D.9 MEDICATION REVIEW FORM.pdf

YES NO N/A

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

FOR MEDICATION MANAGEMENT:

AS REQUESTED, PERSONS SERVED ARE PROVIDED INFORMATION ABOUT

RESOURCES FOR ADVOCACY TO ASSIST THEM IN BEING ACTIVELY

INVOLVED IN MAKING DECISIONS RELATED TO THE USE OF MEDICATIONS

AS REQUESTED, PERSONS SERVED ARE PROVIDED INFORMATION ABOUT

TRAINING AND EDUCATION REGARDING MEDICATION

ORGANIZATION HAS WRITTEN PROCEDURES REGARDING MEDICATIONS

THAT PROVIDE FOR COMPLIANCE WITH ALL APPLICABLE LAWS AND

REGULATIONS PERTAINING TO MEDICATIONS AND CONTROLLED

SUBSTANCES

HOMES PROJECT CODE:

MEDICATION REVIEW

SITE ADDRESS:

ORGANIZATION HAS DOCUMENTATION OR CONFIRMATION OF INFORMED

CONSENT FOR EACH MEDICATION ADMINISTERED, WHEN POSSIBLE

ORGANIZATION DOCUMENTS THAT THE USE OF ALL MEDICATIONS BY

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

PHYSICIAN OR QUALIFIED PROFESSIONAL LICENSED TO PRESCRIBE

MEDICATIONS

ORGANIZATION HAS WRITTEN PROCEDURES THAT ADDRESS

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

APPROPRIATE DISCIPLINE(S) SHOULD COMPLETE

THIS SECTION ATTACHING THEIR RESPECTIVE

REPORT FORMAT(S)

ORGANIZATION HAS WRITTEN PROCEDURES THAT ADDRESS STORAGE

AND HANDLING OF MEDICATIONS, SAFE DISPOSAL, AND DOCUMENTATION

OF MEDICATION USE

AN UP-TO-DATE INDIVIDUAL RECORD OF ALL MEDICATIONS, INCLUDING

PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS, USED BY

PERSONS SERVED

ATTACHMENT D.9- MEDICATION REVIEW FORM RFQ 36C24226Q0118

YES NO N/A

YES NO N/A

SELF-ADMINISTERED MEDICATIONS ARE STORED IN A SAFE AND SECURE

MANNER IN THE RESIDENT'S ROOM ACCORDING TO THE FACILITY'S

POLICIES AND PROCEDURES

ALL MEDICATIONS ARE STORED IN A SECURE LOCKED AREA, EXCEPT

WHEN UNDER THE DIRECT SUPERVISION OF APPROPRIATE STAFF

ALL MEDICATIONS ARE PERIODICALLY CHECKED FOR EXPIRATION DATES

OR DETERIORATION

ALL MEDICATIONS ARE STORED ACCORDING TO MANUFACTURER’S

RECOMMENDATIONS

PROGRAM STAFF RESPONSIBLE FOR MONITORING ARE FAMILIAR WITH

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.

PROGRAM STAFF RESPONSIBLE FOR MONITORING ARE PROVIDED

ORIENTATION, CONTINUING EDUCATION AND TRAINING, AS APPROPRIATE

KEYS OR COMBINATIONS TO LOCKS FOR THE MEDICATION AREA ARE

UNDER THE CONTROL OF AUTHORIZED STAFF

FOR INDIVIDUAL STORAGE:

ORGANIZATION PROCEDURES ENSURE THE IDENTIFICATION,

DOCUMENTATION, AND REQUIRED REPORTING, INCLUDING TO THE

PRESCRIBING PROFESSIONAL, ANY MEDICATION REACTIONS OR

MEDICATION ERRORS, AS APPROPRIATE

FOR MEDICATION MONITORING:

METHOD OF STORAGE CAN NOT BE EASILY REMOVED FROM THE

FACILITY (I.E. LOCK BOX IS SECURED TO A LARGE DRESSER OR THE

STRUCTURE OF THE BUILDING)

ORGANIZATION HAS WRITTEN PROCEDURES THAT ADDRESS STORAGE

AND HANDLING OF MEDICATIONS, SAFE DISPOSAL, AND DOCUMENTATION

OF MEDICATION USE

ORGANIZATION HAS WRITTEN PROCEDURES WHICH INTEGRATE ANY

PRESCRIBED MEDICATIONS INTO A PERSON'S OVERALL PLAN,

INCLUDING, IF APPLICABLE, SPECIAL DIETARY NEEDS AND RESTRICTIONS

ASSOCIATED WITH MEDICATION USE

ORGANIZATION HAS WRITTEN PROCEDURES WHICH INCLUDE ACTIONS

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

AN UP-TO-DATE INDIVIDUAL RECORD OF ALL MEDICATIONS, INCLUDING

PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS, USED BY

PERSONS SERVED

YES NO

YES NO

Medication Inspection Team Members Signature Medication Management Inspection Team Members Name ( Print)

Date

MEDICATION REVIEW

CHECKLIST

HOMES PROJECT CODE:

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