F761 – Maintaining Compliance through Strong Partnerships
Maintaining compliance with F761 – Storage and Labeling of Drugs and Biologicals requires ensuring medications are properly stored, secured, and destroyed based on state and federal guidelines. Partnering with a contracted pharmacy service may improve survey outcomes and ongoing compliance. A few steps towards a successful partnership include:
- Choosing a pharmacy partner specializing in, or familiar with long-term care facilities and regulatory requirements
- Clearly defining roles and responsibilities in contractual service agreements, including:
- Proper labeling
- Controlled substance tracking and destruction procedures
- Routine audits of medication storage including carts, medication rooms, and destruction documentation
- Oversight of proper labeling and storage:
- Labels should contain resident name, medication name, strength, route and expiration
- Opened medications should indicate open date and discarded based on manufacturer guidelines
- Regular audits should be conducted to monitor compliance
- Working together for strong drug destruction protocols to ensure:
- DEA compliance related to storage and handling of Scheduled I-IV medications
- Documentation of drug destruction
- Regular pickups for expired or unusable medications
- Details logs for storage temperatures, narcotic administration, and medication destruction
- Providing staff education and support related to:
- Labeling, storage, and destruction practices
- Written protocols and checklists
- Survey preparation and routine audits
Directors of nursing, administrators, consultant pharmacists and account managers should connect regularly to review potential regulatory issues, audit results, potential performance improvement opportunities, and documentation concerns. Overall, clear and frequent communication between facility leadership and contracted pharmacies is imperative for ongoing compliance and positive survey outcomes.
Next steps:
- Access on-demand training on F761 compliance to identify additional action items to ensure survey success
- Contact Proactive to schedule a mock survey that includes a review of all 9 mandatory tasks
- Subscribe to the Proactive Solutions Center and gain access to comprehensive compliance resources including up to date policies and procedures for Medication Administration
Written By:
Liz Wheeler, BSN, RN, CHPN, IPCO, QCP, CDP
Clinical Consultant
Proactive LTC Consulting
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