Policy Manual


Residential Program Administration, Storage, and Transportation of Medications      

Type: Procedure                 Category: Service Delivery                 Level: Community Care 

Parties: Community Care Residential Programs Employees and/or Contractees

Printer Friendly Version: http://apps.comcareme.org/policymanual/default.aspx?code=3.MEP.31&nonav=yes

Supporting References: COA Standard RPM 3: Medication Control and Administration; MH Core Regulations MED 1-13; MH Residential Regulations Medications e and f; Community Care's Emergency Pager procedure.

Parent Effective Date Approval Level Revision Dates Last Reviewed
N/A  1-1-2004  Management Team  11/95,5/97,1/99,1/01,7/01,11/02, 2/03, 1/09  1-1-2009
Related Document Code Related Document Name Type
3.ME.14 Medication Policy

Procedure:  .

(Non-controlled, Schedule III, IV, V drugs)

1. Information regarding all prescribed medications will be documented in the client case record on the Consent to Medication Form. This information will include the prescribing doctor's name, name of the medication, dosage, frequency, purpose for prescription, common risks, common benefits, and possible alternative treatment(s). The Consent to Medication form must be signed by the client and/or the legal guardian prior to the administration of the medication. This includes prescribed medications that the client brings with them to the facility.

2. When a medication is prescribed, information including the name of medication, dosage, and frequency must be documented on the Medication Administration Record Form and filed in the client's case record.

3. All employees are responsible for knowing the common risks and benefits and for documenting observed side effects and/or benefits of the medication being administered to clients they serve on the Medications Monitoring Report.

4. All medications must be stored in a locked cabinet. Medications must be kept in original containers and clearly labeled with the client's name, date, medication name, administering instructions, expiration date and physician's name. If more than one client's medications are stored in the same cabinet, they must be separated. Medications that require refrigeration must be separated from food items. Medications marked �for external use only� will be stored separately from other medications.

5. A designated employee must carry the keys to the medications storage cabinet on their person. This individual is also responsible for administration and keeping inventory of medications during their shift.

6. Employees shall immediately report observed or stated drug reactions, medication errors, refusals, other concerns and/or questions to their direct supervisor and/or the emergency pager. Medication errors include omission and commission errors. Employees will complete a Medication Incident Report Form for all such situations.

7. Once received by an employee, a prescription is in effect until a stop order to discontinue medication is issued. Time limited prescriptions (i.e., 10 day prescription for antibiotics) do not require a stop order. Three consecutive refusals to take a prescribed medication by a child that is 14 years of age or older is considered revoked consent. If this occurs, the employee will complete the Medication Incident Report Form, notify the guardian and prescribing doctor, and contact the residential supervisor or on-call residential supervisor if after regular business hours.

8. When an employee transports medication, each medication label must include the client's name, name and dosage of medication, name of prescribing doctor, and expiration date. If an employee is transporting a client and medication together, the employee must store the client�s medication in a locked container, which is then locked in the vehicle�s glove compartment or trunk.

9. A record of all appointments for review of medications will be kept in the client's case record by the case manager, including unscheduled or cancelled medication review appointments.

10. Disposing of medications shall be in accordance with Community Care's procedure for disposing of prescribed medications.

11. Client complaints regarding the availability or accessibility of the prescribing doctor will be documented on the appropriate grievance form. Submitted grievance forms will follow Community Care's grievance policy and procedure.

Note: Controlled drugs (Schedule II Drugs) identified by the large red "C" on the prescription bottle or bubble pack, are medications which have been legally designatedControlled Substances.� The drugs in this category are considered to have a high potential for abuse. Schedule II drugs will be administered following the procedures listed above, unless contraindicated by the following:

A. For all Schedule II Drugs, there shall be an individual record maintained, including the name of the client, prescription identification number, date prescribed, name of medication, dosage, route of administration, signature of the individual administering, and balance on hand.

B. There shall be a record and signed count of all Schedule II controlled substances at least once a day, if such substances have been used that day.

C. All Schedule II Drugs on hand will be counted at least weekly, and records kept of the inventory in a bound book, from which no pages shall be removed.

D. All Schedule II Drugs shall be stored in a locked container, in a separate locked box. Scheduled II controlled substances will be transported using similar methods described in this procedure.