Section 370.840  Medication Policies


a)         Every facility shall adopt and function in conformity with written policies and procedures, for assisting residents in obtaining individually prescribed medication for self-administration and for disposing of medications prescribed by the attending physicians.


1)         These policies and procedures shall be developed with consultation from an Illinois registered professional nurse and a registered pharmacist.  These policies and procedures shall be part of the written program of care and services.


2)         All medications taken by residents in this type of facility must be ordered by the attending physician directly from a pharmacy.  Facility staff may not order medication from a pharmacy.


3)         If the policies of the facility permit residents to be totally responsible for their own medication, when the attending physician gives written permission for such action, the policies of the facility shall provide that the resident and attending physician shall be given written statements concerning the relative responsibilities of each of the three parties, (facility, resident and physician), in cases where the resident, or any other person suffers harm due to the resident's actions in handling his/her own medications.




1)         This type of facility shall not stock drugs.


2)         No pharmacy shall be operated in this type of facility.




1)         All medications on individual prescription or from the physician's personal supply shall be properly labeled as set forth in Section 370.840(m).


2)         All other medications shall be authorized by a physician for individual resident use, and shall be clearly identified with the resident's name.




1)         All medications used by residents shall be properly recorded by facility staff at time of use.


2)         A medication record need not be kept for those residents for whom the attending physician has given permission to keep their medication in their room and to be fully responsible for taking the medications in the correct dosage and at the proper times themselves.


e)         Medications administered by hypodermic shall not be given in a facility unless administered by a physician, registered nurse, or licensed practical nurse.  A resident who has been trained in self-administration of a drug by hypodermic may be permitted to do so upon the written order of the physician.


f)         Bottled oxygen may not be administered in this type of facility, except in an emergency.  Not more than one 12 pound portable size tank of oxygen for such an emergency use shall be kept in the facility. However, the use of an oxygen concentrator is permitted when prescribed by a physician for a resident.  The facility must be in compliance with directions for use of such equipment as established by the manufacturer.


g)         All discontinued legend or controlled drugs, all medications having an expiration date that has passed, and all medications of residents who have expired, shall be disposed of in accordance with the rules and regulations of the Federal Drug Enforcement Administration by the prescribing physician or the consultant pharmacist.  A notation of their disposition shall be made in the resident's record.




1)         All medications shall be stored in a locked area at all times.  Areas shall be well lighted and of sufficient size to permit storage without crowding.  This area may be a drawer, cabinet, closet, or room.


2)         This area may be a locked drawer or cabinet in the resident's room for those residents whom the attending physician has given written permission to be totally responsible for their own medication, including the obtaining, storage and self-administration of the medication.


i)          The key to the medicine area shall be the responsibility of, and in the possession of, the staff persons responsible for overseeing the self-administration of medications by residents.


1)         The general medicine area shall not be used for any other purpose.  It shall not be located in residents' rooms, bathrooms, or the kitchen.  However, for those persons whom the attending physician has given written permission to handle their own medications, medications may be stored in a locked drawer or cabinet in the resident's room along with other possessions of that resident.


2)         Residents for whom the attending physician has given permission to be totally responsible for their own medication shall maintain possession of the key to their own medication storage area.  A duplicate key shall be kept by the facility in its safe, or some other secure place, for emergency use, such as if the resident should lose or misplace his/her key.


j)          Medications for external use shall be kept in a separate area in the medicine cabinet area or in a separate locked area.


k)         All poisonous substances and other hazardous compounds shall be kept in a separate locked area away from medications.


l)          Biologicals or medications requiring refrigeration shall be stored in a properly covered locked container in a refrigerator.


m)        The label of each individual medication container filled by a pharmacist shall clearly indicate the resident's full name, physician's name, prescription number, name and strength of drug, amount of drug, date of issue, expiration date of all time-dated drugs; name, address, and telephone number of pharmacy issuing the drug; and the initials of the pharmacist filling the prescription.  If the individual medication container is filled by a physician from his/her own supply, the label shall clearly indicate all the proceeding information except that pertaining to the identification of the pharmacy, pharmacist, and prescription number.


n)         Medication containers having soiled, damaged, incomplete, illegible, or makeshift labels shall be returned to the issuing pharmacist, pharmacy, or dispensing physician for relabeling or disposal. Containers having no labels shall be destroyed in accordance with Federal and State laws.


o)         The medications of each resident shall be kept and stored in their originally received containers.  Medications shall not be transferred between containers.


(Source:  Amended at 8 Ill. Reg. 24706, effective December 7, 1984)