Assisted Living Rule Review – Narcotics protocols

The last rule in the assisted living rules for medications includes 481-67.5(2)g which requires the programs registered nurse to establish protocols including destruction and reconciliation for the program.

Narcotic protocols in assisted living programs may be challenging to implement with the potential for limited nurses and medication managers in the building at one time. However, reconciliation and timely destruction are crucial elements of preventing and detecting drug diversion.

Review of the Iowa Board of Pharmacy rules on controlled substances administered in a care center under 657-10.14(2) registrants under the controlled substances act must have policies and procedures that identify at a minimum adequate storage for all controlled substances to ensure security and proper conditions with respect to temperature and humidity, access to controlled substances and records of controlled substances by employees, proper disposition of controlled substances, reconciliation of controlled substances in schedule II, and accountability measures for controlled substances in Schedules III through V, an accountability program to document review of controlled substances inventory adjustments, review patterns of controlled substance loss, and create an action plan following a report of theft or loss.

While the rules are vague for requirements here are some best practice ideas for assisted living programs.

• Dispensing – A medication manager or licensed nurse can administer Schedule II-V drugs. Each medication should have an inventory form that identifies the date, time, dose, and person administering each dose. These forms should be monitored routinely monitored to ensure that staff are completing them as they should be.
• Reconciliation – Best practice for reconciliation is when a new person assumes responsibility for the controlled substances. This will quickly identify if there are controlled substances that are not accounted for on the inventory form. Reconciling controlled substances frequently also potentially will reduce the amount of time that will need to be investigated if drug diversion is suspected. Reconciliation should occur by both the person counting the pills in the dispensing system and verifying the number on the form matches. Each person completing reconciliation shall sign or initial indicating that reconciliation was completed for that date/time.
• Disposal – Controlled substances shall be disposed of or wasted as soon as practical after the medication has been discontinued or the tenant was discharged from the program. Disposal or wasting shall always be witnessed by two individuals. Based on your program policy this could be a medication manager and a nurse or two medication managers. Best practice would be to utilize a nurse depending on the frequency they are on-site.