Medication Management in Assisted Living Homes
In a list promulgated by Arizona’s Department of Health Services in April of 2022, three (3) of the “Top Ten” deficiencies for Assisted Living Homes were in the area of Medication Services. Whether you are an assisted living operator in Arizona, or another state, you may want to self-audit your business operations in the following areas:
1. When medication is stored by an assisted living facility, a manager shall ensure that: Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage… (9 Ariz. Admin. Code § 10-816.F.1)
Many assisted living homes maintain “medi-sets,” which are typically 4-part weekly cartridges filled once a week with each resident’s compliment of breakfast, lunchtime, dinnertime and bedtime medications divided up into separate sections for ease of administration. If these medi-sets are kept in a kitchen cabinet or other stored area accessible to the caregivers, it must not only be locked in some manner so that the residents would not have access to it, but also kept separate from other food or inventory supplies. In other words, don’t put the coffee and sugar in the same cabinet as the medication. Also, keep it locked at all times. State surveyors have a habit of arriving at breakfast time, and if that cabinet is not locked because the care team is in the middle of administering medications, the surveyor may still issue a citation under this rule.
In addition to the medi-sets, assisted living homes typically have a basket or plastic tub that contains a 30 or 90-day supply of the bottled medications, labeled by each resident name. This (backstock) inventory supply must likewise be locked separately if they are in a location apart from the medi-sets. Generally, other medical-related supplies, such as over-the-counter medications and topical creams, first aid supplies (i.e. bandages; peroxide; wipes, etc.) can be maintained in that same closet or cabinet, as long as it is locked and not used for other items, such as a resident’s clothing or activity “toys” storage).
2. A medication administered to a resident: c. Is documented in the resident's medical record., (9 Ariz. Admin. Code § 1816(B)(3)(c))
Every licensed assisted living home that provides medication administration assistance needs to chart when (and by whom) those medications were administered. These charts can be maintained electronically or on paper (commonly known as MARs). Either way, the charting should be done in compliance with both this regulation and the home’s written Policies and Procedures. The standard is for the caregiver or manager who administered the medications to place their initials on a chart next to the date/time of mediation administration next to the name and dosage after the medication given on each resident’s record. Where there are blanks in the chart, or a medication is not listed in the chart even though there is an order for it, or some other administration anomaly, the state surveyor will note this as a deficiency, which may be a stand-alone citation, or in addition to other subsets of the Rule.
The manager is responsible for ensuring that all medications administered are properly charted, but ultimately, the governing authority (i.e. owner of the business) may be cited if MAR records are not properly-maintained.
3. A medication administered to a resident: … b. Is administered in compliance with a medication order… (9 Ariz. Admin. Code § 1816(B)(3)(b))
This is very similar to the subset of the Rule cited above, but refers to having a written Rx script or electronically-signed prescription order in the resident’s chart that corresponds with both the label on the bottle, and the medication administration record (“MAR”) maintained by the facility. It should be noted, however, that sometimes the doctor gives a verbal phone order, or the family gives the written order to the pharmacy and doesn’t retain a copy to provide to the assisted living home. Thus, there is another regulation that addresses this common occurrence: 9 Ariz. Admin. Code § 1816(A)(2)(c)) states that: “If a verbal order for a resident's medication is received from a medical practitioner by the assisted living facility: … c. A written order verifying the verbal order is obtained from the medical practitioner within 14 calendar days after receiving the verbal order.” Thus, if a licensed assisted living facility received a deficiency that, for example, an antibiotic ordered by the physician less than 2 weeks ago did not have a written order on file to be compliant with 9 Ariz. Admin. Code § 1816(B)(3)(b), the facility may submit an Informal Dispute Resolution (“IDR”) challenging that deficiency on the basis of timeliness and 9 Ariz. Admin. Code § 1816(A)(2)(c), asking that the deficiency be removed from the inspection report.
Coincidentally, this is the only Medication-Services deficiency that is also found to be in the Top Ten list of Deficiencies against assisted living centers in AZ (i.e. facilities with 11 beds and more). Thus, if you are a residential assisted living owner that is accepting a resident from a center, pay careful attention to the list of medications and actual medications delivered along with the resident, because it is likely that you may need some written orders (or changes to prior orders) submitted from the medical provider.
Similarly, it is a good practice to review the list of medications against written orders on a routine basis, and ask the primary care provider to likewise review and sign off on a list of medications routinely. The Manager’s job description should include a reference to checking the MARs for compliance on a scheduled basis, and ensuring compliance with these requirements.
If you would like Pinkowski Law & Policy Group to review your Policies and Procedures against your MAR practices, do not hesitate to contact us for a compliance consultation.
Look for more weekly blog posts on topics of interest to Assisted Living and Behavioral Health operators. The information herein is intended to be educational and an introduction to the subject matter presented. It is NOT specific legal advice to be relied upon for specific individual circumstances. Contact your own legal professional or reach out to our firm if you would like specific advice on this topic. We welcome topic suggestions! Write to info@pinkowskilaw.com if you are curious to learn more about a certain topic impacting assisted living or other group housing concerns.