Behavioral Health Services, Inc.
Subject: Detoxification – Chemical Dependency Recovery Hospitals Policy#: 4.5.14.9
Title: Controlled Medications
Effective Date of This Revision: January 9, 2009
Contact: Medical Director 310-679-9126
Administration Applies to:
Officers
Other agents
Staff
Visitors
Student clinicians
Contractors
Volunteers
Subcontractors / Business Associates
PURPOSE:
The purpose of this document is to outline policy and procedures for controlled medications in the Detoxification Units of BHS’s Chemical Dependency Recovery Hospitals.
POLICY:
The BHS Chemical Dependency Recovery Hospitals shall be licensed by the Drug Enforcement Administration for the administration of C-III and C-IV controlled medications. These medications shall be handled in accordance with all state and federal regulations.
PROCEDURES:
All stock supplies of controlled drugs shall be stored in a double locked safe or a cabinet made for this purpose. The Director of Nursing, and/or the Consultant Pharmacist shall be the only person having access to this cabinet. During a planned absence, the Director of Nursing will, with administrative approval, give keys to an approved licensed staff member. The Director of Nursing shall maintain a separate perpetual inventory for each C-II through C-IV item stocked by the facility. As these items are received from suppliers or distributed as floor stock, they shall be added or subtracted from the inventory sheets accordingly, so that all doses
are accounted for. The Consultant Pharmacist shall take a physical count of each of these
controlled items on a monthly basis, to verify the accuracy of the inventory sheets.
Discrepancies shall be reported to the Administrator and the Medical Director.
All C-II through C-IV controlled drugs that are on the Facility Formulary shall be issued as floor stock by the Director of Nursing, or Consultant Pharmacist. The medication nurses shall account for each dose on a Controlled Drug Record Sheet. When a dose of a controlled medication is taken from stock, the nurse shall immediately sign for it on the Controlled Drug Record Sheet and verify that the count is correct. When formulary controlled drugs are issued to the nursing unit, the addition will be entered in red ink onto the corresponding Controlled Drug Record.
Controlled Drugs issued as stock shall be stored in a double locked cabinet within the
medication area or in a double locked medication cart and shall be accessible only to licensed nurses.
At the change of each shift, the medication nurse coming on shift shall count the controlled medications and verify with the medication nurse going off shift that the count is accurately documented. Any discrepancies in the count must be accounted for or otherwise reported immediately on an Incident Report to the DON by both nurses.
No controlled medication shall be self-administered by any patient.
All records of formulary controlled drugs shall be maintained for a period of at least three (3)
years. When a non-formulary controlled drug is needed for any patient, a personal prescription must be obtained from the contract pharmacy and administered by persons licensed for this function.
The prescription shall be obtained in minimal quantities (never to exceed 30 dosage units).
The prescription must be stored separately from facility stock in a locked individual
medication bin that is accessible only to facility personnel who are authorized to administer medications.
All doses must be recorded on the patient’s individual controlled drug record sheet and on the patient’s medication administration record. Both records shall become a part of the permanent chart.
The medications shall be counted by nurses at each change of shift to verify accuracy of the Individual Controlled Drug Record. Any discrepancy shall be reported on an Incident Report Form.
Unused doses shall be disposed of according to facility Policy 4.5.14.14 “Discontinued and Defective Medications.”
Detoxification - CDRHs Controlled Medications Policy # 4.5.14.9
Reviewed by: Medical Director, Directors of Nursing Review Date: 1/09/2009
Approved by: Board of Directors Approval Date: 1/09/2009
Effective Date 1/09/2009
Supersedes Policy/Date: 4.5.15.7 (Number change only)
