Form DCF-2272 "Monthly Medication Administration Program Supervision and Review" - Connecticut

What Is Form DCF-2272?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2018;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DCF-2272 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-2272 "Monthly Medication Administration Program Supervision and Review" - Connecticut

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Connecticut Department of Children and Families
MONTHLY MEDICATION ADMINISTRATION PROGRAM SUPERVISION AND REVIEW
DCF-2272
4/18 (Rev)
Page 1 of 2
Agency:
Month Covering:
Program Name(s):
Review Date:
Medication Certified Staff
Yes
No
Is the List of certified staff up-to-date?
Is the list of certified staff posted?
Is list of certified staff adequate to meet the facility needs? If “No” what is the “Corrective Action Plan?” (Please explain below):
Are the medication keys carried by the medication certified staff at all times?
Medication Administration Records
Yes
No
Are the prescriptions current?
Are prescriptions reviewed per policy by a licensed practitioner?
Are prescriptions accessible to staff when medication is administered?
Are prescriptions accurately transcribed on the MAR/Kardex?
Are prescriptions accurately transcribed on the Pharmacy’s Labels?
Does MAR/Kardex reflect that all medications were administered as ordered?
Are standing orders current?
Are standing orders signed by the licensed practitioner every 90 days?
Is the Medication
Clean?
Storage Area:
Locked?
Immobile?
Accessible to licensed or certified staff only?
Arranged so that external and internal medications are separated?
Kept between 36 and 46 degrees F (36° and 46°) for refrigerated medications?
Contain only medication and medication supplies?
Are controlled
Kept in a double-locked, immobile container?
medications:
Accessible only be a key kept on a separate key ring?
Counted by designated staff at every change of shift and/or whenever there is a change in responsibility of the meds?
Date:
Date of last quarterly review of med policies and procedures by the licensed practitioner and supervising nurse:
Date:
Date of last medication review by the licensed practitioner and supervising nurse
Connecticut Department of Children and Families
MONTHLY MEDICATION ADMINISTRATION PROGRAM SUPERVISION AND REVIEW
DCF-2272
4/18 (Rev)
Page 1 of 2
Agency:
Month Covering:
Program Name(s):
Review Date:
Medication Certified Staff
Yes
No
Is the List of certified staff up-to-date?
Is the list of certified staff posted?
Is list of certified staff adequate to meet the facility needs? If “No” what is the “Corrective Action Plan?” (Please explain below):
Are the medication keys carried by the medication certified staff at all times?
Medication Administration Records
Yes
No
Are the prescriptions current?
Are prescriptions reviewed per policy by a licensed practitioner?
Are prescriptions accessible to staff when medication is administered?
Are prescriptions accurately transcribed on the MAR/Kardex?
Are prescriptions accurately transcribed on the Pharmacy’s Labels?
Does MAR/Kardex reflect that all medications were administered as ordered?
Are standing orders current?
Are standing orders signed by the licensed practitioner every 90 days?
Is the Medication
Clean?
Storage Area:
Locked?
Immobile?
Accessible to licensed or certified staff only?
Arranged so that external and internal medications are separated?
Kept between 36 and 46 degrees F (36° and 46°) for refrigerated medications?
Contain only medication and medication supplies?
Are controlled
Kept in a double-locked, immobile container?
medications:
Accessible only be a key kept on a separate key ring?
Counted by designated staff at every change of shift and/or whenever there is a change in responsibility of the meds?
Date:
Date of last quarterly review of med policies and procedures by the licensed practitioner and supervising nurse:
Date:
Date of last medication review by the licensed practitioner and supervising nurse
DCF-2272
MONTHLY MEDICATION ADMINISTRATION PROGRAM SUPERVISION AND REVIEW
Page 2 of 2
ERRORS
Please note the number of errors, by types:
Omission:
#
Pharmacy Error
#
Documentation
#
Lack of Med Cert Staff:
#
Violation of 5 Rights:
#
Other (List below):
#
Please list the details of “Other” Error:
Please note the number of Errors requiring medical attention / serious errors / Significant Events:
How many errors required medical attention?
#
Were copies of the Med Error Report / SE Report forwarded to Risk Management within 12 hours?
Yes
No
N/A
What Corrective Action was taken, if any. Please explain:
STAFF TRAINING
Are any staff due for annual on-site observation or post course one-site internship?
Yes
No
Identify any medication certified staff suspended from medication administration. Please include name, date and reason for suspension
Please list topics of any training you provided to the medication certified staff this month.
Were medical policy and procedures reviewed this quarter?
Yes
No. If “yes”, please provide the date of review:
EMERGENCY PROCEDURES
Are procedures for contacting Chain of Command and Emergency Medical Care clearly written, understood and available to staff?
Yes
No
Is information regarding children’s allergies readily available to all staff?
Yes
No
Are rescue inhalers and Epi Pens kept in a secure location, easily and quickly available in the event of an emergency need?
Yes
No
Are appropriate facility staff members trained at least annually in the emergency use of inhalers and Epi Pens, including the indications,
Yes
No
side effects and any special precautions?
Is a list of these trained staff maintained?
Yes
No
Additional comments:
Name of Nurse:
Signature of Nurse:
Date:
Name of Director:
Signature of Director:
Date:
E-Mail Completed Form to:
DCF.RISKMANAGEMENT@ct.gov
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