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3.17 – ICF Pharmacy Review


The primary function of the pharmacist during the quarterly drug review is to identify possible drug interactions, check for evidence of any side effects associated with the drug usage, determine if laboratory results associated with the drug are within normal limits and verify that the facility is administering the medication appropriately. The review should also comment upon the efficacy of the drug use. (blood sugar controlled, blood pressure WNL).


At least quarterly, the pharmacist must review the drug regimen of each individual.

The pharmacist must clearly indicate and report any apparent irregularities on the quarterly review document during each review for each individual.  The pharmacist will provide the recommendation document directly to the nursing staff at Park West or to the QIDP at Johnstown. 

The Nursing staff/or QIDP at Johnstown will be responsible to immediately route any pharmacy review recommendation forms securely to the Interdisciplinary team via designated scan/email.    The nursing staff are responsible to directly review the pharmacy recommendation forms with the Physician during their weekly consultations.

The physician and interdisciplinary team members must discuss any irregularities noted and review the recommendations of the pharmacy review.  The physician in conjunction with the team must make the final determination as to whether to accept or reject the recommendations in the report.  The physician must clearly indicate their response on the form with any follow-up needs or referrals.  If the physician and team are rejecting the recommendation, they must clearly indicate the contraindication or reasons behind doing so on the form or in the consultation.

Committee Review

Each quarter, the pharmacy recommendations will be reviewed during the Medical team review meeting to ensure that all follow-up has been completed according to the procedures above.  The nursing chairperson or designee is responsible to compile and prepare these reports for review during the meeting.

Last Revised: 2/23/24

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