D.C. Mun. Regs. r. 22-A8015
Providers shall maintain all controlled substances in accordance with applicable Federal and District laws and regulations.
Providers shall implement written policies and procedures to govern the acquisition, safe storage, prescribing, dispensing, labeling, administration and self-administration of medication. This section shall include medications individuals bring to the program.
A provider shall ensure that any prescription medication that an individual brings to the program has a record of the prescribing physician's order, including the prescribing physician's approval to self-administer the medication, if applicable.
No medication brought into the facility may be administered or self-administered until the medication is identified and the attending practitioner's written order or approval is documented in the individual's record.
Verbal orders may only be given by the attending practitioner to another physician, PA, APRN, RN, or pharmacist. Verbal orders shall be noted in the individual's record as such and countersigned and dated by the prescribing practitioner within twenty-four (24) hours. However, pursuant to District law and regulations, orders for seclusion or restraint shall always be made as written orders.
Providers shall ensure that medication, both prescription and over-the-counter, brought into a facility is packaged and labeled in accordance with Federal and District laws and regulations.
Providers shall ensure that medication, both prescription and over-the-counter, brought into a facility by an individual that is not approved by the attending practitioner is packaged, sealed, stored, and returned to the individual upon discharge.
The administration of medications, excluding self-administration, shall be permitted only by licensed individuals pursuant to applicable Federal and District laws and regulations.
Medications shall be administered only in accordance with the prescribing practitioner's order.
Only a physician, APRN, RN, or PA shall administer controlled substances or injectable drugs, excluding self-administered drugs.
Program staff responsible for supervising the self-administration of medication shall document consultations with a physician, APRN, RN, or pharmacist, or referral to appropriate reference material regarding the action and possible side effects or adverse reactions of each medication.
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 self-administered medications.
Medication administration training shall be facilitated by the following Qualified Practitioners, as led by signature and date on the training certificate:
Only staff trained pursuant to the requirements of this chapter shall be responsible for observing the self-administration of medication.
A program shall ensure that medication is available to individuals as prescribed.
A program shall maintain records that track and account for all medication, ensuring the following:
An attending practitioner shall be notified immediately of any medication error or adverse reaction. The staff responsible for the medication error shall complete a major unusual incident report ("MUI"). The provider shall document the practitioner's recommendations and the program's subsequent actions in response to the medication error or adverse reaction in the individual's record.
A program shall ensure that all medications, including those that are self-administered, are secured in locked storage areas.
The locked medication area shall provide for separation of internal and external medications.
A program shall maintain lists of personnel with access to the locked medication area and personnel qualified to administer medication.
A program shall comply with all Federal and District laws and regulations concerning the acquisition and storage of pharmaceuticals.
Each individual's medication shall be properly labeled as required by Federal and District laws and regulations, shall be stored in its original container, and shall not be transferred to another container or taken by anyone other than the individual for whom it was originally prescribed.
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°F) degrees Fahrenheit.
A program shall conspicuously post in the drug storage area the following information:
A program shall conduct monthly inspections of all drug storage areas to ensure that medications are stored in compliance with Federal and District laws and regulations. The program shall maintain records of these inspections for verification.
Where applicable, the program shall implement written policies and procedures for the control of stock pharmaceuticals.
The receipt and disposition of stock pharmaceuticals must be accurately documented as follows:
A program shall implement written procedures and policies for the disposal of medication.
Any medication left by the individual at discharge shall be destroyed within thirty (30) calendar days after the individual 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.
The disposal of all medications shall be witnessed and documented by two (2) staff members.
D.C. Mun. Regs. r. 22-A8015