Standards for Pharmacists Providing Services to Licensed Long-Term Care Facilities

Effective January 1, 2007


The purpose of the Standards for Pharmacists Providing Services to Licensed Long Term CareFacilities (Standards for LTC) is to identify the level of pharmacy services required to ensure the safe and effective use of medications that will improve the quality of life of the long-term care resident. The following Standards for LTC represent those pharmacy functions that are the responsibility of the pharmacist providing the service. The Standards for LTC do not stand alone but focus on a special area of care. These standards are utilized in conjunction with theStandards of Practice, the Standards of Practice for Pharmacy Managers, the Code of Ethics and the Ontario College of Pharmacists (OCP) Documentation Guidelines. The pharmacist works in conjunction with the resident and/or resident’s agent and the interdisciplinary care team to determine residents’ needs, and what care should be provided by the pharmacist to meet these needs through the responsible provision of drug therapy. The pharmacist acts as a resident advocate for the pharmaceutical aspects of resident care.


Standard 1


As a member of the interdisciplinary team, which is responsible for providing quality health care for long-term residents, the pharmacist interacts with other health care professionals to develop and implement patient-centred care and optimize therapeutic outcomes.


Clinical Services

1.1 The pharmacist communicates using effective and appropriate skills / tools to the relevant long-term care facility staff member (s), resident and/or agent of the resident.

1.2 The pharmacist utilizes various documentation tools as evidence of such communication.

1.3 The pharmacist participates in clinical activities relevant to the provision of drug therapy for the purpose of optimizing patient care. Activities may include but are not limited to, a comprehensive medication review and drug utilization reviews.

1.4 The pharmacist participates in educating members of the interdisciplinary team, residents and/or agents on drug therapy or medication use.

1.5 Continuous Quality Management


    1.5.1 The pharmacist promotes safe medication practice and participates in the development, implementation and evaluation of these practices.

    1.5.2 The pharmacist participates in the review of medication related incidentsand provides recommendations to prevent recurrence.


Standard 2


Prescription Record Management

2.1 Prescription Authorization


    2.1.1 Signed Quarterly Review/Three Month Review
    The pharmacist ensures that a system is in place to obtain signed Quarterly Reviews/Three Month Reviews.

    2.1.2 Transcribed Verbal Orders
    The pharmacist ensures that a system is in place to verify that verbal orders received and transcribed by the nurse have been signed by the prescriber.

    2.1.3 New Order Permanent filling record
    The pharmacist verifies and signs the permanent filling record.

    2.1.4 Refill Order Permanent filling record


      2.1.4.1 The pharmacist signs either each individual permanent filling record or the multi-prescription permanent filling record. The pharmacist is required at a minimum to sign on each page in the case where a multi-prescription permanent filling record is used or per patient if there is more than one patient per page.

      2.1.4.2The pharmacist signs for prescriptions that he/she has personally checked.


    2.1.5 Quantity determination, reductions & documentation (facility specific policy)
    The pharmacist follows a facility specific prescription quantity protocol to determine prescription quantity where the prescriber has not specified unless precluded by specific legislation. (Controlled Drug and Substances Act)


2.2 Record Keeping


    2.2.1 Retrievable filing of Quarterly Review/Three Month Review
    The pharmacist ensures that signed Quarterly Review / Three Month Review are readily retrievable.

    2.2.2 Retrievable filing of New Order permanent filling record
    The pharmacist ensures original prescription orders are cross-referenced to the permanent filling records, and are readily retrievable.

    2.2.3 Retrievable filing of Refill Order permanent filling record
    The pharmacist ensures that the permanent filling record is filed in a manner that is readily retrievable.


2.3 Invoicing and Receipts
Legislation dictates that pharmacists must provide receipts to all patients including those in long-term care facilities at the time of dispensing.


    2.3.1The pharmacist provides receipts to residents of long-term care facilities in a manner that is mutually acceptable to the resident or agent, the pharmacist as well as the facility.

    2.3.2 The pharmacist invoices residents of long-term care facilities in a manner acceptable to residents or their agents.


2.4 Emergency Medication Supply


    2.4.1 The pharmacist is involved in the establishment of policies and procedures for the emergency medication supply.

    2.4.2 The pharmacist provides medications to fill a long-term care emergency medication supply upon the issuance of a prescription by a facility physician.

    2.4.3 Where an emergency medication supply is provided to a long-term care facility, the pharmacist (or designate) periodically verifies the contents to ensure products are within their expiry date and are properly accounted for.


Standard 3


Drug Destruction

If participating in drug destruction in a long-term care facility, the pharmacist acts in accordance with environmental requirements and ethical principles.

3.1 When a pharmacist is witness to the destruction of drugs at the long-term care facility it must be in compliance with the appropriate legislation, in accordance with the Standards of Practice and the disposal must be in an environmentally appropriate manner.


Standard 4


Pharmacy Level Requirements


4.1 The Consultant Pharmacist

    4.1.1 The long-term care pharmacy provider identifies at least one pharmacist who acts as a liaison between the providing pharmacy and the long-term care facility.

    4.1.2 The pharmacist(s) identified in section 4.1.1 maintains current knowledge in the provision of long-term care services and best practice in that setting.

    4.1.3 The pharmacy manager shall ensure the availability of the relevant personnel during the College Inspection Process.

    4.1.4 The consultant pharmacist has access to resources that include but are not limited to:

    • Journals related to the provision of long-term care services
    • References relevant to long-term care practice
    • Current Long Term Care legislation
    • Copy of Pharmacy Services section of the Ministry of Health and Long-Term Care Program Manual


4.2 Facility specific Policies & Procedures Manual / Resource Manual


    4.2.1 The pharmacy manager ensures that a minimum of resources shall be readily available at the place of practice including drug dosing references as follows:
    • Drug dosing references which include geriatric dosing
    • Facility specific quantity protocol policy

1 Licensed long-term care facilities are defined under the auspices of three pieces of legislation: Nursing Home Act (privately/corporately owned facilities), Homes for the Aged and Rest Homes Act (municipal or county owned facilities) and the Charitable Institutions Act (facilities owned by charitable organizations). All beds in these facilities are deemed “approved” beds by the Ministry of Health and Long-Term Care and as such are given an ODP billing number for pharmacy billing purposes.


2 A Medication Incident includes a “medication discrepancy” – an event which does not involve the actual administration of a drug to a patient, but where an error in the medication process has been detected and corrected before reaching the patent – and “medication error” – an event which involves the actual prescribing, dispensing, delivery or administration of a drug or the omission of a prescribed drug to a patient. Reference: Standards of Practice O.C. 1.8


3 The Quarterly Review (or Three Month Review) is a documented review of each resident’s medication that is done every three months or more frequently. The review is signed by the physician and serves as the prescription authorization.


4 The Permanent Filling Record represents the prescription hardcopy. This record may exist in different formats.


5 The Consultant Pharmacist is a pharmacist registered with the OCP who is knowledgeable about the legislation and pharmacy practice in the long-term care setting; and who provides clinical services for the residents of the long-term care facility. The pharmacist providing the drugs and drug products may or may not be the same pharmacist providing clinical pharmacy services.


6 The long-term care provider is a pharmacy accredited by the OCP that is retained to provide the drugs and drug products to the long-term care facility.