One of the key components for meeting the CMS requirements for the proper provision of pharmaceutical services is the requirement to properly store medications.  First, we address the general requirements of medication storage.  Second, we address the specific requirements for medication rooms and refrigerators.

According to F-Tag 761, facilities must store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys.

A facility, in coordination with a licensed pharmacist, which is generally its consultant pharmacist, must provide safe and secure storage, limited access, and mechanisms to minimize loss or diversion of all medications.

According to CMS, storage areas include, but are not limited to, drawers, cabinets, medication rooms, refrigerators, and carts. Depending on how the facility locks and stores medications, access to a medication room may not necessarily provide access to the medications (for example, medications stored in a locked cart, locked cabinets, a locked refrigerator, or locked drawers within the medication room). When medications are not stored in separately locked compartments within a storage area, only appropriately authorized staff may have access to the storage area.

Additionally, a facility must have procedures regarding safe storage of medications for residents who can self-administer.  If medications are kept at the bedside, the medications must be secured.

ACTION ITEM: Is your pharmacist assessing medication storage in your facility?  Do they document examples of non-compliance and work with you to remediate issues in preparation for survey?