07.001 Medications

MEDICATIONS

Purpose:

Recovery Works wishes to ensure the safety of the administration or self-administration of medications for its clients and has adopted the following strict guidelines to ensure the safety of both the client and the staff of Recovery Works.

Policy:

1. Medications are prescribed by the client’s physician, and/or other prescribing practitioner as allowed by state law.

2. The risks and benefits of the medications must be explained to the client (and parent, guardian, or responsible party, if applicable) by the physician or prescribing practitioner as allowed by state law. This explanation may be delegated in writing by the responsible prescribing practitioner, with the documentation of the delegation and explanation being documented in the client’s record.

3. In order to enroll in Recovery Works, clients must meet the criteria for self-administration of medication. Any controlled substance taken by a client while enrolled, must be taken under supervised self-administration.

4. In the event that self-administration is impossible, a physician, physician’s assistant or nurse may administer medications provided no pharmacy services are provided on site and the self-administration procedure below is then followed.

5. Adverse drug reactions or errors are reported to a physician immediately and corrective action is initiated. The adverse reaction or error is recorded in the drug administration record and the individual treatment plan, and all persons who are authorized to administer medication or supervise self-medication are alerted.

6. All medications shall be stored under lock and key when not being administered or self-administered.

7. Program staff shall adhere to all federal and state laws and rules regarding controlled substances.

8. No on site pharmacy services will be provided. All medications will be obtained from a local Pharmacy after admission physical assessment and when orders are revised or changed. If a client goes for an interperiodic medical visit and is prescribed a medication, this may be obtained from the pharmacy by calling the pharmacy with the order or by the client taking the written prescription directly to the identified pharmacy (when on PHP/IOP level of care) and having it filled.

Procedures:

1. SELF-ADMINISTRATION

   1. Client education is provided to each client initially for each medication including any medications clients will be continuing from before admission.

   2. In order for a client to be eligible for the Partial Hospitalization or Intensive Outpatient level of care, the client must demonstrate the skills and understanding of the medication to independently self-medicate.

   3. The Physician must assess the client’s ability to demonstrate knowledge of self-medication procedures. The physician is to document in the client’s chart regarding the client’s ability.

At intake any medications currently prescribed to the client will be noted on the Medication Reconciliation Form and given to the medical professional responsible for the physical assessment and then added to the client’s record. Exhibit A

1. ASSESSMENT OF CLIENTS FOR SELF-ADMINISTRATION OF MEDICINES

   1. The following must be documented in the client’s chart prior to the self-administration of medication (Exhibit C)

      1. Determination of Self-Administration

         1. Has the physician authorized client to self-administer medication?

         2. Is the client confused or disoriented?

         3. Can the client read the label?

         4. Possible barriers to learning.

   2. Client Education

      1. Explain self-medication to the client fully

         1. Explain which tablets/medications they will be taking

         2. Explain the dosage, frequency and route

         3. Inform them of the reason for taking medications

         4. Explain the common side effects of each medication

   3. If the client is deemed unable to self-administer their medications, based on the self-administration assessment, the client may be referred to another facility to help manage the client’s medications.

2. MEDICATION ADMINISTRATION RECORD

   1. Any medications prescribed, administered or self-administered under supervision are documented on an individual medication administration record that is filed with the individual treatment plan, the log shall provide the following details;

      1. Name of medication;

      2. Date prescribed;

      3. Dosage;

      4. Frequency;

      5. Route of administration;

      6. Date and time administered; and

      7. Documentation of staff administering medication or supervising self-administration.

3. SELF ADMINISTRATION PROCEDURE

   1. All medication will be stored using a double lock system.

   2. Prescribed medication shall be administered by orders of a licensed practitioner only.

   3. Outdated or discontinued prescription medication containers along with the medications will be given to the nurse or other designated staff who will follow indicated procedure for disposal of medications.

   4. In the event a client receives a home pass, or end of program day the client will be provided with a their labeled medication prescriptions to take with them until they return to program. Medication may be returned to them at this time by staff authorized to do so. The appropriate labeled prescription bottle/containers/packages will be pulled from the client’s storage box of medication and given to the client when they leave the therapeutic program day. In the event that a client is released or discharged from the program while on a regiment of medication, the entire amount of medication will be made available to the client along with instructions for use according to Recovery Works disposition of medication policy and procedure.

   5. Orders for prescribed medications will be transcribed by the nurse or authorized staff when a medication is added on the client medication record or MAR. This MAR will list the name of the medicine, date prescribed, frequency, dosage route, date and time of self-administration of medications. The identified qualified staff will document by initialing a copy of the MAR that the client was observed taking the medication.

   6. When a client is scheduled to take medication, the prescribed medication is obtained by the client under the supervision of the along with drinking water. The client is to take the medication in view of the staff member. The staff member should closely inspect the client’s hands and mouth to insure that the medication was swallowed.

   7. Liquid medications are to be measured in appropriate dosage and placed in a medication cup. The staff member will observe medication dosage and client taking medications. Creams, salves, and other topical medications to be applied to the skin are to be dispensed to the client according to the physician’s orders or in cases of over-the-counter topical medication.

   8. The physician or nurse will assess the client for self-medication as noted below. The physician will document the self-administration order in a physician order form in the client chart.

   9. If Clients is diagnosed with diabetes the client’s physician may order and authorize the client to manage their own personal glucometer and insulin medication, including insulin pens, syringes or an insulin pump.

   10. Medications will be obtained from a local Pharmacy after admission physical assessment and when orders are revised or changed. If a client goes for an interperiodic medical visit and is prescribed a medication, this may be obtained from the pharmacy by calling the pharmacy with the order or by the client taking the written prescription directly to the identified pharmacy (when on PHP/IOP level of care) and having it filled.

Exhibit A

Exhibit B

MEDICATION AADMINISTRATION RECORD(MAR)

NAME:_________________________________________________DATE:______________

DRUG ALLERGIES___________________________________________________________

Check One:

Risks & benefits explained Not receiving medication from program

____________________________________________________ ______ DATE:_________

(Staff Signature)

Exhibit C

ASSESSMENT OF CLIENTS FOR SELF-ADMINISTRATION OF MEDICINES

Determination of Self-Administration

1. Has the physician authorized client to self-administer medication? ☐ Yes ☐ No

2. Is the client confused or disoriented? ☐ Yes ☐ No

3. Can the client read the label? ☐ Yes ☐ No

4. Are there any barriers to learning evident? ☐ Yes ☐ No

1. Client Education

   1. Explain self-medication to the client fully

☐Explain which tablets/medications they will be taking

☐Explain the dosage frequency and route

☐ Inform them of the reason for taking medications

☐ Explain the common side effects of each medication

1. Client is able to Self-Administer medications ☐ Yes ☐ No

1. If Client is unable to Self-Administer was client referred to another professional? ☐ Yes ☐ No