Pa. Code 5320.53

Medication

This section requires providers operating Long-Term Structured Residences (LTSRs) under 55 Pa. Code Chapter 5320 to establish and implement written medication policies and procedures covering resident education, assistance with self-administration, medication administration by licensed medical staff, physician order documentation and renewal, telephone order protocols, staff training, medication storage requirements, and quarterly pharmacist drug-regimen reviews. Operators must ensure medications are stored securely in locked containers, kept in original labeled containers, and that pharmaceutical services include annual policy reviews and emergency access procedures.

55 Pa. Code § 5320.53 - Medication 

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(a)
 The provider
 shall establish and implement written medication policies and procedures that
 conform to Pennsylvania law. Medication administration policies and procedures
 shall address: 
(1)
 How the education of
 residents regarding their medication will be accomplished.

(2)
 How residents who need assistance with
 medication prescribed by a physician for self-administration receive it. 
 
(i)
 For residents who need assistance, the
 least assistance necessary should be provided within the context of a planned
 program toward self-administration of medication.

(ii)
 Assistance with self-medication
 including handling the medication containers or taking medication out of its
 container for the resident is considered medication administration and shall be
 done by licensed medical staff.

(3)
 How medications and treatments shall be
 administered by the licensed medical staff person who prepared the dose for
 administration.

(4)
 Documentation
 of the written orders provided by the attending physician for each resident
 receiving medication.

(5)
 Recording
 of physicians' orders in each resident's clinical record that is reviewed,
 renewed and signed by the physician every 30 days.

(6)
 Documentation of the reason a prescribed
 medication was not given and notice of same to the prescribing
 physician.

(7)
 The taking and
 recording of telephone orders by only licensed medical staff, pharmacists or
 other individuals authorized by law to accept a physician's telephone orders
 for medication.
(i)
 Oral orders are recorded
 immediately on the resident's record, dated and signed by the person receiving
 the order.

(ii)
 Oral orders are
 countersigned by the prescribing physician within 48 hours.

(8)
 Training by a physician or
 other licensed medical staff person that will cover, at minimum, medications
 used by the residents, their purposes and function, major side effects and
 recognition of signs that the medication is not being taken or is being
 misused.

(b)
 The
 circumstances under which the provider stores medication for residents shall
 include the following limitations:
(1)
 Only
 medications which are prescribed for self-administration or that will be
 administered by an individual appropriately licensed to administer medication
 is stored in the LTSR.

(2)

 Medications stored in the LTSR are kept in a locked container in a locked
 room.

(3)
 Each prescription
 medication ordered for a resident is kept in the original prescription
 container labeled by the dispensing pharmacist for the sole use of the
 resident.

(4)
 If over-the-counter
 drugs are maintained in the facility, they will bear the original label and the
 name of the resident for whom the drug is ordered.

(c)
 Pharmaceutical services shall include: 
 
(1)
 A written quarterly review of the drug
 regimen of each resident by a licensed pharmacist and the findings submitted to
 the program director and prescribing physicians.

(2)
 A pharmacist or licensed medical staff
 annual review of the provider's medication policies and procedures including
 inspection of the medication storage areas. A written report of the review
 including inservice training recommendations, if any, is submitted to the
 program director.

(3)
 A policy
 developed or approved by a pharmacist that specifies the disposition of
 discontinued, unused, outdated or deteriorated medication.

(4)
 A written procedure for accessing
 pharmaceutical services on an emergency basis.

Notes

55

 Pa. Code §
 
5320.53

This section cited in 55 Pa. Code §
 
5320.22
 (relating to governing
 body); and 55 Pa. Code §
 
5320.53a
 (relating to
 clarification of the term "written"-statement of
 policy).

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