Conn. Agencies Regs. § 17a-210-6

Current through October 16, 2024

Section 17a-210-6 - Documentation

(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.

(b) In individual and family support settings trained non-licensed personnel shall document the administration of medication to consumers in accordance with the consumer's individual plan.

Conn. Agencies Regs. § 17a-210-6

Effective May 31, 1996; Amended December 3, 2009