Medications Brought into a Facility by Clients

Behavioral Health Services, Inc.

Subject: Detoxification – Chemical Dependency Recovery Hospitals Policy#: 4.5.14.7
Title: Medications Brought Into Facility by Patients

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 medications brought into the facility by patients in the Detoxification Units of BHS’s Chemical Dependency Recovery Hospitals.

POLICY:
Personal medications brought into the facility by the patient shall be received by facility staff and stored in accordance with all applicable state and federal regulations. These medications may be used while in the facility if prescribed and authorized by the Medical Director or alternate physician. Medications that have been stored by the facility shall be returned to the patient at the time of discharge. No controlled substances or “drugs of abuse” (except Phenobarbital for seizure disorders) shall be stored by the facility unless the Medical Director or alternate physician on duty explicitly approves such storage.

PROCEDURES:
Medications Brought in from Home Personal medications brought into the facility by patients that are not currently prescribed shall
be sent home with the patient’s family, if possible. The Admissions staff shall record pertinent information regarding any past and current use of medications on the Admission Assessment form.
Patients shall be asked to leave controlled substances or “drugs of abuse” (except
Phenobarbital) at home or personally destroy them as a condition of admission. Any question regarding a psychotropic medication that a prospective patient may be using therapeutically shall be directed to the Medical Director or alternate physician prior to admission.
Medications are turned over to the Admissions staff, who place them in a medication storage envelope, which includes patient name and ID number and identifies the medications, which were brought in on a “Medications Surrendered” form. This shall not be sealed at this time.

When the patient is admitted, the medications received are routed directly to the admitting nursing staff for each unit.
Medications Not Approved by Physician for Use in Facility The admitting physician or physician’s assistant reviews these medications. Medication not approved for use in the facility is permanently sealed in the medication envelope. The nursing staff then completes the disposition portion of the Medication Surrender Sheet and signs his/her
name. The Medication Surrender Sheet is then removed from the envelope and placed in front of the property sheet in the chart under Miscellaneous. The medication envelope is then stored in a designated locked cabinet in the medication room, accessible to the assigned medication nurses, Director of Nursing, and Pharmacist only.
Stored medications are released ot the patient upon discharge if approved by the Medical
Director, or alternate physician on duty. The patient then signs the Medication Surrender Sheet for receipt of medications. Nursing staff returning the medication notes date of return and signs his/her name verifying patient’s receipt of medications on the Medication Surrender Sheet. This becomes a permanent part of the patient health record. If not approved, the medication shall be destroyed according to Policy 4.5.14.14 “Destruction of Discontinued and Defective Medications”.
All medications left by a patient at the facility will be retained for at least 7 days after patient departure and then disposed of in accordance with policy on Defective and Discontinued Medications.
Medications Approved for Use in Facility
Personal medications brought with a patient to the facility shall only be used if authorized in writing by the Medical Director or alternate physician on duty. In addition to a specific order of authorization to use a personal medication, the written order must be complete and include the name of the medication, dose, route, and frequency of administration.
Medications brought with a patient to the facility upon admission shall not be used until the contents of the containers have been examined and positively identified by the Medical Director, a pharmacist, or the alternate physician on duty. Initialing the label shall indicate such review has been completed.
After admission, all medications used for patient treatment shall be obtained in accordance with the Policy 4.5.14.5 on Ordering of Stock Medications and Policy 4.5.14.6 on Ordering of Medications through Contract Pharmacy.
Medications brought in by patients and approved for facility use shall be stored in the patient’s own individual lockable drawer or cabinet accessible only to authorized personnel as stated in the procedure on Medications Brought Into Facility by Patients that are not approved by the physician.
Prescription drugs shall remain in their original container and shall be clearly labeled showing:
 Name of the patient
 Prescriber
 Date filled
 Strength
 Quantity
 Prescription number
 Name of dispensing pharmacy
 Expiration date
 Administration information
 Any appropriate warnings
Non-prescription drugs shall remain in the manufacturer’s original container and shall be clearly labeled with the name of the patient to whom it belongs.

Detoxification - CDRHs Medications Brought Into Facility by

Patients

Policy # 4.5.14.7
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: 4.5.15.5 (new number only)