Pharmacy Policy - JIRDC Home

J.IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Pharmacy Services JIRDC Number: 1:1Page: 1 of 4Effective Date: 09/12/02Supersedes: 09/23/98_____________________________________________________________________PURPOSE:To describe J. Iverson Riddle Developmental Center’s Pharmaceutical Services andOrganizational Structure.POLICY:The Pharmacy Department of J. Iverson Riddle Developmental Center is committed toproviding comprehensive, progressive pharmaceutical services, based on availableresources, to the in-patient population at J. Iverson Riddle Developmental Center’sPharmaceutical Services in this 475 bed, North Carolina State developmentallydisabled center include provision of services to age groups ranging from Adolescent toGeriatric. Diagnoses in this population include acute and chronic psychiatric disorders,mental retardation, and dual diagnosis. Many patients in this population haveconcurrent physical disorders which can require medical and/or surgical monitoring orinterventions. Therefore, the scope of medications utilized in the treatment of thispopulation includes a wide range of both psychiatric and medical medications.Organizationally, the Pharmacy Department is responsible to the Director of MedicalServices. The staff of the Pharmacy Department currently consists of a PharmacyServices Manager II, a Pharmacy Services Manager I, two Clinical Pharmacists, threePharmacy Technicians, and one Office Assistant III.Scheduled pharmacy hours are 8 a.m. to 5 p.m., Monday through Friday and8 a.m. to 12 noon on holidays with a limited staff. The Pharmacy also provides an afterhours pharmacy service which consists of a Night Drug Cabinet and a pharmacist oncall.Pharmacy Services provided to J. Iverson Riddle Development Center includeadministrative services, distributive services, and clinical pharmacy services. Theseservices are

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Pharmacy Services JIRDC Number: 1:1Page: 3 of 4Effective Date: 09/12/02Supersedes: 09/23/98_____________________________________________________________________Any distributive functions performed by a pharmacy technician arechecked by a registered pharmacist before the medication isdispensed. All new orders are checked against existing clientorders for drug interactions and therapeutic duplications by apharmacist.2. Maintenance of a pharmacy based I.V. Admixture service.3. Pharmacy staff performs inspections in drug storage areas on amonthly basis, and checks quality assurance for controlledsubstances in all cottages every three weeks.4. The Pharmacy prepares medication for off-campus trips, visits,and discharges as appropriate.5. The Pharmacy provides an after hours pharmacy service whichconsists of a Night Drug Cabinet and a pharmacist on call.6. The Pharmacy maintains 18 Emergency Medication Boxes forJ. Iverson Riddle Developmental Center.7. The Pharmacy prepackages oral solids and liquids in unit dosewhen cost of availability does not permit purchasingmanufacturer's unit dose.8. Responsible for storage, dispensing, and maintenance ofinformation for investigational drugs.Clinical Service1. The Pharmacy provides the following clinical services which arerequired for all ICF/MR consumers:Coordinates treatment team meetings, performs quarterlydrug-regimen reviews and actively participates in discussionof cases as a member of the treatment team.b. Provides written evaluations for all post-admission and

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Pharmacy Services JIRDC Number: 1:1Page: 4 of 4Effective Date: 09/12/02Supersedes: 09/23/98_____________________________________________________________________for all annual reviews meeting criteria.c. Pharmacists attend all annual assessment meetings forconsumers meeting attendance criteria.Pharmacists attend and participate in discussion of consumersFollowed in the facility Neurology Clinic.2. The Pharmacy provides drug information and patient consultationto J. Iverson Riddle Developmental Center staff upon request.3. The Pharmacy publishes a monthly newsletter made available on thefacility website.4. Pharmacists are involved in providing in-service training toJ. Iverson Riddle Developmental Center staff and continually update their owneducational needs by participating in continuing educationprograms.5. Pharmacist utilize patient medication profile information tomonitor drug therapy including dosages, frequency of administration,drug interactions, incompatibilities, and allergies.6. Pharmacists offer training, drug information, and consultativeservice to communities in the Western Region of North Carolina.The Pharmacy Department serves as an internship site for Doctor ofPharmacy students.8. Maintains a website which provides information regarding Pharmacyservices and current formulary.Note: See Figure 1:1A for Pharmacy Department Organizational Chart.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Departmental Rules JIRDC Number: 1:2Page: 1 of 1Effective Date: 09/23/98Supersedes: __04/15/92_____________________________________________________________________PURPOSE:To establish basic departmental guidelines which will help assure an efficient pharmacy operation.POLICY:A. Scheduled pharmacy hours are 8 a.m. to 5 p.m., Monday through Friday and 8 a.m. to 12noon on holidays with a limited staff. The Pharmacy also provides an after hours pharmacy servicewhich consists of a Night Drug Cabinet and a pharmacist on call.B. Time sheets shall be filled out according to J. Iverson Riddle Developmental Center Policiesand Procedures.C. Leave time shall be requested from appropriate supervisors far enough in advance so thatthe work schedule can be properly planned.D. If it is necessary to be absent without previous notice (illness, death in family, etc.) theappropriate supervisor shall be notified at the earliest possible time.E. Pharmacy employees shall become familiar with and comply with all appropriate State,Center and Pharmacy policies and procedures.F. Each pharmacy employee is responsible for helping to maintain a clean and orderlydepartment.G. Each pharmacy employee will go to lunch at their scheduled time. Any change in the lunchschedule shall be approved by the appropriate supervisor.H. Personal phone calls shall be limited as to number and duration.I. There will be a Pharmacy Staff meeting at least once monthly.J. Regular and assigned responsibilities shall be completed as scheduled.K. Any injuries occurring at work shall be reported immediately to a supervisor.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Pharmacy Telephone Policy JIRDC Number: 1:3and Procedure Page: 1 of 2Effective Date: 04/15/92Supersedes: N/A_____________________________________________________________________PURPOSE:To define the policy and outline a procedure pertaining to the use of the telephone inthe Pharmacy.GENERAL:The telephone is our most common means of communication with people outside of theDepartment. Although it is a common means of communication, the telephone is notthe best way. Therefore, it is prudent to keep certain points in mind.1. Every time you make or receive a call, you are the Pharmacy to theperson at the other end of the line. The Department is judged byyour voice - by what you say and how you say it.2. There are five things to strive for in a good telephone voice.They are:POLICY:a. Alertnessb. Pleasantnessc. Naturalnessd. Distinctnesse. Expressiveness1. Answer the telephone promptly at the first ring, if possible.2. Identify the Department and yourself.3. Be friendly and helpful.4. Transfer a call only when necessary.5. Hang up gently.When a call is received on one Pharmacy line and is to be transferred to anotherdepartment within the facility, the following procedure is to be used:

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Pharmacy Telephone Policy JIRDC Number: 1:3and Procedure Page: 2 of 2Effective Date: 04/15/92Supersedes: N/A_____________________________________________________________________Inform the caller that their call is about to be transferred andgive the caller the appropriate number in case you are unable tocomplete the transfer, then transfer the call.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Monthly Inspection of Drug JIRDC Number: 1:4Storage Areas Page: 1 of 3Effective Date: 3/01/92Supersedes: N/A___________________________________________________________PURPOSE:To assure that adequate precautions are taken to store medications underproper conditions of sanitation, temperature, light, moisture, ventilation,segregation, and security.POLICY:A monthly inspection of drug storage areas shall be conducted by anappropriately trained or experienced member of the Pharmacy staff. Theoriginal of the Drug Storage Area Inspection Form shall be posted in thedrug storage area and a copy shall be filed in the Pharmacy. If anydiscrepancies are noted, the member of the Pharmacy staff performing theinspection shall give the appropriate medication nurse a corrective actionform. The Corrective Action Form shall be completed and returned to theDirector of Pharmacy within 72 hours. A Monthly Drug Storage AreaInspection Summary shall be a part of the Pharmacy, Therapeutics, andInfection Control Committee minutes. The summary which shall include astatement of corrective action for noted discrepancies shall be reviewed bythe Pharmacy and Therapeutics Committee and appropriaterecommendations made.Note: See Figure 1:4A for the Drug Storage Area Inspection Form(Form1).Note: See Figure 1:4B for Corrective Action Form (Form17).

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Puncturing of Multidose Vials JIRDCP Number: 1:5Page: 1 of 1Effective Date: 03/15/06Supersedes: 07/01/05_____________________________________________________________________POLICY AND PROCEDURE:1. At the time of puncturing a multidose vial of medication, a label shall be affixed tothe vial indicating the date of puncturing and the initials of the individual puncturing thevial.2. If the multidose vial is not used within 30 days, the medication shall be returned tothe pharmacy. Unused contents of punctured insulin vials must be returned to thepharmacy after 28 days.3. A member of the pharmacy staff will monitor compliance with this policy andprocedure during the monthly inspection of drug storage areas.4. Insulin products must be stored in the refrigerator prior to opening. However, oncethe vial is opened, it may be stored for 28 days either in the refrigerator or at roomtemperature, unless otherwise specified by the manufacturer.5. Label samples:To be used with non-insulin products:Puncture Date:________________Punctured By:_________________Discard After 30 DaysTo be used with insulin:Insulin Puncture Date:__________Punctured By:________________Discard After 28 Days

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Drug Product Problem JIRDC Number: 1:6Reporting Page: 1 of 2Effective Date: 09/19/96Supersedes: 04/15/92___________________________________________________________POLICY:To provide a mechanism for reporting drug product problems encounteredin practice to the FDA for investigation and compilation.PROCEDURE:Drug product problems encountered in the practice of pharmacy, whichincludes but are not limited to problems in drug product quality,therapeutic ineffectiveness, packaging and labeling problems, and possibleproduct tampering shall be reported to the Food and Drug Administration'sDrug Product Problem Reporting Program using Form FDA 3500 (06/93)and mailing to:MED WATCHFood and Drug Administration5600 Fishers LaneRockville, MD 20852-9787OR FAX to: 1-800-FDA-0178Problem reports received by the FDA are used to inform participatingproduce manufacturers of potential health hazards and defective products.Note: See Figure 16A for Drug Product Problem Reporting ProgramForm (FDA 3500)

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Administration Times for JIRDC Number: 1:7Medication Page: 1 of 2Effective Date: 09/27/00Supersedes: 05/01/92_____________________________________________________________________PURPOSE:To establish center-wide administration times for commonly utilized sigs.POLICY:Unless otherwise specified by the prescriber, the times of administration outlined below shall beassigned to the corresponding sigs by the Pharmacy Department at the time of computer orderentry for each new physician's order. The Pharmacy Department shall generate a MedicationAdministration Record (MAR) label for nursing service to utilize in medication administration withthe hospital approved times of administration printed on the label for the corresponding physician'sorder.StdAdminTimesCed/Willow Ced/Willow Summit Summit Lakeside Lakeside Evergreen/ MCUPalm-Fir-MagnoliaOak-Laural-Ivey-Jun-Thistle-Honey-DandelionBirch-PineHemlock-Spruce-ElmAsh-PoplarMulberry-Maple-MimosaDaily 8am 8am 8am 8am 8am 8am 8amQPM 7pm 8pm 7pm 8pm 6pm 8pm 8pmBID 8-7 8-8 8-7 8-8 8-6 8-8 8-8TID 8-12-7 8-12-8 8-12-7 8-12-8 8-12-6 8-12-8 8-12-8QID 8-12-4-8 8-12-4-8 8-12-4-8 8-12-4-8 8-12-4-8 8-12-4-8 8-12-4-8Q6 hr 6-12-6-12mn 6-12-6-12mn 6-12-6-12mn 6-12-6-12mn6-12-6-12mn6-12-6-12mnQ8 hr 8-4-12mn 8-4-12mn 8-4-12mn 8-4-12mn 8-4-12mn 8-4-12mn 8-4-12mnQ12 hr 8-8 8-8 8-8 8-8 8-8 8-8 8-86-12-6-12mnEXAMPLE: "Tagamet 300 mg PO TID" is transcribed by the Pharmacy Department and MARlabels generated to administer this medication at 7 AM, 12 Noon and 8 PM.Prescribers may circumvent the standard administration times when factors make such timesunsuitable for a particular resident's drug regimen by stating the desired times of administrationwithin the content of the physician's order.EXAMPLE: "Tagamet 300 mg PO TID at 8 AM, 2 PM and 8 PM" would be transcribedand MAR labels generated with the specified times printed (8 AM, 2 PM and 8 PM).

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Administration of Drugs JIRDC Number: 1:8Page: 1 of 1Effective Date: 05/01/92Supersedes: 02/04/80_____________________________________________________________________POLICY:Injectable, oral, rectal, vaginal, topical, aural, ophthalmic, nasal andper Levin's tube medication may be administered in all areas only by anurse or by a physician.Drugs may be administered only after authorization of a physician. Thisauthorization may be oral, but the oral authorization shall be reduced towriting by a nurse, and signed by the nurse with the letters "V.O." toindicate a verbal order from the physician. Certain "routine orders" maybe used for such things as a laxative routine, etc., but such standingorders must be signed by the physician in charge.Only those medications listed as acceptable floor stock may be used formore than one resident. All other medications are dispensed for the useof one resident only. Borrowing of medication from one resident foranother is prohibited.Self-Administration of Medication:No resident will be allowed to administer his own medication unless he/sheexhibits such capabilities and is enrolled in the self-medication program.Such self-medication shall be monitored and under the supervision of a nurse.Admission to the program must be made by a physician.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Pharmaceutical Representatives JIRDC Number: 1:9Page: 1 of 1Effective Date: 04/15/92Supersedes: 04/28/80___________________________________________________________PURPOSE:To provide guidelines for Pharmaceutical Representatives at J. Iverson RiddleDevelopmental Center.POLICY:1. When working at J. Iverson Riddle Developmental Center, PharmaceuticalRepresentatives are requested to stop by the Pharmacy for messages and to servicethe account before proceeding to other areas within the Center.2. A message can be relayed to Pharmaceutical Representatives by contacting thePharmacy Secretary.3. Before introducing non-formulary medications, Pharmaceutical Representativesplease notify the Director of Pharmacy or Assistant Director of Pharmacy in theDirector's absence and provide any formulary and cost information that is needed.4. Pharmaceutical Representatives shall assist the Pharmacy as appropriate with thereturning of overstocked or out-of-date medications to the manufacturer for credit.5. To see physicians, Pharmaceutical Representatives shall contact the appropriatesecretaries and schedule appointments.6. Any samples that are to be used for residents at J. Iverson Riddle DevelopmentalCenter shall be taken to the Pharmacy for appropriate dispensing and to assure thatappropriate security is maintained to protect our residents.7. Pharmaceutical Representatives are not allowed in resident care areas unless invitedby the primary physician.

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Use of Night Drug Cabinet JIRDCP Number: 1:10Page: 1 of 2Effective Date: 03/14/07Supersedes: 09/10/02______________________________________________________________________________PURPOSE:To allow for controlled access to certain drugs by medical and nursing staff when the Pharmacy is notopen.POLICY:The Night Drug Cabinet for the J. Iverson Riddle Developmental Center is located in the Medical CareUnit (MCU) and is to be used only when the Pharmacy is not open. The Pharmacy is open from 8A.M. to 5 P.M., Monday through Friday, and from 8 A.M. to 12 noon on certain holidays. All otherhours are covered by a pharmacist on call.PROCEDURE:The procedure for obtaining medication from the Night Drug Cabinet (NDC) is as follows:A. New Orders1. Medications stocked in the NDC are listed on the Pharmacy Page of the J. IversonRiddle Developmental Center Web Site. The MCU also keeps a notebook that lists themedications stored in the NDC which is more specific with regard to the number ofdoses stocked and the location of the medication within the NDC.2. The cottage nurse shall bring the new order to MCU and the MCU nurse shall assistwith the use of the NDC. Stamp the physician’s order sheet with the NDC stamp andcomplete the information requested from the stamp (Date, Time, Medication Name andStrength, Bag Number, number of doses obtained, Cottage and MCU nurse signatures).3. Fax the completed physician’s order to the Pharmacy.4. Obtain the medication from the NDC stock. The medication is arranged numerically inlabeled baggies; this numerical assignment is referenced in NDC list contained in theMCU notebook. Procure only enough medication to get through the morning dose ofthe next working day. Remove the medication from the baggie and leave the baggie inthe NDC tray.5. Sign out for the medication on the NDC Log in the red notebook stored in the NDC.6. The Pharmacy will pick up the tray, baggies and notebook the next working day toreplenish stock.1

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Use of Night Drug Cabinet JIRDCP Number: 1:10Page: 2 of 2Effective Date: 03/14/07Supersedes: 09/10/02______________________________________________________________________________B. Spilled or Wasted Medications, Shortages in Cart Fills1. Bring a copy of the completed ‘Drug Variance Reporting Sheet” to the NDC asdocumentation for the rationale to retrieve medication from the NDC2. Stamp the Variance Reporting Sheet with the NDC stamp and obtain the medicationneeded as described in A. 2.-6.3. Fax the Variance Form to the Pharmacy and leave the baggie in the tray for thePharmacy to pick up the next working day.C. Refill of Treatment or Non-Unit Dose Medications1. The cottage nurse shall complete the Pharmacy Floorstock Requisition Sheet with themedication refill request and bring to MCU for assistance.2. Stamp the Floorstock Requisition Sheet with the NDC stamp and obtain the medicationneeded.3. Follow the procedure outlined in A.2.-6.4. Fax the Floorstock Form to the Pharmacy and leave the baggie (if applicable) in the trayfor the Pharmacy to pick up the next working day.D. Controlled Substances1. A limited supply of controlled substances is available in the Night Drug Cabinet. Refer toPharmacy Policy and Procedure Number 1:28 Controlled Substances for specific detailsregarding accountability.2. When a controlled substance is needed for a resident, and the Pharmacy is closed, onedose at a time can be transferred from one cottage drug storage area to another by thenurse involved. The nurse obtaining the controlled substance shall sign out for the doseneeded on the correct Controlled Substance Administration Record being sure to indicatethe resident’s name and cottage that the controlled substance is being obtained for. Thepharmacist on call shall be notified and shall, upon the next necessary return to the facility,dispense the needed controlled substance to the appropriate area. The pharmacist on callshall be notified immediately if the needed controlled substance cannot be located.If a needed medication is not available from the NDC, if there are questions related to the NDCprocedures, or if there are drug information questions, the pharmacist on call shall becontacted.2

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: JIRDC Pharmacy JIRDC Number: 1:11Formulary System Page: 1 of 2Effective Date: 09/09/04Supersedes: 07/08/02_____________________________________________________________________PURPOSE:To provide a system for evaluating and selecting medications for use atJ. Iverson Riddle Developmental Center.POLICY:The formulary system is the method used by medical staff working through the Pharmacy andTherapeutics Committee to develop and maintain a formulary of accepted drugs for use in theJ. Iverson Riddle Developmental Center.PROCEDURE:A. Drugs included in the J. Iverson Riddle Developmental Center Formulary are classifiedaccording to the American Hospital Formulary Service classification system. This is basically aclassification system according to pharmacologic type.B. All additions to this formulary shall be by the generic or non-proprietary name.C. Orders or prescriptions calling for trade names or proprietary names shall be filled with areputable generic equivalent but not necessarily with the brand name requested.D. No combinations or mixtures of two or more drugs shall be added to the formulary unless itis determined that such a combination or mixture has a therapeutic advantage over theindividual drugs.E. If a drug is needed that is not listed on the formulary, the physician may request that thePharmacy order a temporary supply so that the treatment shall not be delayed.

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: JIRDC PharmacyJIRDC Number:1:11Formulary System Page:2 of 2Effective Date: 09/09/04Supersedes: 07/08/92_____________________________________________________________________F. In order to have a drug considered for formulary addition, the physician shall complete a"Request For Addition To Formulary" form which can be obtained from the PharmacySecretary. After the form is completed, it should be returned to the Director of PharmacyServices at least two weeks prior to the next Pharmacy and Therapeutics Committee Meeting.This allows adequate time for a pharmacist to review the request, perform a literature review,and prepare a formulary presentation. If the request is approved by the Pharmacy andTherapeutics Committee, the drug shall be added to the formulary.G. The Pharmacy shall utilize the Pharmacy Newsletter to notify staff of formulary additions,deletions and restrictions as well as to provide product information for drugs approved forformulary addition.H. The maximum dosages for the medications used at JIRDC shall be the maximum dosagesrecommended by the manufacture and referenced to the Package Insert, PDR and TheAmerican Hospital Formulary Service. If a physician finds it necessary to utilize a dosageabove the recommended maximum amount, a pharmacist shall contact the prescriber todiscuss the case and document the rational for this usage.NOTE: See Attachment 1:11A (Form8) for "Request For Addition To Formulary" Form.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERDEPARTMENT OF PHARMACYRequest for Addition to Formulary1. Date _______________________________2. Drug Requested ______________________________________________________3. Dosage Form _________________________________________________________4. Strength ____________________________________________________________5. Dosage Schedule (if applicable) _____________________________________6. Duration (if applicable) ____________________________________________7. Requested by Dr. ____________________________________________________8. Specific Therapeutic Reason for requesting this preparation ratherthan a formulary item of similar pharmacologic action.______________________________________________________________________________________________________________________________________________________________________________________________________________Do Not Write Below This LinePharmacist's Comments and Recommendations:________________________________________________________________________________________________________________________________________________Action Taken by P & T Committee:______________________________________________________________________________________________________________________________________________________Chairman of the P&T Committee:____________________________________Date:________Attachment 1:11A (Form8) 9/04

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Poison ControlJIRDCP Number: _1:12_Page: 1 of 3Effective Date: 09/9/04Supersedes: 09/12/02______________________________________________________________________PURPOSE:To provide resources for poison control information and to make appropriate antidotesavailable.POLICY:Poison control information can be obtained from the following sources:1. Antidote charts will be posted in all patient care drug storage areas.2. Poison control center numbers will be posted in all patient care drugstorage areas.Carolinas Medical Center (Charlotte, NC)1-800-222-1222The American Association of Poison Control Centers has issued a nationwide toll freenumber. The number is 1-800-848-6946, which will connect the caller with therespective local poison control center. Carolinas Medical Center is thegeographic poison control center. Thus, by using the direct number (800-222-1222)posted in all patient care drug storage areas, the poison control center will be reachedfaster. Nonetheless, either number may be used successfully to obtain necessaryinformation.3. Pharmacy (if pharmacy is not open the pharmacist on call can be contacted).Poison antidotes and other drugs to be used in the treatment of overdoseand accidental poisoning can be obtained from the following sources: Pharmacy (if thepharmacy is not open the pharmacist on call can be contacted). Flumazenil injection isavailable in all emergency boxes.4. Night Drug Cabinet located in MCU.A stock of antidotes and drugs to be used for treatment of overdose and poisoningshall be maintained in the Night Drug Cabinet in the MCU. This shall include, but is notlimited to, activated charcoal, naloxone injection, and vitamin K injection. Any itemsused shall be signed out as described in JIRDCP 1:10 - "Use of Night Drug Cabinet."NOTE: See Figure 1-12A for Poison AntidotesSee Figure 1-12B for Emergency Action for Poisoning_____________________________________________________

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Confidentiality JIRDC Number: 1:13Page: 1 of 1Effective Date: 08/03/92Supersedes:_______________________________________________________________________PURPOSE:To protect and preserve the confidential nature of client/resident information.POLICY:All members of the Pharmacy Staff will be familiar with and comply with J. Iverson RiddleDevelopmental Center Confidentiality Regulations.PROCEDURE:A. A copy of the Confidentiality Regulations (APSM 45-1, January 10, 1986) shall be kept inthe Pharmacy Office in the J. Iverson Riddle Developmental Center Administrative PolicyManual (I-C-5).B. All members of the Pharmacy Staff will read and understand the ConfidentialityRegulations, and sign an "Assurance of Confidentiality" form confirming this.C. The Confidentiality Regulations will be reviewed yearly and the "Assurance ofConfidentiality" form updated by each Pharmacy Employee.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Drug Information and Drug JIRDC Number: 1:14Related Resident Consultations Page: 1 of 1Effective Date: 08/03/92Supersedes:___________________________________________________________PURPOSE:To provide drug related resident consultations and drug information to J.Iverson Riddle Developmental Center staff and residents.POLICY:The Pharmacy will provide drug related resident consultations and druginformation to J. Iverson Riddle Developmental Center staff and residentsupon request.

J. IVERSON RIDDLE DEVELOPMENTALCENTERPOLICY AND PROCEDURE MANUALSUBJECT: Drug RecallJIRDC Number: _1:15Page: 1 of 1Effective Date: 09/12/02Supersedes: 09/27/00______________________________________________________________________PURPOSE:To provide a mechanism for removing recalled drugs from pharmacy stockand resident care areas.POLICY:Medications recalled by the manufacturer, Food and Drug Administration,or other governmental agencies shall be removed from pharmacy stockand resident care areas as soon as possible.PROCEDURE:A. Check pharmacy stock and remove all medication being recalled.B. A computer search of all resident records is performed todetermine the number of residents at J. Iverson Riddle Developmental Centerwhich are affected by the specific drug recall.C. Notify by phone the area nursing supervisor of each area withresidents affected by the recall. Each resident affected,along with the lot numbers involved, shall be communicated sothat all medications with the recalled lot number can be removedfrom stock and returned to the pharmacy as soon as possible.D. After notifying the area nursing supervisor by phone, a secondnotice of the drug recall in memo form shall be sent to theMedical Director, Director of Nursing, and appropriate areanursing supervisors. This will be a reminder that residentcare areas should be checked for the recalled medication andif any is found to return it to the pharmacy as soon as possible.E. In addition to the verbal and written notification of the drugrecall, pharmacy personnel shall check for any recalled medicationduring the monthly inspection of resident care drug storage areas.F. Any recalled medication removed from stock in the pharmacy orreturned to the pharmacy from resident care areas shall bestored separately from regular stock until it can be returnedto the manufacturer for credit.G. A written log of all drug recalls and action taken shall bekept in the pharmacy and reported to the Pharmacy and TherapeuticsCommittee at each quarterly meeting.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Purchasing and Receiving JIRDC Number: 1:16of Drugs, Chemicals, and Page: 1 of 3Biologicals Effective Date: 08/03/92Supersedes:_____________________________________________________________________PURPOSE:To establish specifications and procedures for ordering and receivingdrugs, chemicals, and biologicals.POLICY:All drugs, chemicals, and biologicals purchased shall meet U.S.P. andN.F. standards. Drugs shall be purchased using primarily the State ofNorth Carolina Drugs and Medicine Contract System. Purchases shall befrom manufacturers with an established reputation for integrity andquality control.PROCEDURE:A. Direct Purchases: Requests for Purchases are completed in duplicate with thefollowing information:Name of medicationStrengthFormPackage sizeCommodity number (when applicable)Unit priceName and address of supplierRequest for purchase authorization numberSignature of Director of Pharmacy or designee.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Purchasing and Receiving JIRDC Number: 1:16of Drugs, Chemicals, and Page: 2 of 3Biologicals Effective Date: 08/03/92Supersedes:_____________________________________________________________________The original of the Request for Purchase is forwarded to the Purchasing Department whotranscribes the request for purchase to an official order form and assigns a purchase ordernumber.The copy of the Request for Purchase is retained in the Pharmacy.A copy of the purchase order is forwarded to the supplier. Another copy is forwarded tothe Pharmacy and filed in an open file until the shipment is received.B. Prime Vendor PurchasesRequests for Purchase are completed in duplicate with the following information:Name and address of supplierRequest for purchase authorization numberThe words "See Attached Invoice" are written across the face of the purchase orderrequest.Both copies of the Request for Purchase are maintained in the Pharmacy until theshipment is received.C. Medication shipments of direct orders are received by the warehouse and thendelivered to the Pharmacy in unopened packages. Prime vendor orders are receiveddirectly in the Pharmacy on a daily basis. Upon receipt of any pharmacy supplies that arewet or appear damaged, receiving personnel are to immediately notify the PharmacyDepartment. A pharmacist or pharmacy technician shall report to the area to assist withevaluation and follow up of the damaged shipment. Any pharmacy supplies receiveddirectly in the Pharmacy that are wet or appear damaged shall be brought to theattention of a pharmacist or pharmacy technician for evaluation and appropriate follow up.D. Upon receipt of the shipment in the Pharmacy, the package(s) are opened andchecked against the packing slip (and/or invoice if packing slip is not sent), the pharmacy'scopy of the Request for Purchase (or list of items requested for prime vendor orders),

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Purchasing and Receiving JIRDC Number: 1:16of Drugs, Chemicals, and Page: 3 of 3Biologicals Effective Date: 08/03/92Supersedes:_____________________________________________________________________and purchase order to verify correctness of medication and quantities. If the shipment iscorrect, the packing slip (and/or invoice if packing slip is not sent) is forwarded to thebudget office and a copy of the packing slip (and/or invoice if packing slip is not sent) isattached to the pharmacy's copy of the purchase order and filed in the Pharmacy. If thereare any discrepancies found, the supplier is contacted by the Pharmacy and detailsworked out to correct the discrepancy. If there are back ordered items, the Pharmacycopy of the purchase order, request for purchase, and packing slip are retained in an openfile until all back ordered items are either received or canceled.After the back order or discrepancy is cleared, the same procedure as described above fora correct shipment is followed.E. After a shipment is received and processed, all new stock shall be placed on propershelves within 12 working hours after it is received with the exception of controlledsubstances and any items that require refrigeration and those shall be placed in thecontrolled drug room and the refrigerator, respectively as soon as possible.F. If a medication (formulary or non-formulary) is needed but is not available through the J.Iverson Riddle Developmental Center Pharmacy and urgency or need does not allowobtaining through regular purchase procedures, a limited supply shall be purchased orborrowed from Broughton Hospital, Grace Hospital, or a local retail pharmacy.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Storage of Pharmaceuticals JIRDC Number: 1:17Page: 1 of 2Effective Date: 09/23/98Supersedes: 08/03/92__________________________________________________________________PURPOSE:To assure that medications are properly stored.POLICY:Medications shall be stored under proper conditions of sanitation,temperature, light, moisture, ventilation, segregation, and security.PROCEDURE:A. Pharmacy Storage:1. An adequate supply of legend and non-legend medications willbe maintained in the Pharmacy work area for daily dispensingactivities. The bulk or back-up inventory will be kept inthe main storage area located within the Pharmacy.2. All supplies of Schedules II, III, IV, and V controlledsubstances will be stored in the Controlled Drug Room in thePharmacy, with the exception of a limited supply of C-III-CIVmedications with perpetual inventory sheets maintained in themain pharmacy for outpatient dispensing.3. Medications requiring refrigeration will be stored in therefrigerator located in the Pharmacy.4. Any outdated drugs shall be removed from stock and storedseparately from regular stock until they can be returnedto the manufacturer for credit.5. Keys to the Pharmacy, Controlled Substance Security Systemand the Controlled Drug Room will be issued to pharmacistsonly.B. Patient Care Storage Area:

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Storage of Pharmaceuticals JIRDC Number: 1:17Page: 2 of 2Effective Date: 09/23/98Supersedes: 08/03/92_____________________________________________________________________1. All medications will be stored in properly locked medicationrooms or medication carts.2. Disinfectants and drugs for external use shall be storedseparately from internal and injectable drugs.3. Medications requiring refrigeration are stored inrefrigerators with a temperature range of 36 - 46 degrees F.Medications should be stored separately from other contentsin the refrigerator.4. Medication shall be stored in the containers they aredispensed in from the Pharmacy.5. There shall be no outdated drugs stocked.6. Controlled Substances outside of the Pharmacy will be properlylocked in medication rooms or medication carts. Distributionand administration of controlled drugs will be adequately documented.7. Medication storage areas will be kept organized, clean, andproperly lighted.8. Keys to medication storage areas will be assigned only tomedication nurses. Medication keys will be kept on thenurses' person at all times while on duty.C. Night Drug Cabinet:1. The Night Drug Cabinet is located in the Hospital area. Itis locked at all times when not being used to obtainmedications or being restocked. One nurse per shift assignedto the Hospital area shall carry and be responsible for theNight Drug Cabinet key.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Storage and Destruction JIRDC Number: 1:18of Physician Medication Page: 1 of 1Samples Effective Date: 6/14/2006Supersedes: 8/3/1992_____________________________________________________________________PURPOSE:To provide for the safe storage and appropriate destruction of complimentary medicationsamples left with physicians by pharmaceutical representatives.POLICY:A. All medication samples received by physicians shall be stored securely and notaccessible to residents or other employees.B. Any medication samples that are to be used for residents of the J. Iverson RiddleDevelopmental Center shall be taken to the Pharmacy for appropriate dispensing with theexception of controlled substance samples, which cannot be used for residents due torecord keeping requirements.C. With the exception of controlled substances, physicians may send expired or unneededsamples to the Pharmacy for proper disposal.D. Expired or unneeded controlled substance samples must be stored securely until theN.C. Drug Commission is available to supervise the destruction of these medications.These samples may also be destroyed by a company approved and contracted by the J.Iverson Riddle Developmental Center for the purpose of destroying outdated, unusablemedications . Physicians having expired or unneeded controlled substances in theirpossession can notify the Pharmacy Department of such medications. The Pharmacy willmaintain a list of physician(s) desiring medication destruction, and will notify thesephysicians when the N.C. Drug Commission or the pharmaceutical destruction companywill be at the J. Iverson Riddle Developmental Center. The Pharmacy will help coordinatethe destruction of these controlled substances.

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Automatic Stop Orders JIRDC Number: 1:19Page: 1 of 1Effective Date:6/17/04Supersedes: 9/01/00__________________________________________________________________________PURPOSE:To establish automatic stop dates for medication orders that do not specifyduration of therapy or number of doses.POLICY:1. Schedule II controlled substances are discontinued after 72 hours unless the duration oftherapy or number of doses is specified.2. Antibiotics (I.V., I.M., oral, and topical) are discontinued after 10 days unless the durationof therapy or number of doses is specified.3. Corticosteroids (topical) are discontinued after 10 days unless the duration oftherapy is specified.4. Teriparatide (Forteo®) is discontinued after 2 years of therapy unless discontinuedsooner by the physician.5. All medications with the exception of those specified in 1-4 above shall have90 day stop date unless otherwise noted by the prescribing physician.6. All medication orders shall be reviewed quarterly by the responsible physician or dentist.7. It is recommended that PRN orders specify a number of doses or duration of therapy;unless otherwise specified by the prescriber, all such PRN orders shall be discontinued after72 hours. The prescribing physician should monitor usage of PRN orders.8. Existing medication orders shall automatically be cancelled when a resident isadmitted to a referral hospital.9. Pre-operative existing medication orders shall automatically be discontinued when aresident undergoes surgery.10. Residents transferred to MCU or the cottage from a referral hospital shall havemedications reordered by the attending physician.Drugs are not to be discontinued without notifying the physician. If the order expires in thenight, it shall be called to the attention of the physician the following morning. (This applies toall of the above.)

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Medication Counseling for JIRDCP Number: 1:20Outpatient PrescriptionPage: 1 of 4__Medications Effective Date: 06/17/04Supersedes: 09/12/02_____________________________________________________________________PURPOSE:To protect resident and employee health and maintain compliance with regulatorystandards by providing patient counseling for all resident off-campus visits, residentdischarges, and employee accident/injury claims which require the dispensing ofoutpatient prescriptions.POLICY:Patient counseling regarding the appropriate use of medication is required for allresidents leaving the facility for a leave of absence or discharge with outpatientprescription medication and for employee accident/injury claims which require thedispensing of prescription medications. This counseling must be performed by apharmacist or other professional qualified to provide such counseling (nurse,physician, physician's assistant). Counseling provided by other disciplines must beconsistent with that which is expected of pharmacists by regulatory agencies.Counseling must include, at minimum, the following information:1. Name, description, and purpose of medication2. Route, dosage, administration, and continuity of therapy3. Special directions for use by the patient4. Common severe side effects or adverse effects or interactions and therapeuticcontraindications which may be encountered, including their avoidance, and the actionrequired if they occur.5. Techniques for self-monitoring drug therapy6. Proper storage

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Medication Counseling for JIRDCP Number: 1:20Outpatient PrescriptionPage: 2 of 4__Medications Effective Date: 06/17/04Supersedes: 09/12/02______________________________________________________________________7. Prescription refill information8. Action to be taken in the event of a missed dose.The provision of such counseling, or the refusal of counseling by theresident/employee or representative, shall be documented.PROCEDURE:I. InpatientsFor all residents leaving the facility for the purpose of leave ofabsence or discharge in which prescription medication is dispensed,appropriate medication counseling shall occur as follows:A. The Pharmacy Department shall prepare medications for a leave or discharge.B. The Pharmacy Department shall generate a patient advisory leaflet coveringthe information described in 1-8 of the Policy Section above for each outpatientprescription medication dispensed to the resident.C. The completed package (medication, patient advisory leaflets), Home MedsChecklist sticker and a compliance sticker affixed to the medication bag, shallbe sent to the nursing unit prior to the resident leaving the facility. Thedispensing of both the medication and counseling information shall bedocumented in records maintained in the Pharmacy.D. A nurse shall go over the advisory leaflet information with each resident orcaregiver prior to the resident's departure. This activity shall be documentedby use of the Home Meds Checklist sticker provided with each set of offcampusor outpatient medications.

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Medication Counseling for JIRDCP Number: 1:20Outpatient PrescriptionPage: 3 of 4__Medications Effective Date: 06/17/04Supersedes: 09/12/02______________________________________________________________________The completed sticker may be placed on the back of the corresponding resident'smedication administration record. The sticker contains the following informationand signature/date blanks to be completed:The compliance sticker affixed to each bag containing leave of absence ordischarge medications & corresponding information leaflets shall list the J. IversonRiddle Developmental Center Pharmacy phone number if questions arise at a latertime regarding the medication. The sticker reads as follows:E. If feasible, residents may be sent to the Pharmacy Department for Pharmacistprovidedcounseling to occur prior to departure.II. Employee Health PrescriptionsFor all employees involved in a job related accident or injury requiring prescriptionmedications to be dispensed from the Pharmacy, medication counseling shall occur asfollows:

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Medication Counseling for JIRDC Number: 1:20Outpatient Prescription Page: 4 of 4Medications Effective Date: 6/17/04Supersedes: 09/12/02_______________________________________________________________________A. A "Confidential Patient Information Form" shall be picked up in the InpatientClinic and completed prior to coming to the Pharmacy (see Attachment A). Thisform outlines person specific demographic and health information forappropriate medication counseling.B. The employee shall present the employee health prescription and thecompleted information form to Pharmacy personnel.C. Pharmacy personnel shall prepare the medication and a patient advisory leaflet.A pharmacist shall check the prepared medication, review the directions forcorrect dosage and duration of treatment, and review the patient specificinformation for potential drug therapy problems such as clinical abuse ormisuse, therapeutic duplication, drug-disease contraindications, durg-druginteractions or drug-patient allergy.D. The pharmacist shall then provide the employee with the patient advisory leafletand discuss the eight specific items outlined in the Policy Section above, alongwith any clinically significant findings noted in Section C above.E. Such counseling shall be documented in a log maintained in the PharmacyDepartment. Each employee shall be asked to sign a statement that theyreceived or refused medication counseling.F. The “Confidential Patient Information Form” shall be filed and maintained in thePharmacy.See Attachment A – Confidential Patient Information Form (Form 53)

CONFIDENTIAL PATIENT INFORMATION FORMOur pharmacists want to provide the highest quality pharmaceutical care to our patients. Pharmaceutical careincludes medication education, routine review of your medicine records to detect possible interactions withother medicines or other drug problems and providing advice concerning use of non-prescription medicines.Each time you have a prescription dispensed by our pharmacists, you will be offered counseling about yourmedicine which may include:- The name and purpose of the medicine- Common side effects and what to do if they occur and how to avoid them if possible- Proper storage of your medicine and special directions for preparation and use- What to do if you miss a dose- Special information regarding use of non-prescription medicineTo help us counsel you, please complete this information form about your current health status and apharmacist will review it and help you with any questions.Name _________________________________________ Date of Birth ___________________ (Circle) M FAddress ______________________________________________________ S.S. #_________________________________________________________________________________________________________________Home Telephone Number ___________________________ Work Telephone Number__________________Family doctor or primary medical physician _____________________________________________________List any drug or food allergies ________________________________________________________________List any known problems with prescriptions or non-prescription medicine_____________________________List the prescription medicine you now are taking or list non-prescription medicine you often take:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________List any medical devices you use, such as blood pressuremeter, blood glucose meter, etc.______________________________________________________________________________________________________Over Please

HAS A DOCTOR EVER TOLD YOU THAT YOU HAVE ANY OF THE FOLLOWING CONDITIONS?HaveNowHadinPast╔════════════════════════════════════╦═══╤═══╗ ╔════════════════════════════════════╦═══╤═══╗║ ║ │ ║ ║ ║ │ ║║Allergies or Hay Fever ║ │ ║ ║Lungs - Emphysema ║ │ ║╟────────────────────────────────────╫───┼───╢ ╟────────────────────────────────────╫───┼───╢║ ║ │ ║ ║ ║ │ ║║Anemia or Blood Disorders ║ │ ║ ║Lungs-Obstructive Pulmonary Disease ║ │ ║╟────────────────────────────────────╫───┼───╢ ╟────────────────────────────────────╫───┼───╢║ ║ │ ║ ║ ║ │ ║║Angina or Heart Disease ║ │ ║ ║Lupus Erythmatosus ║ │ ║╟────────────────────────────────────╫───┼───╢ ╟────────────────────────────────────╫───┼───╢║ ║ │ ║ ║ ║ │ ║║Arthritis ║ │ ║ ║Mental Illness ║ │ ║╟────────────────────────────────────╫───┼───╢ ╟────────────────────────────────────╫───┼───╢║ ║ │ ║ ║ ║ │ ║║Artheriosclerosis, including Stroke ║ │ ║ ║Multiple Sclerosis ║ │ ║╟────────────────────────────────────╫───┼───╢ ╟────────────────────────────────────╫───┼───╢║ ║ │ ║ ║ ║ │ ║║Cancers or other Tumors ║ │ ║ ║Muscular Distrophy ║ │ ║╟────────────────────────────────────╫───┼───╢ ╟────────────────────────────────────╫───┼───╢║ ║ │ ║ ║ ║ │ ║║Cystic Fibrosis ║ │ ║ ║Myasthenia Gravis ║ │ ║╟────────────────────────────────────╫───┼───╢ ╟────────────────────────────────────╫───┼───╢║ ║ │ ║ ║ ║ │ ║║Diabetes ("Sugar Diabetes") ║ │ ║ ║Parkinson's Disease ║ │ ║╟────────────────────────────────────╫───┼───╢ ╟────────────────────────────────────╫───┼───╢║ ║ │ ║ ║ ║ │ ║║Epilepsy ║ │ ║ ║Prostate Disease ║ │ ║╟────────────────────────────────────╫───┼───╢ ╟────────────────────────────────────╫───┼───╢║ ║ │ ║ ║ ║ │ ║║Glaucoma ║ │ ║ ║Psoriasis or other Skin Disease ║ │ ║╟────────────────────────────────────╫───┼───╢ ╟────────────────────────────────────╫───┼───╢║ ║ │ ║ ║ ║ │ ║║High Cholesterol or Blood Fats ║ │ ║ ║Thyroid Disease ║ │ ║╟────────────────────────────────────╫───┼───╢ ╟────────────────────────────────────╫───┼───╢║ ║ │ ║ ║ ║ │ ║║Kidney Disease ║ │ ║ ║Ulcers or other Stomach Problems ║ │ ║╟────────────────────────────────────╫───┼───╢ ╟────────────────────────────────────╫───┼───╢║ ║ │ ║ ║ ║ │ ║║Lungs - Asthma, Chronic Bronchitis ║ │ ║ ║Ulcerative Colitis ║ │ ║╚════════════════════════════════════╩═══╧═══╝ ╚════════════════════════════════════╩═══╧═══╝Please list any other conditions not specified above including the medical conditionrequiring this prescription:________________________________________________________________________________________________________________________________________________________________________________________Have there been changes in drug regimen or I have received/refused counseling frommedical condition since last prescription a pharmacist regarding my medicationdispensed from J. Iverson Riddle Dev. Ctr? dispensed today.(If yes, note changes) Prescription #/ Signature / Date__________________________________________________________________________________________________________________________________________________________________________________________________________________2/06 (Form 53)______________/___________________/________________________/___________________/________________________/___________________/________________________/___________________/________________________/___________________/__________

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Medication for Craft VillageJIRDC Number:1:21Self Medication Residents Page:1 of 4Effective Date: 01/19/93Supersedes: N/A_______________________________________________________________________PURPOSE:To provide a system of accountability and documentation forresidents attending Craft Village workshops who are candidates forself administration of medications with appropriate supervision.POLICY AND PROCEDURE:1.The Pharmacy Department shall be notified in advance of allresidents attending the Craft Village workshops who arecandidates for self medication with supervision. Pharmacynotification of changes in attendance at the workshops (newresidents, changes in days of attendance, or discontinuingattendance) shall be the responsibility of Nursing Service.2.The Pharmacy Department shall prepare the noon dose of alloral medications for designated residents in appropriatelylabeled safety closure prescription vials. Each vial shallalso have the resident's photograph affixed to the containerto assist in identification. Each resident shall have aCraft Village medication administration record (MAR) fordocumentation of administration of each dose of medication(see Attachment A).3.Both the resident and the responsible staff shall documentthe daily medication administration on the MAR in thedesignated area. At the end of each week, the MAR shallbe returned to nursing personnel, who shall affix it to theresident's permanent cottage MAR.4.A Pharmacist shall verify the accuracy of the "Craft VillageDispensing Log" (see Attachment B) each Thursday afternoon,making all necessary changes to the log in ink, then signingthe appropriate area which designates that the check has

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Medication for Craft VillageJIRDC Number:1:21Self Medication Residents Page:2 of 4Effective Date:01/19/93Supersedes: N/A_______________________________________________________________________occurred. This step captures and updates any changes in 12 noon medicationadministration which has occurred since the last dispensing.5.All such changes identified in step #4 shall have correspondingchanges made in the Craft Village MAR sheet for that resident.6.Medications (in unit dose packaging to assist with medicationidentification) shall be prepared on Friday. A Pharmacistshall check the completed medications for accuracy in labeling,correct medication, and correct quantity of medication. Thecorresponding Craft Village MAR shall also be checked foraccuracy. After all described checks are made, the Pharmacistshall initial the Craft Village Dispensing Log, verifying thatthis step has been completed.7.No controlled substances shall be dispensed to the Craft Village.If a controlled substance is required, a member of Nursing Serviceshall be responsible for medication administration.8.The completed Craft Village Dispensing Log shall be given to thePharmacy Secretary, after completion on Friday, for updating andfiling. The secretary shall update noted changes and provide arevised dispensing log and set of Craft Village MARs for the nextweek, to be completed by the following Thursday at 12 noon.9.Medications shall be separated into bags with resident's name and location toassist nursing personnel with the transfer to the appropriate location.

J.IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Medication for Resident JIRDCP Number: 1:22Off-Campus Visits Page: 1 of 2Effective Date: 12/14/2005Supersedes: 09/10/2002PURPOSE:To provide a system of accountability for physician ordering and pharmacist dispensingof appropriately labeled and packaged medications for resident off-campus trips.POLICY AND PROCEDURE:A. Authorization and dispensing of off-campus medications:1. Off-campus visit authorization shall be provided by physician review andsigning of Quarterly Medication Order Update which includes the statement “Mayhave off campus visit with routine oral medications for up to 5 days unlessacutely ill.” An off-campus visit of duration greater than 5 days shall require aseparate authorization order.2. A nurse shall notify the Pharmacy Department in advance of each residentgoing on an off-campus visit which will require the dispensing of medicationslabeled for outpatient use, as well as the projected length of the visit.3. The Pharmacy Department shall prepare the medication(s) with quantitysufficient for the duration of the visit with appropriate labeling, auxiliary labels,and patient counseling information per J. Iverson Riddle Developmental CenterPharmacy Policy #1:20. A Pharmacist shall check each medication for accuracyand labeling prior to dispensing.4. Dispensing of off-campus medications as described above shall bedocumented on the outpatient dispensing record (see Figure 1:22, Attachment,Form 26). A duplicate copy of the labeled directions for use for each medicationdispensed shall also be maintained with dispensing records.5. A member of the Nursing staff shall receive the completed visit medicationand patient counseling information. The nurse shall validate the contents forsufficient quantity prior to providing them to the resident’s caregiver. Patientcounseling information shall also be provided and documented as described in J.Iverson Riddle Developmental Center Pharmacy Policy # 1:20.6. All off-campus visits which require the dispensing of medications in DEASchedule C-II, require the attending physician to provide an appropriatelycompleted outpatient prescription to cover the period of the off-campus visit.

J.IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Medication for Resident JIRDCP Number: 1:22Off-Campus Visits Page: 2 of 2Effective Date: 12/14/2005Supersedes: 09/10/20027. Treatment medications will not be sent on off-campus visits unlessspecifically ordered by the attending physician. Such treatment medications shallbe returned to the Pharmacy Department for outpatient labeling prior to and offcampus visit, if it is desired to send the medication on the visit. However, if atreatment or bulk medication, such as an oral contraceptive, is known to beroutinely dispensed on off-campus visits, the medication may be labeled foroutpatient use at the time of inpatient dispensing. (Refer to NursingPolicy NS I-M_10, Medical Treatments – Off Campus.)B. Obtaining medications for off-campus use when only one dose of eachmedication is required:1. Such dosages should be obtained from the resident’s medication drawerin the medication cart in the cottage. Each medication should be placed in aseparate medication envelope. Each envelope must be labeled with theresident’s name, the date, the instructions, the medication name and strength,the physician’s name, and initials of the nurse preparing such dosages. Theempty envelopes should later be used to chart in the Medication AdministrationRecord the doses administered to the resident while on off-campus events.C. Obtaining medications for off-campus use when the Pharmacy is closed:1. The pharmacist on call shall be contacted by phone or pager to return tothe facility to prepare the necessary medications. The authorization anddispensing of off-campus medications shall follow the same procedure asoutlined in Section A of this policy. The family may also elect to have theprescriptions phoned to a pharmacy in their community.(See also NS I-M-7 Medication: Obtaining When the Pharmacy is Closed andObtaining Prescriptions for Off-Campus Use)NOTE: See Figure 1:22A Pharmacy Record of Medications Prepared forConsumers Going Home (Form 26)Revised: 12/12/05, 9/10/02, 9/23/98, 2/93

PHARMACY RECORD OF MEDICATIONS PREPAREDFOR RESIDENTS GOING HOMEResident's NameResidentID #CottageLeavingDateReturnDate# ofDays#MedsFilledByCheckedByCounsel.Inf. Sent02/99 (FORM26)

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Medication for Employees JIRDC Number: 1:23Page: 1 of 2Effective Date: 02/03/93Supersedes: (P-11)12/1/76___________________________________________________________PURPOSE:To provide medication for employee emergencies and job related injuries.POLICY:1. Emergency medication for employees shall be provided as describedin the J. Iverson Riddle Developmental Center Administrative Policy and ProcedureManual under Employee Health, A.P.M. #I-E-2.2. Prescriptions for job related injuries shall be filled by J. Iverson Riddle DevelopmentalCenter Pharmacy only if the prescription is authorized by Employees' Health Service andif the prescription is for a formulary medication. If the prescription is not for a formularymedication, the employee shall be informed of the procedure to obtain the medication.Such prescriptions should have the phrase "Worker's Compensation," "Employee Health,"or adequate information for Pharmacy personnel to recognize this as a valid Worker'sCompensation claim. Prescriptions without this designation shall not be filled.3. If medication is needed for an employee due to a job related injury after regularPharmacy working hours, one dose of medication can be obtained from the Night DrugCabinet to be administered by appropriate nursing personnel. To obtain a dose ofmedication from the Night Drug Cabinet, a prescription for one dose of the medicationwith the directions to read, "To be administered now," shall be taken to the Night DrugCabinet by appropriate nursing personnel. The nurse responsible for the Night DrugCabinet shall stamp the back of the prescription with the "Night Cabinet Stamp." Therequired information shall be entered in the stamped area including the signatures of bothnurses. The prescription shall be placed in the tray on the medication cart to be pickedup by a member of the Pharmacy staff the following morning. The Pharmacy shall file theprescription and restock the Night Drug Cabinet.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Medication for Employees JIRDC Number: 1:23Page: 2 of 2Effective Date: 02/03/93Supersedes: (P-11)12/1/76_______________________________________________________________________4. If a controlled substance is needed for an employee due to a job related injury afterregular Pharmacy working hours, one dose of a controlled substance may be obtainedfrom controlled substance stock in the Night Drug Cabinet by appropriate personnel. Toobtain a dose of controlled substance, the physician must write a prescription for onedose of the controlled substance with the directions to read, "To be administered now."This prescription shall be taken to the Night Drug Cabinet and the controlled substanceobtained by making an entry on the appropriate Night Drug Cabinet sign-out record,designating that the medication recipient is a Western Carolina Center employee. Theprescription for the controlled substance shall be forwarded to the Pharmacy forappropriate record keeping the next working day.5. The pharmacist on call may be contacted when more than one dose of a medication isneeded or for assistance with other questions regarding medications for job relatedinjuries occurring after regular Pharmacy working hours.6. Pharmacy personnel shall not dispense or administer non-prescription or prescriptionmedications in single or multiple doses without authorization from the physicianresponsible for Employee Health Service. Those employees requesting anymedication without a prescription shall be referred to the In-patient Clinic.NOTE: Any medication obtained from the Night Drug Cabinet shall be administered tothe injured employee by appropriate nursing personnel. No medication may be issued tothe employee.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Safety JIRDC Number: 1:24Page: 1 of 2Effective Date: 09/12/02Supersedes: 03/01/93______________________________________________________________________PURPOSE:To provide a safe environment for employees, residents, and visitors.POLICY:A. All Pharmacy employees shall be oriented to departmental andcenter safety policies.B. Each Pharmacy employee is responsible for helping to maintaina clean and orderly department and for recognizing and reportingsafety hazards to a supervisor.C. Any injuries occurring at work shall be reported immediately toa supervisor and the employee shall be referred to EmployeeHealth Service as described in the Administrative Policy Manual,I-E-2: Employee Health, and in the Nursing Policy Manual:NS I-A-1: Accidents – Employees.D. Sharps including needles, razor blades, broken ampules, andbroken glass shall be placed in a sharps container for disposalby incineration.E. Uses syringes shall be disposed of as described for “sharps” in(D) above.F. Equipment1. Pharmacy employees shall be instructed in the safe andproper use of electrical equipment, including laminarflowhood, unit dose packaging equipment, and computers.2. All electrical equipment shall be inspected and maintainedaccording to J. Iverson Riddle Developmental Center safetypolicies and procedures.G. Security

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: SafetyJIRDC Number: 1:24__Page: 2 of 2Effective Date: 09/12/02Supersedes: 03/01/93______________________________________________________________________1. The Pharmacy controlled substance alarm system shall bechecked and appropriate documentation made monthly.2. All Pharmacy doors shall be locked and checked by apharmacist at the end of each work day.H. Fire Safety1. Employee shall be familiar with the hospital fire plan.2. Employees shall know the procedure for reporting a fireincluding the location of fire alarms and telephonenumber to call in the event of a fire.3. Employees shall be aware of fire exits and the locationof and proper use of fire extinguishers.4. Employees shall participate in fire drills as instructed.I. A notebook of “safety Data Sheets” shall be maintained in thePharmacy for hazardous materials stored in the Pharmacy andfor all other areas of J. Iverson Riddle Developmental Center. Eachemployee shall be familiar with the “Safety Data Sheets” and shall reviewthese sheets annually. There shall be appropriate documentationthat this review has taken place.J. Disposal of unusable drugs, biologicals, and chemicals:1. When possible, unusable drugs, biologicals, and chemicalsshall be returned to the manufacturer for credit.2. When these items cannot be returned to the manufacturer,the method of disposal shall be by incineration. Materialconsidered to be an environmental hazard shall be disposedof in accordance with hospital policy for hazardousmaterials and waste.K. Injectable cytotoxic agents are not dealt with in this facility,therefore, specific policies and procedures are not applicableat this time.

L. Refer to J. Iverson Riddle Developmental Center Safety Procedure Manualfor the J. Iverson Riddle Developmental Center Bloodborne Pathogen Policyas well as for addressing of other safety issues.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Material Safety Data Sheets JIRDC Number: 1:25Page: 1 of 5Effective Date: 09/20/01Supersedes: 03/01/93_____________________________________________________________________PURPOSE:To provide employees with information regarding proper handling ofmedications, chemicals, and other products routinely stored and/orused in the Pharmacy Department.POLICY:A. GeneralMSDS are chemical information sheets provided by manufacturers of achemical giving vital information about the use and storage of thechemical with any special precautions for employees use or exposure.MSDS are available for chemicals and medications. An internet basedwebsite with this information is: www.msds.pdc.cornell.edu/msdssrch.aspThe drug package insert may be used in place of MSDS for FDA approvedmedications. The MSDS are grouped together by type of hazard(ex: corrosive, combustible, or poisonous).B. Contents of Material Safety Data SheetsMSDS generally contain the following information:Product Identification – chemical formula, other names, tradename, hazardous ingredients.Physical Data – appearance, odor, solubility, information toidentify the substance.Precautions – a warning statement concerning handling or/storageof the material (ex. avoid breathing vapor).

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Material Safety Data Sheets JIRDC Number: 1:25Page: 2 of 5Effective Date: 09/20/01Supersedes: 03/01/93_____________________________________________________________________Emergency First Aid – directions to follow in case of contact withmaterial.Fire and Explosion Information – information on flammability andappropriate type of extinguishing media to use.Reactivity Data – information on incompatibility with othersubstances and materials.Leak and Spill Information – directions to follow for safe cleanup of spills and proper disposal of material.Health Hazard Information – describes how this material affectsyour health and some first aid treatment; also lists toxicity dataif known.Occupational and Work Area Recommendations – lists recommendedprotection guidelines to follow.Storage – lists proper storage conditions.Special Information – lists any special requirements for safe use of the material, specialhandling or storage information.NFPA hazard rating scale for health, fire, and reactivity as listed below:0 = minimal1 = slight2 = moderate3 = serious4 = severeC. Definitions Related to Potential HazardsThe following definitions are listed to help in understanding the potential hazards.

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Material Safety Data Sheets JIRDC Number: 1:25Page: 3 of 5Effective Date: 09/20/01Supersedes: 03/01/93_____________________________________________________________________Carcinogen – the chemical is a known cancer causing agent or isconsidered a potential carcinogen.Combustible – certain liquids that will burn; may also denoteordinary combustibles, such as wood or paper.Corrosive – a material that causes visible destruction orirreversible damage in living tissue at the site of contact.Flammable – materials or liquids that will ignite easily or areliable to cause fires if mishandled.Hazardous Material – any substance having special destructiveproperties capable of producing adverse effects on health orsafety of a human being.Irritant – substance which causes an inflammatory response uponcontact.Material Safety Data Sheets (MSDS) – chemical information sheetsprovided by manufacturer of a chemical giving vital informationabout the use and storage of the chemical with any special precautions for employeesuse or exposure.Poison – a substance causing illness, tissue or organ damage, ordeath when taken orally, inhaled or absorbed even in relatively small quantities.Toxic – adverse effects from exposure leading to acute reactions to the chemical.Exposure is generally by the mouth, skin, or respiratory tract.D. Safety GuidelinesThe following safety guidelines shall be followed:Use appropriate equipment and technique for handling chemicals and medication.

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Material Safety Data Sheets JIRDC Number: 1:25Page: 4 of 5Effective Date: 09/20/01Supersedes: 03/01/93_____________________________________________________________________Do not allow other persons in the manufacturing work area when hazardous materialsare being used.Be familiar with MSDS for any hazardous material you are using. Ask supervisor forhelp or instructions in handling unfamiliar materials.Avoid inhaling vapor or dust from all chemicals and medications.Avoid physical contact with all chemicals and medications.Seek assistance from supervisor in case of accident, leak, or spill.When repackaging a hazardous material any warnings on the original labelmust be included on the label of the repackaged product.In case of spill or leak, use proper clean-up procedures. Use cat litter as an inertabsorbent material. A respirator mask is available in the Maintenance Department ifrequired.E. Disposal of Chemicals and Hazardous MaterialsDisposal of chemicals and hazardous materials should adhere to properguidelines. Follow MSDS or package insert for disposal precautions.Contact the J. Iverson Riddle Developmental Center Safety Officer forassistance if needed.In case of accident, follow MSDS or package insert for directions.Always notify supervisor of any accident with chemicals or medications.Contact Employee Health if indicated.

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Material Safety Data Sheets JIRDC Number: 1:25Page: 5 of 5Effective Date: 09/20/01Supersedes: 03/01/93_____________________________________________________________________F. Material Safety Data Sheet Safety List by CategoryExamples of potentially hazardous products maintained in the Pharmacy:1. Corrosive - Silver NitratePotassium HydroxideHydrochloric Acid 37%Combustible – Flammable – “Hibistat”“Hibiclens”Potassium PermanganatePoisonous – Toxic – Absolute EthanolPhenolPodophyllum

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Drug Interaction Screening andJIRDC Number:1:26Clinician Notification Page: 1 of 1Effective Date: 09/21/02Supersedes: N/A_____________________________________________________________________PURPOSE:To establish guidelines for pharmacist disposition and follow up regarding pharmacygenerated drug interaction notices.POLICY:1) All physician's orders shall be entered into the pharmacyComputer database which has internal mechanisms for screening the new order againstthe resident's current medication regimen for therapeutic duplications, drug-druginteractions, and patient-drug allergies.2) When a drug interaction is screened and flagged by the pharmacycomputer (MCPLUS)system, the pharmacist with drug distribution responsibility shallcontact the prescriber or nurse,as dictated by the clinical situation, and document thenotification on the physician's order.3) The drug distribution pharmacist or a certified pharmacy technicianshall route the printed drug interaction form to the responsible clinical pharmacist for reviewand follow-up; a copy will be sent to the nursing unit as per routine process for clinicianreview and information, when the pharmacist feels this is clinically relevant information(examples of when it may not be necessary to send is when a nonsignificant change occursin administration times of drugs that interact, lowering the dose of one of two drugs thatinteract)4) The clinical pharmacist that has clinical coverage responsibilityfor the case will review, follow-up, and document any actions required on the D-I form,then file in the appropriate location within the pharmacy. The filed reports shall bereviewed, recorded, and filed monthly.

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Controlled Substances JIRDCP Number: 1:28Page: 1 of_10_Effective Date:09/09/04Supersedes: 09/16/02________________________________________________________________________PURPOSE:To assure that State and Federal regulations for Controlled Substancesare observed at J. Iverson Riddle Developmental CenterPOLICY:Controlled Substances shall be purchased, stored, dispensed, administered,and disposed of according to State and Federal regulations.APharmacy Ordering and Receiving of Controlled Substances1. Schedule II Controlled Substancesa. Schedule II drugs are ordered using Form DEA-222 which has three copies.After Form DEA-222 is completed, one copy is retained by J. Iverson RiddleDevelopmental Center Pharmacy and the two remaining copies of Form DEA-222are forwarded to the supplier. The supplier which receives two copies of Form DEA-222 shall retain one copy and send the other copy to the Drug Enforcement Agency.b. Upon receiving a shipment from the supplier, the packing slip is checked foraccuracy against the purchase order and Form DEA-222.c. Form DEA-222 is then attached to the purchase order and the supplier’s invoiceand properly filed in the controlled drug room. A copy of this information isforwarded to purchasing.d. When new stock is received, the amount received, the supplier, and theinvoice number is recorded on the appropriate Schedule II Controlled SubstanceBalance Sheet and in the computer software utilized to track controlled substancemovement.2. Schedule III, IV, and V Controlled Substancesa. The procedure for ordering and receiving Schedule III, IV and V controlledsubstances is the same as the procedure for ordering schedule II drugs with theprocedure for ordering schedule II drugs with the exception that a DEA order formis not required.B. Pharmacy Dispensing of Controlled Substances1. Schedule III, IV, and V Controlled Substances

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Controlled SubstancesJIRDCP Number: 1:28__Page: 2 of _10_Effective Date:09/09/04Supersedes: 09/16/02___________________________________________________________________a. When a physician or dentist writes an order for a controlled substance, the nurseshall requisition the controlled substances from the Pharmacy using theControlled Substance Requisition which is located at the bottom of thePharmacy Floorstock Sheet (see Attachment 1). The following information shallbe included on the Controlled Substance Requisition Sheet:1. Name of drug2. Strength of drug3. Number of units or amount needed4. Cottage or area to receive the drug5. Signature of nurse ordering the controlled substanceb. Upon receiving an order for a controlled substance, a pharmacist or his designeeshall sign out the number of units requested from the perpetual inventory for thatparticular controlled substance via use of the computer tracking system (seeAttachment 2). In addition to the number of units or amount being signed out, thefollowing information shall also be included on the computer generateddocumentation sticker affixed to the perpetual inventory sheet for each controlledsubstance:1. Date of issue2. Area receiving the drug3. Initials of person filling the requisition4. Reference (sheet) numberA computer generated sticker with the above stated information is affixed to the perpetualInventory sheet, the JIRDC Controlled Substance Administration Record (referred to hereafteras Controlled Substance Administration Record) or CSAR (see Attachment 3) and a perforatedreference tab attached to the controlled substance administration record. The followinginformation is thus included on both the controlled substance administration record and theperforated reference tab:1. Date2. Cottage or area receiving the controlled substance3. Drug and strength4. Number of units or amount issued5. Initials of person filing the order and initials of pharmacist checking the orderif the order is not filled by a pharmacist6. The medication dispensed shall be charged to cottage floor stock through thePharmacy computer systemc. After the order is properly processed, it is ready to be picked up by designated area’snurse. The person receiving the order shall check the drug and the number of unitsfor accuracy. If the drug and count are accurate, the person receiving the drug shall

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Controlled SubstancesJIRDCP Number: 1:28__Page: 3 of _10Effective Date:09/09/04Supersedes: 09/16/02________________________________________________________________________sign the Controlled Substance Administration Record and perforated reference tabdocumenting that the controlled substance was received and that the drug and countwere accurate. The perforated reference tab will then be removed from the ControlledSubstance Administration record and maintained on file in the controlled drug room untilthe Controlled Substance Administration record is returned to the Pharmacy. Thecottage physician’s name shall be written in the top right hand corner of the CSAR uponreceipt of the controlled substance.d. The home nurse shall pick up the controlled substance ordered for the individual home.In the event that this is not feasible, another nurse may sign for the medication asDescribed above, then deliver the controlled substance to the ordering nurse. If theHome nurse in not available for the physical transfer of the controlled substance, theNurse may lock the controlled substances in the appropriate medication cart. Thedelivering nurse shall make an entry on the receiving home’s “Controlled SubstanceShift Change Documentation Form” as follows:In the block corresponding to the date and shift at time of delivery, the nurseshall make an asterisk (*) in red ink. Then the nurse shall describe at the bottomof the sheet the CSAR number, medication name/strength, and number of unitsdelivered, then initial and date the entry. Example: *CSAR#1257,Phenobarbital 30mg., #50, JM, 10/07/94.e. If a controlled substance is no longer needed, it may be returned to the Pharmacy alongwith the Controlled Substance Administration Record. The number or amount beingreturned shall be counted and noted on the Controlled Substance Administration Recordto assure that the balance on the CSAR and the number of units or amount beingreturned correspond. If the Controlled Substance Administration Record and the countcorrespond, the drug shall be placed back into stock and added back on the perpetualinventory. The Controlled SubstanceAdministration Record and the matching perforated reference tab are then stapledtogether and dated as having been returned and then filed according to this date whichwill correspond to the date the returned drug was placed back into stock. The number ofunits of medication returned shall be credited back to the cottage through the Pharmacycomputer system.f. It is the responsibility of the home nurse to request controlled substances for dentalsedation needs. When the routine dental exams are completed for the home, anymedications felt to be no longer needed may be returned to the Pharmacy, along withthe corresponding CSAR. Dental sedation orders for Diazepam 10 mg or 15 mg perdose will be dispensed as Diazepam 5 mg, for administration purposes. One time onlydental sedations may be procured from another home by signing out on the CSAR perpolicy, provided the needed controlled substance is available.g. When a completed Controlled Substance Administration Record is returned to the

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Controlled Substances JIRDCP Number: 1:28Page: 4 of_10_Effective Date:09/09/04Supersedes: 09/16/02______________________________________________________________________Pharmacy, the matching perforated reference tab is attached to the ControlledSubstance Administration Record and the returning date noted on both. The returnedsheet is also entered into the computer tracking system. The Controlled SubstanceAdministration Record is then filed according to the return date noted on the perpetualinventory.h. If a resident is receiving a Schedule II, III, IV, or V controlled substance, the followinginformation shall be included in the computerized resident medication profile:1. Name of physician/dentist2. Date order was written3. Name and dose of medication4. Route of administration5. Direction for administrationC. Pharmacy Dispensing of Controlled Substances for Visits and Discharges1. Schedule II, III, IV, and V Controlled Substancesa. To obtain Schedule II, III, IV, and V controlled substances for a resident going ona visit or being discharged, the Pharmacy shall be notified of the visit or dischargethrough the established procedure. A completed outpatient prescription is requiredfor controlled substance dispensing for all C-II medications or for any controlledsubstance (C-II through C-V) for a discharged resident. (Reference JIRDC 1:37Discharge Medications).b. The correct number of units of the controlled substance shall be signed out of theperpetual inventory to the individual resident.c. A label shall then be prepared with the following information:1. Name of the resident2. Date3. Directions for use4. Name of prescribing physician5. Name and strength of medications6. Name of dispensing pharmacist7. Number of units or amount dispensed8. Pharmacy computer assigned prescription numberd. The prescription reference number shall be written on the perpetual inventory logsheet. The prescription number assigned by the pharmacy system shall be utilizedas the reference number for Schedule III-V medications.e. The label shall then be affixed to a safety-closure container to which the medication

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Controlled Substances JIRDCP Number: 1:28Page: 5 of_10_Effective Date:09/09/04Supersedes: 09/16/02___________________________________________________________________has been added. A federal non-transfer warning label shall also be affixed to thesafety-closure container.f. The dispensing pharmacist shall verify accuracy and consistency of inpatientmedication with visit/discharge medication by checking the controlledsubstance prescription label against a copy of the resident medication profile.After making this check, the pharmacist shall initial the resident medication profileand file appropriately.2. Schedule II Controlled Substancesa. Outpatient dispensing of a Schedule II controlled substance requires anappropriately completed outpatient prescription prior to dispensing. Afterreceipt of the prescription, dispensing shall occur as designated in C 1: a-fabove.D. Administration of Controlled Substances1. Schedule II, III, IV, and V Controlled Substancesa. When a Schedule II, III, IV and V controlled substance is to be administered,the nurse shall nurse complete the Controlled Substance Administration Record withthe following information:1. Date2. Time3. Resident’s Name4. First initial and last name of the person administering the medication5. Any pertinent remarks6. Home or area where the medication is being administered (if resident is not incottage listed at top of CSAR, document in remarks section)b. When multiple tablets are required for a single dose to be administered (example 2x Phenobarbital 60 mg., to make a 120 mg., dose), two lines on the CSAR must becompleted. It is imperative to remember that each dosage form (tablet or capsule)is equivalent to one line on the CSAR and must be accounted for completely. Onlythe resident’s name may be dittoed on the second or third lines of multiple doseadministration documentation. The date, time, and administered by sections mustbe completed fully for each line. The following example displays the intendeddocumentation format:

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Controlled Substances JIRDCP Number: 1:28Page: 6 of_10_Effective Date:09/09/04Supersedes: 09/16/02_______________________________________________________________________Consumer Adm.# Date Time Name By Remarks50 09/15/94 8AM John Doe J.Swearingen _____49 09/15/94 8AM " " J. Swearingen _____48 ________ ___ ________ _______ _____c. For off-campus trips which meet the “one dose from the cart” policy which involvesa controlled substance (see JIRDC # 1:22 Medication for Resident Off-CampusVisits), the nurse should sign for the controlled substance medication for the tripon the Controlled Substance Administration Record (CSAR) per policy, with theexception of making the notation “for off-campus trip” in the remarks section of theCSAR. If the medication is returned un-administered, is should be wasted with awitness and the documentation made per policy.2. When a controlled substance is administered, in addition to the Controlled SubstanceAdministration Record, the resident medication administration record shall also becompleted as is necessary when any medication is administered.E. Disposal of Controlled Substances1. Controlled substances shall be disposed of in compliance with State and Federalregulations.2. Outdated, contaminated, or otherwise unusable controlled substances shall be storeddrug room in the Pharmacy until they can be returned to the manufacturer for credit ordestroyed by the North Carolina Drug Commission or other authorized personnel.3. Contaminated or unused portions of controlled substances may be destroyed by anurse if the following procedures are followed:a. Both the amount of controlled substances administered and the amount destroyedshall be recorded on the Controlled Substance Administration Record.b. If a controlled substance is contaminated and has to be destroyed, the reason for thedestruction shall be noted on the Controlled Substance Administration Record.c. The initials of the nurse destroying the controlled substance and a witness shall beentered in the remarks section of the Controlled Substance Administration Record.d. Contaminated or unused portions of controlled substances will be destroyed byflushing in a toilet or sink and the method of destruction shall be documented on theControlled Substance Administration Record.

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Controlled Substances JIRDCP Number: 1:28Page: 7 of_10Effective Date:09/09/04Supersedes: 09/16/02_______________________________________________________________________F. Storage of Controlled Substances in Resident Care Drug Storage Areas1. Controlled substances shall be properly locked in a substantially constructed cabinet ordrawer.G. Storage of Emergency Drug Boxes Containing a Controlled Substance1. Emergency Drug Boxes containing a controlled substance shall be stored in a lockedarea inaccessible to residents.H. Obtaining Controlled Substances When the Pharmacy is Closed1. When a controlled substance is needed for a resident, and the Pharmacy is closed, onedose at a time can be transferred from the one resident care drug storage area toanother by the nurse involved. The nurse obtaining the controlled substance shall signout for the dose needed on the correct Controlled Substance Administration Recordbeing sure to indicate the resident’s name and cottage that the controlled substance isbeing obtained for. The pharmacist on call shall be notified and shall, upon the nextnecessary return to the facility, dispense the needed controlled substance to theappropriate area.I. Accountability of Controlled Substances in Resident Care Drug Storage Areas1. For a particular resident care drug storage area, only one nurse each shift shall have akey to the drawer or cabinet containing controlled substances. When keys cannot bephysically transferred from the off-going nurse to the on-coming nurse with medicationadministration responsibilities, the key shall be left in the secured key drop box asdesignated in each area.2. At the change of shifts, the nurse responsible for controlled substance administrationgoing off duty and the nurse responsible for controlled substances coming on duty shallcount all controlled substances to verify that the balance on the Controlled SubstanceAdministration Record and the actual physical count correspond. This shall beperformed using the Controlled Substance Shift Change Accountability Record,hereafter referred to as the Shift Change Record (See Attachment 4). Due to staffingpatterns which do not allow for off-going and on-coming nurses to physically count thecottage controlled substances together, appropriate completion of this form isnecessary. The completion of this document makes it necessary to check the CSARagainst the actual quantity of controlled substances on hand as the nurse accepts, then

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Controlled Substances JIRDCP Number: 1:28Page: 8 of_10_Effective Date:09/09/04Supersedes: 09/16/02_______________________________________________________________________transfers responsibility for the controlled substances and medication cart keys for thecottage. This process allows for early detection of any discrepancies which may occur,making resolution of any problems simpler.3. The following procedures should be followed when verifying and administeringcontrolled substances in cottages:a.At the beginning of first shift, the nurse shall verify the amount of each controlledsubstance present in the cottage’s designated locked area and document this counton the Shift Change Record. The nurse shall also verify that is count matches theoff-going second shift nurses count. If discrepancies are noted which cannot becorrected, the procedure outlined below shall be followed to document thediscrepancy. At the end of first shift, the nurse shall repeat the count anddocumentation procedure outlined above. The second shift nurse shall follow thesame procedure when coming on and leaving duty.b. Controlled substance medication administration is not routinely required on thirdshift. If a controlled substance is administered on third shift due to an acutesituation, the medication administration should be documented per policy on theCSAR. The on-coming first shift nurse will find that the count (for the controlledSubstance administration on third shift) does not match the second shift off count.The nurse should check the corresponding CSAR to assure that a dose was signedout, then document the count as it is found.4. The following procedures should be followed regarding shift exchange accountability forthe controlled substances stored in the night drug cabinet (NDC):a. All controlled substances in the NDC will be maintained in the secure locked boxin the designated area.b. The secure locked box has a closure with a lock-out security tab affixed.c. The lockout tab shall be inspected visually on each shift by the MCU nurse anddocumented on one line of the Controlled Substance Shift Exchange DocumentationForm, using the letter “1” for “seal intact”, along the nurses’ initials.(See Attachment 5).d. This process described is c above shall be repeated on each shift, until the lockoutdevice is broken. Once the tab is broken (to allow access to a needed controlledsubstance located in the locked box), each controlled substance shall be countedand documented in the usual manner until the pharmacy replaces the lockout tab.e. Only pharmacy has access to the supply of lockout tabs. Pharmacy shall be notifiedvia fax message when the controlled substance lockout tab is broken, so that it canbe replaced at the earliest opportunity. If the tab is broken after hours or onweekends, pharmacy will replace the tab the next working day, or if a pharmacistreturns to the facility for another purpose. Pharmacists will not return to the facility

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Controlled Substances JIRDCP Number: 1:28Page: 9 of_10Effective Date:09/09/04Supersedes: 09/16/02_______________________________________________________________________after hours expressly to replace the tab. A mechanism (described in letter d above)is in place to account for the controlled substances in the case that the tab is brokenafter hours, until it is replaced.f. Pharmacy personnel shall visually check the lock-out tab on daily NDC replacementrounds.g. Controlled substances balances on hand for each CSAR will be carried forward toeach new Controlled Substance Shift Exchange Documentation form at the beginningof each month by the responsible nurse.h. The explicit purpose of this procedure is to minimize work required in countingcontrolled substances in a limited access environment.5. If a discrepancy is noted that cannot be immediately resolved, the discrepancy shall beindicated on the Shift Change Record and the nurse in charge of the area for theappropriate shift shall be notified immediately and shall investigate the discrepancyfurther. If it is discovered that there is a controlled substance discrepancy, a pharmacistshall be notified, or if the Pharmacy is closed, the pharmacist on call shall be notified. Afternotifying a pharmacist, a Controlled Substance Discrepancy form shall be completed by thenurse discovering the error (see attachment 6). The nurse in charge of the area shall signthe Controlled Substance Discrepancy Form, place the form in a paper bag along with theCSAR and the controlled substance, staple the bag closed and return to the Pharmacy. Ifthe Pharmacy is closed, the nurse in charge of the area shall store the bag in a lockedlocation as designated in each area to assure accountability until the bag and specifiedcontents can be returned to the Pharmacy. The Shift Change Record shall be returned tothe Pharmacy for filing at the end of each month.6. If an error is made in signing out a controlled substance on the Controlled SubstanceAdministration Record, a pharmacist shall be notified and the controlled substance and theControlled Substance Administration Record returned to the Pharmacy as soon as possible.7. To return any controlled substance to the Pharmacy, the nurse wishing to return thecontrolled substance shall bring the medication and Controlled Substance AdministrationRecord to the Pharmacy. Pharmacy personnel shall record the date, cottage, name ofnurse, name of controlled substance, controlled substance number, and quantity to bereturned in a log.8.The controlled substance medication and Controlled Substance Administration Record shallthen be handled as described in B. 1d above.9. For questions regarding controlled substances, a pharmacist shall be contracted.

J. Inventory of Controlled Substances within the Pharmacy1. A complete Controlled Substance Inventory shall be performed weekly. The actual countat the time of the time of the inventory shall be compared to the balance shown on theJ. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Controlled Substances JIRDCP Number: 1:28Page: 10 of_10Effective Date:09/09/04Supersedes: 09/16/02_______________________________________________________________________perpertual inventory. If there is a discrepancy between the actual count and the balanceshown on the perpetual inventory, this shall be noted on the Controlled Drug InventorySheet. The perpetual inventory shall be corrected to show the actual count at the timeof inventory and appropriate documentation made.See Attachment 1 – Controlled Substance Requisition (Bottom of Pharmacy Floor StockRequisition)See Attachment 2 – Controlled Substance Inventory Record (Perpetual Inventory Sheet)(Form 9)See Attachment 3 - JIRDC Controlled Substance Administration RecordSee Attachment 4 – Controlled Substance Shift Change Documentation Record (Form 48)See Attachment 5 – Controlled Substance Shift Exchange Documentation Form forNDC (Form 48)See Attachment 6 – Controlled Substance Discrepancy Form (Form 50)

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Intravenous Admixture JIRDC Number: 1:29Service Page: 1 of 6Effective Date:Supersedes: 03/26/94_______________________________________________________________________PURPOSE:To provide a pharmacy based Intravenous Admixture Program.POLICY:Small volume intravenous admixtures shall be prepared by a pharmacist or under the directsupervision of a pharmacist. In an emergency situation, a nurse or authorized prescribermay prepare the admixture. When the Pharmacy is closed, the nurse shall follow the Policyand Procedure for "After Hours Intravenous Admixture Service."PROCEDURE:A. The operational efficiency of the hood shall be inspected and certified every six monthsby qualified inspectors.B. The laminar flow hood prefilters shall be checked monthly and replaced as necessary. Arecord of when the prefilters are replaced shall be maintained in the Pharmacy.C. The laminar flow work area (work surface, sides, and top) shall be wiped down with 70%alcohol first thing every morning before use. The work surface shall then be wiped downwith 70% alcohol before and after all aseptic manipulations.D. The blower shall be turned on and allowed to run for at least thirty minutes before startingan aseptic manipulation.E. Work shall be done at least six inches within the hood to avoid turbulence which maybring contaminated air from outside the hood into the working area.F. Arrange objects and the work flow in the hood in such a manner that clean air does notwash over dirty articles and contaminate other articles that must remain sterile. Keepturbulence at a minimum.

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Intravenous Admixture JIRDC Number: 1:29Service Page: 2 of 6Effective Date:Supersedes: 03/26/94________________________________________________________________________G. Each port of entry for vials and solutions shall be swabbed thoroughly with alcohol swabsor sprayed with 70% alcohol prior to each entry.H. All unnecessary items shall be kept out of the laminar flow hood. The work area shall bekept free of spilled medications, used syringes, used needles, and so on.I. Wash hands and forearms thoroughly with surgical soap before entering hood.J. Upon receipt of a facsimile copy of the physician's order in the Pharmacy, each new I.V.admixture order shall be checked and interpreted by a pharmacist. The I.V. admixture ordershall be entered into the appropriate consumer's computerized I.V. medication record. ThePharmacy computer system screens the information entered for incompatibilities andallergies. The pharmacist entering or verifying the order shall check for drug interactions andappropriate dosages. If there are any questions about the order, the pharmacist shallcontact the prescribing physician.K. After the order is reviewed by a pharmacist and entered into the computer system, theI.V. admixture shall be prepared as follows:The following information shall be entered on an I.V.Admixture Record (See Attachment 1):a. Name and location of consumerb. I.V. additive and dosec. Primary fluid and volumed. Dosing intervale. Time and rate of administrationf. Physician

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Intravenous Admixture JIRDC Number: 1:29Service Page: 3 of 6Effective Date:Supersedes: 03/26/94________________________________________________________________________g. Date and number senth. Initials of pharmacist preparing and/or checking final product (admixture)i. Order number of I.V. admixture2. An appropriate number of computer label(s) shall be generated at the time of order entryfor a supply of admixtures sufficient to last the consumer until the next 24 hour supplyof I.V. admixture is prepared. Each label shall include the following information:a. Name of consumerb. Cottagec. Bag or bottle numberd. Infusion rate (if appropriate)e. Time and date to be startedf. Name and amount of medication addedg. Name and volume of primary fluidh. Initials of prescribing physiciani. Time and date preparedj. Initials of pharmacist preparing and/or checking admixturek. Date and time to return to Pharmacyl. Order number of admixture3.Medication shall be added to a solution using a syringe and needle or other appropriateequipment. Particulate matter shall be removed using filters, as appropriate.4.Solution bags or syringes must be inspected for leaks and particulate matter afterpreparation of the admixture is completed.L. Unless there is a problem with stability or otherwise ordered by physician, a 24 hoursupply of I.V. admixture shall be prepared and refrigerated until 30 minutes, prior toadministration, with the exception of weekends, when a 72 hour supply is prepared.M. If the I.V. admixture is prepared by a technician, the admixture order, the label, theadmixture drug, the solution, the syringe and needle, other equipment, and the finished

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Intravenous Admixture JIRDC Number: 1:29Service Page: 4 of 6Effective Date:Supersedes: 03/26/94________________________________________________________________________product shall be checked by a pharmacist. The pharmacist checking the I.V. admixture shallinitial the I.V. Admixture Record and admixture label to document that the proper checkshave been made.N.All syringes and needles used in the preparation of I.V. admixtures shall be placed in theSHARPS A GATOR. When the SHARPS A GATOR is full, it shall be incinerated and thedevices within rendered inoperable.O.After the admixtures have been prepared and delivered to the appropriate area, aregistered nurse shall check the admixture and label against the physician's order beforeadministering.P. I.V. sets used in the delivery of intravenous solutions containing admixtures shall bechanged every 48 hours. I.V. sets used in the delivery of intravenous solutions withoutadmixtures shall be changed every 48 hours.Q. All Pharmacy employees preparing I.V. admixtures shall have appropriate training in thearea of sterile products preparation prior to being designated as qualified for theperformance of this operation. Such training shall include, but is not limited to, the ASHPtraining film - "Aseptic Preparation of Parenteral Products"; the Travenol publication -"Training Manual for Central I.V. Admixture Personnel"; "hands on" training, observation andcritique of technique by other qualified personnel, and selected references from theliterature.R. Pharmacy staff shall participate as requested in the inservice training of nursingpersonnel involved in the preparation or administration of sterile parenteral medications andsolutions including the provision of incompatibility information.S. If an I.V. admixture order is written after established Pharmacy hours of operation, or inthe case of a medical emergency, admixtures shall be prepared by a nurse as described in"T" below.T. After Hours Preparation of Intravenous Admixtures and Preparation of Large VolumeParenterals

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Intravenous Admixture JIRDC Number: 1:29Service Page: 5 of 6Effective Date:Supersedes: 03/26/94________________________________________________________________________1. When there is a routine order for a large volume admixture or an I.V. admixture afterhours, the registered nurse shall verify the interpretation of the order with the prescribingphysician.2. The pharmacist on call can be contacted to assist the nurse with calculations, druginteractions, incompatibilities, and other questions or problems when desired.3. A registered nurse can prepare one bag at a time using the following procedure:The I.V. admixture preparation area shall be kept clean.Counter tops shall be washed prior to each procedure with alcohol.Hands shall be washed before each procedure with surgical antiseptic soap.Patient specimens of any kind shall be kept away from the preparation area.During preparation, traffic flow must be kept to a minimum.Preparation area shall not have any windows open or be exposed to direct air movementduring time of preparation. (e.g. air conditioner)All supplies necessary for preparation of the admixture shall be assembled before actualpreparation begins.Each port of entry for vials and solutions shall be swabbed thoroughly with alcohol swabsprior to each entry.A filter needle shall be used when withdrawing any reconstituted solution or any medicationfrom an ampule before adding the medication to the primary fluid.After preparation each solution shall be checked for particulate matter.Each completed solution shall be checked against the physician's order.

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Intravenous Admixture JIRDC Number: 1:29Service Page: 6 of 6Effective Date:Supersedes: 03/26/94________________________________________________________________________After preparation the solution shall be properly labeled with the patient's name, cottage, timeof hanging, date, name and amount of medication added, primary solution, time ofpreparation, person preparing solution, and prescribing physician.4. Once in the Pharmacy, the admixture order will be appropriately processed and ifadditional bags are needed, these will be prepared and sent to the cottage.5. The nurse should not hesitate to contact the pharmacist on call to prepare the admixture ifhe/she is concerned about preparing a particular admixture.See Attachment 1: I.V. Admixture Record (Form10)

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Infection Control Policy JIRDC Number: 1:30Page: 1 of 3Effective Date: 03/26/94Supersedes: P-25___________________________________________________________PURPOSE:To assure a sanitary environment for storage, preparation, anddispensing of medication.POLICY:A.Personnel1. All new Pharmacy employees shall be oriented to facility infection controlpolicies and procedures during general orientation. New Pharmacyemployees shall also be oriented to departmental infection control policiesand procedures during Pharmacy orientation.2. All Pharmacy employees shall participate as appropriate in InfectionControl Inservices offered periodically.3. Good hygiene shall be practiced at all times.4. Employees with an infection shall not prepare or participate in thepreparation of medication if there is reasonable potential for spread ofinfection.5. Employees shall thoroughly cleanse their hands with surgical soap asappropriate when working in the dispensing area.6. Food brought into the Pharmacy shall be stored and disposed ofappropriately. Items requiring refrigeration shall be stored in therefrigerator designated for this purpose.7. Smoking shall be prohibited inside the facility.8. The Director of Pharmacy Services participates as a member of thePharmacy, Therapeutics, and Infections Committee.

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Infection Control Policy JIRDC Number: 1:30Page: 2 of 3Effective Date: 03/26/94Supersedes: P-25___________________________________________________________B. Traffic Control1. Only authorized persons or persons accompanied by a member of thePharmacy staff shall be allowed in the drug distribution area.C. Waste Management and HousekeepingDisposal of non-infectious liquid waste shall be through the sewagesystem. Non-infectious solid waste shall be disposed of in lined trashcontainers which are emptied daily.2. Used syringes and sharps including needles, razor blades, brokenampules, and broken glass shall be placed in a SHARPS A GATOR fordisposal by incineration.3. Disposal of unusable drugs, biologicals, and chemicals shall be placedin a designated "Biohazard" container and stored for incineration.4. Pharmacy staff is responsible for maintaining a neat and orderlyPharmacy. Housekeeping provides cleaning services to the Pharmacydaily. Pharmacy staff is responsible for necessary cleaning betweenhousekeeping visits.5. Soiled towels shall be placed in a covered hamper after use and taken tothe soiled linen area at least weekly.D. Equipment and Supplies1. Laminar airflow hood - see JIRDC Intravenous Admixture Servicespolicy and procedure for certification, maintenance, and appropriate use ofthe laminar flow hood.2. Unit-dose packaging machine - See JIRDC Unit Dose Packaging ofCapsules, Tablets, and Liquids policy and procedure for maintenanceand appropriate use of the unit-dose packaging machine.

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Infection Control Policy JIRDC Number: 1:30Page: 3 of 3Effective Date: 03/26/94Supersedes: P-25___________________________________________________________3. Counting trays and spatulas shall be used at all times when working withbulk medications. The counting trays and spatulas shall be cleaned asneeded with isopropyl alcohol.4. Drug storage areas in the Pharmacy are checked monthly by membersof the Pharmacy staff to rotate stock and assure that only in-date items areused. Drug storage areas in patient-care areas are inspected monthly asdescribed in JIRDC 1:4 Monthly Inspection of Drug Storage Areas.5. Medication which has been recalled shall be removed from pharmacystock and patient care areas as soon as possible as described in JIRDC1:15 Drug Recall.E. Surveillance1. The Pharmacy shall collaborate with the Infection Control Nurse andMedical Laboratory regarding sensitivity and resistance trends.2. Pharmacy staff shall be aware of infection potential and shall cooperatewith Infection Control Nurse and Pharmacy, Therapeutic, and InfectionCommittee to resolve any infection related problems regarding servicesprovided by the Pharmacy Department.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Unit-Dose Packaging of JIRDC Number: 1:31Capsules, Tablets, and Liquids Page: 1 of 3Effective Date: 06/13/07Supersedes: 09/12/02__________________________________________________________________________PURPOSE:To assure appropriate conditions of safety, sanitation, and quality control forunit dose packaging of capsules, tablets, and liquids.POLICY:Oral solids and liquids will be packaged in unit dose using proper procedure under thesupervision of a pharmacist.PROCEDURE:The supply of unit dose medications is constantly monitored by pharmacy technician staff.When a supply of unit dose medication becomes low, the name and strength of themedication and when it will be needed will be conveyed to a pharmacy technicianeither verbally or in writing. If the medication is required immediately, thetechnician with packaging duties shall be informed verbally.A pharmacy technician will determine the priority of packaging for the differentitems on the list. If necessary, a computer report may be generated regarding utilization ofthe medication in question to project the needed amount to package.A. Oral SolidsOral solids may be packaged in unit dose form via one of three methods. The threemethods are by: (1) the Sargent Auto-Print Medical Packager, (2) the Automed ATCMachine, or (3) Unit Dose Solutions Packaging Company. The first two methods areprocesses that can be performed within the pharmacy department. The later is onethat is performed by a packaging company contracted by the State of North Carolinaby the J. Iverson Riddle Developmental Center, and utilized for packaging oral solidsthat are dispensed in great volume but have caused problems with in-house packagingsystems. An example of such a medication is the fish oil capsules, which have burstwithin the packaging equipment, causing oil to be spread throughout vital equipmentmechanisms, and have caused damage that is difficult to repair.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Unit-Dose Packaging of JIRDC Number: 1:31Capsules, Tablets, and Liquids Page: 2 of 3Effective Date: 06/13/07Supersedes: 09/12/02__________________________________________________________________________Regardless of the method in which oral solids are packaged, all methods must have apredetermined number of units to be packaged. This number of projected need iscalculated by the technician using computerized data-collecting reports specific to thatdrug, prepackaging logs and experience. All unit dose packages must contain thefollowing information:a. Generic nameb. Trade name (if applicable)c. Strengthd. Manufacturer and lot numbere. Expiration date which will not exceed 12 months from the date packaged or thestated manufacturer’s expiration date, whichever is shorter.Prior to packaging an item, the technician shall ask another technician or a pharmacistto check the packaging equipment’s computer screen against the product beforeinitiating the packaging run. If packaging an item requires a new computer entry, apharmacist shall check the computer screen before the technician begins the run.After packaging is completed, the technician will check their work for correctness anddocument unit dose packaging on the Packaging Log. Afterwards, the pharmacistshall review the product packaged, check for correct medication, labeling anddocumentation, and initial the Packaging Log. Documentation must be written in ink.Before packaging begins each day and after each medication is packaged, theSargent Packaging Machine’s tablet/capsule disc and chute shall be cleaned withalcohol. A complete cleaning of the machine, including the sealing jaws, shall beperformed weekly as described in the “Sargent Service Manual.”Before the Automed ATC Machine is utilized for packaging unit doses, the tray inwhich the medications are placed should be cleansed with alcohol and sprayed withcanned air if necessary.To place an order for medication to be packaged by Unit Dose Solutions, Inc., the bulkcontainer of that item is ordered from the pharmacy’s prime vendor on a separateaccount specific for unit dose packaging purposes. This bulk product is forwarded toUnit Dose Solutions with a faxed request for quantities of dosage units desired. Uponreceipt of the packaged product within the pharmacy, it should be inspected forcorrectness and quality.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Unit-Dose Packaging of JIRDC Number: 1:31Capsules, Tablets, and Liquids Page: 3 of 3Effective Date: 06/13/07Supersedes: 09/12/02__________________________________________________________________________B. LiquidsLabels and expiration dating for unit dose liquids shall contain the same information asdescribed for oral solids. The procedure for packaging the unit dose liquids variesonly in the type of machinery utilized. The three methods include: (1) the BaxaRepeater Pump, (2) the MacBick Heat Sealing Machine, and by (3) Unit DoseSolutions, Inc.The Baxa Repeater Pump tubing shall be cleaned after each product is packaged andchanged every two weeks or more frequently if required. Cleaning shall beaccomplished via use of a mild soap solution followed by thorough rinsing.The MacBick Heat Sealing Machine utilizes single use unit dose cups of various sizesto accommodate various volumes of liquids. Liquid medications are never in touchwith the equipment. The medication information label is heat sealed to the cup afterthe appropriate volume has been poured into the cup. Due to space limitations on thelabel, a reference lot number is contained on the label which cross-references to thePackaging Log where the full description of required labeling information is provided.The process in which liquids are obtained from Unit Dose Solutions, Inc., is the sameas described for oral solid unit dose medication.The technician packaging an item shall ask a pharmacist to check all liquids packagedat the end of half-day intervals (i.e., at the end of the morning and at the end of theafternoon). The pharmacist shall review the product packaged, check for correctmedication, labeling and documentation, and initial the Packaging Log.C. General Guidelines:1. Only one product packaged and sealed at a time (solids or liquids).2. Only one packager per set-up.3. The pharmacist checking the product shall inspect samples of the finished productto verify labeling and contents for accuracy.4. As a security precaution, a complete count of all controlled substance stock bottlesshall be performed on a monthly basis.5. Accuracy is expected with all unit dose packaging.6. Nonsterile examining gloves are to be worn by the packager when handling oraltablets and capsules, along with proper use of handwashing techniques.

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Pharmacy, Therapeutics, andJIRDC Number: 1:32____Infections CommitteePage: 1 of 2___Effective Date: 09/12/02_Supersedes: 09/29/95__________________________________________________________________________PURPOSE:To define the composition, function, frequency of meetings, andattendance requirements of the Pharmacy and Therapeutics Committee.POLICY:A. Composition1. The Pharmacy and Therapeutics (PT) Committee shall consist oftwo representatives from the Medical Staff, two from PharmacyServices, two from Nursing Services, and one representativefrom Laboratory, one Nutritionist and ex officio members(Pharmacists, Medical Staff, Medical Director)B. FunctionsThe functions of the PT Committee shall be as follows:1. All medications made available in the facility for use bythe Medical Staff shall be approved by the PT Committee.2. PT Committee shall be responsible for the development andsurveillance of all drug utilization policies and practiceswithin the facility, in order to assure optimumclinical results and a minimum potential for hazard.3. The Committee shall assist in the formulation of broadpharmacy professional policies regarding the evaluation,appraisal, selection, procurement, storage, distribution,use, safety procedure, and all other matters relating tomedication use in the facility.4. The Committee shall have the ongoing responsibility forfacility formulary development and review. In so doing, the

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Pharmacy, Therapeutics, andJIRDC Number: 1:32__Infections CommitteePage: 2 of 2_____Effective Date: 09/12/02Supersedes:09/29/95____________________________________________________________________________Committee shall prevent unnecessary duplication of medicationshaving the same type and/or amount of therapeutic ingredients.5. The Committee shall be responsible for facility drug usageevaluation activities to assure that medications are utilizedappropriately, safely, and effectively.6. The Committee shall be responsible for the development ofpolicies and procedures relating to and the ongoingmonitoring of adverse drug reactions in this facility.7. The Committee shall evaluate and make recommendationsregarding medications to be floorstocked in the facility.C. MeetingsThe PT Committee Meeting shall be held quarterly at a date and timeagreed upon by the members in the Dental Office Conference Room.An agenda shall be distributed to all Committee members prior tothe meeting. A permanent record shall be maintained of each meetingproceedings by the secretary to the Committee. Such minutes shallbe approved by the Committee after inspection.Refer to J. Iverson Riddle Developmental Center Medical Care Unit/Dental Staff Bylaws,Rules and Regulations - Article 7.

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Emergency Medications and JIRDCP Number: 1:33Supplies Page: 1 of 3Effective Date: 12/14/06Supersedes: 3/17/05________________________________________________________________________PURPOSE:To describe a policy and procedure regarding the provision and maintenance ofemergency medications and supplies to all residential care areas and in departmentswhere medical procedures may by performed.POLICY AND PROCEDURE:A. The contents of the Emergency Medication Boxes and Medical Care Unit (MCU)Crash Cart shall be approved by the Pharmacy and Therapeutics Committee andMedical Staff. The contents of the Emergency Medication Boxes (a tackle boxconstructed of metal or plastic) are limited to the basic medications and suppliesnecessary to initiate emergency treatment. The contents of the MCU Crash Cart(a metal cart on wheels designed to roll to the emergency site) are morecomprehensive in medications and supplies allowing for more advancedemergency care.B. The Emergency Medication Boxes, located in the cottages and Dental Clinic, andthe MCU Crash Cart, located in the Medical Care Unit, shall be stored in a securearea accessible only to staff.C. Each Emergency Medication Box shall have a complete list of its contentsattached to the outside and contained within the box. (See Attachment 1). TheMCU Crash Cart shall have a list of its medications attached to the outside andcontained within the cart. (See Attachment 2).D. Affixed to the MCU Crash Cart list of medications and to each EmergencyMedication Box shall be a label indicating the earliest expiration date of any drugcontained within the unit, and this date shall be considered the expiration date ofthe unit. The expiration date on any emergency unit shall not exceed one yearfrom the time the box or cart was sealed. The cart and boxes shall be lockedusing a plastic breakable seal. These breakable seals are maintained by thePharmacy Department. When the seal for the MCU Crash Cart is broken, thePharmacy should be notified by Medical Care Unit staff. When the seal on anEmergency Medication Box is broken, the box shall be returned to the Pharmacy.All such emergency units shall be inspected by Pharmacy Department,medications replaced or updated, and locked by the application of a new seal.

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Emergency Medications and JIRDCP Number: 1:33Supplies Page: 2 of 3Effective Date: 12/14/06Supersedes: 3/17/05________________________________________________________________________E. The Emergency Medication Boxes shall be maintained by the PharmacyDepartment. The MCU Crash Cart medications shall be maintained by thePharmacy Department and its supplies maintained by Medical Care Unit staff (seeAttachment 3) under the direction of the physician designated to coordinate thecart. The expiration dates on the boxes and cart shall be monitored by a memberof the Pharmacy Department during routine cottage inspections every four weeks.The units will be inspected for their expiration date and for seal integrity. If a sealis broken or unit expired, the Emergency Medication Box shall be returned to thePharmacy for inspection and updating. The cottage nurse shall be notified whenthe Emergency Medication Box is removed the cottage. The updated box shall bereturned to the cottage as soon as possible, before the end of the workday. If theseal is broken or medication(s) within the MCU Crash Cart expired, a pharmacistshall inspect and update the medication(s) as soon as possible, before the end ofthe workday. An updated expiration date will be assigned and a new seal affixedto the emergency unit once the process of inspection and updating/replacing iscomplete.F. Emergency Medication Box only: If a controlled substance (Phenobarbitalinjection) is utilized from the Emergency Medication Box, the resident receivingthe controlled substance, name of medication, dosage, physician name, nurse’sname, and date of medication administration, shall be documented on theappropriate area of the “Emergency Medication Box Contents” list located insideeach box (see Attachment 1). When less than the entire contents of the controlledsubstance unit dose are administered, the wastage of the remainder of thecontrolled substance shall be appropriately documented on the “WastedControlled Substances Sign Out Slip” located in the Emergency Medication Box(see Attachment 4). Both the “Emergency Medication Box Contents” list and the“Wasted Controlled Substance Sign Out Slip” shall be appropriately completedand returned to the Pharmacy along with the opened Emergency Medication Boxwhen used.G. A physician’s order must be written for the administration of any medicationobtained from an Emergency Medication Box or MCU Crash Cart (seeAttachment 4). In the event of a code and the MCU Crash Cart utilized, thecompletion of the “Code Blue Worksheet” (see Attachment 5) shall serve as thevehicle for the physician’s orders. A copy of the physician’s orders shall be sentto the Pharmacy Department following its completion.

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Emergency Medications and JIRDCP Number: 1:33Supplies Page: 3 of 3Effective Date: 12/14/06Supersedes: 3/17/05________________________________________________________________________H. Refer to the J. Iverson Riddle Developmental Center Nursing Manual 2.2“Emergency Equipment” and the Facility Management Manual Policy 1.4.1“Emergency Care” for information regarding the Emergency Procedure during aCode Blue.Attachment 1: Emergency Medication Box Contents (Pharmacy Form 14)Attachment 2: MCU Crash Cart Medications ListAttachment 3: MCU Crash Cart Supply List (Nursing Policy)Attachment 4: Wasted Controlled Substance Sign Out Slip (Pharmacy Form 7)Attachment 5: J. Iverson Riddle Developmental Center Code Blue Worksheet

Attachment 1EMERGENCY MEDICATION BOX CONTENTSUPPER TRAY ## Used Item Used Form Stocked______ Benadryl 50mg(Diphenhydramine) 1 ml syr 1______ Epinephrine 1:1000 1 ml amp 2______ Narcan 0.4mg (Naloxone) 1 ml amp 2______ Phenobarbital 130mg 1 ml vial 1______ Phenergan 25mg (Promethazine) 1 ml amp 2______ Romazicon 0.5mg/5ml(Flumazenil)5 ml vial 1______ SoluCortef 100mg(Hydrocortisone)2ml vial 1______ Water, Sterile 5 ml amp 2MIDDLE TRAY:______ Glucose Oral Gel 15gm tube #1______ 21G 1” Ndl #2 ______ 23G 1” Ndl #2______ 21G 1&1/2” Ndl #2 ______ 25G 5/8” Ndl #2Supplies: alcohol swabs, tape, tourniquetBOTTOM OF BOX:______ Dextrose 50% Inj 50ml syr 1______ Normal Saline 1000ml IVF 1______ Bioclusive Transparent Dressing 2”x3” 4______ IV Cath 20G #2 ______ IV Cath 22G #2______ IV Tubing #1______ Safety Syr 3cc #4 ______Safety Syr 10cc #2Resident: Doctor: Nurse: Date_______________ _____________ ___________ __/__/_________________ _____________ ___________ __/__/__Pharmacist Check/Date ___________________12/06 (Form14)

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Medication Variances JIRDC Number: 1:34Page: 1 of 3_____Effective Date: 09/12/02Supersedes: 03/26/94________________________________________________________________________PURPOSE:To define a mechanism for the reporting, review, and analysis ofmedication variances at this facility.POLICY AND PROCEDURE:A. Reporting and Documentation1. All nursing medication variances, including chartingvariances as well as pharmacy dispensing variances, shallbe reported on the “Medication Variance Reporting Form”(See Attachment) which is included with medication cart fill.2. Variances reaching the consumer shall be reported to aphysician immediately and any follow-up treatment administeredby a nurse. Advocacy shall be informed of all medicationvariances reaching a consumer.3. Pharmacy variances in dispensing shall be reported toPharmacy immediately upon discovery for corrective action.The variance shall also be documented on the “MedicationVariance Reporting Form.” If the dispensing variance reachesa consumer, the steps outlined in #2 above shall be followed.4. The original copy of each two-part “Medication VarianceReporting Form” shall be returned to the Pharmacy with thesuccessive cart refill pickup. The duplicate NCR copy shallbe forwarded to the Nurse Supervisor for that area.B. Review and Analysis1. The Director of Pharmacy and Nursing Service shall compileand review all medication errors including Pharmacy dispensingvariances monthly. The purpose of this process shall be toidentify system problems that require correction ormodification, as well as to identify individuals that havean apparent high rate of errors to allow for counseling and/or

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Medication Variances JIRDC Number: 1:34Page: 2 of 3Effective Date: 09/12/02Supersedes: 03/26/94_________________________________________________________________________disciplinary action.2. The compiled medication variance report shall be forwarded tothe center-wide Quality Assurance Committee for review twiceyearly. Reporting of medication variances to the MedicalStaff shall be via the semi-annual Quality Assurance CommitteeReport. (Refer also to J. Iverson Riddle Developmental Center NursingPolicy Manual, NS I=M-6 “Medication Variances.”Attachment: Medication Variance Reporting Form

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Mental RetardationJIRDC Number 1:35__Intermediate Care FacilityPage: 1 of 9____Clinical Pharmacy Service Effective Date: 06/14/06Supersedes: 09/10/02________________________________________________________________________PURPOSE:To provide a detailed description of clinical pharmacy services for all residents of thisIntermediate Care Facility for the Mentally Retarded (ICF-MR) facility.POLICY AND PROCEDURE:A pharmacist shall participate, as appropriate, in the interdisciplinary evaluations ofindividual residents to provide drug therapy information as it relates to the total care of theresident (also See JIRDC1:1 Pharmacy Services).I. Medication HistoriesA. A medication history shall be performed by a pharmacist on each newadmission to the facility, with the exception of short-term (30 day or less) respiteadmissions. The resident's parent, guardian, and/or caregiver shall be interviewed duringthis process, if possible.B. An initial Pharmacy assessment shall be completed for each new admission,as defined above, by a pharmacist. The initial assessment shall include an assessment ofthe drug regimen with regard to indications for use of medication, outcome measuringsystems, and other drug therapy monitoring (i.e. laboratory tests) that should be utilized.The assessment shall also include a review for potential adverse reactions, allergies, druginteractions, or contraindications.II.Annual AssessmentsA. The ICF-MR regulations outline that a pharmacist needs to participate in thePCP (Person Centered Planning) process when the drug regimen of the individual indicatescomplicated drug therapy strategies, side effects, and drug interactions, and at the requestof the interdisciplinary team. This latitude allows the pharmacist to best determine when tointeract in the PCP process in order to utilize limited pharmacy resources most effectivelyand efficiently.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Mental RetardationJIRDC Number 1:3___Intermediate Care FacilityPage: 2 of 9____Clinical Pharmacy Service Effective Date: 06/14/06Supersedes: 09/10/02_____________________________________________________________________B. The criteria for participation in the PCP process for J. Iverson RiddleDevelopmental Center shall be:1. Individual is receiving more than one psychoactive medication.2. Individual is receiving three or more anticonvulsant agents.3. Individual is currently, or within the last year, has been in crisis.4. Individual has a complicated medical treatment plan.5. Interdisciplinary team requests pharmacist participation.C. Pharmacist participation in the PCP process shall include, but is not limited to,attendance and interaction at the PCP Meeting, and documentation of the medicationhistory/overall treatment strategy for the last year to be maintained in the resident'spermanent medical record. The Pharmacy Department will maintain a copy of the annualassessment document and a log stating attendance.III.Initial Screening of All Medication OrdersA. The Pharmacy Department receives a facsimile copy or direct copy of allphysicians’ orders written. Each new physician’s order information is entered into thePharmacy computer system database. Contained in this database are the demographics(age, sex, height, weight, date of birth, diagnosis, diet, allergy history) and medicationprofile information for each resident in the facility.B. The computer system screens each new physician's order for therapeuticduplication, resident-drug allergies, drug-drug interactions, and food-drug interactions. Anon-screen notification occurs for each potential clinical problem. A paper monograph isprinted if the warning is overridden and the order is implemented. The pharmacist shallcontact the prescribing physician for information purposes. Information contained within themonograph includes: etiology of the interaction, significance of the potential problem,management parameters to minimize the implications of the potential problem.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Mental Retardation JIRDC Number: 1:35Intermediate Care FacilityPage: 3 of 9_____Clinical Pharmacy Service Effective Date: 06/14/06Supersedes: 09/10/02_____________________________________________________________________IV.Drug Regimen ReviewA. A Treatment Team consisting of a physician, pharmacist, nurse, psychologist,home coordinator, advocate, social worker, and nutritionist shall perform a Drug RegimenReview for each ICF-MR resident on at least a quarterly basis. The reviews are to assessdrug therapy with regard to the resident's diagnosis, laboratory data, diet, programming,and behavioral concerns. The drug therapy assessment shall include review for potentialadverse reactions, allergies, drug interactions, contraindications, rationale for use,laboratory test modifications, and outcome assessment. This Drug Regimen Review shallbe documented on a Drug Regimen Review form that will be placed in the resident'srecord.B. Pharmacists attend and participate in discussion of residents followed in thefacility Neurology Clinic.C. The following are not practice standards or limitations but are potential drugtherapy problems which should be considered when performing Drug Regimen Reviews:1. The pharmacist should comment on multiple orders of the same drug for thesame patient (e.g. by different routes of administration, or the same chemicalentity ordered by different brand names).2. The pharmacist should comment on drugs being administered beyondestablished stop order policies.3. The pharmacist should comment on as needed (PRN) drug orders which areadministered as directed every day for more than 30 days.4. The pharmacist should comment on residents receiving more than onemultivitamin per day.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Mental RetardationJIRDC Number 1:35___Intermediate Care FacilityPage: 4 of 9____Clinical Pharmacy Service Effective Date: 06/14/06Supersedes: 09/10/02_________________________________________________________________________5. The pharmacist should comment on residents taking three or more laxativesconcurrently. Commonly used laxatives are as follows:BulkCitrucelFiberconBenefiberLubricantMineral OilFecal SoftenersColaceStimulantDulcolaxSenokotNeoloidSalineMilk of Magnesia (MOM)Fleets Enema6. The pharmacist should comment on the continuous use of thesedative/hypnotic drugs listed below for more than 30 days.GENERICNAMESedative/HypnoticsChloral HydrateFlurazepamTemazepamTriazolamZaleplonZolpidemRECOMMENDED MAXIMUMDAILY DOSE FOR ADULTS1500 mg30 mg30 mg0.5 mg20 mg10 mg7. The pharmacist should comment on the concomitant use of thesedative/hypnotic drugs listed in #6 above.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Mental RetardationJIRDC Number 1:35___Intermediate Care FacilityPage: 5 of 9_____Clinical Pharmacy Service Effective Date: 06/14/06Supersedes: 09/10/02________________________________________________________________________8. The pharmacist should comment on doses of the sedative/hypnotic drugslisted in #6 above which are administered in excess of the listed dosages.9. The pharmacist should comment on the concomitant use of any of thefollowing antipsychotic drugs.GENERICNAMEDepo-antipsychotic DrugsFluphenazineDecanoateHaloperidolDecanoateRisperidone ConstaGENERICNAMEAntipsychotic DrugsAripiprazoleChlorpromazineClozapineFluphenazineHaloperidolLoxapineMesoridazineMolindoneOlanzapinePerphenazineQuetiapineThioridazineThiothixeneTrifluoperazineRisperidoneZiprasidoneRECOMMENDED MAXIMUMDOSE FOR ADULTS100 mg q 2 wks300 mg q 4 wks50 mg q 2 wksRECOMMENDED MAXIMUMDAILY DOSE FOR ADULTS30 mg1600 mg900 mg40 mg100 mg250 mg400 mg225 mg20 mg64 mg800 mg800 mg60 mg40 mg16 mg200 mg

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Mental RetardationJIRDC Number 1:35___Intermediate Care FacilityPage: 6 of 9_____Clinical Pharmacy Service Effective Date: 06/14/06Supersedes: 09/10/02________________________________________________________________________10. The pharmacist should comment on the use of the antipsychotic drugs listedin #9 above in excess of the listed dosages.11. The pharmacist should comment on the use of the anti-anxiety drugs listedbelow which are administered in excess of the listed dosages.GENERICNAMEAnti-Anxiety DrugsAlprazolamBuspironeChlorazepateChlordiazepoxideClonazepamDiazepamHydroxyzineLorazepamRECOMMENDED MAXIMUMDAILY DOSE FOR ADULTS4 mg60 mg90 mg100 mg4 mg90 mg400 mg10 mg12. The pharmacist should comment on the concomitant use of the anti-anxietydrugs listed in #11 above.13. The pharmacist should comment on more than two changes of anantidepressant within a 7-day period. Commonly used antidepressants areas follows:GENERICNAMERECOMMENDED MAXIMUMDAILY DOSE FOR ADULTSSelective Serotonin Reuptake InhibitorsBupropion450 mgCitalopram60 mgEscitalopram20 mgFluoxetine80 mg

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Mental RetardationJIRDC Number 1:35___Intermediate Care FacilityPage: 7 of 9_____Clinical Pharmacy Service Effective Date: 06/14/06Supersedes: 09/10/02_________________________________________________________________________GENERICNAMERECOMMENDED MAXIMUMDAILY DOSE FOR ADULTSSelective Serotonin Reuptake Inhibitors continuedFluvoxamine300 mgParoxetine50 mgSertraline200 mgTrazodone600 mgSerotonin/Norepinephrine Reuptake InhibitorsDuloxetine60 mgVenlafaxine350 mgTetracyclic AntidepressantsMaprotiline225 mgMirtazapine45 mgTricyclic AntidepressantsAmitriptylineAmoxapineClomipramineDesipramineDoxepinImipramineNortriptylineProtriptylineTrimipramine300 mg600 mg250 mg300 mg300 mg300 mg150 mg60 mg300 mg14. The pharmacist should comment on the use of the antidepressants listed in#13 that are administered in excess of the listed dosages.15. The pharmacist should comment on the concomitant use of theantidepressants listed in #13.J. IVERSON RIDDLE DEVELOPMENTAL CENTER

POLICY AND PROCEDURE MANUALSUBJECT: Mental RetardationJIRDC Number 1:35___Intermediate Care FacilityPage: 8 of 9_____Clinical Pharmacy Service Effective Date: 06/14/06Supersedes: 09/10/02____16. The pharmacist should comment on residents who are takingantihypertensives and have not had a blood pressure recorded at leastweekly.17. The pharmacist should comment on residents who are on anticoagulanttherapy and have not had some assessment of blood clotting function at leastevery month.18. The pharmacist should comment on residents who are on cardiotonic therapy(e.g. Digoxin, Digitoxin) and have not had a pulse rate recorded in the chartor exhibit a pulse consistently below 60 or above 100.19. The pharmacist should comment on residents who are taking insulin or oralhypoglycemics and have not had a urine sugar test at least daily or a fastingblood sugar or a 2-hour post-prandial at least every 60 days.20. The pharmacist should comment on residents who are taking beta blockersand have no pulse rate recorded on the chart or have a pulse rateconsistently below 50.21. The pharmacist should comment on residents who are taking ironpreparations, folic acid or Vitamin B-12, and have not had a hematocrit orhemoglobin checked within the first month of therapy.22. The pharmacist should comment on residents who are taking antiarrhythmicdrugs and have not had a pulse rate recorded daily.23. The pharmacist should comment on two or more orders for analgesics usedin combination.24. The pharmacist should comment on residents taking diureticswho have not had a serum electrolyte (Na, K. Cl, CO2) determination within30 days after initiation of therapy and at regular intervals thereafter.J. IVERSON RIDDLE DEVELOPMENTAL CENTER

POLICY AND PROCEDURE MANUALSUBJECT: Mental RetardationJIRDC Number 1:35___Intermediate Care FacilityPage: 9 of 9____Clinical Pharmacy Service Effective Date: 06/14/06Supersedes: 09/10/02________________________________________________________________________25. The pharmacist should comment on residents taking diuretics andcardiotonics (e.g. Digoxin) who have not had a serum electrolytedetermination within 30 days after initiation of therapy and at regular intervalsthereafter.26. The pharmacist should comment on the use of anticholinergic drugs for thetreatment of extrapyramydal symptoms for more than four months without anattempt to decrease the dosage or discontinue the anticholinergic drug.27. The pharmacist should comment on residents who are receivinganticonvulsants and have not had periodic anticonvulsant levels and labevaluations or have levels outside the therapeutic range.Rev. 03/94, 09/02, 06/06

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Mechanism for Detecting and JIRDC Number 1:36Reporting of Adverse Drug Page: 1 of 6_ReactionsEffective Date:09/16/02Supersedes: 03/26/94________________________________________________________________________PURPOSE:To define an adverse drug reaction and describe the mechanism foridentification, reporting, and review of such reactions at J. Iverson Riddle DevelopmentalCenter.POLICY:All medication use shall be monitored for manifestations of sideeffects or other unintended effects. All suspected problems shallbe reported to medical staff for immediate management, thenappropriate documentation provided to enable tracking and reportingof such events.PROCEDURE:A. Definitions1. Adverse Drug Reactions: An adverse event which isnoxious and unintended, occurring at doses used for theprophylaxis, diagnosis, or therapy of disease, or for themodification of physiological function; or an adverse eventoccurring from drug overdose, whether accidental orintentional.2. Significant Adverse Drug Reaction: A reaction that isa) life-threatening or contributes to the death of aconsumer;b) is permanently disabling,c) requires intensive medical care (i.e. outside physicianreferral or hospitalization).3. Unexpected Adverse Drug Reaction: Reactions not listed

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Mechanism for Detecting and JIRDC Number 1:36Reporting of Adverse Drug Page:2 of 6_Reactions Effective Date: 09/16/02Supersedes: 03/26/94________________________________________________________________________in the current FDA approved labeling; reactions related toside effects listed on the labeling but differing due togreater severity or specificity; drug interactions not listedin the current labeling of the suspected drug(s);idiosyncratic reactions; or hypersensitivity/allergic reactions.B. Detections of Adverse Drug Reactions1. Caregivers shall observe for and report to nursing staff, anysymptoms in a consumer which are perceived as being relatedto the prescribed medication.2. Residents shall be observed on all shifts for adverse drugreactions signs and symptoms by caregivers.3. Pharmacists reviewing physician's orders shall be aware oforder sets which may be indicative of an adverse drug reaction.Such orders may include:a) sudden discontinuation of a medicationb) stat laboratory testsc) orders for drugs commonly utilized in the treatment of anadverse drug reaction.If such a situation is encountered, the pharmacist shall takeaction to determine that rationale for the order(s) and thelikelihood that an adverse drug reaction has occurred. If itappears that an adverse drug reaction has occurred, thepharmacist shall request that the adverse drug reaction bereported according to facility policy.4. Nursing staff shall note on each cart fill Medication VarianceReporting Form (See Attachment 1) the presence or absence ofany suspected adverse drug reactions, in their consumerpopulation, during the preceding cart fill period. This stepshall serve as a reminder of the importance of adverse drug

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: Mechanism for Detecting and JIRDC Number 1:36Reporting of Adverse Drug Page: 3 of 6_Reactions Effective Date: 09/16/02Supersedes: 03/26/94_________________________________________________________________________reaction monitoring and reporting.C. Reporting of Adverse Drug Reaction1. If an adverse drug reaction is suspected, the nurse shall reportimmediately to the prescribing physician or physician on calland follow immediate orders to manage the event.2. Nursing personnel shall carefully document all signs, symptoms,treatment, and outcome of treatment of the adverse event untilthe clinical situation is resolved.3. An "Adverse Drug Reaction Report Form" (See Attachment 2) shallbe completed by nursing for each adverse drug reaction observed.This report shall be forwarded to the Pharmacy Department.4. A pharmacist shall review and investigate each Adverse DrugReaction Report and follow with a report to the Pharmacy,Therapeutics, and Infections Committee regarding eachsuspected reaction.5. The committee shall review each report and forward reports ofeach significant or unexpected adverse drug reaction to theFood and Drug Administration using FDA Medwatch Form 3500(See Attachment 3).D. Documentation of Medication Allergies Detected1. Allergies to medications detected during the process outlinedin this policy and procedure shall be recorded on the red andwhite "allergy" sticker on the outside of the consumer'smedical record and on the Medication Administration Record.Attachment 1: Medication Variance Reporting FormAttachment 2: Adverse Drug Reaction Report FormAttachment 3: FDA Medwatch Form 3500(Refer to J. Iverson Riddle Developmental Center Nursing Policy Manual NS I-M-4:Medication Adverse Drug Reactions).

J.IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Writing Discharge Medication JIRDCP Number: 1:37Orders Page: 1 of 6Effective Date: 12/14/2005Supersedes: 08/15/1994POLICY:To devise a mechanism to provide for the safe and effective communication ofdischarge orders which complies with state and federal regulations.PROCEDURE FOR WRITING DISCHARGE MEDICATION ORDERS:A. Discharge medications shall be ordered on either Physician’s Order FormMRM 2-10-91 (A) Rev. or Physician Order Update Form MRM 2-10-94(c)Rev.B. Format for discharge medication orders:1. Date and time order is written2. The date the discharge will begin3. Specific number of days supply or number of doses needed4. Name, strength, and route of medication5. Dosing schedule/directions for use6. Physician/dentist signatureEXAMPLE: 12/10/05 Discharge resident on 12/14/05 with 2 weeks supplyof medications: Zyprexa 5mg po qhs; Lipitor 10 mg po daily;Phenobarbital 30 mg po qhs---John Doe, MDC. If the resident is taking a controlled drug, it is necessary to send aprescription on a J. Iverson Riddle Developmental Center prescription blank to thePharmacy. The following format shall be used in writing these prescriptions:

J.IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Writing Discharge Medication JIRDCP Number: 1:37Orders Page: 2 of 6Effective Date: 12/14/2005Supersedes: 08/15/19941. Resident’s name2. Resident’s cottage3. Date4. Medication5. Strength and route of medication6. Number of doses to be dispensed7. Directions for use8. Physician/dentist signature9. Physician/dentist printed or stamped name10. Physician/dentist printed or stamped DEA numberDischarge orders may be sent to the Pharmacy using a facsimile (fax) machine,provided that all areas of A-C above are satisfied.If a controlled substance prescription is sent to the Pharmacy via facsimile machine, theoriginal document shall be forwarded to the Pharmacy for filing.PROCEDURE FOR WRITING PRESCRIPTIONS TO BE FILLED AT A PHARMACYOTHER THAN J. IVERSON RIDDLE DEVELOPMENTAL CENTER:A. J. Iverson Riddle Developmental Center prescription blank shall be usedfor writing prescriptions to be filled at a pharmacy other than J. Iverson RiddleDevelopmental Center Pharmacy.

J.IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Writing Discharge Medication JIRDCP Number: 1:37Orders Page: 3 of 6Effective Date: 12/14/2005Supersedes: 08/15/1994B. The following format shall be used for writing these prescriptions:1. Resident’s name2. Resident’s address3. Date4. Medication5. Strength and route of medication6. Number of doses to be dispensed7. Directions for use8. Refill information9. Physician/dentist signature10. Physician/dentist printed or stamped name11. Physician/dentist printed or stamped DEA numberNOTE: See Figure 1:37A for Physician’s Order Form MRM 2-10-091 (A)Rev. or Figure 1:37B for Physician’s Order Form MRM 2-10-94(c) Rev.and format for writing inpatient medication orders. See Figure 1:37C forexample of prescription to obtain Controlled Substances from J. IversonRiddle Developmental Center Pharmacy for discharge.

J.IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Writing Discharge Medication JIRDCP Number: 1:37Orders Page: 3 of 6Effective Date: 12/14/2005Supersedes: 08/15/1994B. The following format shall be used for writing these prescriptions:1. Resident’s name2. Resident’s address3. Date4. Medication5. Strength and route of medication6. Number of doses to be dispensed7. Directions for use8. Refill information9. Physician/dentist signature10. Physician/dentist printed or stamped name11. Physician/dentist printed or stamped DEA numberNOTE: See Figure 1:37A for Physician’s Order Form MRM 2-10-091 (A)Rev. or Figure 1:37B for Physician’s Order Form MRM 2-10-94(c) Rev.and format for writing inpatient medication orders. See Figure 1:37C forexample of prescription to obtain Controlled Substances from J. IversonRiddle Developmental Center Pharmacy for discharge.

J.IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Medication Brought Into JIRDCP Number: 1:38The Facility By Residents Page: 1 of 3Effective Date: 12/14/2005Supersedes: 09/29/1995PURPOSE:To establish a system for appropriately storing, returning, or disposing of medicationsbrought into J. Iverson Riddle Developmental Center by residents.POLICY AND PROCEDURE:I. Medication Brought in at Time of AdmissionA. When a resident that is admitted to J. Iverson Riddle DevelopmentalCenter brings his/her personal medication, the medication shall be identified bythe attending physician, another responsible prescribing practitioner, or apharmacist and returned to the family if possible.B. Personal medications brought in by a resident shall not be administeredexcept in the case of medical necessity. If it is necessary to administer thepersonal medications, an order to that effect shall be written in the resident’schart. Any such medication must be properly identified by a pharmacist andstored in the Pharmacy prior to administration.C. If the medication cannot be returned with the family, it shall be placed in apaper bag with the resident’s name and cottage and sent to the Pharmacy, alongwith a completed “Record of Resident’s Personal Medication” which includes thefollowing information:1. Addressograph (upper right corner)2. Type of Personal Medications (medication brought in at time ofadmission vs. controlled substance returned from visit)3. Prescription Number4. Medication Name5. Dose

J.IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Medications Brought Into JIRDCP Number: 1:38The Facility By Residents Page: 2 of 3Effective Date: 12/14/2005Supersedes: 09/29/19956. Number of Units7. Signature of Nurse Receiving and Counting Medications8. DateThe top sheet is then detached and placed in a file maintained on the nursingunit and shall be maintained for a period of two years. The pharmacy copy andthe medication are placed in a paper bag with the resident’s name and cottageand sent to the Pharmacy.D. When the medication is received in the Pharmacy, the followinginformation is documented on the Pharmacy copy:1. Number of units of the medication2. Explanation of difference in count (if applicable)3. Pharmacy employee counting medications4. Date5. Number assigned to bag of personal medicationsThe Pharmacy shall store the medication in the bag with an assigned bagnumber, and the Pharmacy copy of the “Record of Resident’s PersonalMedication” is filed alphabetically according to resident name. The medicationshall be returned to the resident or resident representative at the time ofdischarge, if requested. If personal medications are returned to the resident,resident representative, or picked up in the Pharmacy Department, theappropriate information shall be documented on the back of the “Record ofResident’s Personal Medication.”

J.IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Medications Brought Into JIRDCP Number: 1:38The Facility By Residents Page: 3 of 3Effective Date: 12/14/2005Supersedes: 09/29/1995At the end of 60 days, if the medication has not been claimed, non-controlledmedications shall be disposed of by the waste disposal company contracted by J.Iverson Riddle Developmental Center. Controlled substances are placed in abag with the copy of the “Record of Resident’s Personal Medications” andtransferred to the Pharmacy Controlled Substance Room to be securely storeduntil the NC Board of Pharmacy approved waste disposal company contracted byJ. Iverson Riddle Developmental Center transfers this inventory to theirpossession for destruction. Destruction of non-controlled medications ormovement of controlled medications to the Controlled Substance Room shall bedocumented on the back of the “Record of Resident’s Personal Medication.”II.Controlled Substances Returned From a VisitA. When a resident returns from a visit with a controlled substance whichwas issued by the J. Iverson Riddle Developmental Center Pharmacy pursuant tophysician’s orders, the nurse receiving the medication shall complete a “Recordof Resident’s Personal Medication” as described in I-C above.B. For accountability purposes, controlled substances shall be handled asdescribed in II-A above when nursing staff receives visit medications, but the visitis cancelled.C. When the controlled substance is received in the Pharmacy, thePharmacy copy of the “Record of Resident’s Personal Medication” is completedas described in I-D above.D. Non-controlled visit medications are disposed of by the waste disposalcompany contracted by J. Iverson Riddle Developmental Center.Controlled substances are placed in a bag with the Pharmacy copy of the“Record of Resident’s Personal Medication” and transferred to theControlled Substance Room to be securely stored until the NC Board ofPharmacy approved waste disposal company contracted by J. IversonRiddle Developmental Center Pharmacy transfers this inventory to theirpossession for destruction. Movement of controlled medications to theControlled Substance Room shall be documented on the back of the“Record of Resident’s Personal Medication.”See Attachment “Record of Resident’s Personal Medication”

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Pharmacy Services Disaster JIRDCP Number: 1:39Plan Page: 1 of 2Effective Date: 10-27-04Supersedes: 05-13-98_______________________________________________________________________PURPOSE:To provide pharmacy services to the consumers of J. Iverson Riddle DevelopmentalCenter in the event of a disaster.POLICY:All members of the Pharmacy Staff will be familiar with the regular procedures noted belowand with the basic principles and guidelines noted in the Pharmacy Services Disaster Plan.PROCEDURE:MCPLUS Backup Tapes:Daily Backup: These tapes are stored in the Pharmacy Controlled Substance vault whichhas less likelihood of being destroyed during a natural disaster than free-standing areas.Program Libraries Backup: There will be two identical versions of this backup tapemaintained at all times. One version will be stored in the Controlled Substance vault andthe other copy is maintained by Medical Cybernetics.NarcTrak Backup Diskettes:The daily backup diskettes are stored in the Controlled Substance vault. There are twocopies of the Master Backup Program diskette with one copy stored in the ControlledSubstance vault and the second copy in the Pharmacy Director's office in a locked filecabinet.ATC Jaz Medium Backup Diskettes:There will be two identical daily backup diskettes maintained at all times. One copy ismaintained in the ATC dispensing device area and the second copy maintained in thePharmacy Controlled Substances Vault.Disaster Plan:1. In the event of a disaster, appropriate Pharmacy personnel will be notified.2. Pharmacy Department Operable but Without Power:a. Contact Western Regional Maintenance Department to inquire about status ofgenerator used to provide power to this area.b. Contact power/telephone companies to request emergency service, if needed.

J. IVERSON RIDDLE DEVELOPMENTAL CENTER PHARMACYPOLICY AND PROCEDURE MANUALSUBJECT: Pharmacy Services Disaster JIRDCP Number: 1:39Plan Page: 2 of 2Effective Date: 10-27-04Supersedes: 05-13-98____________________________________________________________________c. Prior to power restoration, manual dispensing mechanisms will be employed byretrieval of cottage MARs for access to most current information. Physicians’ orderswill be either manually delivered or picked up from cottages. Following restorationof power, the dispensing activity performed during the “down time” will be enteredinto the pharmacy computer system in a timely manner.d. An alternative to retrieving cottage MARs for the purpose of filling twice weekly cartfills would be to refer to the most recent medication cart fill slips for the specificcottage(s) for the basis of filling routine medications. Physicians’ orders receivedsince the last “cart fill” will be referred to and medications will be dispensedaccordingly (changed, new or discontinued medication orders will be so noted). If amedication is not packaged in unit dose form or the supplies of unit dosemedications are depleted, medications may be dispensed in vials utilizinghandwritten labels indicating medication and resident information. Upon receipt ofthe medications, nurses should closely inspect and verify medications receivedagainst the Medication Administration Record. As stated above, followingrestoration of power, the dispensing activity performed during the “down time” will beentered into the pharmacy computer system in a timely manner.3. Inoperable Pharmacy Department:a. The Night Drug Cabinet will be used to provide immediately needed drugs.b. The following institutions/drug suppliers may be used to provide emergency drugsupplies:1. Broughton Hospital2. Grace or Valdese Hospitals (Blue Ridge Healthcare)3. Pharmacy prime vendor (Cardinal Distribution)4. Community Pharmacies5. Black Mountain Centerc. Broughton Hospital and/or Black Mountain Center may be used to restore data fromthe most current copy of backups. These sites also may be used as emergency operatingsites until pharmacy services at JIRDC are reestablished. Medical Cybernetics, Inc.may be contacted to assist in restoration of the MCPLUS computer system, as needed.In the event of total or partial loss of drug inventory, the appropriate regulatory agencieswill be notified.

J. IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: MOSES/Nursing Assessment Monitoring JIRDC Number:1:40And Documentation Page: 1 of 4Effective Date: 09/21/02Supersedes: NA________________________________________________________________PURPOSE:To establish a standardized, sytematic, and ongoing process to monitor residentsfor potential adverse effects of medication.POLICY:All residents will be regularly and systematically assessed and monitored forpotential medication induced adverse effects via the Monitoring of Side EffectsScale (MOSES)/Nursing Assessment (attachment A). This assessment is notintended to be a substitute for other appropriate professionally mandated clinicalcare.Detailed instructions for the approprate use of the MOSES/NursingAssessment are on the back of the tool.All residents shall be assessed by a member of nursing staff at least quarterly,using the MOSES/Nursing Assessment as the assessment instrument. Thismay be done in conjunction with the quarterly treatment team meeting. Thisinformation shall be shared at the treatment team meeting.Teams may request that the MOSES/Nursing Assessment be conducted morefrequently if medications are being added, doses increased, or doses decreased.Such increased monitoring may be prudent and is team driven.A baseline MOSES/Nursing Assessment shall be conducted for each newadmission within 7-10 days of admission.The nursing staff member conducting the assessment shall determine if thefindings may be reviewed at the next treatment team meeting, or if they requiremore immediate evaluation by the cottage physician. If the need for more

J, IVERSON RIDDLE DEVELOPMENTAL CENTERPOLICY AND PROCEDURE MANUALSUBJECT: MOSES/Nursing Assessment Monitoring JIRDC Number 1:40And Documentation Page: 2 of 4Effective Date: 09/21/02Supersedes: NA________________________________________________________________immediate review is determined, the nurse shall bring this to the attention of thephysician. After the review, the physician shall make any neccesarydocumentation and sign the assessment in the appropriate location. Any followupactions required subsequent to the findings of the MOSES/NursingAssessment shall be documented in the medical record in the usual manner.The completed assessment shall be filed in the Medical Record in the nursingclinical section.