7 Medication Review Template.docx

MEDICATION REVIEW

HOMES PROJECT CODE:

SITE ADDRESS:

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE

THIS SECTION ATTACHING THEIR RESPECTIVE

REPORT FORMAT(S)

TYPE OF MEDICATION CONTROL SYSTEM USED BY AGENCY (CHECK ALL THAT APPLY, AT LEAST ONE ITEM MUST BE CHECKED, IF AN ITEM IS CHECKED THEN N/A MAYNOT BE SELECTED FOR ANY ITEMS IN THAT SECTION):

MEDICATION MANAGEMENT: PRACTICE OF PRESCRIBING, ADMINISTERING, AND/OR

___ DISPENSING MEDICATION BY QUALIFIED PERSONNEL, INCLUDING TAKING PILLS OUT OF

BOTTLES, MEASURING LIQUIDS, OR GIVING INJECTIONS

MEDICATION MONITORING: PRACTICE OF PROVIDING A COMBINED SECURE STORAGE AREA AND CONTROLLED ACCESS FOR MEDICATIONS THAT ARE BROUGHT INTO A PROGRAM AND USED BY THE VETERAN. THE PERSON TAKES THE MEDICATION WITHOUT ANY ASSISTANCE FROM STAFF

INDIVIDUAL STORAGE: PRACTICE OF ALLOWING INDIVIDUALS TO STORE (I.E. LOCK BOX,

INDIVIDUAL APARTMENT UNIT) AND SELF-ADMINISTER THEIR MEDICATIONS

PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS, USED BY PERSONS SERVED

AND HANDLING OF MEDICATIONS, SAFE DISPOSAL, AND DOCUMENTATION OF MEDICATION USE

RESOURCES FOR ADVOCACY TO ASSIST THEM IN BEING ACTIVELY

INVOLVED IN MAKING DECISIONS RELATED TO THE USE OF MEDICATIONS

PERSONS SERVED IS REVIEWED ON AT LEAST AN ANNUAL BASIS BY A

PHYSICIAN OR QUALIFIED PROFESSIONAL LICENSED TO PRESCRIBE MEDICATIONS

ADMINISTRATION OF MEDICATIONS BY PERSONNEL, INCLUDING STAFF

CREDENTIALS AND COMPETENCIES, DOCUMENTATION OF MEDICATION

ADMINISTRATION, AND DOCUMENTATION OF THE USE AND BENEFITS, OR LACK THEREOF, OF AS NEEDED DOSES

THAT PROVIDE FOR COMPLIANCE WITH ALL APPLICABLE LAWS AND

REGULATIONS PERTAINING TO MEDICATIONS AND CONTROLLED SUBSTANCES

PRESCRIBED MEDICATIONS INTO A PERSON'S OVERALL PLAN,

INCLUDING, IF APPLICABLE, SPECIAL DIETARY NEEDS AND RESTRICTIONS ASSOCIATED WITH MEDICATION USE

DOCUMENTATION, AND REQUIRED REPORTING, INCLUDING TO THE

PRESCRIBING PROFESSIONAL, ANY MEDICATION REACTIONS OR

MEDICATION ERRORS, AS APPROPRIATE

TO FOLLOW IN CASE OF EMERGENCIES RELATED TO THE USE OF

MEDICATIONS, INCLUDING READY ACCESS TO THE TELEPHONE NUMBER

OF A POISON CONTROL CENTER BY BOTH PROGRAM PERSONNEL AND PARTICIPANTS

PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS, USED BY PERSONS SERVED

AND HANDLING OF MEDICATIONS, SAFE DISPOSAL, AND DOCUMENTATION OF MEDICATION USE

ALL MEDICATIONS STOCKED. THEY HAVE KNOWLEDGE OF/OR ACCESS

TO INFORMATION (e.g. CURRENT PHYSICIANS DESK REFERENCE OR OTHER RESOURCE) THAT INCLUDES INDICATIONS, SIDE EFFECTS, TOXIC EFFECTS, INTERACTIONS, AND POTENTIAL ALLERGIC REACTIONS.

ORIENTATION, CONTINUING EDUCATION AND TRAINING, AS APPROPRIATE

MANNER IN THE RESIDENT'S ROOM ACCORDING TO THE FACILITY'S POLICIES AND PROCEDURES

FACILITY (I.E. LOCK BOX IS SECURED TO A LARGE DRESSER OR THE STRUCTURE OF THE BUILDING)

INSPECTION DEFICIENCIES & CORRECTIVE ACTIONS

ANY CHECKLIST ITEMS WHERE “NO” WAS INDICATED MUST HAVE DOCUMENTATION PROVIDED BELOW DETAILING THE SPECIFICS OF THE DEFICIENCY; CORRECTIVE ACTIONS TAKEN; AND THE DATE THE PROVIDER WAS IN COMPLIANCE. ANY DEFICIENCIES NOT CORRECTED AND APPROPRIATELY DOCUMENTED WILL RESULT IN AN INCOMPLETE INSPECTION PACKAGE.

Deficiencies were present for items on this checklist during inspection (If Yes list deficiencies and confirm resolution below)

THESE ARE ITEMS THAT WOULD NOT CAUSE THE CONTRACT PROVIDER TO BE DEFICIENT IN ANY PROGRAM REQUIREMENTS BUT, MAY OFFER AN OPPORTUNITY FOR PROGRAM IMPROVEMENT.

ALL APPROPRIATE CHECK LIST ITEMS HAVE BEEN ADDRESSED AND THE FACILITY IS APPROVED FOR PLACEMENT OF VETERANS

Members Name ( Print) Date