Download DAYMARK RECOVERY SERVICES PROCEDURES CARF Section

11/30/2015
DAYMARK RECOVERY SERVICES
PROCEDURES
CARF Section/Subsection:
Section 2 – General Program Standards; E. Medication
Use
Procedure Title: Consumer Use of Medications and Medical
Services
Effective Date: 7/03/14
Review By: 7/03/15
Replaces:
Procedure #: 6040
Title: Consumer Use of Medications and Medical Services
Effective Date: 12/01/03; 6/01/08; 12/02/10; 4/22/11
Procedure #: 2210
Page: 1 of 3
Approved By:
Signature on file
Name: Billy R. West, Jr.,
Executive Director
7/03/14
Title:
Date:
Scope: These procedures apply to all Daymark Recovery Services, Inc. (DAYMARK) service
sites.
Purpose: To assure that medication is accessible and administered safely.
Responsibility: All employees trained and designated to provide these services.
Process:
1) Each consumer that engages our clinic for assessment and treatment has the right to see
our medical staff for additional treatment through pharmacology.
2) A consumer may be referred to our medical services by any of the following,
a) Referral from emergency services;
b) Self referral;
c) Referral from a primary care physician or other provider;
d) Referral from our treatment teams, emergency services, primary therapist or case
manager.
3) Typically referrals first see a therapist for an intake to complete all necessary clinical,
medical and regulatory paper work. From this meeting it is determined with the
consumer if an appointment with medical services is needed and if so with whom and if it
is an urgent need or not. Then the referral is made accordingly.
4) Each consumer receiving services shall have the right to be free from unnecessary or
excessive medication.
5) Medication shall be prohibited when used as punishment, discipline or for staff
convenience
6) Medication shall be dispensed by acceptable standards and only upon the order of a
licensed physician, nurse practitioner or physician assistant as documented in the
consumer record.
7) When prescribing medications our physicians shall consider a consumer’s whole system
of care and pay special attention to drug interactions, side effects, allergies, dietary
concerns, needs for lab work, ability of the consumer to continue the medication and
1) other indications as applicable and unique to each consumer as documented in the
psychiatric evaluations and medication check notes.
2) Effectiveness of medications will be reviewed at each medication check and the
consumer’s overall symptom relief, benefit and overall satisfaction noted.
3) To promote state-of-the-art prescribing and to ensure safety of the consumer, the
prescribing of medications will be based on the current standard of care as defined by
psychiatric training, continuing medical education activities, and published guidelines
from the American Psychiatric Association, the American Association of Child and
Adolescent Psychiatrists or other reputable professional organizations.
4) Safeguards shall be instituted in accordance with sound medical practice when a
medication is known to present serious risks to the individual receiving services is
prescribed.
5) Particular attention shall be given to the use of neuroleptic medications.
6) Each individual receiving service shall have the right to receive medication
education and information that shall detail the benefits and the potential negative
side effects of the medication. Evidence of such medication education shall be
maintained in the individual’s medical record. Medication education shall include,
but not be limited to, explaining how the drug works, side effects, contraindications,
benefits of medications, other wellness and recovery programs that may be beneficial and
others as medically indicated. When the consumer is a minor or has a legal guardian this
information will be provided to the appropriate party.
7) Each consumer receiving services shall retain the right to refuse the use of medication
except when ordered to do so by a court of competent jurisdiction.
8) Each DAYMARK employee engaged in the administration of medication to individuals
receiving services shall do so only when properly trained according to the applicable
standard. Documentation of training in medication administration will be maintained in
the employee file.
9) Prescription medication shall be dispensed/administered only on a written order
signed by a physician, nurse practitioner or physician assistant (or verbal order to a
registered nurse or licensed practical nurse and co-signed by a physician, nurse
practitioner or physician assistant.)
10) Consumer requests for medication changes or checks shall be recorded and kept in the
electronic health record or with the MAR file and followed up by appointment or
consultation with a physician.
11) Over the counter medication shall be administered only on the written approval of a
physician or person authorized to prescribe legend drugs. If the consumer is a minor or
incompetent adult, the authorization of the parent/guardian should be secured.
12) Authorization for the use of non-prescription medication shall be so designated through
the completion of a non-prescription medication authorization form developed by the
medical director.
13) At 24 hour facilities, non-prescription drug containers not dispensed by a pharmacist
shall retain the manufacturer's label with expiration dates clearly visible;
In general, DAYMARK Staff administer only injections in administering medications to
consumers. All other medications should be dispensed to the consumer for self-
1) consumption unless otherwise clinically indicated or the consumer is part of a residential
or inpatient program operated by DAYMARK.
2) DAYMARK has a psychiatrist available 24 hour per day, seven days per week to field
medication questions related to side effects, benefits, refills or other consultation.
3) Daymark provides staff and consumers ready access to the phone number for a poison
control center.
4) Daymark Medical Directors periodically (at least annually) review a sample of each
prescriber’s records to assess the appropriateness of medication treatment.
Definitions: CARF Behavioral Health Standards Manual: Prescribing is the practice of
evaluating, prescribing, dispensing and/or administering medications to persons served in
response to specific symptoms, behaviors and conditions for which the use of medications is
indicated and efficacious and of giving direction to the person served in the preparation and
administering of a remedy to be used in the treatment of disease.
Training: All employees designated to provide these services shall be licensed, certified and
otherwise trained in the practice of evaluating, prescribing, dispensing and/or administering
medications.
Monitoring: Pharmacotherapy services shall be monitored in accordance with DAYMARK
performance improvement criteria.
References: APSM 30-1; CARF 2014 Behavioral Health Standards Manual
Appendices: See other related documents as contained on the Daymark intranet
1
11/30/2015
DAYMARK RECOVERY SERVICES
PROCEDURES
CARF Section/Subsection:
Section 2 – General Program Standards; E. Medication
Use
Procedures Title: Dispensing of Medications/Storage of
Sample Medications
Effective Date: 11/6/14
Review Date: 11/6/15
Replaces:
No.: 6060
Title: Dispensing of Medications/Storage of Sample
Medications
Effective Date: 6/01/08;12-01-03; 12-2-10; 03/30/11; 4/16/13;
7/3/14
Procedures #: 2220
Page: 1 of 3
Approved By:
Signature on file
Name: Billy R. West, Jr.,
Executive Director
Title:
Date:
Scope: these procedures apply to all Daymark Recovery Services, Inc. (DAYMARK) outpatient
service sites (NOTE: see also Policy #927 Safeguards Regarding Medications and Research)
Purpose: DAYMARK service sites may maintain a limited supply of prescription
medication samples provided by established pharmaceutical companies for dispensing to
indigent consumers. These medications shall be stored in a safe and secure, double locked
system accessible only to physicians, nurse practitioners, physician assistants and
registered or licensed practical nurses. Daymark does not dispense any medications other
than samples or medications provided through “patient assistance programs” (PAP) by
pharmaceutical companies.
Responsibility: all employees designated and trained, licensed and/or certified to provide these
services.
Process:
1. Receipt and Storage of Prescription medication samples:
a. Physicians, nurse practitioners, and physician assistants shall be in contact
with pharmaceutical company representatives. They will identify
medications typically needed in emergency or “gap” or “starter” situations
and sign for receipt of the identified medication samples.
b. All prescription medications shall be stored in locked cabinets within a locked
room, accessible only to DAYMARK physicians, nurse practitioners, registered
nurses, licensed practical nurses, or staff trained in state curriculum standards for
medication administration in individual cabinets or bins labeled to designate each
medication and identifying the strengths, if applicable.
c. Only prescription medications samples or PAP medications shall be stored in the
designated locked cabinets.
Medications maintained by DAYMARK shall be limited to a small supply of “emergency”
medications most typically ordered by our physicians which
a. indigent consumers are least likely to be able to afford and/or which are
needed most often to use as “starter” doses and sample medications obtained
for specific consumers through pharmaceutical indigent care programs.
b. Medications obtained for specific consumers through pharmaceutical indigent
care programs shall be labeled with each consumers name and date received, and
shall be stored separately from the supply of “starter or gap doses”. A log shall be
maintained of these medications identifying date received, consumer, type of
medication, date dispensed to the consumer and the initials of the physician, nurse
practitioner, or physician assistant who dispensed the medication to the consumer.
c. A separate log shall be kept of sample medications stored for use as “gap” or
“starter” doses for different consumers, which identifies the date received,
type of medication, strengths and number of each received and dispensed.
2. Dispensing of prescription medication samples:
a. Unless clinically indicated and addressed through additional procedures, those
service sites that do maintain medication samples or PAP, provide all medications
directly to the consumer.
b. There shall be accompanying orders for each specific medication written by a
DAYMARK physician, nurse practitioner or physician assistant, or by a
registered nurse and reviewed/confirmed by a qualified prescriber in the
consumer’s record.
c. Medications may be dispensed only by a DAYMARK physician, nurse
practitioner, or physician assistant. A registered nurse or other designated staff
member may assist in this process.
d. Medication samples must be labeled with: date dispensed, consumer name, name
and address of the prescribing physician who ordered medication, name of
medication, strength of medication, quantity and expiration date of the
medication, specific directions to the consumer regarding dosage, times, etc,.
e. Medication samples and instructions must be reviewed and approved by the
physician prior to the consumer receiving them. When the prescriber is working
via telemedicine, the local nurse should physically demonstrate to the prescriber
the medication package and content and full content of the label.
f. Medication sample instructions must be reviewed with the consumer, including
benefits and side effects.
g. Documentation is made on a progress note or med call sheet that the prescriber
reviewed the samples and labeling provided to the consumer.
h. Documentation is made on the designated log regarding date, consumer’s service
record number, medication and strength and dosage.
i. Documentation is made in the service record on the medications orders form or in
the e-prescribing system.
j. Medications shall be dispensed in tamper-resistant packaging that will minimize
the risk of accidental ingestion by children. In the case of unit-of-use packaged
drugs, a zip-lock plastic bag may be adequate
3. Utilizing Medicaid prescription benefits and pharmaceutical indigent care programs:
a. First priority is to ensure all Medicaid eligible consumers are fully utilizing their
prescription medications benefits, including assisting consumers who are eligible
in applying for Medicaid benefits.
b. Staff, including physicians, nurse practitioners, physician assistants and registered
nurses, shall identify those pharmaceutical representatives who provide free
samples of the medications typically used or obtain coupons for frees samples
through the same companies.
c. Staff shall maintain an up-to-date list of pharmaceutical companies that do have
indigent care programs, the contact phone numbers and listing of medications
available, and a supply of the required applications, where applicable.
d. Consumers who are not Medicaid eligible, do not have a prescription drug plan
through their insurance and are unable to afford their prescription medication will
be assisted in completing whatever steps are necessary to become eligible for the
indigent care programs as soon as possible. Medications samples or coupons may
be used in the interim period if the physician believes the consumer needs to start
on the medication for symptom relief/control immediately.
e. Under no circumstances will medications samples or coupons be used on a
continuous, ongoing basis if a consumer is found to be ineligible for Medicaid and
for the indigent care programs.
f. A “tickler” system will be used for each consumer who is receiving assistance
through an indigent care program to assure continuity is maintained.
Training:
All employees designated to provide these services shall be licensed, certified or otherwise trained in the
practice of evaluating, prescribing, dispensing and/or administering medications and documentation of
training shall be maintained in their personnel files.
Monitoring:
Pharmacotherapy services shall be monitored in accordance with DAYMARK performance improvement
criteria.
References:
APSM 30-1; CARF 2014 Behavioral Health Standards Manual
2
11/30/2015
DAYMARK RECOVERY SERVICES
PROCEDURES
CARF Section/Subsection:
Section 2 – General Program Standards; E. Medication
Use
Procedures Title: Medication Documentation in Service
Records
Effective Date: 7/03/14
Review Date: 7/03/15
Replaces:
Procedure #: 6090
Title: Medications Documentation in Service Records
Effective Date: 12/01/03; 6/01/08; 12/01/10; 5/15/11
Procedure #: 2250
Page: 1 of 4
Approved By:
Signature on file
Name: Billy R. West, Jr.
Executive Director
7/03/14
Title:
Date:
Scope: These procedures apply to all Daymark Recovery Services, Inc. (DAYMARK) service
sites.
Purpose: To define methods for documenting medication(s) in the service record of the person
served.
Responsibility: All employees who are designated and trained to provide this service.
Process: Prior to the prescribing or administration of medication, the following information shall
be documented:
Informed Consent- explanation of the purpose, intended benefits, potential risks and possible
side effects of the medication(s), contraindications and documentation of the consumer’s
understanding and consent and/or documentation of the understanding and consent of the legally
responsible person.
Medication History- list of active and discontinued medications, including psychotropic and
non-psychotropic medications, for at least the past six months, noting current or past use,
strength and dosage when known, consumer’s report of whether the medication was helpful, any
side effects reported and whether other family members benefited from taking the same
medication in the past.
Allergies/Hypersensitivities- list of allergies and adverse reactions shall be clearly documented.
A lack of known allergies and sensitivities to medications and other substances shall be noted.
Previous Drug Overdose- The Physician, psychiatric nurse practitioner, or physician assistant
shall document any previous overdose attempt and include the date of overdose when known,
substance when known and record the date that the information was documented in the service
record. This information may be gathered by the admitting/assessing clinician and recorded in
the assessment and/or admission document and confirmed by the physician, nurse practitioner or
physician assistant during the psychiatric assessment/evaluation.
Medication Orders: The Physician, psychiatric nurse practitioner, or physician assistant shall
complete the medication order form or document in the e-prescribing system each time a
prescription is written or a medication is changed. The physician, psychiatric nurse practitioner,
or physician assistant’s orders shall also be recorded in the service record documentation (i.e.
psychiatric evaluation, medication check service note, etc.) when appropriate and/or in the
nurse’s progress note in the event of a verbal order (and co-signed by the physician, nurse
practitioner or physician’s assistant within 72 work hours).
Medication orders shall include: The date the medication is ordered, name of medication without
abbreviations, strength of medications, administration directions, quantity prescribed, number of
authorized refills (or samples to be given as appropriate), and signature of prescribing Physician,
psychiatric nurse practitioner, or physician assistant.
If a medication is discontinued, the date discontinued must be clearly documented and the reason
for the discontinuation documented in the medical record. .
The Physician, psychiatric nurse practitioner, or physician assistant may fill out a Report of
Health Services to Residents Form when the consumer is brought from a Nursing Home, assisted
living/domiciliary home, or group home for medication services. The completed form is
returned to the residential facility. A copy may be maintained in the medical record but is not
necessary because the Physician, psychiatric nurse practitioner, or physician assistant is required
to record all medications prescribed on the agency medication order form.
Orders for lab work and x-rays must be documented on the Physician, psychiatric nurse
practitioner, or physician assistant’s orders, medical monitoring form, or in the service record
documentation. Consumers on psychotropic medications shall be monitored for evidence that
they are being maintained within established therapeutic levels of their medications, when
applicable.
Consumers shall be monitored for evidence of undesirable reactions to medications prescribed
such as weight gain via weight checks, changes in blood pressure via blood pressure checks,
changes in lab results that may indicate the potential for medical problems such as diabetes via
routine orders for labs as recommended in best practices for the use of different types of
psychotropic medications. The results of all monitoring shall be documented in the medical
record within the actual notes or on the medical monitoring form as appropriate. Consumers
shall also be monitored for evidence of potentially irreversible side effects to medication of
tardive dyskinesia via completion of the Abnormal Involuntary Movement Scale (AIMS)
utilizing any approved form or documenting results directly in the evaluation or notes. The
AIMS shall be completed at the initiation of treatment, when applicable, and at least every 6
months thereafter.
Verbal Orders: Verbal or telephone orders may be taken by a Registered Nurse or Licensed
Practical Nurse and shall be documented on the medication order form or in the e-prescribing
system following all requirements of documentation of medication orders and including the
documentation of signature with date (either handwritten or electronic) of the responsible
Physician, psychiatric nurse practitioner, or physician assistant.
Medication Review:
1) If the consumer receives psychotropic drugs, a pharmacist, Physician, psychiatric nurse
practitioner, or physician assistant shall review the consumer’s drug regimen at least every
six months. The findings of the review shall be recorded in the service record along with
corrective action, if applicable. This review can be part of a psychiatric medication
management appointment.
2) Documentation of review with the consumer regarding withdrawal shall include discussion
of Methadone or other medications approved for use in narcotic addiction treatment when
deemed appropriate within a 24 hour facility. Refer to procedures related to Suboxone
treatment at Daymark facility-based crisis.
Medication Education: Whenever a new medication is prescribed, the Physician, psychiatric
nurse practitioner, or physician assistant shall provide medication education prior to the client
taking prescribed medication.
1) Whenever a DAYMARK Physician, psychiatric nurse practitioner, or physician
assistant prescribes medication, there shall be documentation by the Physician,
psychiatric nurse practitioner, or physician assistant or designee to demonstrate
that oral and/or written medication education was provided to either the consumer
and/or legally responsible person, if the ability of the consumer to understand is
questionable.
2) The medication education provided shall be sufficient to enable the client or other
responsible person to make an informed consent, to safely administer the medication and
to encourage compliance with the prescribed regimen.
3) The physician, nurse practitioner, or physician assistant shall document in the client
record that education for the prescribed psychotropic medication was offered and either
provided or declined. If provided, it shall be documented in what manner it was provided
(either orally or written or both) and to whom (client and/or responsible person).
4) Medication Education shall include: date medication prescribed, medication name,
whether consumer can self administer medication, type of medication education given,
via individual or group; frequency/duration – how often medication education is
anticipated; and physician, psychiatric nurse practitioner, or physician assistant signature
after medication education is provided.
Medication Education shall also include:
1) The name, form and dosage regimen, intended use, intended benefits, and any common
side effects of the medication;
2) Potential adverse reactions or uncomfortable side effects that should prompt
calling a physician;
3
11/30/2015
3) Food, drugs, or beverages that should be avoided/taken with medication;
4) An alternative dosage regimen if a dose is missed;
5) The expected length of the medication treatment;
6) Refill instructions;
7) The proper place to store medication;
8) The need to communicate and coordinate with other physicians of the client those
medications prescribed by the program; and
9) For females of child bearing age and ability, the risk factors of medication with
pregnancy and the need for client to report any changes in pregnancy status (LMP, birth
control, intent to become pregnant) to the physician,
10) Additional Education – note if it is desired that the nurse follow-up with additional
medication education. The Physician, psychiatric nurse practitioner, or physician
assistant shall identify through consultation with the nurse or through written
documentation that additional medication education is desired.
Medication Errors:
1) Drug administration error and significant adverse drug reactions shall be reported
immediately to a Physician, psychiatric nurse practitioner, or physician assistant or
pharmacist. The individual making the error will follow the directives of the physician,
nurse practitioner or physician assistant in notifying the consumer and/or the legally
responsible party of the error and any potential harmful effects.
2) An entry of the drug administered and the drug reaction shall be properly recorded in the
drug record.
3) An Incident –Death Reporting Form shall be completed and submitted to required
agencies as indicated following established procedure.
Refusal of Medication: A consumer’s refusal of a drug, and reason for same if known, shall be
documented in the service record and shall be reported to the physician, nurse practitioner or
physician assistant following his/her directives regarding notification.
Training: All employees designated to provide these services shall be licensed, certified and/or
otherwise trained in the practice of evaluating, prescribing, dispensing and/or administering
medications. (See documentation in Human Resources personnel file regarding licensure and
refer to on-site personnel files regarding Medication Administration/Education training in
residential and 24 hour facilities)
Monitoring: Pharmacotherapy services shall be monitored in accordance with DAYMARK
performance improvement criteria.
References: APSM 30-1; CARF 2014 Behavioral Health Standards Manual
Appendices: See other related documents on the Daymark intranet
DAYMARK RECOVERY SERVICES
PROCEDURES
CARF Section/Subsection:
Section 2 – General Program Standards; E. Medication
Use
Procedures Title: Storage and Disposal of Medications and
Equipment
Effective Date: 7/03/14
Review Date: 7/03/15
Replaces:
Procedure #: 6150
Title: Storage and Disposal of Medications and Equipment
Effective Date: 12/01/03; 6/01/08; 12/22/10; 1/31/12
Procedure #: 2270
Page: 1 of 3
Approved By:
Signature on file
Name: Billy R. West, Jr.,
Executive Director
7/03/14
Title:
Date:
Scope: These procedures apply to all Daymark Recovery Services, Inc. (DAYMARK) service
sites.
Purpose: To assure the proper storage and disposal of medications and related equipment.
Responsibility: All employees designated, licensed, certified or otherwise trained to provide
these services.
Process:
1) Storage/Disposal of Medications:
a) Only a small supply of medications will be maintained.
b) Medications are stored in observable, locked storage areas that are accessible only to
authorized personnel.
c) Medications shall be stored under proper conditions of sanitation, temperature, light,
moisture, and ventilation.
d) Medications for external use shall be segregated from medications for internal use.
e) Medication stored in a refrigerator used for other purposes shall be stored in a separate,
securely locked compartment.
f) Medications of consumers, which are stored by DAYMARK personnel, shall be labeled
clearly with the person’s name and specifically ordered dosage of the medication, the
name of the prescribing physician, the expiration date and the dispensing pharmacy/
pharmacist.
g) Medications stored by DAYMARK shall be routinely checked for expiration no less
often than prior to each administration by personnel.
h) Medications will be stored in a secure manner if approved by a physician, nurse
practitioner or physician assistant for a person to self-medicate.
Upon discharge of a patient or resident from a 24-hour facility, the remainder of his or her drug
supply shall be disposed of promptly unless it is reasonably expected that the
a) patient or resident shall return to the facility and in such case, the remaining drug supply
shall not be held for more than 30 calendar days after the date of discharge.
b) All prescription and non-prescription medication shall be disposed of in a manner
that guards against diversion or accidental ingestion.
c) 24-hour facilities may utilize controlled substances and these shall be disposed of in
accordance with the North Carolina Controlled Substances Act, G.S. 90, Article 5,
including any subsequent amendments. (Medication will be incinerated, returned to a
pharmacy, or placed in secure sharps container with 2 witnesses and the disposal of the
medication will be documented and signed by involved parties).
d) Any 24-hour facility which utilizes controlled substances must be currently registered
under the North Carolina Controlled Substances Act and shall be in compliance with the
North Carolina Controlled Substances Act, G.S. 90, Article 5, including any subsequent
amendments.
e) Medications turned in by consumers shall be disposed of by one of the following
methods:
i) Send to the local pharmacy as witnessed by two staff for destruction;
ii) Sent for incineration as witnessed by two staff;
iii) Placed in a secure sharps container in the presence of two staff members.
f) A record of medication disposal shall be maintained and shall include:
i) Name of consumer for whom it was ordered.
ii) Name and strength of the medication;
iii) Quantity of be disposed;
iv) Date of disposal;
v) Signature of person disposing the medication and signature of witness.
2) Storage and disposal of equipment:
a) DAYMARK shall maintain only a small number of supplies needed to administer
injectable medications, such as syringes and alcohol swabs; general first aid supplies and
medical waste clean up supplies. Equipment for injections shall be maintained in secure,
locked storage areas accessible only by authorized staff.
b) Syringes and all sharp instruments shall be disposed of in a container specifically
designed for sharp instruments that prevent accidental punctures immediately after use.
Disposable syringes shall not be broken, recapped or bent, but put in the container as a
whole.
c) All equipment used in the rendering of first aid, such as swabs, etc. or in administration
of injectable medications shall be disposed of in containers specifically designed for
disposal of items that have been contaminated with blood and or other body fluids.
d) Trashcans used in the area where injections are given or first aid is provided shall have
foot-controlled lids.
e) Trashcan liners shall be used and garbage will be double-bagged. Medical staff will
allow access to the area for picking up contaminated equipment to person responsible for
disposing of contaminated supplies.
4
11/30/2015
Training: All employees designated to provide these services shall be licensed, certified and/or
otherwise trained in the practice of evaluating, prescribing, dispensing and/or administering
medications. Non-medical personnel in residential settings will be trained according to state
standards of training.
Monitoring: Pharmacotherapy services shall be monitored in accordance with DAYMARK
performance improvement criteria.
References: APSM 30-1; CARF 2014 Behavioral Health Standards Manual
Appendices: See other related documents on the Daymark intranet
DAYMARK RECOVERY SERVICES
POLICY
CARF Section/Subsection: 2, E. Medication Use
Policy #: 6061
Page: 1 of 3
Policy Title: Medication Use
Approved By:
Effective Date: 5/26/2011
Name & Title: Jim Cook, Board Chairman
Replaces:
No.:
6061
Title: Medication Use
Effective Date: June 2008; 12/1/2010
Date: 08/01/2015
No.:
750
Title: Medication Requirements
Effective Date: Dec. 2003
Reviewed By (name of Board member):
Review Date:
Felicia Wilson
August 1, 2015
Next Review Date (one year from current review
date): August 1, 2016
Scope: this policy shall apply to all Daymark Recovery Services, Inc. (DAYMARK) programs
and service locations that engage in the practice of prescribing, dispensing, and/or administering
medications to persons served.
Purpose: to assure that DAYMARK pharmacotherapy procedures meet the legal, clinical and
ethical standards of best practice.
Responsibility: responsibility for implementing the intent and requirements of this policy is
delegated to the DAYMARK executive leadership who shall appoint a medical team that assures
that all applicable State and Federal standards are followed while practicing pharmacotherapy.
The executive leadership shall assure that:
1) Persons served (and/or their responsible parties) have access to pharmacotherapy
services
2) Indigent medications (when applicable) are made available whenever possible
3) Persons served (and/or their responsible parties) are provided with education that
includes the benefits and risks of medication
4) Procedures for safe handling and storage are observed
5) The safety and well-being of persons served shall take precedent in the practice of
pharmacotherapy
6) Each person served has the right to be free from unnecessary or excessive medication.
Medication shall not be used for punishment, discipline or staff convenience.
7) Use of drugs and medications as a treatment measures shall be governed by G.S. 122-C-57
and G.S. 90, Articles 1, 4A and 9A
Directive:
1) DAYMARK provides pharmacotherapy practices that include evaluating, prescribing,
dispensing and/or administering medications.
2) Daymark shall also monitor the use of medications prescribed, dispensed and/or
administered by licensed and authorized DAYMARK medical personnel (within the
limits imposed by the collaboration of the persons served). An order from personnel
licensed to prescribe will be maintained in the record.
3) DAYMARK shall develop procedures that describe the methods utilized in providing
pharmacotherapy practices including safe handling, safe storage, safe disposal and
documentation of medication use.
4) DAYMARK shall also develop procedures that include:
a) Access, when needed, through direct provision or referral.
b) Continuity of pharmacotherapy.
c) Integrating medications into a person's overall plan.
d) Identifying and documenting medication reactions.
e) Actions to follow in case of emergencies related to the use of medications.
f) Continuing the prescribed medication if a generic medication is not available.
5) DAYMARK shall develop procedures that include:
a) Compliance with all applicable local, state or provincial, and federal laws and
regulations pertaining to medications and controlled substances, including on-site
pharmacy services and dispensing.
b) Availability of a physician for consultation 24 hours a day, 7 days a week.
c) Documentation of reported medication reactions.
d) Review of past medication use, including:
i) Effectiveness
ii) Side effects.
iii) Allergies or adverse reactions.
e) Screening for common medical co-morbidities using evidence- or consensus-based
protocols.
f) Evaluation of co-existing medical conditions for potential impact.
g) Identification of alcohol, tobacco and other drug use.
h) Documentation or confirmation of informed consent for each medication prescribed,
when possible.
i) Documentation and reporting of medication errors.
j) Use of over-the-counter medications.
k) Use of medications by women of child bearing age.
l) Use of medications during pregnancy.
m) Management of biohazards associated with the use of medications.
n) Ready access to the telephone number of a poison control center by:
i) The program personnel.
ii) The persons served.
o) Review of pharmacotherapy activities, including medication errors and drug reactions, as part of
the quality monitoring and improvement system.
5
11/30/2015
a) Special dietary needs and restrictions associated with medication use.
b) Notification of the prescribing professional regarding medication reactions or
problems, including errors.
c) Necessary laboratory studies, tests, or other procedures.
d) Coordination when a medication is prescribed by a source other than the organization.
e) Coordination with the physician providing primary care needs.
2) In addition, DAYMARK shall develop procedures that address:
a) To the extent possible, the use of treatment guidelines and protocols to:
i) Promote state-of-the-art pharmacotherapy.
ii) Ensure safety of the person served.
b) A program of medication utilization evaluation, which includes measures of:
i) Effectiveness.
ii) Satisfaction of person served.
3) Daymark shall develop procedures that address:
a)
b)
c)
d)
e)
f)
g)
h)
i)
Purchase.
Transportation and delivery.
Storage.
Safe handling.
Packaging and labeling.
Safe disposal.
Inventory.
Off-site use.
Administration of medications by personnel, including:
i) Staff credentials and training.
ii) Documentation of medication administration, errors, and reactions.
iii) Documentation of the use and benefits of as needed (prn) doses.
References:
CARF 2011 Behavioral Health Standards Manual: Medication use is the practice of evaluating,
prescribing, dispensing and/or administering medications to persons served in response to
specific symptoms, behaviors and conditions for which the use of medications is indicated and
efficacious. It is the process for persons served to obtain medications and/or desired
treatment/service outcomes.
APSM 30-1
6