Form LIC622 "Centrally Stored Medication and Destruction Record" - California

What Is LIC 622 Form?

Form LIC 622, Centrally Stored Medication and Destruction Record, is a document developed by the California Department of Social Services (CDSS). The purpose of the document is to keep a record of centrally stored medication and to keep a record of the destruction of medication. The form was last revised on September 1, 2019. A fillable LIC 622 Form is available for download below.

How Often Is LIC 622 Supposed to Be Completed?

According to the instructions, medication records for each resident of the facility (or client) are supposed to be kept in the facility for at least one year. Medical destruction records are supposed to be kept for at least one year as well. However, residential care facilities for the chronically ill and residential care facilities for the elderly shall keep their medical destruction records for at least three years.

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Form LIC 622 Instructions

The document starts with short instructions on how to keep centrally stored medication and a few lines that are supposed to be completed by the filer, including:

  1. The name of the resident or client to whom the medication was prescribed.
  2. Admission date.
  3. The name of the prescribing physician.
  4. Facility name and number.
  5. Administrator.

The LIC 622 Form consists of two parts, each one of them serves its own purpose. The first part is dedicated to centrally stored medication. For each resident (or client), the facility maintains a log of centrally stored medications. It is presented in the form of a schedule with ten columns, including

  • Medication name;
  • Strength and quantity;
  • Instructions (if there are any, regarding control and custody of medication);
  • Date of expiration;
  • Date filled;
  • Date started;
  • Prescribing physician;
  • Prescription number;
  • Number of refills;
  • Name of pharmacy (name of the issuing pharmacy).

Logs of currently approved personnel are supposed to be maintained onsite at the facility. The second part of the form is the medical destruction record. Medication that is supposed to be disposed of includes:

  1. Medication that wasn't taken with the client upon termination of services.
  2. Discontinued medication.
  3. Deteriorated, contaminated, or expired medication.

It is required that these kinds of medication shall be destroyed in the facility by the administrator or designated representative and witnessed by one other adult who is not a client or resident. It must be recorded in the form and signed by the facility administrator or a designated substitute and one other adult who is not a client. The information that is supposed to be entered in the form includes:

  • Medication name;
  • Date filled;
  • Strength and quantity;
  • Prescription number;
  • Name of pharmacy;
  • Disposal date;
  • Signature of the administrator or designated representative;
  • Signature of witness adult (non-client or resident.

Since the LIC 622 Form contains such a wide range of information on the medication of each client, it's important that the facility administrators fill it out precisely and keep it in accordance with the requirements.

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Download Form LIC622 "Centrally Stored Medication and Destruction Record" - California

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State of California – Health and Human Services Agency
California Department of Social Services
CENTRALLY STORED MEDICATION AND DESTRUCTION RECORD
I. CENTRALLY STORED MEDICATION
Facility Name:
INSTRUCTIONS:
Centrally stored medications shall be kept in a safe and locked place that
is not accessible to any person(s) except authorized individuals. Medication
Facility Number:
records for each client/resident shall be maintained for at least one year.
Name: (Last
First
Middle)
Admission Date:
Attending Physician:
Administrator:
Strength/
Instructions
Expiration
Date
Prescribing
Prescription
No. of
Name of
Medication Name
Date Filled
Quantity
Control/Custody
Date
Started
Physician
Number
Refills
Pharmacy
LIC 622 (9/19)
Page 1 of 4
State of California – Health and Human Services Agency
California Department of Social Services
CENTRALLY STORED MEDICATION AND DESTRUCTION RECORD
I. CENTRALLY STORED MEDICATION
Facility Name:
INSTRUCTIONS:
Centrally stored medications shall be kept in a safe and locked place that
is not accessible to any person(s) except authorized individuals. Medication
Facility Number:
records for each client/resident shall be maintained for at least one year.
Name: (Last
First
Middle)
Admission Date:
Attending Physician:
Administrator:
Strength/
Instructions
Expiration
Date
Prescribing
Prescription
No. of
Name of
Medication Name
Date Filled
Quantity
Control/Custody
Date
Started
Physician
Number
Refills
Pharmacy
LIC 622 (9/19)
Page 1 of 4
State of California – Health and Human Services Agency
California Department of Social Services
Strength/
Instructions
Expiration
Date
Prescribing
Prescription
No. of
Name of
Medication Name
Date Filled
Quantity
Control/Custody
Date
Started
Physician
Number
Refills
Pharmacy
LIC 622 (9/19)
Page 2 of 4
State of California – Health and Human Services Agency
California Department of Social Services
II. MEDICATION DESTRUCTION RECORD
INSTRUCTIONS: For facilities other than Residential Care Facilities for the Chronically Ill (RCFCI) and Residential Care Facilities
for the Elderly (RCFE), prescription medication that is not taken with a client or resident when services are terminated or otherwise
disposed of must be destroyed in the facility by the administrator or designated representative and witnessed by one other adult who is
not a client or resident. Medication destruction records must be retained for at least one (1) year.
For RCF-CIs: Prescription medication that is not taken with a resident when placement is terminated or which is not to be retained
must be destroyed by the administrator and the facility manager. Medication destruction records must be retained for at least three
(3) years.
For RCFEs: Prescription medications which are not taken with a resident when services are terminated, not returned to the issuing
pharmacy, not retained in the facility as ordered by the resident’s physician and documented in the resident’s record, not disposed of
according to the established procedures of a hospice agency, or not otherwise disposed of must be destroyed by the administrator and
one other adult who is not a resident of the RCFE, in the RCFE. Records documenting destruction of medication must be retained for
at least three (3) years.
Signature of Administrator
Strength/
Date
Prescription
Disposal
Name of
Signature of Witness Adult
Medication Name
or Designated
Quantity
Filled
Number
Date
Pharmacy
Non-Client/Resident
Representative
LIC 622 (9/19)
Page 3 of 4
State of California – Health and Human Services Agency
California Department of Social Services
Signature of Administrator
Strength/
Date
Prescription
Disposal
Name of
Signature of Witness
Medication Name
or Designated
Quantity
Filled
Number
Date
Pharmacy
Adult Non-Client/Resident
Representative
LIC 622 (9/19)
Page 4 of 4
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