S02 - SOLICITATION ATTACHMENT - D.8 HEALTH CARE FOR HOMELESS VETERANS CONTRACT PROGRAM MEDICATION REVIEW FORM.pdf

HOMES PROJECT CODE:

MEDICATION REVIEW

APPROPRIATE DISCIPLINE(S) SHOULD SITE ADDRESS:

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

FOR MEDICATION MANAGEMENT: YES NO N/A

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

PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS, USED BY PERSONS SERVED

ORGANIZATION HAS WRITTEN PROCEDURES THAT ADDRESS STORAGE AND

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

USE

AS REQUESTED, PERSONS SERVED ARE PROVIDED INFORMATION ABOUT

69 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 DOCUMENTS THAT THE USE OF ALL MEDICATIONS BY PERSONS

71 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

72 COMPETENCIES, DOCUMENTATION OF MEDICATION ADMINISTRATION, AND

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

DOSES

ORGANIZATION HAS WRITTEN PROCEDURES REGARDING MEDICATIONS THAT

73 PROVIDE FOR COMPLIANCE WITH ALL APPLICABLE LAWS AND REGULATIONS

PERTAINING TO MEDICATIONS AND CONTROLLED SUBSTANCES

ORGANIZATION HAS DOCUMENTATION OR CONFIRMATION OF INFORMED CONSENT

FOR EACH MEDICATION ADMINISTERED, WHEN POSSIBLE

36C24222R0035: D.8 HCHV CONTRACT PROGRAM MEDICATION REVIEW FORM

ORGANIZATION HAS WRITTEN PROCEDURES WHICH INTEGRATE ANY PRESCRIBED

75 MEDICATIONS INTO A PERSON'S OVERALL PLAN, INCLUDING, IF APPLICABLE,

SPECIAL DIETARY NEEDS AND RESTRICTIONS ASSOCIATED WITH MEDICATION USE

ORGANIZATION PROCEDURES ENSURE THE IDENTIFICATION, DOCUMENTATION, AND

76 REQUIRED REPORTING, INCLUDING TO THE PRESCRIBING PROFESSIONAL, ANY

MEDICATION REACTIONS OR MEDICATION ERRORS, AS APPROPRIATE

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

FOR MEDICATION MONITORING: YES NO N/A

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

PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS, USED BY PERSONS SERVED

ORGANIZATION HAS WRITTEN PROCEDURES THAT ADDRESS STORAGE AND

79 HANDLING OF MEDICATIONS, SAFE DISPOSAL, AND DOCUMENTATION OF

MEDICATION USE

ALL MEDICATIONS ARE STORED IN A SECURE LOCKED AREA, EXCEPT WHEN UNDER

THE DIRECT SUPERVISION OF APPROPRIATE STAFF

KEYS OR COMBINATIONS TO LOCKS FOR THE MEDICATION AREA ARE UNDER THE

CONTROL OF AUTHORIZED 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

84 (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

FOR INDIVIDUAL STORAGE: YES NO N/A

SELF-ADMINISTERED MEDICATIONS ARE STORED IN A SAFE AND SECURE MANNER

86 IN THE RESIDENT'S ROOM ACCORDING TO THE FACILITY'S POLICIES AND

PROCEDURES

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)

MEDICATION REVIEW

HOMES PROJECT CODE:

CHECKLIST 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.

YES NO

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.

YES NO

ALL APPROPRIATE CHECK LIST ITEMS HAVE BEEN ADDRESSED AND THE FACILITY IS

APPROVED FOR PLACEMENT OF VETERANS

Medication Inspection Team Members Medication Management Inspection T earn Members Date

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