NORTHPOINTE BEHAVIORAL HEALTHCARE SYSTEMS



REVISIONS TO POLICY STATEMENT: YES NO OTHER REVISIONS: YES NO

APPLIES TO:

All Northpointe Staff

POLICY:

It is the policy of Northpointe Behavioral Healthcare Systems that all medications be handled, supplied and stored safely.

PURPOSE:

To establish and provide procedures for appropriate, safe handling, packaging, labeling, storage, inventory and off-site usage of medications.

PROCEDURE:

1. Northpointe receives medications from a variety of sources which include: samples from pharmaceutical representatives, medications ordered through pharmacies, patient assistance programs, OTC medications purchased by the individual (limited to NBHS approved list of OTC medications). Only those medications which have been prescribed by an authorized prescriber (which may include Non –CMH providers) will be accepted and stored in these areas.

2. Medication and medication related equipment (i.e.: syringes, needles, etc) shall be stored in an appropriate manner.

a. Medications are stored in double locked areas (cabinet, cupboard, drawer, refrigerator etc.) at all times except when stocking or at administration times. Medications shall be stored in their original containers/blister packs or pill minders in individual’s specific storage units.

b. All medication storage cabinets will have a monthly medication room inspection completed by an RN

c. If it is determined that the individual needs assistance with scheduled controlled substances follow the directives of the controlled substance policy and procedures.

d. Medications are stored under conditions that will maintain their integrity. Proper handling will assure they are free from contamination, alteration and deterioration. Universal precautions apply when handling medication.

e. Medications for external use, internal use, and injections are stored separately.

f. Keys for the medication storage area shall be kept with authorized staff or in a secured location.

g. Medications shall be labeled with the drug name, dosage, and direction of use, expiration date, and lot number, if applicable. Blister packed medications are checked for accuracy by comparing the practitioner’s order to the actual medications in the pack. Blister packs that are not accurate are to be returned to the pharmacy for corrections.

h. Medications which need to be discarded will be disposed of per policy.

i. All medication being transferred off site will be placed in a locked and labeled Return to Northpointe (Site specific address and phone number) container for safety and security.

j. Consent for Handling Medications form (Form H.130) will be signed by all individuals/guardians for whom Northpointe handles their medications in a non-NBHS residential setting.

k. The Poison Control number will be posted at all sites (1-800-222-1222).

3. Sample and Patient Assistance Medications. Patient assistance and sample medications are received, recorded and supplied by the RN using the appropriate medication log. Patient assistance and sample medications are supplied to individuals as prescribed by the provider with written instructions and inventoried each time one is given out. Sample medications will also be inventoried monthly.

4. Medication Recall

a) When a notification of a medication recall is received the RN will immediately remove the recalled medication, mark them as recalled and place in a separate storage area.

b) The RN will complete the required forms (if applicable) and dispose of or return the medication per the pharmaceutical guidelines given by the manufacturer or pharmacy.

c) If an individual was given a recalled medication they will be notified to return the medication to NBHS

5. Medication Disposal:

Procedure:

a) When possible obtain consent for medication disposal if individual is community based.

b) All unused or expired medication will be returned to the dispensing pharmacy or to the RN for disposal.

c) Two staff or staff and individual will witness and document medication disposal.

d) Staff may dispose of any non narcotic medication that has already been prepared and will not be administered. If there is a spill two staff will witness the clean up and document on the disposal record and complete a medication incident report.

e) All controlled medications that need disposal will be done by the agency RN and another staff. Medications will be stored per policy until they can be disposed of. If there is a spill agency RN must be notified. Two staff will witness the clean up and document on the disposal record and complete a medication incident report

6. If the medication is a controlled substance, follow the Controlled Substance Policy and Procedure.

7. For medications that are stored in clinical offices:

a) Unless there are safety reasons the medication should be stored in the individual’s home.

b) Clinicians can go to the home to assist with medications, or the individual can set up the medication and bring them in to be checked by the clinician, or bring the medication to the office for assistance with clinician

c) Clinician, prescriber & individual will determine if assistance is needed with medication management and on site storage. The practitioner will document the rationale as to why the service is needed and provide a written order. The order should be kept in the individual’s medication storage container.

d) If assisting with medication management and storage there needs to be a goal or objective relating to medications with a measurable timeline to promote independence.

e) If medications are stored in the office consider blister packing until they can be stored in the individual’s home. The medication, dosage, purpose, etc. need to be reviewed with the individual and the medication log (h.102) needs to be completed. Do not remove medication from the blister packs.

f) A consent for handling medication (h.130) must be obtained.

g) Medications are to be stored in a clearly labeled storage bin with the individual’s name on it. Keep the medication boxes free of other clutter to avoid confusion. Medications are to remain in the medication storage cabinet until the individual is present for the set-up.

h) Copies of current NBHS orders and Non-CMH orders for each medication listed are to be kept in the individual’s bin. If you are not sure how to print updated NBHS prescriptions from ELMER ask a nurse. You can obtain Non-CMH orders from the pharmacy or their PCP. Notify the nurse of any changes to NON-CMH meds or update the ELMER record if they see an NBHS practitioner.

i) Record the required information on the medication log (h.102) and store in the individual’s medication container. The individual and each clinician that assists with the set up need to sign the log and initial that the set up is correct. When using a two sided log, the information on the top of the form needs to be transcribed to the other side. Do not leave completed forms in the bin they are to be scanned into ELMER.

j) If a medication is discontinued highlight in yellow the medication on the log, indicate the date, initial and note that it was discontinued (d/c’d). If the medication needs to be disposed obtain a Permission to Dispose of medications form (h.114), bring the medication to a nurse for proper disposal. If changes are made update the medication log to reflect them, date and initial.

k) Medications should be set-up with the individual in the medication room whenever possible.

l) Do not set up medications if the individual is not present, leave the individual alone during medication set-ups, or combine medication from one bottle to another.

m) Medications should not be left in the front office for the individual to pickup. They must remain in the medication cabinet until the individual is present for assistance.

n) There must be a corresponding progress note with each medication set-up or when medication assistance is provided.

o) For individuals that do not see an NBHS practitioner, and we are managing their medication, there needs to be a prescription for the medication and an order from the PCP stating that the service is needed with rationale as to why and for how long. Consider blister packing.

p) As a courtesy to other co-workers if the clinician knows they are not going to be able to assist their individual with their medication set up they need to make arrangements to setup the meds on a different day or setup an appointment date & time with another clinical staff.

CROSS REFERENCE:

Consent for Handling Medications form h.130

Medication Log form h.102

Medication Administration Policy

Scheduled/Controlled Medications Policy

Permission to Dispose of Medication h.114

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