Section 3100.520  Emergency Medication Kits

Long term care facilities may store controlled substances in an emergency medication kit if permitted by the licensing regulations of the Illinois Department of Public Health for the facility's particular level of care ("DPH Standards").  The following requirements must be met when controlled substances are stored in emergency medication kits:

a)         Controlled substances for emergency medication kits must be obtained from a DEA registered hospital, pharmacy or practitioner.

b)         Emergency medication kits shall be safeguarded as provided in DPH Standards.

c)         Only the director of nursing services, registered nurse on duty, licensed practical nurse on duty, or consultant pharmacist or practitioner shall have access to controlled substances stored in emergency medication kits.

d)         No more than 10 different controlled substances shall be placed in an emergency medication kit, and there shall be no more than three single, injectible doses of each controlled substance.

e)         Controlled substances in emergency medication kits may be administered only under the emergency conditions set forth in DPH Standards and only by registered nurses, licensed practical nurses or practitioners, in compliance with 21 CFR 1306.11 and 1306.21 (April 1, 2014).

f)         A proof-of-use sheet shall be contained in the emergency medication kit for each separate controlled substance included.  Entries shall be made on the proof-of-use sheet by the nursing staff or practitioner when any controlled substances from the kit are used.  The consultant pharmacist shall receive and file for two years a copy of all completed proof-of-use sheets.

g)         Whenever the emergency medication kit is opened, the consultant pharmacist shall be notified within 24 hours.  During any period that the emergency kit is opened, a shift count shall be done on all controlled substances until the kit is closed or locked by the consultant pharmacist. Shift counts are not mandatory when the kit is sealed.  Proper forms for shift counts shall be contained in the emergency medication kit.

h)         The consultant pharmacist shall check the controlled substances in the emergency medication kit at least monthly and so document inside the kit.

i)          Failure to comply with any provision of this Section, or of any applicable provision of State or federal statutes or regulations pertaining to controlled substances will result in loss of the privilege of having or placing controlled substances in emergency medication kits.

(Source:  Amended at 39 Ill. Reg. 3656, effective February 27, 2015)