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Santa Barbara County Department of Behavioral Wellness Office of Quality and Strategy Management

Alice Gleghorn, PhD

Section Sub-section

Psychiatric Health Facility (PHF) Nursing

Effective: 4/6/11

Policy Policy #

Controlled Substance Management Last Revised:

9/28/16

Director’s Approval Date

PHF Medical Director’s Approval

Date

Supersedes: NM – Controlled Substances

Audit Date:

9/28/19

1. PURPOSE/SCOPE

1.1. To provide standards and procedures for the safe inventory, management and administration of controlled substances at the Psychiatric Health Facility (PHF).

1.2. To ensure the PHF’s medication management policies are in compliance with all federal

and state laws and standards of professional practice.

2. DEFINITIONS

The following terms are limited to the purposes of this policy: 2.1. Licensed Nursing Staff (LNS) – an individual employed or contracted by the PHF who

holds a valid California license as a: registered nurse (RN); licensed vocational nurse (LVN); or psychiatric technician (PT).

2.2. Schedule II, III-V controlled substances – a classification of drugs as defined by the United States Controlled Substances Act that have a high potential for abuse and may lead to physical and psychological dependence.

3. POLICY 3.1. Medications classified by the Drug Enforcement Administration (DEA) as Schedule II,

III-V controlled substances shall be subject to special management, oversight and accountability. In accordance with all relevant federal and state laws and regulations, the Psychiatric Health Facility (PHF) shall enforce strict controls in the access, storage, record-keeping and disposal of controlled substances.

Leslie Lundt, MD

Programmatic Policy and Procedure

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4. STORAGE AND ACCESS 4.1. All controlled substances will be stored in PHF’s designated medication room and

locked in cabinet designated specifically for controlled substances (i.e. double-locked). These will be kept separate from non-controlled substances.

4.2. During each shift, a dedicated Medication Nurse will be assigned to hold the key to the

controlled substance cabinet. 1. The controlled substance key will be turned over to the shift’s Team Leader for the

duration of the Medication Nurse’s scheduled break.

5. RECEIPT OF CONTROLLED SUBSTANCES 5.1. All controlled substances delivered to the PHF will be accompanied by a delivery receipt

and a patient-specific Controlled Drug Record (see Attachment A). On arrival, the delivery receipt must be signed, dated and timed by the Medication Nurse.

5.2. A copy of the signed delivery receipt will be placed in the PHF’s Narcotic Count Binder. 5.3. On the Controlled Substance Delivery Log (see Attachment B), the Medication Nurse

will record the medication name, dosage and prescription (Rx) number. 1. After all delivered controlled substances are accounted and documented, the

Medication Nurse and Team Leader will co-sign the Controlled Substance Delivery Log.

6. SHIFT COUNT 6.1. At each shift change, a count of all controlled substances will be conducted by the

incoming and outgoing Medication Nurses The completion of the count will be signed on the Controlled Drug Count Sheet (see Attachment C) by both staff.

6.2. During the count, the incoming and outgoing Medication Nurses will review the Controlled Substance Delivery Log (see Attachment B) to verify that controlled substances inventoried match with those delivered.

7. CONTROLLED SUBSTANCE ADMINISTRATION 7.1. When a controlled substance is administered, the Medication Nurse will enter the date

and time of administration on the patient’s Controlled Drug Record (see Attachment C) and Medication Administration Record (MAR). The Medication Nurse will sign and/or initial these forms where indicated.



7.2. When a dose of a controlled substance is prepared for administration but refused by the patient or not given for any reason, it cannot be returned to its original container. The controlled substance must be removed from inventory and disposed. Each disposal must be fully documented on the Controlled Drug Record with the time and date of disposal and initialied by a LNS and a registered nurse (RN). 1. Please see PHF policy “Medication Disposal” for further details.

7.3. Once all doses of a controlled substance have been utilized (i.e. bubble pack or container is empty), the Controlled Drug Record and the delivery receipt will be pulled from the Narcotic Count Binder. These will be stapled and filed together in the Completed Narcotics Binder. Documentation of said controlled substance prescriptions will be highlighted on the Controlled Substance Delivery Log (see Attachment B) indicating its completion. All documentation will be stored for a minimum of 3 years. 1. If a delivery receipt lists more than one prescription, highlight the controlled

substance prescription.

8. CONTROLLED SUBSTANCES AT DISCHARGE 8.1. Controlled substances at discharge will be processed according to the PHF’s “Patients’

Own Medications” policy.

8.2. Controlled substances remaining at the PHF after a patient is discharged will be disposed. 1. Please see PHF policy “Medication Disposal” for further details.

9. REPORTING AND DOCUMENTING DISCREPENCIES 9.1. Any discrepancy in the count of a controlled substance must be reported immediately to

the Team Leader, Nursing Supervisor and on-call administrator.

9.2. An Unusual Occurrence Incident Report must be completed by reporting staff immediately but no later than the end of the shift. Incident reports will be forwarded to the PHF Nursing Supervisor, PHF Medical Director, PHF Program Manager and PHF Quality Care Management (QCM) Coordinator. A determination will be made by these parties in regards to any disciplinary action, possible notification of local law enforcement and other actions and interventions.

9.3. The Nursing Supervisor will submit incident findings and recommendations to the

Quality Assessment and Performance Improvement (QAPI) Committee.



ASSISTANCE Charlotte Balzer-Gott, RN, PHF Nursing Supervisor

REFERENCE Code of Federal Regulations Title 42, Section 482.25 (a)(3), (b)(2)(ii), (b)(7) Controlled Substances Act Title 21, Chapter 13, Part B, Section 812

Code of Federal Regulations

Title 21, Part 1317, Section 1317.95 California Code of Regulations – Social Security Title 22, Section 77079.9

ATTACHMENTS Attachment A – Controlled Drug Record Attachment B – Controlled Substance Delivery Log Attachment C – Controlled Drug Count Sheet

RELATED POLICIES Medication Disposal Unusual Occurance Incident Report

REVISION RECORD

DATE VERSION REVISION DESCRIPTION

Culturally and Linguistically Competent Policies The Department of Behavioral Wellness is committed to the tenets of cultural competency and understands that culturally and linguistically appropriate services are respectful of and responsive to the health beliefs, practices and needs of diverse individuals. All policies and procedures are intended to reflect the integration of diversity and cultural literacy throughout the Department. To the fullest extent possible, information, services and treatments will be provided (in verbal and/or written form) in the individual’s preferred language or mode of communication (i.e. assistive devices for blind/deaf).



Attachment A



Attachment B



Attachment C

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