Records for Long-Term Care Facilities (LTCF)

PURPOSE: This rule sets requirements for record keeping by longterm care facility registrants. (1) Long-term care facilities (LTCFs) and their suppliers shall maintain written records of transfers of controlled substances from the supplier to the LTCF emergency kit. (2) The records shall include the date of transfer; the name of each controlled substance, the strength, dosage form and quantity; the name, address and controlled substance registration number of the supplier and the name, address and controlled substance registration number of the LTCF. Federal Drug Enforcement Administration (DEA) official order forms shall not be used to record transfers of controlled substances to LTCF emergency kits. (3) No physician’s order or prescription shall be used for initial stocking or replacement of controlled substances in the emergency kit. Controlled substances contained in the kit shall be obtained from a pharmacy, hospital or practitioner who holds a controlled substances registration. (4) The administration and medical staff of the LTCF, in conjunction with the primary supplier, shall designate in written protocols and procedures who may have access to the emergency kit, who may administer controlled substances from the emergency kit and under what circumstances and a list of the controlled substances it intends to maintain in the emergency kit. These protocols and procedures shall be subject to review and approval by the Department of Health. Only those individuals designated in the LTCF’s written policies and procedures shall have access to or administer controlled substances from the emergency kit. (5) Each administration of controlled substances from the emergency kit shall be based upon a practitioner’s order and shall be recorded in an administration record separate from the patient’s medical record. This administration record shall include: the date, patient’s name, drug name, drug strength, dosage, ordering practitioner’s name and name of the person administering the controlled substance. AUTHORITY: sections 195.050 and 195.195, RSMo 1994.* Original rule filed April 14, 2000, effective Nov. 30, 2000. *Original authority: 195.050, RSMo 1939, amended 1971, 1989 and 195.195, RSMo 1957, amended 1971, 1989, 1993.