Form LIC622 Centrally Stored Medication and Destruction Record - California

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.