Policy Manual sample

MDT Home Health Care Agency, Inc. 204 MEDICATION SAFETY POLICY: The organization has a system in place to ensure patient safety by accurately and completely reconciling patient medications across the continuum of care. PROCEDURE: • During the initial skilled assessment visit, the appropriate discipline (SN, PT, ST) obtains a complete list of the patient’s currently prescribed and over-the-counter medications, including herbal remedies. • The Medication Profile is completed in its entirety, including dosage, frequency and administration routes, according to organization policy. • The patient’s/caregiver’s/significant other’s involvement in development of the list and agreement as to the accuracy of the list is evidenced by: • The patient’s/caregiver’s/significant other’s signature on the Medication Profile or • A notation in the record that the patient/caregiver/significant other provided the information/physical medication containers, reviewed the list and agreed that the list was accurate and complete. • Medication information obtained by a therapist (PT/ST) is verified with the physician and/or dispensing pharmacy by the Case Manager/Nursing Supervisor. • A copy of the completed medication list remains in the patient’s home chart and is distributed to all healthcare team members providing care, treatment and/or services to the patient. • The Medication Profile is reviewed and updated as necessary according to organization policy. • The completeness and accuracy of the medication record is audited monthly and quarterly summary reports submitted to the Board of Directors and Professional Advisory Committee. • Any permanent harm or death that occurs that is related to medications is a sentinel event and is reported to the ACCREDITATION as per the organization’s Sentinel Event policy. • Root cause analysis is conducted on any identified variances and a plan of correction is developed, implemented and evaluated.