Assisted Living Medication Management: Policy/Procedures Development and Quality Assurance

Assisted living facilities should have written policies and procedures for safe and effective medication management, storage, and administration. Policies could address, but not be limited to, the following issues:

  • Medication orders, including telephone orders
  • Medication packaging
  • Medication storage
  • Disposal of medications
  • Pharmacy review
  • Self-administration of medications by the resident
  • Medication administration by staff – specific procedures (including documentation)
  • Medication error definition, detection, follow-up and reporting
  • Medication error prevention/reduction
  • Monitoring for adverse effects of medications
  • Drug interactions
  • Storage and accountability of controlled substances
  • Use of psychotropic medications
  • Use of medications ordered as needed (PRN)
  • Staff training, qualifications and supervision

In addition to developing policies and procedures related to medication administration, assisted living facilities should develop a quality assurance process to monitor the effectiveness of the medication system. A quality assurance program could include:

  • A systematic, routine review of the medication delivery system
  • Observation of medication administration
  • Review of the medication storage system
  • Investigation of medication errors to identify cause
  • Audit of medication administration records for accuracy and completeness
  • Evaluate results of pharmacist’s medication regimen reviews
  • Identification and implementation of corrective actions when necessary

Relevant Regulations

Adult Day Care (ADC):
Certification Standard I.F.(1) – The adult day care program shall have a written policy for medication management and shall designate which staff are authorized and trained to administer medications in accordance with (3). The policy shall indicate the program’s role in the supervision of self-administered medications and/or staff administered medications.

Family ADC:
Certification Standard I.D.(1) – The adult day care program shall have a written policy for medication management and shall designate which staff are authorized and trained to administer medications in accordance with (3). The policy shall indicate the program’s role in the supervision of self-administered medications and/or staff administered medications

Community-Based Residential Facility (CBRF):
Wis. Admin. Code § DHS 83.37(1)(c)
Wis. Admin. Code § DHS 83.37(1)(g)3

Resources

FAQs

1. Does an adult family home or residential care apartment complex need to have quality assurance program since there are no relevant regulations?

All providers should have a quality assurance program specific to medications. Quality assurance programs can prevent future medication errors and adverse events.

2. Can facilities with shared ownership have the same policies?

Often times policies can be shared but when facilities are in different communities or have different types of residents often times the policies need to be individualized for that community.

Last Revised: March 2, 2018