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Ohio Administrative Code (Last Updated: January 12, 2021) |
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5122 Department of Mental Health - Administration and Director |
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Chapter5122-26. Policies and Procedures for the Operation of Mental Health Services Agencies |
5122-26-15. Medication handling and theft
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(A) The provider shall have written policies and procedures regarding the purchasing, receipt, storage, distribution, return, and destruction of medication that include accountability for and security of prescription and over-the-counter medications located within any of its facilities. These policies and procedures shall include, but not be limited to the requirements that providers handling medications shall:
(1) Hold a valid and current terminal distributor of dangerous drugs license from the Ohio board of pharmacy if maintaining a stock supply of prescription medications, if participating with the department's central pharmacy to receive dispensed prescriptions, or when otherwise required by rules of the Ohio board of pharmacy.
(2) Locate all medications and prescription blanks in a locked, secure area;
(3) Designate a person having access to or authorized to handle medications and shall maintain a current list of these persons, their credentials and their medication handling responsibilities.
(4) Provide a method to record and follow the medications from the time of receipt to the time of distribution, return to central pharmacy, or destruction. This record shall be retained by the provider for three years and shall include, but not be limited to the following information:
(a) The date and time the medication was received by the provider, distributed to persons served, returned to central pharmacy or, if appropriate, destroyed;
(b) The name, credentials and signature of all persons handling medications; and
(c) The provision that unused medications prescribed for a person shall be appropriately destroyed or returned to central pharmacy, and that, under no circumstances shall the unused medications be issued to another individual. Return of unused medications prescribed to a person is only allowed when the return is to central pharmacy in accordance with rule 4729-9-04 of the Administrative Code.
(5) Ensure that all staff handling medications have basic and ongoing instruction and training in safe and effective handling of medications.
(6) Ensure that medications are handled only by authorized persons and that others do not have access to the medications; and
(7) Ensure that controlled substances may be destroyed only by an agent of the Ohio board of pharmacy, or the federal drug enforcement agency, or by transfer to persons registered under Chapters 3719. and 4729. of the Revised Code and according to rule 4729-9-06 of the Administrative Code.
(B) Providers maintaining a limited stock supply of medications shall:
(1) Allow only a physician or pharmacist to dispense medications, although the following individuals may personally furnish samples of some medications if issued a certificate to prescribe:
(a) Certified nurse practitioner and clinical nurse specialist in accordance with division (D) of section 4723.481 of the Revised Code; and
(b) Physician's assistant in accordance with division (A) of section 4730.43 of the Revised Code.
(2) Have visibly posted the phone number of the nearest poison control center.
(C) Each provider that permits clients to self-administer medication shall have written policies and procedures that include, but are not limited to, the following:
(1) Procedures for storing medications in a locked and secured cabinet, or similar storage.
(2) Procedures for self-medication.
(3) Procedures for accounting for medications that are kept for the client while they are at the program site.
(4) Each provider shall describe in its policies and procedures whether clients are permitted to self-administer medication at the provider site, and whether clients are permitted to have unsecured prescription and over-the-counter medication in their possession while at the client site. When clients are not permitted to have medication in their possession, the provider shall have written procedures for obtaining, accounting for, and returning medication at the time of departure or discharge.
(D) The provider shall have a policy on employee medication theft and shall inform all employees concerning this policy. The policy shall include attention to prescription as well as over-the-counter medications maintained for client use.
(1) An employee, intern or volunteer with knowledge of medication theft by an employee or any other person shall report such information to the executive director of the provider. If the executive director of the provider is suspected of medication theft, the employee or volunteer shall notify the department.
The provider shall take all reasonable steps to protect the confidentiality of the information and the identity of the person furnishing the information.
(2) Suspected medication theft shall be reported to the Ohio board of pharmacy. For controlled substances, suspected medication theft shall also be reported to the federal drug enforcement administration. Providers participating in medication services with the Ohio department of mental health and addiction services central pharmacy shall also notify central pharmacy.
(3) Failure to report information of medication theft shall be considered in determining the eligibility of the employee to continue to work in a secure area where medications are stored.
(4) If an employee violates the provider's medication theft policies, the provider shall assess the seriousness of the employee's violation, whether the violation has a direct and substantial relationship to that employee's position, the past record of employment, and other relevant factors in determining whether to suspend, transfer, terminate, or take other action against the employee.