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

What Is Form LIC 622?

Form LIC 622, Centrally Stored Medication and Destruction Record, is a document developed by the California Department of Social Services. 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 in May 2019.

An LIC 622 fillable 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.

ADVERTISEMENT

LIC 622 Instructions

The application starts with a short instruction on how to keep centrally stored medication and a few charts that are supposed to be filled out by an applicant, such as:

  • Name (the name of the resident or client to whom the medication was prescribed);
  • Admission Date;
  • Attending Physician (the name of the prescribing physician);
  • Facility Name;
  • Facility Number;
  • 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, such as:

  • Medication Name;
  • Strength / 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:

  • Medication that wasn't taken with the client upon termination of services;
  • Discontinued medication;
  • 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 / Quantity;
  • Prescription Number;
  • Name of Pharmacy;
  • Disposal Date;
  • Signature of Administrator or Designated Representative;
  • Signature of Witness Adult (Non-Client / Resident).

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

ADVERTISEMENT

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

1009 times
Rate (4.5 / 5) 45 votes
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
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)
FACILITY NUMBER
except authorized individuals. Medication records on each client/resident shall be maintained for at least one year.
NAME
(LAST
FIRST
MIDDLE)
ADMISSION DATE
ATTENDING PHYSICIAN
ADMINISTRATOR
STRENGTH/
INSTRUCTIONS
EXPIRATION
DATE
DATE
PRESCRIBING
PRESCRIPTION
NO. OF
NAME OF
MEDICATION NAME
QUANTITY
CONTROL/CUSTODY
DATE
FILLED
STARTED
PHYSICIAN
NUMBER
REFILLS
PHARMACY
LIC 622 (3/99) (CONFIDENTIAL)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
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)
FACILITY NUMBER
except authorized individuals. Medication records on each client/resident shall be maintained for at least one year.
NAME
(LAST
FIRST
MIDDLE)
ADMISSION DATE
ATTENDING PHYSICIAN
ADMINISTRATOR
STRENGTH/
INSTRUCTIONS
EXPIRATION
DATE
DATE
PRESCRIBING
PRESCRIPTION
NO. OF
NAME OF
MEDICATION NAME
QUANTITY
CONTROL/CUSTODY
DATE
FILLED
STARTED
PHYSICIAN
NUMBER
REFILLS
PHARMACY
LIC 622 (3/99) (CONFIDENTIAL)
STRENGTH/
INSTRUCTIONS
EXPIRATION
DATE
DATE
PRESCRIBING
PRESCRIPTION
NO. OF
NAME OF
MEDICATION NAME
QUANTITY
CONTROL/CUSTODY
DATE
FILLED
STARTED
PHYSICIAN
NUMBER
REFILLS
PHARMACY
II. MEDICATION DESTRUCTION RECORD
INSTRUCTIONS: Prescription drugs not taken with the client/resident upon termination of services or otherwise disposed of shall be destroyed in the facility by the Administrator or
Designated
Representative and witnessed by one other adult who is not a client/resident. All facilities except Residential Care Facilities for the Elderly (RCFEs) shall
retain destruction
records for at least one year. RCFEs shall retain records for at least three years.
STRENGTH/
PRESCRIPTION
DISPOSAL
SIGNATURE OF ADMINISTRATOR OR
SIGNATURE OF WITNESS
MEDICATION NAME
DATE FILLED
NAME OF PHARMACY
QUANTITY
NUMBER
DATE
DESIGNATED REPRESENTATIVE
ADULT NON-CLIENT
Page of 2