CENTRALLY STORED MEDICATION AND DESTRUCTION …

1 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCYDEPARTMENT OF SOCIAL SERVICESCOMMUNITY CARE LICENSINGCENTRALLY STORED MEDICATION AND DESTRUCTION RECORDI. CENTRALLY STORED MEDICATIONINSTRUCTIONS: CENTRALLY STORED medications shall be kept in a safe and locked place that is not accessible to any person(s)except authorized individuals. MEDICATION records on each client/resident shall be maintained for at least one (LASTFIRST MIDDLE)ADMISSION DATEATTENDING PHYSICIANADMINISTRATORFACILITY NAMEFACILITY NUMBERMEDICATION NAMESTRENGTH/QUANTITYINSTRUCTIONSCONTROL /CUSTODYEXPIRATIONDATEDATEFILLEDDATESTAR TEDPRESCRIBINGPHYSICIANPRESCRIPTIONNUMBE RNO. OFREFILLSNAME OFPHARMACYLIC 622 (3/99) (CONFIDENTIAL)II. MEDICATION DESTRUCTION RECORDINSTRUCTIONS:Prescription drugs not taken with the client/resident upon termination of services or otherwise disposed of shall be destroyed in the facility by the Administrator orDesignated Representative and witnessed by one other adult who is not a client/resident.

2 All facilities except Residential Care Facilities for the Elderly (RCFEs) shallretain DESTRUCTION records for at least one year. RCFEs shall retain records for at least three NAMEMEDICATION NAMESTRENGTH/QUANTITYSTRENGTH/QUANTITYIN STRUCTIONSCONTROL/CUSTODYEXPIRATIONDATED ATEFILLEDDATE FILLEDDATESTARTEDPRESCRIBINGPHYSICIANPRE SCRIPTIONNUMBERPRESCRIPTIONNUMBERDISPOSA LDATENAME OF PHARMACYSIGNATURE OF ADMINISTRATOR ORDESIGNATED REPRESENTATIVESIGNATURE OF WITNESSADULT NON-CLIENTNO. OFREFILLSNAME OFPHARMACY