedRx with the following:
• Parties who are financially responsible for the resident • Medicaid programs that need to be billed • Insurance companies to which the pharmacy can attempt to submit claims
Please be sure to include a copy of any Medicaid card and both the front and back of any insurance card. This will assist in the timely processing of claims and assist in providing customers with accurate billing statements.
The financial agreement section indicates who will be held financially responsible for pharmacy services. If the party signing is not the financial responsible party, but is a trustee of a fund or is merely managing the finances of the resident, please indicate this in the Relationship to Resident area. This form should be completed at the time of admission and faxed, with the new medication orders, to the pharmacy.
Notice of Privacy Practice – HIPAA (Required)
This notice describes how medical information about the resident may be used and disclosed and how the resident can get access to this information.
Under the Federal HIPAA Privacy Rule, we are required to give you our Notice of Privacy Practices and make a good faith effort, before providing services, to get the residents Acknowledgement of Receipt of Notice of Privacy Practices.
If the resident refuses to sign this form or it is otherwise not possible to obtain an acknowledgement of receipt of the Notice of Privacy Practices, please identify the good faith efforts made to obtain the patient’s acknowledgement by signing the reverse of the form and return to UNITEDRX.
Notice of Intent to Purchase Medication from an Outside Provider (IF APPLICABLE)
This form should be completed only if you have decided not to use the services of UnitedRx, the preferred provider of pharmaceutical services selected by the facility. It is imperative that this form be completed and that the pharmacy receives a copy of this form prior to dispensing medications. Without this form, medications may be sent from our pharmacy to the resident. To avoid complications, please be sure that the Admissions Coordinator has faxed a copy of this form to the pharmacy.
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See following pages for example forms.
AGREEMENT FOR PHARMACEUTICAL SERVICES
Facility______________________________________________________________
Note: This form is required even if the client is admitted to the home under Medicare A benefit.
UnitedRx Pharmacy has contracted with this facility to provide pharmaceuticals drugs, and/or other medical supplies on 24-hour basis, and in accordance with all State and Federal regulations. In accordance with our contract with UnitedRx each resident/authorized agent required to complete this agreement.
Patient Name: ______________________________________________________________________
Patient’s Social Security No. _______ - _____ -______ Date of Birth _____/ _____/ _____ Sex ______
Payer Information (select all that apply)
☐Medicare A ☐Managed Care ☐Veteran ☐Private ☐Hospice ☐Pending Medicaid ☐Medicaid ☐Insurance/Medicare D please provide a copy of the front and back of insurance card
Prescription Insurance Plan: _________________________________________________________ Insurance Phone _________________________________
Cardholder ID # ______________ Plan Group # __________ BIN #_________ PCN #_________
Hospice Name and Address: _____________________________________________________________________________________
Medicaid Case # ___________________ Caseworker Name/ Phone #__________________________ Medicaid Recipient # _____________________
FINANCIAL RESPONSIBILITY AGREEMENT BETWEEN UNITEDRX, LCC AND
Responsible Party/Guarantor: (Circle One) Attorney POA Guardian Other______________
Responsible Party Guarantor: __________________________________________ (Name/Relationship) Telephone Number ___________________________
Address ___________________________________________________ City _____________________________ Alternate Phone #/ E-Mail____________________________
State _________________ Zip Code_____________
Statement should be sent to: ☐ Check this box if statements should be sent to responsible party’s address.
Name ___________________________________________________________________
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Address ___________________________________________________ City ________________________________ State _________________ Zip Code_____________
INSURANCE COVERAGE: Please attach or include a copy of the front and back of all
insurance cards. These cards needed even if the resident has Medicaid/ Medicare coverage.
The Undersigned certify that he/she/they/ have read the above and hereby accept the terms and conditions contained herein.
Responsible Party/ Guarantor Signature:
X____________________________________________________ Date ________________________
Recurring Monthly Payment? Yes___ No ____ (check one) Credit Card (Check One) ☐ Visa ☐ Master Card ☐ Discover ☐ American Express
Name on Card: ___________________________________________________________Card Number ____________________________________ Exp. Date_______
Cardholder Signature _______________________________________________3 Digit Security Code_________ Zip Code____________
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UnitedRx LLC 150 Fencl Lane Hillside, IL 60162
Phone (708)449-7600 Fax (855)422-0782
****************HIPAA FORM****************
Authorization by Representative of Patient (in Nursing Home/ Group Home) for use and disclosure of Protected Health Information
(Please Print Clearly)
I, ____________________________________________ as the legally authorized personal representative of ________________________________ do hereby authorize UnitedRx, LLC to use and disclose the PHI for the purpose of providing a copy of the patient drug profile with the monthly statement for payment purposes.
The Authorization is effective as of the date signed by the personal representative of the patient below and shall expire upon occurrence of discharge of the facility. Whichever occurs first, unless sooner revoked by execution of the Revocation of Authorization below or other written form of revocation submitted by the personal representative of the patient.
Understand and Acknowledgement
1. I understand that the Pharmacy will not use or disclose PHI except as described in this Authorization. 2. I understand that the Pharmacy may not condition treatment, payment, enrollment, or eligibility for
benefits on whether I sign this Authorization when the prohibition on placing such conditions applies. 3. I understand that I may revoke this Authorization at any time, provided that the revocation is in
writing, and can do so by signing the revocation section at the end if this Authorization or by submitting some other form of written document to the pharmacy revoking this Authorization, except to the extent that the pharmacy has taken action in reliance on this Authorization.
4. I understand that the PHI to be used and disclosed pursuant to this Authorization is subject to redisclosure by the recipient and no longer protected.
5. I understand that I must be provided a copy of this signed Authorization. 6. I understand that this Authorization will not be valid Authorization under the following conditions.
A) the expiration date has passed or the expiration event is known by the pharmacy to have occurred; B) the Authorization has not been filled out completely: C) the Authorization is known by the pharmacy to have been revoked: and D) any material information in the Authorization is known by the pharmacy to be false.
Signature of Authorized Representative ______________________________________Date_____________
Notice: This Authorization required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) authorizes us to use and disclose Protected Health Information/ Individually Identifiable Health Information (Collectively referred to herein as “PHI”) as described below.
Notice: UnitedRx, LLC may require documentation of legal authority of the personal representative of the patient, including but not limited to, a valid durable power of attorney for health care or valid court order.
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Notice of Intent to Purchase Medications From an Outside Provider
I request the privilege of purchasing drugs from the pharmacy of my choice for __________________ ___________________________ ,a resident, at__________________________________________.
It is understood that residents are allowed free choice of a pharmacy provider as long as such pharmacy adheres to the following rules and procedures established by the Pharmacy Service Committee to insure that all State and Federal regulations are met and that the safety and well-being of the residents is paramount.
Drugs shall be dispensed only pursuant to orders in the resident’s medical records by a physician or other person licensed to prescribe in the State.
Drugs shall be dispensed only pursuant to medication orders transmitted to the pharmacy by a licensed person who is an employee of the facility via telephone, facsimile, or approved order form.
Drugs shall be shipped directly from the pharmacy to the nursing station. Shipment may be conveyed by: A pharmacist, an independent agent of the pharmacist or pharmacy, parcel delivery (i.e. UPS, Federal Express), and/or a physician.
The outside pharmacy shall furnish a copy of the RESIDENT’S DRUG PROFILE, the format of which has been approved by the facilities Pharmacy Service Committee, to the consultant pharmacist on a monthly basis. The pharmacist of the outside provider shall do a monthly drug regimen review of medication provided by them. In lieu of this, the outside provider or responsible party agrees to pay $25.00 per patient per month to provide pharmacist consulting and medical records.
In the absence of a specific order, automatic stop-order policies specified in the facilities Policy and Procedures Manual shall be followed. Controlled Substances in quantifies greater than 72-hour supply must be furnished in unit dose, tamper evident containers.
All medications whether non-prescription or prescription, shall be properly labeled in accordance with the procedures of this facility and shall be packaged in the manner as the home’s unit dose system shall not exceed a 1-montly supply at any one time.
Copies of the stop-order policy, labeling procedures, and this agreement shall be forwarded to the provider pharmacy by the responsible party or agent signing this agreement.
No medications shall be left by the resident’s bedside, whether non-prescription or prescription, unless approved by the physician and or facility policy.
In the event that the outside provider is unable to unwilling to deliver medications in a timely manner, I will pay UnitedRx $50.00 for an emergency delivery.
I understand that, although care is exercised to avoid misdirection, occasionally a medication order may be conveyed to the facility’s regular provider pharmacy. I will be reasonable in accepting cost for any such orders directed to the regular provider pharmacy and not discovered in time to return the order for
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credit, as the law allows. I also understand that if there is a delay in ordered drugs from an outside pharmacy, the facility must reserve the right to order from the facilities regular provider pharmacy as an emergency measure.
________________________________________________________________________________
RESIDENT OR RESPONSIBLE PARTY (PLEASE PRINT)
_________________________________________________________________DATE__________
SIGNATURE OF RESIDENT OR RESPONSIBLE PARTY
________________________________________________________________________________
STREET ADDRESS CITY ZIP PHONE NUMBER
___________________________________________________________
WITNESS
________________________________________________________________________________
NAME OF OUTSIDE PHARMACY
IF APPLICABLE; FAX OR MAIL COMPLETED FORM TO UNITEDRX BILLING OFFICE.
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9.3: INSURANCE COVERAGE
If you or your loved one has insurance coverage, UnitedRx may be able to bill your insurance company electronically. Unfortunately, we cannot process claims for all insurance companies. To verify whether we can process your claims, please contact your billing representative.
Why don’t you take my insurance?
As insurance companies look for ways to reduce their costs, they design programs that mandate mail order prescription service or other restrictive plans that do not allow long-term care pharmacies to participate. Consequently, UnitedRx cannot process claims with every insurance company. Most insurance company plans are designed for retail pharmacies and do not take into account special packaging and quantity restrictions of the nursing facility resident. Therefore, we undergo a strict process to determine whether or not we can participate with an insurance company to provide services under their plan.
My statement does not indicate that you billed my insurance. Can you bill those claims to my insurance?
If we did not receive information regarding your insurance coverage before providing the medication, and your insurance is one that we accept, we will attempt to bill your insurance after we are notified. However, insurance companies have strict restrictions about submitting late claims electronically. If we cannot process your claims, we will recommend that you submit a handwritten, paper claim form, to the insurance company. UnitedRx cannot submit paper claim forms as we are only reimbursed for electronic claims. However, our friendly staff will help you fill out those forms.
I am not sure if you billed my insurance; how can I tell if you did by looking at my statement?
At the end of the description of each medication the letter “C” (for co-pay) will appear indicating how much of an insurance co-payment is due. The co-payment amount is indicated in the “AMOUNT” column. When the “C” appears, you know that we billed your insurance.
Dealing with insurance companies can be a complex and frustrating ordeal. At UnitedRx we are willing to offer any help we can to alleviate these frustrations and make the process easier for you. If you have any questions about insurance coverage, please contact your billing representative at 708-449-7600.
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9.4: TERMS OF PAYMENT
How long do I have to pay my bill?
We give our customers twenty (20) days to make a payment on their account, something most retail pharmacies do not offer. Retail pharmacies usually require payment upon receipt of medications. We wait until the end of the month to generate a statement of account and then offer twenty (20) days from that date to make a payment. The due date will appear in the bottom right hand corner of the bill.
What happens if I don’t make a payment or my balance becomes past due?
Because we offer this service, we rely on the responsibility of our customers to ensure that accounts do not become past due. If an account does become past due, UnitedRx will contact the individual managing it to assist in resolving the past due balance. Our response may be in the form of a letter, a courtesy phone call, or both. If balances become seriously past due, UnitedRx may have to take action to assist in the management of the account. Listed below are the usual steps of the collection process:
Accounts 30 days past due: Customers will receive a courtesy reminder that the account is past due
Accounts 60 days past due: Customers will receive a collection letter with information that collection process has been initiated.
Accounts 90 days past due: Service suspended until payment issues resolved.
What if I send a “Non-Sufficient Funds” check?
If a customer ends a “Non-Sufficient Funds” check or NSF, UnitedRx will charge a $25.00 NSF check fee and give the customer an opportunity to rectify the payment by issuing another check. Should the next check also be NSF, or no payment is received, the resident’s account will be suspended until further payment arrangements can be established.
At UnitedRx we realize that the cost of long-term healthcare continues to spiral upward. Therefore, we encourage our customers to contact us if they feel there may be issues with an account balance. It is better to contact our friendly billing representatives to make payment arrangements than for us to take action on a past due account.
If you have any questions regarding these actions or regarding an account, please contact your billing representative at 708-449-7600.
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9.5: BILLING INFORMATION
UNDERSTANDING YOUR PHARMACY INVOICE
Admission Information: UnitedRx receives billing information from the facility when you are admitted.
Financial Responsibility Agreement form defines who the pharmacy bills for medication dispensed to the resident.
Copy of Insurance Card (front and back) defines Prescription Drug coverage and resident eligibility.
You may receive a follow up phone call or letter from your UnitedRx Billing Agent verifying that the admission information is accurate.
Dispensing Medications: Our pharmacy dispenses medication to the resident in the facility pursuant to the physician’s order. These transactions are captured on your monthly pharmacy invoice.
Date is the date the prescription was dispensed to the resident.
Rx Number is the “Prescription Number” that appears on the dispended medication labeling.
Description is the amount the pills or volume of liquid medication dispensed.
Amount is the price assigned to the quantity of medication dispensed in that particular transaction.
Type identifies whether the medication is an “Rx” prescription drug or “OTC” Over-the-Counter drug (not eligible for coverage under any insurance plan). Occasionally, you will see other types such as “IV” (intravenous medication) or “SUPP” (a medical supply item or nutritional supplement).
Paying Your Bill: Our pharmacy prints all of the medication transactions and their respective charges on the invoice that is mailed to you every month. You have twenty (20) days to pay the pharmacy for these medication transaction. Finance charges are assigned for payments not received by the Due Date identified on your invoice.
Due Date is when your payment must be received by UnitedRx. This date is located in the upper right corner of the invoice.
Amount Due is the total of all medication transaction charges owed to the pharmacy as of the invoice date. This amount is found in two places on the invoice; in the upper right corner of the invoice located near the Due Date, and designated a Total Due in the lower right corner at the bottom of all the individual transactions.
Previous Balance is the amount owed to the pharmacy from the last invoice.
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Payments is the amount you paid pharmacy on the last invoice.
Credits is the amount taken OFF of your current invoice for unused portions of medications eligible for return to the pharmacy.
Adjustments are the amount adjusted on your current invoice for charges re-billed to another payer.
Finance is the amount of late fees you are charged for not paying your last invoice by the designated Due Date.
Current Charges is the sum of all individual transactions listed on your current invoice
Total Due is the amount you pay the pharmacy for all transactions past and current.
Questions regarding your pharmacy invoice: Contact your UnitedRx Billing representative at the number listed on your pharmacy invoice.
