Nonavailability of Medications in Assisted Living
There are times when assisted living wellness staff experiences difficulties in obtaining residents’ necessary medications; there are various reasons for these difficulties and methods to address them.
For residents needing medication assistance and/or medication administration services, the facility is required to ensure the medications are delivered as ordered by the prescriber. When this is impossible due to unavailability of one or more medications, there are guidelines and best practices that might aid in alleviating the issue while keeping the resident safe. Some situations where medications might not be available, along with possible solutions, are listed below. Of note, thorough documentation of efforts, plans, and methods to monitor the resident for a decline in health condition will aid in demonstrating the facility’s attempts to rectify the situation promptly while at the same time meeting the resident’s needs.
INSURANCE PRE-APPROVAL REQUIRED. There are times when the prescriber writes an order for a medication that must be pre-approved by the resident’s health insurance. Most Medicare drug plans have their own list of medication they will cover called a formulary. In these instances, the facility staff should consider contacting the doctor to discover if there is an alternative to the prescription that is covered by insurance. Most LTC pharmacies will assist with this process. They will let you know what is covered or not and if an alternative is available via fax. Contact the prescriber who can discontinue the current order and write a prescription for the alternate medication. If there is not an alternative, and the insurance company requires a prior authorization for the medication, ask the prescriber if you can have a “hold” on the order until it is approved by the insurance company allowing the pharmacy to dispense the medication. The LTC pharmacy will send documentation to the prescriber to fill out additional information required by the insurance company. This process can take up to 72 hours. The facility staff should continue checking with the pharmacy and the insurance company to determine the possible approval timeframe.
FAMILY DOES NOT ORDER/OBTAIN/DELIVER THE MEDICATION. Family assistance with medications and treatments is an optional service that facilities might allow. The documented and agreed-upon family plan must include an alternate plan should the family member be unable to fulfill his/her obligations in ensuring medication services are available for the resident. Some ways to correct this issue include but are not limited to:
- Creating a policy whereby the alternate plan is standardized, moving the resident’s medication services to the wellness center for medication management.
- Ensuring the resident and/or the legal representative signs a “back-up” agreement with the facility’s preferred long term care pharmacy upon moving into the facility, so medications can be ordered there if needed.
- Ensuring that the family is storing all the resident’s medications onsite, either locked in the resident’s apartment or stored in the wellness office.
MEDICATIONS ARE NOT ORDERED BY STAFF IN A TIMELY MANNER. The assisted living must have systems in place to ensure medications are available. If using an electronic medication administration record (MAR) and your system is integrated with the pharmacy provider, there should be a “reorder” button for each medication; work with the long-term care pharmacy to determine the correct timeframe for reordering medications (i.e. when there are three doses left) to ensure staff is not reordering too soon (and therefore the pharmacy cannot send the medications). A manual system can be set up for those facilities that use paper MARs. Retraining staff might be warranted. A complete medication check-in process should be maintained for electronic or manual records including what to do when the medication is too soon to fill/dispense. Having a satellite agreement with a local pharmacy is also beneficial, particularly when residents receive prescriptions during times when the facility’s long term care pharmacy is closed or when a prescriber orders a medication to be started right away. Most LTC pharmacies already have these agreements in place.
RESIDENT OR RESIDENT’S FINANCIAL REPRESENTATIVE DOES NOT PAY THEIR PHARMACY CO-PAYS/BILL. There are instances when residents or their responsible family members choose not to pay the copays/bill associated with medications. In these instances, the long-term care pharmacy will notify the resident/representative and executive director of the need to pay and, if they do not, a date when medications will no longer be delivered to the facility. The facility staff has a level of obligation to work with the resident and/or family to ensure no break in medication delivery. Likewise, documenting these efforts is paramount to demonstrating attempts at compliance. Some ideas include:
- Holding a meeting with the resident and responsible representative to discuss what the issues are with nonpayment and strategize ways to minimize and/or alleviate these issues.
- If the medications in question are over-the-counter or otherwise deemed a relatively low risk if missed, discuss the possibility of reaching out to the prescriber and explaining the issues of concern and request the medications be discontinued.
- The facility staff can also speak with a billing representative from the pharmacy to learn if there is a coupon or other manufacturer’s discount for any of the medications in question.
- For high-risk medications such as insulin, blood-thinning medications, cardiac medications, or steroids the facility might consider contacting the resident’s Medicaid case manager if the resident is on Medicaid services, and brainstorming methods to address nonpayment with him/her.
- Facility leadership might also consider paying the resident’s co-pay to get the medication onsite and including the invoiced cost of medications on the resident’s monthly facility bill. Continued nonpayment of services rendered could result in a resident receiving an involuntary discharge notice.
- Many LTC pharmacies will work with the resident or responsible party, but they must make arrangements in advance before the medication is suspended.
Because medication services continue to be frequently cited by DSHS, it is important to pay close attention to the potential lack of prescribed medication availability and work with all involved parties to minimize risk of harm to resident while rectifying the reasons associated with lack of medication availability. This often means moving away from standard policies and procedures to creatively address each unique situation.
Questions about assisted living regulations? Email Vicki McNealley or call 1-800-562-6170 extension 107.
Posted in Assisted Living, Survey & Regulatory