Resident Medication Regimen and Administration Review
PDF Version of BQA 06-021
(PDF 11 KB)
Date: September 29, 2006 -- BQA Memo 06-021
To: Community-Based Residential Facilities CBRF 09
From: Kevin Coughlin, Chief, Assisted Living Section
Via: Otis Woods, Director, Bureau of Quality Assurance
Resident Medication Regimen and Administration Review
ISSUE
Wis. Admin. Code § HFS 83.33(3)(a)2, http://www.legis.state.wi.us/rsb/code/hfs/hfs083.pdf
states that: "The administrator or designee shall arrange for a
pharmacist or a physician to review each resident's medication regimen for
positive resident outcomes and assurance of proper medication
administration."
What is required in the review of a resident's medication regimen for
positive outcomes? Is an on-site visit by the physician or pharmacist
required in order to properly review medication administration?
The purpose of this memo is to clarify each element of this provision,
namely the "residents' medication regimen review" and
"proper medication administration."
RESPONSE
Medication Regimen Review:
Each resident's medication regimen must be reviewed by a physician or
pharmacist for positive outcomes not less than every 12 months following
admission, or as otherwise stated in Wis. Admin. Code § HFS 83.33(3)(a)2 http://www.legis.state.wi.us/rsb/code/hfs/hfs083.pdf
A physician's or pharmacist's review of a resident's medication regimen is
typically done at their place of work. The physician or pharmacist may
review records of medications, orders, lab results, etc., to evaluate a
resident's medication regimen. The facility shall maintain a written
report of findings from the physician or pharmacist in each resident's
record.
Proper Medication Administration:
A review to determine proper medication administration, must include
observations of actual medication administration. In a community-based
residential facility (CBRF) where staff administers medications, there
must be an annual on-site review of medication administration. This should
include a review of medication handling and storage practices.
A physician or pharmacist may have a registered nurse (RN) conduct
observations of staff administering medications and provide information to
the physician or pharmacist to consider as part of the medication
administration review. The facility shall maintain a written report of
findings from this annual on-site review.
When the medication administration review is done by someone other than
the prescribing practitioner, the prescribing practitioner shall receive a
copy of the report when the person conducting the review recommends a
change to the resident's medication regimen or a change in the
administration of a medication.
Residents who control and administer their own medications may provide
information directly to the reviewer as to how the resident
self-administers any medications, which may be done on-site, at the
physician's office, or at the pharmacy, and may be part of the medication
regimen review.
In summary, a physician or pharmacist must review and
document each resident's medication regimen for positive outcomes not less
than once every 12 months. The facility shall keep a copy of the
medication regimen review in each resident's record. In a CBRF where staff
administers medications, there must be an annual on-site review of the
medication administration process; which, at a minimum, includes a review
of medication storage.
The on-site portion of the medication administration
review may be conducted by an RN. The facility shall keep a written record
of findings from the on-site review, and also have the written report
available for Department review.
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