Connecticut Administrative Code › Title 17a - Social and Human Services and Resources › 210 - Administration of Medications: Residential Facilities, Respite Centers, Day Programs, Community Training Homes, and Individual and Family Supports › Section 17a-210-6 - Documentation

Current through July 10, 2024
(a) In residential facilities, respite
			 centers and day programs, administration of medication shall be documented
			 under the direct supervision of a supervising nurse as follows:
(1) All documentation on the administration
			 of medications shall be made in ink.
(2) A signed original of all licensed
			 prescriber's orders shall be maintained in the consumer's file at each site of
			 administration. Copies of orders may be used only if they contain an original
			 signature. A facsimile transmission of the original order that is received
			 directly from the licensed prescriber, shall be considered a signed original if
			 it contains the required identification information for the consumer and the
			 licensed prescriber. This facsimile shall not be considered an original order
			 if it is re-transmitted to another site.
(3) A licensed prescriber's telephone order,
			 for any medication can only be received by licensed personnel as defined in
			 subsection (s) of section
			 17a-210-1 of the
			 Regulations of Connecticut State Agencies. The licensed prescriber shall sign
			 such order as soon as is practicable, but not later than two weeks from the
			 date of receipt of the order.
(4)
			 Any change in medication, dosage level of medication, route of administration
			 or frequency of administration shall be considered a new medication order for
			 the purpose of documentation.
(5)
			 Documentation of each administration of all medications shall be made by the
			 residential facility, respite center or day program on a separate medication
			 record for each consumer.
(6)
			 Medication records shall include the following information:
(A) The consumer's name;
(B) The name of the medication;
(C) The name of the licensed
			 prescriber;
(D) The dosage of the
			 medication;
(E) The frequency of
			 administration;
(F) The route of
			 administration;
(G) The initials
			 and signatures of employees who have administered the medication;
(H) The renewal date of the original order
			 from the licensed prescriber;
(I)
			 Whether the medication was administered;
(J) When the medication was
			 administered;
(K) The expiration
			 date of the original order from the licensed prescriber;
(L) Consumer allergies to food and
			 medication;
(M) Information on
			 non-compliance of a consumer in accepting medication; and
(N) For medication ordered on an
			 as-needed-basis, the reason for the administration and the consumer's response
			 to the medication.
(7)
			 The receipt by a residential facility, respite center or day program of each
			 prescription for a controlled medication and the documentation of the
			 administration of such controlled medication shall be made on receipt and
			 disposition forms.
(8) The receipt
			 and disposition forms shall include the following information:
(A) The consumer's name;
(B) The prescription number;
(C) The prescription date;
(D) The name of the pharmacy;
(E) The name of the licensed
			 prescriber;
(F) The date of receipt
			 of the controlled medication;
(G)
			 The quantity of the controlled medication;
(H) The name of the medication;
(I) The dosage of the medication;
(J) The form of the medication;
(K) The signature of the employee who
			 received the controlled medication;
(L) The frequency of
			 administration;
(M) The route of
			 administration;
(N) The initials
			 and signatures of employees who have administered the medication;
(O) The month, day, year and time the
			 medication was administered;
(P)
			 The amount of medication remaining;
(Q) The expiration date of the medication;
			 and
(R) Consumer allergies to food
			 and medication.
(9) Any
			 errors in the administration of medications shall be documented in accordance
			 with subsections (o) and (r) of section
			 17a-210-2
			 of the Regulations of Connecticut State Agencies.
(10) At the end of each month, the consumer's
			 medication record shall become a permanent part of the consumer's record. The
			 receipt and disposition forms shall be kept in a location separate from the
			 consumer's medical record.