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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 22. HEALTH |
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SubTilte 22-A. MENTAL HEALTH |
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Chapter 22-A63. CERTIFICATION STANDARDS FOR SUBSTANCE USE DISORDER TREATMENT AND RECOVERY PROVIDERS |
Section 22-A6315. MEDICATION STORAGE AND ADMINISTRATION STANDARDS
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6315 MEDICATION STORAGE AND ADMINISTRATION STANDARDS
6315.1 Controlled substances shall be maintained in accordance with applicable District and Federal laws and regulations.
6315.2 An SUD treatment program shall implement written policies and procedures to govern the acquisition, safe storage, prescribing, dispensing, labeling, administration, and the self-administration of medication, including medications clients may bring into the program.
6315.3 A program shall have a record of the prescribing physician’s order or approval prior to the administration or self-administration of medication.
6315.4 Any prescribed medication brought into a facility by a client shall not be administered or self-administered until the medication is identified and the attending practitioner's written order or approval is documented in the client record.
6315.5 Verbal orders may only be given by the attending practitioner to another practitioner, physician assistant, nurse, or pharmacist. Verbal orders shall be noted in the client's record as such and countersigned and dated by the prescribing practitioner within twenty-four (24) hours.
6315.6 All medication, both prescription and over-the-counter, brought into a facility must be packaged and labeled in accordance with District and Federal laws and regulations.
6315.7 Medication, both prescription and over-the-counter, brought into a facility by a client that is not approved by the attending practitioner shall be packaged, sealed, stored, and returned to the client upon discharge.
6315.8 The administration of medications, excluding self-administration, shall be permitted only by licensed individuals pursuant to applicable District laws and regulations.
6315.9 Medications shall be administered only in accordance with the prescribing practitioner’s order.
6315.10 Only a licensed nurse, practitioner, or physician assistant shall administer controlled substances or injectable drugs, excluding insulin.
6315.11 Program staff responsible for supervision of the self-administration of medication shall document consultations with a practitioner, pharmacist, registered nurse, or referral to appropriate reference material regarding the action and possible side effects or adverse reactions of each medication under their supervision.
6315.12 As applicable, a program shall provide training to the staff designated to supervise the self-administration of medication. The training shall include but not be limited to the expected action of and adverse reaction to the self-administered medication.
6315.13 Only trained staff shall be responsible for observing the self-administration of medication.
6315.14 A program shall ensure that medication is available to clients as prescribed.
6315.15 A program shall maintain records that track and account for all medication, ensuring the following:
(a) That each client receiving medication shall have a medication administration record, which includes the individual's name, the name of medication, the type of medication (classification), the amount of medication, the dose and frequency of administration/self-administration, and the name of staff who administered or observed the self-administration of the medication;
(b) That documentation shall include omission and refusal of medication administration;
(c) That the medication administration record shall note the amount of medication originally present and the amount remaining;
(d) That documentation of medication administration shall include over-the-counter drugs administered or self-administered; and
(e) That SUD treatment programs administering controlled substances, including but not limited to methadone, shall follow the requirements of applicable Federal and District laws and regulations.
6315.16 An attending practitioner shall be notified immediately of any medication error or adverse reaction. The staff responsible for the medication error shall complete an incident report, and the practitioner’s recommendations and subsequent actions taken by the program shall be documented in the client record.
6315.17 A program shall have written policies and procedures on how medications are obtained and stored.
6315.18 A program shall ensure that all medications, including those that are self-administered, are secured in locked storage areas.
6315.19 The locked medication area shall provide for separation of internal and external medications.
6315.20 A program shall maintain a list of personnel who have access to the locked medication area and, where applicable, are qualified to administer medication.
6315.21 A program shall comply with all District and Federal laws concerning the acquisition and storage of pharmaceuticals.
6315.22 Each client's medication shall be properly labeled as required by District and Federal laws and regulations, shall be stored in its original container, and shall not be transferred to another container or taken by persons other than the person for whom it was originally prescribed.
6315.23 Medications requiring refrigeration shall be maintained in a separate and secure refrigerator, labeled "FOR MEDICATION ONLY" and shall be maintained at a temperature between thirty-six degrees Fahrenheit (36°F) and forty-six degrees Fahrenheit (46°F). All refrigerators shall have thermometers, which are easily readable, in proper working condition, and accurate within a range of plus or minus two (2) degrees.
6315.24 A program shall conspicuously post in the drug storage area the following information:
(a)Telephone numbers for the regional Poison Control Center; and
(b)Metric-apothecaries weight and conversion measure charts.
6315.25 A program shall conduct monthly inspections of all drug storage areas to ensure that medications are stored in compliance with District and Federal regulations. The program shall maintain records of these inspections for verification.
6315.26 Where applicable, the program shall implement written policies and procedures for the control of stock pharmaceuticals.
6315.27 The receipt and disposition of stock pharmaceuticals must be accurately documented as follows:
(a)Invoices from companies or pharmacies shall be maintained to document the receipt of stock pharmaceuticals;
(b)A log shall be maintained for each stock pharmaceutical that documents receipt and disposition; and
(c)At least quarterly, each stock pharmaceutical shall be reconciled as to the amount received and the amount dispensed.
6315.28 A program shall implement written procedures and policies for the disposal of medication.
6315.29 Any medication left by the client at discharge shall be destroyed within thirty (30) calendar days after the client has been discharged, with the exception of Methadone and other controlled substances which must be returned to the point of issue or destroyed in accordance with federal regulations.
6315.30 The disposal of all medications shall be witnessed and documented by two (2) staff members.